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Stroke rehabilitation is the restoration of patients to their previous physical order generic apcalis sx on line erectile dysfunction treatment options injections, mental and social capability generic 20mg apcalis sx visa impotence blood circulation. Rehabilitation may have an effect upon each level of expression of stroke-related neurological dysfunction cheap apcalis sx 20mg on-line new erectile dysfunction drugs 2011. It is of extreme importance to start rehabilitation as soon as possible after stroke onset purchase apcalis sx toronto injections for erectile dysfunction cost. In stroke units, in cases of severe stroke with decreased level of consciousness, passive rehabilitation is started and active rehabilitation is initiated in patients with preserved consciousness. Rehabilitation is typically started in hospital and followed by short-term rehabilitation in the same unit (comprehensive stroke units), rehabilitation clinics or outpatient settings. A multidisciplinary team approach and involvement and support to carers are key features also in the long term. Several studies have shown that different types of rehabilitation services improve outcome, but less is known about the optimum intensity and duration of specic interventions. Because of a lack of modern rehabilitation equipment and organization of services in the resource-poor countries, proper and prompt rehabilitation (both passive and active) are often decient in the majority of developing countries. Recurrent cerebrovascular events thus contribute substantially to the global burden of the disease. Lowering of blood pressure has been known for years to reduce the risk of rst stroke. The recent trials show that the same applies for secondary stroke prevention, whether ischaemic or haemorrhagic. The relative risk reduction of about a quarter is associated with a decrease in blood pressure of 9 mm Hg systolic and 4 mm Hg diastolic. Although higher plasma cholesterol concentrations do not seem to be associated with in- creased stroke risk, it has been suggested that lowering the concentration may decrease the risk. The risk of stroke or myocardial infarction, and the need for vascular procedures, is also reduced by a decrease in cholesterol concentration but it is still debated whether statins are effective in stroke prevention. Compared with aspirin, clopidogrel reduces the risk of stroke and other important vascular events from about 6. The combination of aspirin and modied-release dipyridamole may also be more effective than aspirin alone. Stroke risk ipsilateral to a recently symptomatic carotid stenosis increases with degree of ste- nosis, and is highest soon after the presenting event. The recent evidence suggests that the benet from surgery is also greater in men, patients aged 75 years, and those randomized and operated upon within two weeks after their last ischaemic event. The undoubted effectiveness of medical and surgical interventions must not detract from lifestyle modication, which should provide additional benets and at lower cost though with more effort by the patient. In spite of a lack of formal randomized evidence, ceasing to smoke, increasing physical activity, lowering body weight and eating a diet rich in potassium seem to be effective measures to prevent stroke. All these measures are less achievable in developing countries where there is also a lack of knowledge and information regarding stroke prevention strategies, including lifestyle modication (18). Antiplatelet agents are not used systematically and anticoagulants are usually under-pre- scribed mainly because of difculties with monitoring. The high-technology preventive measures indicated above are not accessible in the poorest countries. In developing countries, however, cultural beliefs and failure to recognize stroke symptoms may have an impact on the number of patients seeking medical attention, and those who do come may present after complications have developed. In the United States, approximately 60% of stroke patients present within three hours of stroke onset, while in Europe 40 56% arrive at hospital within six hours. In Turkey, only 40% of stroke patients are seen in the hospital within 12 hours (2). Economic policies of developing countries may not allow large investments in health care, hospitals, brain scanners or rehabilitation facilities. Health care in the acute phase of stroke is the most costly component of the care of stroke patients; in low-resource countries hospital care of even a small proportion of all patients with stroke accounts for a disproportionately high share of total hospital costs. Stroke units, which have been shown to reduce mortality, morbidity and other unfavourable outcomes without necessarily increasing health costs, are available in very few developing countries. Costs of consultation, investigation, hospitalization and medication may be beyond the means of poor people, especially those who do not have welfare benets or medical insurance plans. This seriously hampers the provision