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The serving should provide an equivalent of 200--500 mg of eicosapentaenoic and docosahexaenoic acid cheap norfloxacin 400 mg with mastercard antibiotics tired. People who are vegetarians are recommended to ensure adequate intake of plant sources of a-linolenic acid purchase 400mg norfloxacin amex infection taste in mouth. Alcohol Although regular low to moderate consumption of alcohol is protective against coronary heart disease discount 400 mg norfloxacin amex antimicrobial foods, other cardiovascular and health risks associated with alcohol do not favour a general recommendation for its use order norfloxacin uk zombie infection nokia 5228. These relationships apply to both incidence and mortality rates from all cardiovascular diseases and from coronary heart disease. At present, no consistent dose-- response relationship can be found between risk of stroke and physical activity. The lower limits of volume or intensity of the protective dose of physical activity have not been defined with certainty, but the current recommendation of at least 30 minutes of at least moderate-intensity physical activity on most days of the week is considered sufficient. A higher volume or intensity of activity would confer a greater protective effect. The recommended amount of physical activity is sufficient to raise cardio- respiratory fitness to the level that has been shown to be related to decreased risk of cardiovascular disease. Cardiovascular diseases in the developing countries: dimensions, determinants, dynamics and directions for public health action. Summary of the scientific conference on dietary fatty acids and cardiovascular health: conference summary from the nutrition committee of the American Heart Association. Association between trans fatty acid intake and 10-year risk of coronary heart disease in the Zutphen Elderly Study: a prospective population- based study. Dietary fat and risk of coronary heart disease in men: cohort follow-up study in the United States. A prospective study of egg consumption and risk of cardiovascular disease in men and women. Reduction of serum cholesterol with sitostanol-ester margarine in a mildly hypercholesterolemic population. Impact of nondigestible carbohydrates on serum lipoproteins and risk for cardiovascular disease. Whole-grain consumption and risk of coronary heart disease: results from the Nurses’ Health Study. Intake of dietary fiber and risk of coronary heart disease in a cohort of Finnish men. Vegetable, fruit, and cereal fiber intake and risk of coronary heart disease among men. Low dose folic acid supplementation decreases plasma homocysteine concentrations: a randomized trial. Folate and vitamin B6 from diet and supplements in relation to risk of coronary heart disease among women. Homocysteine and cardiovascular disease: evidence on causality from a meta-analysis. Dietary flavonoids, antioxidant vitamins, and incidenceof stroke: the Zutphen study. Dietary antioxidant flavonoids and risk of coronary heart disease: the Zutphen Elderly Study. Urinary sodium excretion and cardiovascular mortality in Finland: a prospective study. Effect of reduced dietary sodium on blood pressure: a meta-analysis of randomized controlled trials. Sodium reduction and weight loss in the treatment of hypertension in older persons. Journal of the American Medical Association, 1998, 279:839--846 (erratum appears in Journal of the American Medical Association, 1998, 279:1954). Changes in sodium intake and blood pressure in a community- based intervention project in China. Fruit and vegetable intake and risk of cardiovascular disease: the Women’s Health Study. Fish consumption and mortality from all causes, ischemic heart disease, and stroke: an ecological study. Nut consumption and risk of coronary heart disease: a review of epidemiologic evidence. Third International Symposium on the Role of Soy in Preventing and Treating Chronic Disease. Randomized trial comparing the effect of casein with that of soy protein containing varying amounts of isoflavones on plasma concentrations of lipids and lipoproteins. Moderate alcohol intake and lower risk of coronary heart disease: meta-analysis of effects on lipids and haemostatic factors. Coffee consumption and death from coronary heart disease in middle-aged Norwegian men and women. Changes in diet in Finland from 1972 to 1992: impact on coronary heart disease risk. Other important determinants of cancer risk include diet, alcohol and physical activity, infections, hormonal factors and radiation. The relative importance of cancers as a cause of death is increasing, mostly because of the increasing proportionof people who are old, and also in part because of reductions in mortality from some other causes, especially infectious diseases. The incidence of cancers of the lung, colon and rectum, breast and prostate generally increases in parallel with economic development, while the incidence of stomach cancer usually declines with development. An estimated 10 million new cases and over 6 million deaths from cancer occurred in 2000 (1). As developing countries become urbanized, patterns of cancer, including those most strongly associated with diet, tend to shift towards those of economically developed countries. Between 2000 and 2020, the total number of cases of cancer in the developing world