By U. Muntasir. Upper Iowa University.
Moisturization with bland emollients and avoidance of overly drying the skin such as bathing too frequently are also helpful cheap imuran 50mg with visa muscle relaxant and alcohol. Contact dermatitis arises as a result of an allergic Diabetes Diabetes mellitus is a disease in which or irritant reaction due to substances touching the skin buy cheap imuran 50mg muscle relaxant 771. Insulin Examples include poison ivy purchase 50 mg imuran amex muscle relaxant list by strength, costume jewelry, or per- is the hormone that regulates blood glucose levels by fumes in soaps or laundry detergent. Signs and symp- signaling cells to take glucose out of the bloodstream toms include redness and itching, and depending on and by signaling the liver not to put more glucose into the severity there can be significant swelling and for- the bloodstream. These skin changes are limited to the organ that lies in the upper abdomen, just below and site of exposure to the substance that elicits the allergic behind the stomach. Treatment consists primarily of iden- pancreas fails to produce enough insulin (type 1 dia- tifying the cause and avoiding it; however, resolution betes) or because cells do not respond normally to can be hastened with topical corticosteroids and, in insulin (type 2 diabetes). Only about 510% of all chronic and the inciting substance is unclear, skin patch diabetes is type 1. About 17 million people in the United States have dia- Seborrheic dermatitis is characterized by greasy betes, accounting for 6. Another yellowish scaling on the scalp and, in severe cases, the 6 million or so cases are undiagnosed. It is more common in adults, but can be seen in was the sixth leading cause of death. The presence of yeast with diabetes are twice as likely to die as those without is thought to play a role in its development. For women and young adults, diabetes occur during times of stress or in people who have neu- increases the death rate by fourfold. It is treated with medicated dandruff American Diabetes Association, in 1997, diabetes cost 213 Diabetes the United States $98 billion. Direct medical costs were before type 2 diabetes is diagnosed, because classic $44 billion. Indirect costs related to disability, loss of symptoms do not occur until glucose levels become work, and premature death were even higher, account- extremely high. However, type 1 diabetes can Classic symptoms of diabetes are increased urina- also develop later in life. There seems to be an inherited following three criteria: (1) fasting glucose greater than predisposition to type 1 diabetes. If one identical twin 126 mg/dl on two or more occasions, (2) random blood has type 1 diabetes, the other twin has a 50% chance of glucose of 200 mg/dl or higher in the presence of symp- developing it. In different cutoff values and is diagnosed with a 3-hr oral the absence of insulin, cells cannot take in glucose for glucose tolerance test that uses a 100-g glucose load. Insulin resistance is the hallmark of type 2 dia- 140 and 200 mg/dl during a 2-hr glucose tolerance test, betes, although type 2 diabetes can also involve with normal fasting glucose levels. This can occur if a diabetic patient Risk factors for developing type 2 diabetes include does not take her insulin or pills or does not follow a increasing age, obesity, family history of type 2 dia- diabetic diet. There is a strong high glucose levels lead to loss of glucose in the urine, genetic basis for type 2 diabetes, likely due to multiple which pulls water along with it, leading to excessive genes. If one identical twin is affected, the other has a loss of water from the kidneys. Certain eth- tion, which further concentrates glucose in the blood nic groups are also at higher risk. Weight loss occurs both Americans, Hispanic Americans, American Indians, as a result of water and calorie loss. Most patients In type 1 diabetes, this scenario can occur abruptly develop type 2 diabetes after the age of 40; however, when insulin is severely deficient. A condition called there are increasing numbers of younger type 2 diabetic ketoacidosis develops. When ketoacid levels rise, the blood becomes acidic, which impairs enzymatic reactions Diabetes can cause many problems in pregnancy. This results in abdominal pain, the first trimester, about 510% of fetuses develop major nausea, and vomiting. Ketones can be detected in the birth defects and 1520% of pregnancies end in miscar- urine and produce a fruity odor on the breath. Now, plications during delivery for both the mother and the about 2% of patients with this condition die. The goal of diabetic treatment in pregnancy is tight In type 2 diabetes, insulin resistance is the main control of glucose levels to reduce the chance of these problem and insulin is not as severely deficient. In gestational diabetes, if glucose levels are Therefore, ketoacidosis does not occur. Instead, glucose not controlled with diet and exercise, then insulin (or levels continue to rise to 1,000 mg/dl or more. Women with preex- duces a condition known as nonketotic hyperosmolar isting diabetes who become pregnant also need intensive state. Patients with diabetes are prone to certain infec- The elderly are more vulnerable, but overall about tions in the urinary tract or skin and soft tissue and fun- 2040% of people with this condition die. Good glucose control helps prevent infections and may also help with wound healing. Generally speaking, type 1 damage to the retina, kidney failure, and nerve damage patients need a long-acting or intermediate-acting (neuropathy).