of care to patients who are otherwise able to seek medical attention. Although hospital care represents a large proportion of the costs of stroke, institutional care also contributes signicantly to overall stroke care costs. Most developing countries do not have well-established facilities for institutional care. The bulk of long-term care of the stroke patient is likely to fall on community services and on family members, who are often ill equipped to handle such issues. There is thus a need for appropriate resource planning and resource allocation to help families cope with a stroke-impaired survivor. Priorities for stroke care in the developing world Governments and health planners in developing countries tend to underestimate the importance of stroke. To compound this difculty, 80% of the population in developing countries live in rural areas, a factor that limits access to specialized services. To achieve this task, stroke prevention awareness must be neurological disorders: a public health approach 161 raised among health-care planners and governments. Another priority is education of the general public and health-care providers about the preventable nature of stroke, as well as about warning symptoms of the disease and the need for a rapid response. Furthermore, allocation of resources for implementation and delivery of stroke services (e. Finally, it is very important to establish key national institutions and organizations that would promote training and education of health professionals and dissemination of stroke- relevant information. The primary focus of this international collaboration will be to harness the necessary resources for implementing existing knowledge and strategies, especially in the middle and low income countries. The purpose of this strategy is threefold: to increase awareness of stroke; to generate surveillance data on stroke; and to use such data to guide improved strategies for prevention and management of stroke (20). The Global Stroke Initiative is only possible through a strong interaction between governments, national health au- thorities and society, including two major international nongovernmental organizations. Increasing awareness and advocacy among policy-makers, health-care providers and the general public of the effect of stroke on society, health-care systems, individuals and families is fundamental to improving stroke prevention and management. Advocacy and awareness are also essential for the development of sustainable and effective responses at local, district and national levels. Policy-makers need to be informed of the major public health and economic threats posed by stroke as well as the availability of cost-effective approaches to both primary and secondary prevention of stroke. Health professionals require appropriate knowledge and skills for evidence-based prevention, acute care and rehabilitation of stroke. Relevant information needs to be provided to the public about the potential for modifying personal risk of strokes, the warning signs of impending strokes, and the need to seek medical advice in a timely manner. One of the major prob- lems of stroke epidemiology is the lack of good-quality epidemiological studies in developing countries, where most strokes occur and resources are limited.
Antiplatelet agents are not used in a systemic manner purchase apcalis sx 20 mg line best male erectile dysfunction pills over the counter, and anticoagulants in atrial brillation are usually under-prescribed because of poor compliance and the need for frequent monitoring of blood coagulation purchase apcalis sx 20 mg on-line erectile dysfunction protocol scam alert. Removal of cerebral haematomas and extensive craniotomy for brain decompression are the main neurosurgical procedures for stroke patients in some parts of the developing world; endarterectomy is rarely used though there are few specic data available discount apcalis sx generic erectile dysfunction symptoms causes. This exible and sustainable system includes three steps: standard data acquisition (recording of hospital admission rates for stroke) discount apcalis sx online visa erectile dysfunction age, expanded population coverage (calculation of mortality rates by the use of death certi- cates or verbal autopsy), and comprehensive population-based studies (reports of nonfatal events to calculate incidence and case-fatality). These steps could provide vital basic epidemiological estimates of the burden of stroke in many countries around the world (20). Primary prevention of ischemic stroke: a guideline from the American Heart Association/ American Stroke Association Stroke Council. Stroke epidemiology: a review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century. Mortality by cause for eight regions of the world: global burden of disease study. Treatment and secondary prevention of stroke: evidence, costs, and effects on individuals and populations. Prevention of recurrent heart attacks and strokes in low and middle income populations: evidence-based recommendations for policy-makers and health