is predicted to increase by 73% and, in the developed world, to increase by 29%, largely as a result of an increase in the number of old people (1). This proportion is thought to be about 20% in developing countries (3), but may grow with dietary change, particularly if the importance of other causes, especially infections, declines. Cancer rates change as populations move between countries and adopt different dietary (and other) behaviours, further implicating dietary factors in the etiology of cancer. Body weight and physical inactivity together are estimated to account for approximately one-fifth to one-third of several of the most common cancers, specifically cancers of the breast (postmenopausal), colon, endometrium, kidney and oesophagus (adenocarcinoma) (4). Dietary factors for which there is convincing evidence for an increase in risk are overweight and obesity, and a high consumption of alcoholic beverages, aflatoxins, and some forms of salting and fermenting 95 fish. There is also convincing evidence to indicate that physical activity decreases the risk of colon cancer. Factors which probably increase risk include high dietary intake of preserved meats, salt-preserved foods and salt, and very hot (thermally) drinks and food. Probable protective factors are consumption of fruits and vegetables, and physical activity (for breast cancer). After tobacco, overweight and obesity appear to be the most important known avoidable causes of cancer.
Always check with your Agency to ensure this rule is correct cheap 400mg norfloxacin visa infection en la garganta, for this rule is different in some States norfloxacin 400mg discount antibiotics for uti leukocytes. Waterborne Diseases ©6/1/2018 339 (866) 557-1746 Where should the repeat samples be collected if the positive sample was collected at the end of the distribution system? If the original sampling site is at the end of the distribution system (or one tap away from the end) the State Drinking Water agency may waive the requirement to collect one of the repeat samples downstream buy norfloxacin discount bacteria en la sangre. Always check with your Agency to ensure this rule is correct purchase 400mg norfloxacin visa oral antibiotics for dogs hot spots, for this rule is different in some States. How many repeats are required if a finished water entry point sample or raw well sample is positive? Only one repeat sample should be collected from the positive finished water entry point location or raw positive location. Raw or finished entry point samples (or raw/entry point repeat samples) are not used when determining compliance. Prior to August 2007, a routine coliform positive finished water (entry point) sample required three or four repeats. Only one repeat is now required and it is to be collected from the same entry point location as the positive (downstream repeat samples are no longer required). Always check with your Agency to ensure this rule is correct, for this rule is different in some States. Always check with your Agency to ensure this rule is correct, for this rule is different in some States. The 24-hour clock starts when the laboratory (or State) notifies the water system of the initial positive coliform result. You have 24 hours from the time of notification to collect your repeat samples and return them to a laboratory for analysis. If you fail to meet this window, a violation will be issued, provided that no extension had been granted. Always check with your Agency to ensure this rule is correct, for this rule is different in some States. Waterborne Diseases ©6/1/2018 340 (866) 557-1746 What if I cannot meet the 24-hour repeat collection requirement? Failure to obtain the extension or failure to meet the terms of the extension will result in a monitoring violation. Always check with your Agency to ensure this rule is correct, for this rule is different in some States. What happens if I am notified on a Friday of positive routine results (or receive repeat bottles on a Friday or Holiday)? You should contact your certified laboratory to arrange a time on Saturday to collect the repeat samples and drive them to the laboratory. Please call the official State water or health agency at at the earliest possible time to request an extension on the 24-hour requirement. It is strongly recommended that all routine coliform samples be collected and mailed on a Monday or Tuesday to avoid this situation. If one or more repeat samples in the set are total coliform positive or invalid, the whole repeat monitoring process must start over. A new “set” of three or four (if only one routine sample is collected per month) repeats must be collected within 24 hours of being notified of the positive or invalid repeat. Every consecutive set of repeat samples must be collected at the same locations as the 1st set of repeat samples. Always check with your Agency to ensure this rule is correct, for this rule is different in some States. Does one (or more) positive routine or repeat sample change the following month’s monitoring requirements? Waterborne Diseases ©6/1/2018 341 (866) 557-1746 The samples can be collected from other approved coliform sites or from other locations in the distribution system. Always check with your Agency to ensure this rule is correct, for this rule is different in some States. Who is responsible for notifying the official