For women a public health department may experience very differ- the common injuries by frequency are sprains and ent exposures than a nurse working in a hospital cheap 50 mg imuran with amex spasms from anxiety. Whether been described as safer workers than men discount imuran 50 mg visa muscle relaxant and nsaid, in 16 of the information is presented by industry or by occupation discount imuran 50mg with visa muscle relaxant flexeril, 35 Women in the Workforce Table 3. Table 4 contains the occupational injury Acute toxicity testing of xenobiotics has usually and illness rates among women and men based on been conducted in test animals of a single sex in order industry codes rather than occupational codes. Women tional cancers and chemical exposures; however, these may also be exposed to mycotoxins from fungi. Pregnancy-induced hypertension has associated with dyes, metals, and other chemicals. In order to define occupational health and safety haz- Table 5 contains reproductive exposures that have ards for women, the actual job content associated with been found associated with specific industries and a specific occupation or job title needs to be under- occupations among working women. As more work is conducted, it has been increas- ingly recognized that men and women with the same job title do not perform the same tasks. These differences than men in the workplace are closely linked to the influence hazards in the workplace in a subtle fashion. Fibromyalgia, repetitive strain injuries, sick build- ment designed for the average-sized man will not fit the ing syndrome, and multiple chemical sensitivity are ergonomic needs of the average-sized woman and may found twice as often among women as among men. Biological makeup certainly influences real illnesses, being often attributed to hysteria or the ability to do certain tasks; however, the structure neurosis. Mass hysteria, that is, physical symptoms sug- of the workplace can influence the ability of some- gesting an organic illness but arising from a psycholog- one to perform the work. Adaptation of workstations ical cause, has been used to explain periodic episodes 38 Women in the Workforce of sick building syndrome when a specific exposure women have different types of work experiences than cannot be identified as the cause. For women, the the risk of reporting symptoms associated with sick highest level of job control is found in gender-integrated building syndrome including tobacco smoke, working occupations. In addition, women were often chosocial aspects of work differ for women and for found living in apartment buildings, increasing the men. However, how these differences relate to risk of complexity of indoor air exposures from multiple distress, mental disorders, and cardiovascular diseases sources. Social sup- research, factors outside the workplace are not consid- port appears to buffer the adverse effects of some occu- ered in the exposure assessment. Pregnancy outcomes in relation to job stress have been shown to be better for working women in the presence of support from others. While robbery was the primary cern of losing ones job due to layoffs and to down- motive of job-related homicides, domestic disputes sizing. Lack of control is having no say in the tasks one accounted for one sixth of the workplace homicides performs, how they are performed, and when they among women workers. The fact that domestic disputes do enter the decisions about the task and the pace of work. Role workplace for women but not for men is an important ambiguity is the uncertainty of a worker about what issue when developing workplace violence prevention expectations are resulting from a lack of feedback on programs. The most extreme example would be rape responsible for a different set of tasks and one person and there is little written about rape in the workplace. Scheduling issues The stress of working in an environment where harass- can include shift work, rotating shifts, night shifts, or ment is accepted has not been extensively addressed in inflexible schedules. Workfamily conflict is complex viewed as legal issues, not medical ones, but clearly but relates to the need to respond to family issues and they are likely to have profound long-term medical con- to work issues where the demands cannot both be met. Inclusion of women and minorities in occupational can- access to medical care, quality food, and safe housing. Journal of Occupational Medicine, The roles women play at home also will influence their 36, 842847. Care must be taken when comparing ill- ness and injury experience between women and men or any two groups of workers, to account for actual expo- Sana Loue sures at a particular job. Use of broad industry categories may lead to erroneous conclusions about the safety risks for specific groups of workers. Advocacy has been defined as taking Suggested