professionals. Recent advances in management of transient ischaemic attacks and minor ischaemic strokes. Guidelines for prevention of stroke in patients with ischaemic stroke or transient ischaemic attack. Rehabilitation, prevention and management of complications, and dis- charge planning. Many years of productive life 173 Conclusions and recommendations are lost, and many people have to suffer years of disability after brain injury. In addition, it engen- ders great economic costs for individuals, families and society. The world is facing a silent epidemic of road trafc accidents in the developing countries: by 2020, road trafc crashes will have moved from ninth to third place in the world ranking of the burden of disease and will be in second place in developing countries. Systematic triage of patients can lead to important economic savings and better use of scant hospital resources. More standardized pre-hospital and in-hospital care, to minimize secondary brain injury, can improve outcomes substantially. Acceleration and deceleration forces may disrupt the nervous tissue and blood vessels of the brain. The intermediate category, moderate head injury, implies a mortality rate of 2 5%. Further classication of the brain injury is made in order to evaluate prognosis, identify pa- tients at risk for deterioration and choose appropriate observation and treatment. Someone who opens his eyes only after painful stimulation, utters only incomprehensible sounds and withdraws his hand only after pinching will be given a score of 8. A fracture detected on the skull X-ray images indicates an increased risk of deterioration, and the patient will need admission. In spite of these reservations, it can be interesting and informative to compile data from different parts of the world. Some of the differences could be as- cribed to variations in study years, inclusion criteria and research methods. Therefore, incidence rates such as 546 per 100 000 per year in Sweden and 91 per 100 000 per year in Spain must be interpreted with caution. Data from many parts of the world consistently show a peak incidence rate in children, young adults and elderly people. Information on how sequelae develop (diminish or increase) over time is scarce (8); better data on prevalence would certainly be useful for improved planning of rehabilitation needs. The average European pre-hospital case-fatality rate was 8%, while the in-hospital rate was 3%, i. Mortality rate per 100 000 population per year is more informative than the case-fatality rate. It has been suggested that heavy alcohol abuse may explain the persistent and high mortality rate in Finland (11). Disability Traumatic brain injury is the leading cause of disability in people under 40 years of age. Disability can be classied in a simple fashion using the Glasgow Outcome Scale (see Table 3. Most patients (90%) had sustained a mild head injury, while a few had suffered moderate (5%) or severe (3%) brain injury. Even among young patients with mild injuries and a good pre-injury status, one third failed to achieve a good recovery. Mostly, patients with severe disability will have a combined mental and physical handicap. It may be transitory, subsiding after a month or so, but may persist in many cases. The persistently vegetative patient needs articial nutrition and hydration and will have a markedly reduced life span, i. In some cases, complicated ethical and legal discussions arise about the purpose of continuing life-sustaining treatment. These variations must be taken into account by health planners who design prevention programmes. Every day about 3000 people die and 30 000 people are seriously injured on the world s roads, nearly half of them with head injuries. Most of the victims are from the low income or middle income countries, with pedestrians, cyclists and bus passengers bearing most of the burden (12). Fatality rates among children are six times greater in developing countries than in high income countries. Terms such as a public health crisis and a neglected epidemic have been used to describe this growing problem (13). People 70 years or older have a relatively high incidence of head injuries, and in these patients falls are the most common cause. These patients can be dismissed after a short clinical examination and adequate information, since their risk of further problems will be very low, i. Before dismissal, they deserve brief information, preferably written, about: warning signs indicating possible complications; how normal and mild symptoms are expected to develop; how to resume normal daily activities. Therefore, a closer examination may be required to identify the individuals with the highest risk of developing complications. Patients who need special attention are those with: decreasing level of consciousness; neurological decit; epileptic seizure; decient blood coagulation; age >60 years; alcohol abuse. A fracture will indicate a higher risk of deterioration and admission is necessary for a short time of observation. Airway obstruction and falling blood pressure are the acute threats to the vulnerable brain-injured patient. On admission, life-supporting measures should be continued, in accordance with Advanced Trauma Life Support recommendations (22). In the United Kingdom, the mortality in patients with epidural haematoma declined progres- sively from 28% to 8% after the introduction of national guidelines for the early management of head injury (22).