State water or health agency if results are positive? A coliform positive can be invalidated when there is a significant reason to believe the test results are not accurate or not representative of the water quality. These samples are not used in compliance calculations and a replacement must be collected within the same monitoring period (same month) at the same location to avoid a possible monitoring violation. There are three conditions in which a total coliform positive sample result may be invalidated: 1. The laboratory establishes that an error in its analytical procedure caused the total coliform positive result. The State water or health agency, on the basis of the results of repeat samples collected determines that the total coliform positive sample resulted from a domestic or other non- distribution system-plumbing problem. The State water or health agency determines that there are substantial grounds to believe that a total coliform positive result is due to a circumstance or condition that does not reflect water quality in the distribution system. The laboratory will invalidate the results if they are unable to obtain a true result according to the test method used to analyze the sample. Always check with your Agency to ensure this rule is correct, for this rule is different in some States. All repeat samples must have been collected in accordance with the repeat sampling requirements. As soon as you feel a sample should be invalidated, the Drinking Water Agency should be contacted by telephone and the situation discussed. If the Drinking Water Agency verbally agrees that the sample is not representative of the water quality, they will direct you as to what certain steps need to be taken (e. Ultimately, the Drinking Water Agency will recommend to the Compliance or Regulatory division whether or not a sample should be invalidated. Failure to get the Drinking Water Agency’s concurrence will result in your request being rejected by the Compliance or Regulatory division. A formal written requested must be mailed to the Drinking Water Agency and Compliance or Regulatory division within four weeks of the original routine sample Waterborne Diseases ©6/1/2018 342 (866) 557-1746 collection date. The written documentation must state the specific cause of the total coliform positive sample and what action the supplier has taken, or will take, to correct this problem. The State water or health agency will not invalidate a total coliform positive sample solely on the grounds that all repeat samples are total coliform negative. At that time, any reason to question validity of a result should be acted on promptly while the situation is fresh at hand. If a sample is invalidated by the State water or health agency or the certified laboratory does it still count towards meeting the monthly monitoring requirements? Remember that all routine samples are marked with a sample purpose of “Routine” on the reporting form. Always check with your Agency to ensure this rule is correct, for this rule is different in some States. If one or more repeat samples in a set are invalid, the whole repeat monitoring process must begin over starting with the collection of a new “set” (3 or 4) of repeat samples within 24 hours.
Blunt trauma to a muscle results in a it extends partly or completely through the meniscus) norfloxacin 400mg discount medicine for lower uti, contusion 400mg norfloxacin with visa antibiotics journal. The radiologist should also note the presence of dis- out from the point of contact in the muscle belly purchase generic norfloxacin online virus x movie. Around the knee cheap norfloxacin 400mg infection japanese horror movie, muscle trauma affects the distal When the abnormality is also present on a T2-weighted hamstrings, distal quadriceps, proximal gastrocnemius, image, when there is a displaced fragment, or when a tear soleus, popliteus, and plantaris muscles. The patellar, examination, the presence of injected contrast within the quadriceps, and semimembranosus tendons are most fre- substance of a repaired meniscus is diagnostic of a quently involved around the knee. Sonographically, a degen- a partial meniscectomy; in these cases both the meniscal erated tendon appears enlarged, with loss of the normal shape and internal signal are unreliable signs of recurrent parallel fiber architecture, and often with focal hypoe- meniscal tear. A gap between the tendon noninvasive test for recurrent meniscal tears following fibers indicates that the process has progressed to partial partial meniscectomy . In those cases in which T2-weighted images show a focus of high signal intensi- T2-weighted images demonstrate ruptures of the cruciate, ty, surgical excision of the abnormal focus can hasten collateral, and patellar ligaments. When macroscopic tearing is present, the radiolo- tion of the ligament fibers . While edema surround- gist should also examine the corresponding muscle belly ing a ligament is typically seen in acute tears, edema sur- for fatty atrophy (which indicates chronicity) or edema rounding an intact ligament is a nonspecific finding, (suggesting a more acute rupture). If the tear is complete, which can be seen in bursitis or other soft tissue injuries, the retracted stump should be located on the images as in addition to ligament tears . Synovium Secondary findings of ligament tears, such as bone