Resources a position on an issue, and initiating actions in a delib- erate attempt to influence private and public choices Bradley, H. A century-long quest for meaningful and accurate occupational injury and illness statistics. Occupational Medicine: State of the Art and many are used simultaneously to effectuate impor- Reviews, 9, 435469. A historical perspective of some right of women to practice in a health care profession, occupationally related diseases of women. Journal of such as Elizabeth Blackwell, who became the first Occupational Medicine, 38, 826831. Others, like Gender differences in work-related injury/illness: Analysis of Helen Brooke Taussig, were pioneers in their fields and workers compensation claims. American Journal of Industrial made outstanding discoveries that led to improved Medicine, 39, 8491. One-eyed science: Occupational health and Still other women have created significant change women workers. Occupational and environmental reproductive by acting as reformers, creating change by establishing hazards: A guide for clinicians. Although many of experience of women with repetition strain injury and the search these reform efforts, such as those of Matilda Evans, for credibility. Journal of Occupational Medicine, 36, brought numerous benefits to the communities and 814825. The legality of their marriage was questioned and pioneering achievements of women. The women because the then-existing nonmiscegenation laws who are highlighted in this chapter are only a fraction prohibited cohabitation and marriage between mem- of those who have worked for or advocated for bers of different races; Lucy was of African American improvements in health; it would be impossible to and Mexican heritage and her husband was African describe the efforts of so many in only one chapter. When they arrived in Chicago in 1873, the Instead, this chapter illustrates the breadth of contribu- country was in the midst of a depression due to high tions that women have made to improve health and rates of unemployment.
They permit the needle to separate or split through the thin layers of scleral or comeal tissue and travel within the plane between them imuran 50mg free shipping muscle relaxant modiek. The smaller taper point needles pierce and with the design of each specific angles and increased cutting-edge spread tissue without cutting it cheap imuran 50 mg online spasms to right side of abdomen. Taper point needles are usually procedures order imuran 50mg amex spasms between ribs, general closure, and used in easily penetrated tissue Although initially designed for hernia repair. They are fascia, periosteum, and tendon features of the reverse cutting edge also used in internal anastomoses where separation of parallel tip and taper point needles. Three to prevent leakage which can connective tissue fibers could occur cutting edges extend approximately subsequently lead to contamination with a conventional cutting needle. The point, Coronary) for anastomosis of small connective tissue lying between sometimes referred to as a trocar fibrotic and calcified blood vessels. This needle configuration has flattened body than conventional The taper body portion provides a slimmer geometry than other taper needles. It also minimizes the risk of leakage from friable vessels or vascular graft material. They have a taper body with a rounded, blunt point that will not cut through tissue. Due to safety considerations, surgeons also use Smooth Jaws Jaws with tungsten Jaws with blunt point needles in obstetric carbide particles teeth and gynecological procedures when working in deep cavities which are prone to space and visibility optimum needleholder stability. In addition, blunt Because this tool actually drives the The following guidelines are offered point needles for general closure are needle, its performance will have an to the scrub person for needleholder especially helpful when performing impact upon the entire suturing use: procedures on at-risk patients. Therefore, the placing the holder on or near the scrub person should check before swaged area which is the weakest each procedure to make sure that part of the needle. Always check alignment of the rosive, high strength, good quality steel alloy with jaws designed for It must be the appropriate size needleholder jaw to make certain holding the surgical needle securely. The larger and flat, concave or convex, smooth or heavier the needle, the wider and 4. Pass the needleholder to the It should be an appropriate size surgeon so that he or she will not damage the suture or needle if too for the procedure. Make sure not all, needleholders have a ratchet cavity, a longer needleholder is the needle is pointing in the lock near to thumb and finger rings. The surgeon begins closure needle should be returned to the needleholder with the needle with theswaged suture. The scrub person