Nevertheless order apcalis sx 20 mg with amex erectile dysfunction treatment drugs, hyperresponsiveness consists of bronchoconstriction order generic apcalis sx line erectile dysfunction 2014, hypersecretion apcalis sx 20 mg lowest price erectile dysfunction in diabetes ayurvedic view, and hyperemia (mucosa edema) discount 20mg apcalis sx mastercard intracavernosal injections erectile dysfunction. The bronchial responsiveness detected after challenge with histamine or methacholine measures bronchial sensitivity or ease of bronchoconstriction ( 106). As stated, an additional finding in some patients with asthma is excessive bronchoconstriction, which can be attributable to associated increases in residual volume and possibly more rapid clinical deterioration ( 106). Often, on opening the thorax of a patient who has died from status asthmaticus, the lungs are hyperinflated and do not collapse ( Fig. In some cases, complicating factors, such as atelectasis or acute pneumonia, are identified. Upon histologic examination, there is a patchy loss of bronchial epithelium with desquamation and denudation of mucosal epithelium. Other histologic findings include hyperplasia of bronchial mucus glands, bronchial mucosal edema, smooth muscle hypertrophy, and basement membrane thickening (Fig. Occasionally, bronchial epithelium is denuded, but histologic studies do not identify eosinophils. Similarly, although many autopsy examinations reveal the classic pattern of mucus plugging ( Fig. Eosinophils have been identified in such cases in airways or in basement membranes, but a gross mechanical explanation, analogous to mucus suffocation, is not present. A third morphologic pattern of patients dying from asthma is that of mild to moderate mucus plugging (107). Some patients dying from asthma have evidence of myocardial contraction band necrosis, which is different from myocardial necrosis associated with infarction. Contraction bands are present in necrotic myocardial smooth muscle cell bands in asthma and curiously the cells are thought to die in tetanic contraction whereas in cases of fatal myocardial infarction, cells die in relaxation. Pleural pressure becomes more negative, so that as inspiration occurs, the patient is able to apply sufficient radial traction on the airways to maintain their potency. Air can get in more easily than it can be expired, which results in progressively breathing at higher and higher lung volumes. The residual volume increases several-fold, and functional residual capacity expands as well. The lung hyperinflation is not distributed evenly, and some areas of the lung have a high or low ventilation-perfusion ratio ( / ). Overall, the hypoxemia that results from status asthmatics occurs from reduced /, not from shunting of blood. The lung hyperinflation also results in dynamic autopeep as the patient attempts to maintain airway caliber by applying some endogenous positive airway pressure. There is no evidence of chest wall (inspiratory muscle) weakness in patients with asthma. Nevertheless, some patients who have received prolonged courses of daily or twice-daily prednisone or who have been mechanically ventilated with muscle relaxants and corticosteroids can be those who have respiratory muscle fatigue. After successful treatment of an attack of status asthmaticus, the increases in lung volume may remain present for 6 weeks. Small airways may remain obstructed for weeks or months; in some patients, they do not become normal again. At the same time, it can be expected that the patient has no sensation of dyspnea within 1 week of treatment of status asthmaticus despite increases in residual volume and reduced small airways caliber. This divergence between symptom recognition in asthma and physiologic measurements has been demonstrated in ambulatory patients who did not have status asthmaticus (114). The reduction in trapped gas in the lung can result in symptom reduction even without improvement in expiratory flow rates. In summary, asthma pathophysiology includes poor or impaired symptom perception in some patients. There may be poor sensitivity or discrimination (recognizing improvement or worsening status) (115). Even this list is oversimplified because asthma must be considered a very complex condition in terms of airway caliber and tone. Selected neuropeptides and their proposed actions in asthma Mediator release caused by mast cell activation results in acute and late bronchial smooth muscle contraction, cellular infiltration, and mucus production. The neurotransmitter for postganglionic parasympathetic nerves is acetylcholine, which causes smooth muscle contraction. However, there appears to be little