con- tusions or subluxations, are useful when present, but do While radiographs can show medium and large knee ef- not supplant the primary findings, and do not reliably dis- fusions, other modalities better demonstrate specific syn- tinguish acute from chronic injuries, nor partial from ovial processes. In the knee, the anterior cruciate liga- hanced through-transmission on ultrasound images. At least 11 other named bursae occur around will be placed on the detection of clinically suspected or the knee. The most commonly diseased ones are proba- occult soft-tissue and bone abnormalities that could be bly the prepatellar, superficial infrapatellar, medial col- exacerbated by repeat trauma or could lead to chronic in- lateral ligament, and semimembranosus-tibial collateral stability and joint degeneration unless treated. Power Doppler ultrasound or the use of ultrasound contrast agent may in- Kinematic laws dictate normal joint motion and the bio- crease sensitivity for active synovitis . Although the knee moves pri- amination, thickening of the usually imperceptibly thin marily as a hinge joint in the sagittal plane, it is also de- synovial membrane and enhancement of the synovium signed for internal-external rotation and abduction-ad- following intravenous contrast administration indicates duction. The signal intensities of the bodies logical, but the menisci must shift with the contact points vary depending on their composition. Diffuse pigmented to avoid entrapment and crush injury by the femoral villonodular synovitis and focal nodular synovitis demon- condyles. Paired cruciate and collateral ligaments func- strate nodular, thickened synovium, which enhances fol- tion collectively with the menisci to maintain joint con- lowing contrast administration. In external rota- echo images – is an important, though inconstant, clue to tion, for example, the cruciate ligaments are lax whereas the diagnosis . Conversely, in internal rotation, the collateral lig- aments are lax whereas the cruciates become twisted Biomechanical Approach to Knee Trauma around each other, pulling the joint surfaces together and resisting varus or valgus rocking. Within the physiological Knee trauma often produces predictable groupings of lig- range of motion, the knee ligaments perform extremely amentous and meniscal injuries . In both contact and non-contact sports, ture is disrupted, synergistic structures are jeopardized. Valgus force is directed at and osseous injury all provide clues about the mechanism the lateral aspect of the joint, and varus force is directed of injury. The lateral compartment normality in one structure should lead to a directed is distracted during varus stress, tearing the lateral collat- search for subtle abnormalities involving anatomically or eral ligament. In the weight-bearing knee, valgus force al- functionally related structures, thereby improving diag- so creates compressive load across the lateral compart- nostic confidence. The medial compartment is images are interpreted with an understanding that struc- compressed during varus stress, leading to impaction of tures with strong functional or anatomical relationships the medial femoral condyle against the tibia. By deducing the traumatic the most common traumatic mechanisms combine valgus mechanism, it is possible to improve diagnostic accuracy force with axial load. Therefore, compression with im- by taking a directed search for subtle, surgically relevant paction injury usually occurs in the lateral compartment, abnormalities that might otherwise go undetected. It may whereas tension with distraction injury occurs in the me- also be possible to communicate more knowledgeably dial compartment. Trauma-re- Acute ligamentous injuries are graded clinically into lated medial meniscal tears tend to be located at the pos- three degrees of severity. In mild sprain (stretch injury), teromedial corner (posterior to the medial collateral liga- the ligament is continuous but lax. The ligament can re- ment) because the capsule is more organized and thick- turn to normal function with appropriate conservative ened in this location, and its meniscal attachment is tight- treatment. In moderate sprain (partial tear), some but not all Although the posterior oblique ligament can be dissected fibers are discontinuous. Remaining intact fibers may not free in most cadaver knees, it is only rarely identified on be sufficient to stabilize the joint. Degenerative (attrition) tears of the medial bundles hang loosely, and intact fibers are overstretched meniscus also predominate posteromedially, but they in- with marked edematous swelling and ecchymosis. In severe sprain (rupture), the liga- a vertical orientation that can extend across the full thick- ment is incompetent. At operation, torn fiber bundles ness of the meniscus (from superior to inferior surface), hang loosely and can be moved easily. Once established, this vertical tear can propagate over time following the normal fiber architecture of the menis- cus. Propagation to the free margin creates a flap, or par- Meniscal Injury rot-beak, configuration. If the tear propagates longitudi- nally into the anterior and posterior meniscal thirds, the Why are most trauma-related medial meniscal tears pe- unstable inner fragment can become displaced into the in- ripheral in location and longitudinally