controls the free end of the likely to be lost if they are passed suture to prevent dragging it across the sterile field, and to one-for-one (one returned for keep the suture from entering each one received). Apply force in the tissue to be needle from the holder and reclamps the holder onto the body of the sutured in the same direction as needle near the point end to pull the needle and strand through tissue. Do not force a dull needle require the use of a heavier gauge should be undertaken for through tissue. Under these replace it in the tissue, or use a circumstances, proceed with Needles should be protected from larger needle. Avoid using the needle to bridge during handling by adhering to the or a different curvature may help or approximate tissues for following guidelines: and a second needleholder suturing. If a glove is punctured by a needleholder to pull the needle needle, the needle must be 2. Depending upon the patient, the safety of the patient, as well as they do not have rough or sharp tissue may be tougher or more the surgical team. Employ the nontransfer since they must then be handled technique to avoid inadvertent individually to count them. This needlesticks: the surgeon places can potentially contaminate the needle and needleholder gloves and increase the risk of an down in a neutral area of the accidental puncture. If a needle breaks, all pieces must dual role that suture and needle be accounted for. Count all needles before and after Packaging does much more than use according to hospital keep the needle and suture sterile. Retain the packets Package design can help or containing descriptive informa- seriously hinder the efficiency of tion on quantity and needle type the surgical procedure. Use sterile adhesive pads with or without magnets or disposable magnetic pads to facilitate counting and safe disposal. Needle point geometry packaging is designed to permit fast unused suture packets to be 7. The single layer overwrap proper rotational flow without of primary packaging is made of A package insert with detailed infor- mixing lots within the boxes. Absorbable sutures are should be familiar with this informa- type or size, or by use (i. The opening appear in the box opening, before environmentally conscious, can accommodate the removal of the box is completely empty. This will are made of recyclable paper negative impact to the environment help to avoid mixing lot numbers and printed with either water or upon incineration or disposal. Others the same color-coding as its important criteria necessary for may contain one or two-dozen dispenser box. Type and size of needle suffix G = 1 dozen, D = 1 dozen, T = 2 dozen, H = 3 dozen). The Primary packets of suture material Other important product dispenser boxes are held securely for may contain sutures in one of information found on all suture easy dispensing by firmly pushing five styles: boxes includes: the box into a "lock" in the back of 1. Metric diameter equivalent of Individual sutures and multiple may be cut in half, third, or suture size and length suture strands are supplied sterile quarter lengths for ligating 5. This type is appropriate for procedures requiring numerous interrupted sutures of the same type. Each suture may be the palm of the hand as blood procedure, surgeon, or surgical delivered to the surgeon individ- vessels are ligated. The reel, gauze sponge, metal bobbin, coordinate multiple individual inner folder for these products is or other device.
Edema Definition: Edema is increased fluid in the interstitial tissue spaces or it is a fluid accumulation in the body cavities in excessive amount generic 50mg imuran visa xanax muscle relaxant dosage. Depending on the site order imuran 50 mg fast delivery spasms of pain from stones in the kidney, fluid accumulation in body cavities can be variously designated as: a) Hydrothorax fluid accumulation in pleural cavity in a pathologic amount order 50 mg imuran with amex muscle relaxant withdrawal symptoms. Mechanism of edema formation: Approximately 60% of the lean body weight is water, two-thirds of which is intracellular with the remainder in the extracellular compartment. The capillary endothelium acts as a semipermeable membrane and highly permeable to water & to almost all solutes in plasma with an exception of proteins. Proteins in plasma and interstial fluid are especially important in controlling plasma & interstitial fluid volume. Normally, any outflow of fluid into the interstitium from the arteriolar end of the microcirculation is nearly balanced by inflow at the venular end. Edema formation is determined by the following factors: 1) Hydrostatic pressure 2) Oncotic pressure 3) Vascular permeability 4) Lymphatic channels 5) Sodium and water retention We will discuss each of the above sequentially. There are four primary forces that determine fluid movement across