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Although the presence of a unidirectional conduction block in the myocardium is necessary for the creation of reentry tachycardias buy kamagra oral jelly 100 mg visa impotence kidney stones, it is not buy cheap kamagra oral jelly 100 mg line erectile dysfunction age 16, by itself buy kamagra oral jelly on line erectile dysfunction juice drink, sufficient to set up a circus rhythm. The area of myocardium that receives action potentials from the reentry circuit as they emerge from the injured tissue zone must be over their refractory period for the cycle to be initiated anew. Consequently, any condition that slows but does not block the conduction of action potentials through the myocardium or shortens the refractory period of healthy cardiac cells will increase the probability of creating ventricular reentry tachycardias. Furthermore, should these factors enhance automaticity in cardiac cells, there is a good chance that such tachycardias will be initiated. Unfortunately, myocardial ischemia, by causing partial membrane depolarization, brings cells closer to their activation threshold and creates action potentials of small amplitude, which are conducted slowly through the myocardium, thus enhancing the probability of creating reentry tachycardias. Because cardiac muscle is an electrical syncytium, any cell or group of cells that act as ectopic foci can activate the rest of the myocardium. This in turn will result in extra, abnormal, activations of myocardial contraction. In some cases, these ectopic foci fire only occasionally, but they can fire repetitively and at high intrinsic rhythms in a manner that impairs the performance of the heart as a pump. Problems occur when such action potentials are generated in the myocardium in a random fashion or when the myocardium becomes paced by the ectopic foci at rates too high to allow proper filling of the ventricular chambers with blood (ventricular tachycardias). Ischemia inhibits Na /K + 2+ pump activity, resulting in intracellular accumulation of Na and Ca and partial membrane depolarization. This places the resting membrane potential in the affected cells closer to their threshold for the activation of action potentials. In this state, small additional depolarizing stimuli, which would be insufficient to push normal cells to their threshold, will push the membrane potential of affected cells beyond their threshold, causing them to fire and activate the rest of the heart. Hyperkalemia, hypercalcemia, distention of the heart chambers (as occurs in congestive heart failure and hypertension), + + clinical treatment of chronic heart failure with cardiac glycosides (which partially inhibits the Na /K pump), all can partially depolarize the resting membrane potential and predisposes affected cells to become ectopic foci. Any factor that reduces potassium conductance at rest or increases intracellular calcium concentration can also partially depolarize cardiac cells (e. Fatigue and emotional or physical stress predispose a person to the formation of ectopic foci because such states activate the sympathetic nervous system and release catecholamines onto the heart. The probability of the formation of ectopic foci in the heart is also increased by an individual’s use of caffeine or nicotine, the former which increases intracellular calcium concentration in myocardial cells through multiple mechanisms. Besides partial depolarizing factors, agents that shorten the refractory period of cardiac cells allows affected cells increased time to be reactivated by any depolarizing stimulus and thus + increase the probability of ectopic foci occurring in the heart. Catecholamines, which increase gK in phase 3 of the action potential, and a class of drugs called calcium channel blockers, used to treat angina and hypertension, are examples of agents shortening the refractory period of myocardial cells. However, this is simply an electrophysiologic classification in that there are never any inwardly directed potassium currents during the cardiac action potential (the cell membrane never reaches the potassium reversal potential of −90 to −100 mV). It is the outward current through these channels that is physiologically important. They are thought to be one link between cardiac metabolism and membrane potential. These channels may be responsible for the reduced refractory period seen during myocardial ischemia. These channels may mediate cholinergic-mediated atrial arrhythmias (abnormally slow heart rates) as well as certain antiarrhythmic effects of adenosine, which is used to treat certain arrhythmic conditions. Triggered activity Triggered activity is a type of ventricular arrhythmia in which the abnormal beats are not generated de novo from ectopic foci. Instead, such activity follows a previous action potential or action potentials, which “triggers” an abnormal depolarization of ventricular muscle before the prior action potential is complete. Such conditions in the heart are difficult to terminate as one abnormal action potential triggers another and another, etc. Triggered activity is not self-activating, but it is thus considered self- sustaining. Triggered activity is classified by the timing of the appearance of the abnormal depolarization. They are more likely to be induced by factors that prolong the action potential duration, such that slow calcium channels have time to recover and, thus, fire an additional low-amplitude action potential. Tachycardias increase the number of times per minute calcium channels open during phase 2 and thus can bring calcium into the cell faster than it can be removed, allowing its concentration to rise over time. When a portion of the myocardium becomes depolarized from an action potential, its polarity is temporarily reversed, becoming positive on the inside and negative on the outside relative to the neighboring inactivated tissue. When this reversal occurs, it temporarily creates two