orientated, where- tercondylar notch (bucket handle tear). When a distractive force sepa- dists recognize an association between longitudinal tears rates the femorotibial joint, tensile stress is transmitted and mechanical symptoms, and may decide to repair or across the joint capsule to the meniscocapsular junction, resect the inner meniscal fragment before it becomes dis- creating traction and causing peripheral tear. Compressive placed and causes locking or a decreased range of mo- force entraps, splays and splits the free margin of menis- tion. If an unstable fragment detaches anteriorly or pos- cus due to axial load across the joint compartment. Since teriorly, it can pivot around the remaining attachment site the most common traumatic mechanisms in the knee in- and rotate into an intraarticular recess or the weight-bear- volve valgus rather than varus load, the medial femorotib- ing compartment. The identification and localization of a ial compartment is distracted whereas the lateral compart- displaced meniscal fragment can be important in the pre- ment is compressed. Lateral compression means sile stress can avulse the capsule away from the menis- that the lateral meniscus is at risk for entrapment and tear cus (meniscocapsular separation), with or without a along the free margin. Meniscocapsular injury avulsed at sites where they are fixed, but can escape in- may be an important cause of disability that can be jury in regions where they are mobile. Compared to the treated surgically by primary reattachment of the cap- lateral meniscus, the medial meniscus is more firmly at- sule. Since the capsule stabilizes the medial meniscus, tached to the capsule along its peripheral border, and is meniscocapsular separation or peripheral meniscal avul- far less mobile. Normal knee motion involves greater sion can cause persistent pain and lead to posteromedi- translation of the femorotibial contact point in the lateral al instability with eventual degenerative change. In order to shift with the condyle and avoid images, meniscocapsular injury is more difficult to injury, the lateral meniscus requires a looser capsular at- identify than meniscal tear.
Medium of Teaching: English Staffing Full time teaching Faculty in the ratio of 1:6 Minimum faculty: Five faculty by name should be available for the course cheap norfloxacin 400mg antimicrobial agents antibiotics. Chief Co-ordinator: Emergency physician /Anesthesiologist/ Gen Surgeon/Gen Physician Coordinators : Orthopedics surgeon order norfloxacin 400 mg with visa virus and spyware protection, Emergency physician/ Physician/ cardiologist etc Roles of All Faculty should be defined clearly cheap generic norfloxacin canada virus removal tool kaspersky. Course objectives: At the end of the course the student will be able to • Describe the concepts and principals of Emergency Medical Care • Perform basic and advanced life/limb saving skill in pre-hospital & hospital setting • Apply clinical knowledge and practical skills to real life scenarios buy norfloxacin american express antibiotics chart. Budget: There should be budgetary provision for Audiovisual aids, stationary, Library, secretarial help, contingency expenses etc Physical facility 1. Library- permission to use institute library having current text books, internet, trauma journal, Emergency medicine journals etc. Semester System with 20% of total grade as per grading system in internal assessment 3. Assessment should be as grading and report, not marks with written detail report on all the objectives of examination. Knowledge :Assess the knowledge of basic concepts, theory, and principles of Emergency medical care 2. Comprehension; Candidate should be able to recall the knowledge and discuss as per patient requirement 3. Application : The candidate should be able to apply this knowledge to specific situations 4. Analysis: Candidate should be able to divide a problem into its component parts 5. Synthesis: Candidate should have the ability to combine theory and practical skills to solve complex situations 6. Evaluation : Candidate should be able to judge whether an action finally taken is good or bad for the ultimate outcome of the victim. Last but not the least, Does the candidate have positive attitude for care of emergency patient. Number of days/hours It is commonly assumed that these are 180 working days in a year including the days earmarked for admissions and examination. It is presumed that these will be minimum of 360 days for theory & practical teaching in 2 years & with 6 working hours a day, the total member of working hours in a year will be – (360 x 6 = 2160 hours) based on this a 2yrs course. Module Days x hours Total hours ------------------------------------------------------------------------ 1. Setting of ventilator • Cardiovascular: Acute Coronary Event, Chest pain, Shock of different etiology, Tachycardia, Bradycardia, Cardiac arrest 1. The Chief coordinating multidisciplinary services under critical and stressful circumstances is complex and requires the services of a senior consultant with sufficient years of clinical / administrative experience. The main responsibility of the medical officer is to ensure that all patients coming to the department are stabilised and adequately treated with minimum amount of waiting time. The number of medical officers appointed will depend on the patient