if any significant smooth muscle relaxation through stimulation of postganglionic sympathetic nerves. Circulating endogenous epinephrine apparently does not serve to produce relaxation of smooth muscles. Sensory nerves in the respiratory epithelium are stimulated and lead to release of a host of neuropeptides that may be potent bronchoconstrictors or bronchodilators. Respiratory epithelium itself may contain bronchi-relaxing factors that may become unavailable when epithelium is denuded. Although much attention has been directed at understanding the contribution of IgE and mast cell activation in asthma, triggering or actual regulation of some of the inflammation of asthma may occur because of other cells in lungs of patients. These cells, as well as mast cells in the bronchial mucosa or lumen, can be activated in the absence of classic IgE-mediated asthma. Bronchial biopsy specimens from patients with asthma demonstrate mucosal mast cells in various stages of activation in patients with and without symptoms (117,118). Mast cell hyperreleasibility may occur in asthma, in that bronchoalveolar mast cells recovered during lavage contain and release greater quantities of histamine when stimulated by allergen or anti-IgE in vitro (119,120). The latter can be demonstrated by their reduced density upon centrifugation that occurs during acute episodes of asthma. In vitro, for example, peripheral blood mononuclear cells from patients with asthma are stimulated with allergen, and the supernatant is obtained. During an acute attack of asthma, there is an increase in inspiratory efforts, which apply greater radial traction to airways. Patients with asthma have great ability to generate increases in inspiratory pressures. Unfortunately, patients who have experienced nearly fatal attacks of asthma have blunted perception of dyspnea and impaired ventilatory responses to hypoxia ( 115,122). Severe asthma patients have been divided into eosinophil-positive (and macrophage-positive) and eosinophil-negative categories based on results on bronchial biopsy findings (123). Both subgroups of patients were prednisone dependent (average, 28 mg daily) and had asthma for about 20 years ( 123). On biopsy assessments, sub basement membrane thickening was higher in these eosinophil-predominant patients than in eosinophil-negative patients. It is likely that the cellular inflammation and cell products participate in control or perturbation of airway tone, and continued investigations should help clarify this difficult issue. Symptoms vary from patient to patient and within the individual patient depending on the activity of asthma. Some patients experience mild, nonproductive coughing after exercising or exposure to cold air or odors as examples of transient mild bronchospasm.
Some people think it is caused by treading on a snake or frog apcalis sx 20mg cheap impotence bicycle seat, others that it is a curse or form of punishment buy generic apcalis sx 20mg on line erectile dysfunction in early 30s. The swelling begins in the feet and progresses up the legs discount 20 mg apcalis sx erectile dysfunction caused by prostate surgery, and both feet are usually affected apcalis sx 20mg without prescription impotence 36. It cannot be transmitted between people, so close contact with someone who has podoconiosis is totally safe. You may wonder why you are learning about it in a Module on Communicable Diseases; there are two reasons. First, severe podoconiosis looks a lot like lymphatic lariasis, which you learned about in Study Session 37. It is important to know the difference between these diseases because there are differences in their treatment. Second, how you teach patients to reduce the disability due to podoconiosis is exactly the same as the methods you have already learned about for lymphatic lariasis. But there are some questions you can ask the patient that can help you to decide which diagnosis is most likely to be correct. If the patient lives more than about 1,200 metres above sea level, then the leg swelling is likely to be due to podoconiosis. This is because the mosquitoes that transmit lymphatic lariasis cannot survive above this altitude it is too cold at night. If the patient has always lived in dega or woina dega areas, or does not live in zones where lymphatic lariasis is known to be prevalent, then you should diagnose the leg swelling as podoconiosis. If it started in the feet and both feet/legs are affected, then the diagnosis is likely to be podoconiosis. See there is no vector so their houses don t need to be sprayed to kill StudySession5inPart1ofthis mosquitoes (unless, of course, malaria is endemic in the area). There is a major similarity in the experiences of people with podoconiosis and lymphatic lariasis, as we already mentioned in Study Session 37. They may be forced out of school, or even rejected by their church, mosque or idir. Other people may be reluctant to eat with them or associate with them in other ways. Marriage for people in affected families may be restricted to people from other affected families. Many