the capillary membrane. Each of them can be listed under the above two basic categories, the hydrostatic pressure & the oncotic pressure. The capillary hydrostatic pressure (Pc) This pressure tends to force fluid outward from the intravascular space through the capillary membrane to the interstitium. The interstial fluid hydrostatic pressure (Pif) This pressure tends to force fluid from the interstitial space to the intravascular space. The plasma colloid osmotic (oncotic) pressure (p) This pressure tends to cause osmosis of fluid inward through the capillary membrane from the interstitium. The interstial fluid colloid osmotic (oncotic) pressure (if) This pressure tends to cause osmosis of fluid outward through the capillary membrane to the interstitium. The plasma oncotic pressure is decreased when the plasma proteins are decreased in various diseases such as: 1. Edema resulting from increased capillary hydrostatic pressure as in the following diseases: 1. Congestive heart failure Clinical classification of edema: One can also clinically classify edema into localized & generalized types. A) Localized B) Generalized 1) Deep venous thrombosis 1) Nephrotic syndrome 2) Pulmonary edema 2) Liver cirrhosis 3) Brain edema 3) Malnutrition 4) Lymphatic edema 4) Heart failure 5) Renal failure Next, we will elaborate on some of the above examples. Reduction of albumin due to excessive loss or reduced synthesis as is caused by: 1) Protein loosing glomerulopathies like nephrotic syndrome 2) Liver cirrhosis 3) Malnutrition 4) Protein-losing enteropathy b. Increased volume of blood secondary to sodium retention caused by congestive heart failure: 65 Fig. Some of these mediators (See the chapter on inflammation) cause increased vascular permeability which leads to loss of fluid & high molecular weight albumin and globulin into the interstitium. Inflammatory edema differs from non-inflammatory edema by the following features a) Inflammatory edema (exudate) Due to inflammation-induced increased permeability and leakage of plasma proteins. Therefore, obstruction of lymphatic channels due to various causes leads to the accumulation of the proteinaceous fluid normally drained by the lymphatic channels. In these conditions, the retained sodium & water result in increased capillary hydrostatic pressure which leads to the edema seen in these diseases. Hypermia and Congestion Definition: Both of them can be defined as a local increase in volume of blood in a particular tissue. Hypermia - is an active process resulting from an increased inflow of blood into a tissue because of arteriolar vasodilation. Congestion - is a passive process resulting from impaired outflow of blood from a tissue. Acute pulmonary congestion: Alveolar capillaries engorged with blood Septal edema 2. Chronic pulmonary congestion: - Thickened & fibrotic septa - Alveolar spaces contain hemosiderin-laden macrophages resulting in an appearance termed brown indurations. Haemorrhage Definition: Hemorrhage is extravasation of blood outside the blood vessel. Causes: Physical trauma Stabbing - Stick injury - Gunshot - Motor vehicle accident Inadequacies in blood clotting which can be due to: A. Inadequate vitamin K leads to clotting factor deficiency because this vitamin is important in the synthesis of the clotting factors by the liver. Terminology: 1) Haemorrhage enclosed within a tissue or a cavity is knownas hematoma. Effects of haemorrhage: depend on the rate and amount of blood loss: If > 20% the total blood volume is rapidly lost from the body, it may lead to hypovolumic shock & death. Hemostasis and Blood Coagulation Hemostasis Definition: Hemostasis is the maintainence of the clot-free state of blood & the prevention of blood loss via the formation of hemostatic plug. Hemostasis depends on three general components: a) Vascular wall b) Platelets c) Coagulation pathways Whenever a vessel is ruptured or severed, hemostasis is achieved by several mechanisms: A. Eventual growth of fibrous tissue in to the blood clot to close the hole in the vessel permanently. Remark: The student is advised to revise his physiology lecture note on the above topics. Definition: Thrombosis is defined as the formation of a solid or semisolid mass from the constituents of the blood within the vascular system during life. These factors are called Virchows triad: A: Endothelial injury B: Stasis or turbulence of blood flow C: Blood hypercoagulability 71 A: Endothelial injury It is the most important factor in thrombus formation and by itself can lead to thrombosis. B: Turbulence or Stasis (Alterations in normal blood flow) Under physiologic conditions normal blood flow is laminar, that is, the cellular elements flow centrally in the vessel lumen separated from endothelium by slowing moving clear zone of plasma. Disrupt the laminar flow and bring platelets in to contact with the endothelium b.