load and design of the department. Emergency Physicians/ General physicians; Paediatricians, General surgeons, Orthopaedic surgeons, obstetricians, Anaesthetists: From the district hospital or visiting specialist arranged through firm contractual agreements. Nursing Matron: The Nursing matron is responsible for coordinating the various nursing activities. She prepares the duty roster and ensures that the appropriate nursing staff be posted to the various facilities of the department. They should have ongoing training in emergency procedures, investigations and patient stabilisation. Further, they should ensure the replacement of all appropriate drugs in the resuscitation cart as well as miscellaneous disposables. Nurses should ensure the working condition of monitors and other electronic equipment and notify malfunction. They are trained in the knowledge and skills to assist medical and nursing personnel in the Emergency Department. They are the leading cause for long-term absence from work (> 2 weeks) in many countries. Their direct and indirect cost is considerable and their management utilizes a significant part of the gross national product of many countries. For the middle aged and elderly, early detection and treatment of osteoporosis and management of rheumatic diseases at an early stage with available agents can significantly reduce the risk of fractures, deformities and associated morbidity and mortality. This in totality justifies the need for developing a program on a district model for Musculo- skeletal disorders in the country. Special provision for providing Calcium and Vitamin D to infants and women of both child bearing age and post menopause for both prophylactic and therapeutic purpose. Management information system for monitoring and evaluation through a structured data base mechanism for gathering information on availability of manpower, logistics, performance and other relevant information pertaining to the programme. Based on the response, necessity of services and willingness of the states/ medical colleges for implementing the program the medical colleges will be selected on priority. The phase-wise inclusion of medical colleges would be as shown below in the table: Medical 2012-13 2013-14 2014-15 2015-16 2016-17 Total Colleges 10 30 35 25 20 120 New 40 70 105 130 150 150* Cumulative th 150* medical colleges include 30 medical colleges that are targeted to be covered in 11 th Plan and 120 new medical colleges proposed to be covered in the 12 Plan. Amputee rehabilitation These institutions will impart training disability prevention, detection and early intervention for undergraduate and post-graduate medical students and other health professionals. General Objectives- 1) To build capacity in the Medical Colleges for providing comprehensive rehabilitation services and to train adequate manpower required at all levels of Health Care Delivery System. To set up an independent Department of Physical Medicine and Rehabilitation in Central / State Governments or Municipal Corporation totaling around 150 colleges. To train medical and rehabilitation professionals in the districts in adequate numbers for providing secondary and tertiary level rehabilitation services. Training programme on Disability Prevention, Detection and Early Intervention at Undergraduate & Postgraduate level for all Medical Officers in the participating District. Provision of Rehabilitation Services in the setting of rehabilitation services in a comprehensive manner so that all clinical departments are involved and thereby to evolve a strategy of continuation of care even in the domiciliary and community set up. Setting up of independent Physical Medicine and Rehabilitation Department in 150 th medical College/Training Institutions during the end of the 12 Five Year Plan. Training of 1000 Medical doctors and allied health professionals in disability assessment and early identification. Develop Linkages and registration of Medical Rehabilitation to impairments and functional limitation arriving out of acute and chronic conditions undertaking treatment at Medical Colleges. Training of Medical Officers in disability assessment and computation for issue of disability certificates. The medical college will have to provide their space and infrastructure for the Department. Given below are the requirements for a well developed department but starting of a departing or its development can be planned according to the sources available and requirement of the facilities in the area. No Name of Post monthly pay Posts Expenditure (Consolidated) 1 Consultant 60000 2 1440000 2 Programme Assistant 30000 1 360000 3 Data Entry Operator 15000 2 360000 Total 130000 6 2160000 222 B. No Name of Post monthly pay Posts Expenditure (Consolidated) 1 Assistant Professor 55000 1 660000 2 Sr. Equipments would be supplied in phased manner as given below- st 1 year of inclusion: Rehabilitation equipment for diagnosis & treatment, Workshop equipments. Apex Institutions (Centre of Excellence) for Medical Rehabilitation- It is proposed to Establish National Centres for Medical Rehabilitation in field of Medical Rehabilitation in 4 different parts of the country either by up-gradation of the existing Institution or by starting new centres in response to scaled up needs of disabled population.
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