of these social problems arise because people mistakenly fear that podoconiosis is infectious, and that they may catch it from patients. People with swollen legs due to In addition to this social stigma, people with podoconiosis often nd it lymphatic lariasis face the same difcult to do physical work because their legs are heavy and uncomfortable. Whole communities are also poorer because people with podoconiosis cannot work on their farms. Most people do not know that leg swelling from podoconiosis can be treated but it can! The basic steps of treatment will be familiar from Study Session 37, but are summarised again briey here: 1 Foot hygiene. First soak the feet for 20 minutes in a basin of cold water into which half a capful (about 10 drops) of berekina (bleach) have been added. Experience in Southern Ethiopia has shown that more than 90% of patients with podoconiosis can be successfully treated without need of referral for care within the government health system. Sometimes, people with podoconiosis develop bacterial superinfection ( added infection by bacteria that usually live on the skin) in the swollen leg. They report aching pain and increased heat and swelling in the leg, fevers or chills, and sometimes headaches. After an injury, a person with podoconiosis is more likely to develop an open wound that may not heal easily. Careful wound care using clean techniques and local dressing materials will be needed, most likely at a health centre. So if children wear shoes all the time, the next generation will not suffer from podoconiosis. More severe grades of trachoma should be referred for specialist treatment, often involving simple surgery to stop the eyelashes from rubbing the cornea. Sometimes, patients with podoconiosis need urgent referral for treatment of superinfection with bacteria or fungi, open wounds, or skin cancer. Some of the questions test your knowledge of earlier study sessions in this Module. B A newborn with red and swelling conjunctiva should be treated by putting tetracycline ointment into the eyes. F Disability resulting from podoconiosis and lymphatic lariasis can be reduced by foot and leg hygiene, exercising the affected part and raising the legs when sitting or sleeping. G Trachoma, scabies and podoconiosis are all communicable diseases found in conditions of poverty, overcrowding and poor access to clean water and sanitation. Communicable diseases spread easily from person to person in the community and can cause many illnesses and deaths. In this study session you will learn in detail about public health surveillance, which consists of close observation, recording and reporting of cases of important communicable diseases or conditions in your community. A good understanding of public health surveillance will enable you to detect the occurrence of excess cases of communicable diseases in your locality (that is, more than expected), and report them to the higher authorities. Using public health surveillance data, you can also assess the magnitude (or burden) of major communicable diseases in your locality by counting the number of cases occurring over a period of time. Collecting and analysing public health data will help you to plan appropriate measures to control communicable diseases, for example, distributing appropriate medicines and educating the community about disease prevention. This study session will describe in detail the basic concepts of public health surveillance, the types of surveillance and the activities you will undertake in recording and reporting disease. Learning Outcomes for Study Session 40 When you have studied this session, you should be able to: 40. Based on the information, health workers like you, supported by the higher authorities, can take appropriate disease control measures. As part of a healthcare team with reponsibility for around 500 families in your community, you will routinely need to collect, analyse and interpret health- related data, and send reports of your ndings to the nearby Health Centre. As part of your routine practice, you are expected to collect health data from patients when they come to your Health Post. You are also expected to collect data during home visits about illnesses and deaths due to major communicable diseases, as well as about other health-related factors such as nutrition, immunization coverage and use of family planning methods. Remember, you should only collect data that you can use is a waste of your time, energy to improve health programmes in your area. D F 10 yrs Fever, severe muscle pains with Poliomyelitis paralysis of the lower limbs 10 7/5/96 D. D F 24 yrs Fever, headache, neck stiffness Meningitis 98 Study Session 40 General Principles of Public Health Surveillance Serial Date Name Kebele Sex Age Signs and symptoms Suspected disease/ No. C F 24 yrs Vaginal bleeding at four weeks Spontaneous abortion pregnant 15 8/5/96 G. Data interpretation is the process of understanding and interpretation are given in the communicating the meaning of your data.
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