neighboring regions of opposite charge, or polarity, within the myocardium (Fig. Electrical currents readily flow from one pole of a dipole to the other through any media between the poles that can conduct them. The intracellular and extracellular fluids in the body are largely composed of electrolyte solution, which is a good conductor of electricity. Thus, any dipole, formed at any time and in any direction within the myocardium, is transmitted through the body as a current between the ends of the dipole. This current then radiates outward through the body to the surface of the skin where it can be detected. Arrows show the direction of the net dipole caused by depolarization of a portion of the myocardium. Dipoles are present only when a portion of the myocardium is in the process of depolarization or repolarization while other portions are not. It results from the composite effect of all the different types of action potentials generated in the myocardium during activation and the resulting magnitude and orientation of the dipoles created by them. Other tools must be used for such an evaluation, and these will be discussed in later chapters. After a short interval, a complex, short-duration, high- amplitude, spike-like potential is observed. By definition, within this complex, the first downward deflection after the P wave is called a Q wave, the next upward deflection is called an R wave, and the next subsequent downward deflection is called an S wave. Next, ventricular repolarization produces a broad wave of modest upward amplitude called a T wave. The normal conduction pathway through the bundle branches, Purkinje fibers, and ventricular muscle is the most efficient and rapid mode of action potential travel. To explain further, consider the voltage changes produced in which the body serves as a volume conductor and the heart generates a collection of changing dipoles (Fig. In this example, an electrocardiographic recorder is connected between points A and B such that point A is positive relative to point B. The black arrows are projected vectors that represent the magnitude and direction of a major dipole in the myocardium, which is depicted as a red arrow in the diagram. The direction is determined by the orientation of depolarized and polarized regions of the myocardium. In panel 5, the last areas of the ventricles to depolarize are the first to repolarize (i. The projection of the vector (black arrow) for repolarization points to the more positive electrode (A) as opposed to the less positive electrode (B) and so an upward deflection is recorded on this lead.

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The concentration of hair follicles laid down per unit area of facial skin difers little between men and women cheap kamagra oral jelly 100mg with visa erectile dysfunction see urologist, but does difer between HiRsUtisM/viRiLisM races and ethnic groups cheap kamagra oral jelly 100 mg free shipping l-arginine erectile dysfunction treatment. For example buy kamagra oral jelly overnight delivery erectile dysfunction treatment gurgaon, Asian women with androgen-secreting tumours are rarely hirsute Anne Clark, revised by Harry Gibson because of their low concentration of hair follicles per unit skin area. Hirsutism is defned as excessive body hair growth in The diagnosis of hirsutism/virilisation may seem women where it is not normally found, usually with daunting, but a basic history, examination, transvagi- a central body distribution. In about 10–15 per cent nal ultrasound scan of the ovaries and a few laboratory of hirsute women, hormone levels are within the nor- investigations will give the diagnosis in the majority of mal range and a diagnosis of ‘idiopathic hirsutism’ 1 cases. Medical history The more severe state of virilism (defeminising symptoms: clitoromegaly, deepening of the voice, The focus should be on the onset and duration of the balding, increased muscle mass, and changes to a symptoms of hirsutism/virilisation, and menstrual male-like body habitus) is rarely seen and is usu- and medication history. Hirsutism associated with ally secondary to adrenal hyperplasia, androgen- a history of menstrual irregularity since the teenage producing tumours of adrenal and ovarian origin, or years or early 20s, or an increased body weight with exogenous steroid use. Table 1 shows the sources and incidences of conditions that result in increased androgens, which of hirsutism. Constellations of symptoms may suggest other Tere are two types of hair that grow in adults: sources of endocrinopathy. Hirsutism associated with central weight distribution, excessive sweat- vellus hair: the downy unpigmented hair associated with ing, and skin atrophy with purple striae suggests the prepubertal years; Cushing’s syndrome. Fatigue, poor concentration, terminal hair: the coarse pigmented hair that grows on feeling cold, constipation, weight gain, and menor- various parts of the body during the adult years. Hirsutism occurs when resting vellus hairs are If there is a history of sudden onset and rapid pro- transformed to terminal hairs following exposure gression of androgen excess leading to virilisation, HiRsUtisM/viRiLisM 165 Table 1 Differential diagnoses and incidence of hirsutism/virilism Polycystic ovary syndrome 10% of all women Idiopathic hirsutism 10–15% of hirsute women Ovarian Benign tumours: the vast majority of ovarian androgen-secreting tumours <1% of all ovarian tumours, of which 75% are benign; are benign. The other virilising condition that occurs the woman develops hirsutism later than the age of in pregnancy, theca-lutein cyst, occurs when high 25 years. Ovarian tumours are more common than levels of human chorionic gonadotrophin are pres- adrenal tumours. The solid lesion is unilateral in 45 per cent of cases, causes virilisation in 35 per The purpose of the physical and laboratory evalua- cent of women, and regresses postpartum. Signs of increased insulin levels: ● acanthosis nigricans – this grey–brown velvety Box 1 Revised diagnostic criteria discoloration of the skin can be found in the neck, of polycystic ovary syndrome (2003 groin, axillae and vulva. Clinical and/or biochemical signs of hyperandro- genism Polycystic ovariesa investigations and exclusion of other aetiologies (congenital adrenal The investigations will include blood tests and imag- hyperplasia, androgen-secreting tumours, Cushing’s ing designed to look for the underlying diagnosis. There is no absolute level a that is pathognomonic for a tumour; however, a serum Using ultrasound criteria, polycystic ovaries are defned testosterone >5 mmol/L is highly suggestive. The presence or absence of the following adrenal hyperplasia; if baseline level is equivocal, should be assessed. Signs of virilisation: Blood tests if acanthosis nigricans or insulin resistance ● clitoromegaly, deepening of the voice. Clinical Gynaecologic Computed tomography is preferable as it gives better res- Endocrinology and Infertility, 7th edition. The Practice Committee of the American Retrograde venous catheterisation may be required to Society for Reproductive Medicine. Many patients with idiopathic criteria and long-term health risks related hirsutism whose self-esteem is not afected will be to polycystic ovary syndrome. Evaluation of ovarian func- and androgen balance in the majority of patients, tionality after a dietary treatment in obese and while this will not reverse terminal hairs back women with polycystic ovary syndrome. J Obstet Gynecol Reprod Biol 2005; 119: Bleaching, shaving, chemical washes, and mechani- 87–93. Aldosterone antagonist spironolactone Matthew Toal and androgen antagonist futamide compete with circulating androgens and are second- and third-line Hot fushes of varying severity are common in options. Finasteride (a 5a reductase inhibitor reduc- women leading up to and during their menopause. Reviewing the diferential diagno- libido and cause feminisation of a male fetus, and sis will help in detecting other ‘red fag’ conditions therefore careful contraception is crucial. Rarely, this type of fushing can be associated with scombroid food poisoning from ingesting spoiled or decaying mackerel or tuna. Defnition 5 Drug-associated fushes are associated with: Hot fushes are episodes of redness of the skin together Vasodilators – nitroglycerine, prostaglandins. Tese attacks are transient, last- Anti-oestrogens such as tamoxifen and clomiphene. Repeated fushing over a Luteinising hormone-releasing hormone agonists or period of time can lead to telangiectasia and occasion- antagonists. Fermented alcoholic beverages (beer, sherry) that may Mastocytomas – benign proliferative disorders of the contain tyramine or histamine. This condition may following exposure to industrial solvents (trichloroeth- be associated with headache, shortness of breath, ylene vapour, carbon disulphide, xylene, etc. This type of fushing lasts more than 7 Dumping syndrome usually following gastric outfow 30 minutes, unlike the carcinoid or menopausal fush, surgery. However, it is important to ensure the patient has had a diet free of substances that may compound these results prior to Diagnostic approach to a patient with testing. The character of the fushing and its frequency, severity, and location help to determine the impact on a patient’s life. It is always important to assess the Management of hot fushes symptoms in the context a patient’s quality of life and Lifestyle measures how the symptoms impact on her everyday activi- Adopting certain lifestyle changes may help decrease ties. Whether the fushing is patchy or confuent in the severity of hot fushes and a woman’s ability to distribution will help to distinguish the symptoms of cope with its inconvenience. It is recommended that menopausal hot fushing from other dermatological all women be counselled regarding these changes, causes such as dermatitis. In particular, avoidance avoidance of triggering factors such as caffeine, alcohol, of certain foods can reduce carcinoid fushing and spicy foods and hot beverages; avoidance of alcohol can reduce fushing secondary avoidance of smoking; to mastocytosis and medullary thyroid carcinoma. Tis can then be followed by a trial period of exclusion of suspected foods to see whether symp- Non-pharmacological measures toms resolve. Sweating and palpitations occur with menopausal Cognitive behavioural intervention and diversion tech- hot fushes. If symptoms are mild, then lifestyle modifcations should Hydrops fetalis refers to the presence of two or more be the mainstay of treatment. Vitamin E supplementa- of the following abnormal fetal fuid collections tion may be considered in addition. If complementary therapies are being used, the patient should be advised that: the effcacy of these products it not yet established; there is very little control over the quality of these Figure 1 Hydrops fetalis. Widespread use of Rh-D immunoglobulin has dramatically decreased the prevalence of Rh-D alloim- The condition is subdivided into immune and munisation and associated hydrops. Immune hydrops is caused now accounts for almost 90 per cent of hydrops cases by red cell antibodies (red cell alloimmunisa- in developed countries. However, Non-invasive Doppler ultrasonographic assess- intervention that results in reversal of fetal hydrops ment of the peak velocity of systolic blood fow in can also reverse the maternal disorder.

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Measles Early diagnosis and prompt initiation of treatment is the immunization to susceptive children obviously reduces mainstay of any blindness control program buy 100mg kamagra oral jelly visa erectile dysfunction treatment tablets. The global cataracts existed in rural area alone and that further 32 target is to ultimately reduce blindness prevalence to less million eyes had immature cataract and 18 million than 0 order cheapest kamagra oral jelly impotence 24. It is estimated that the number of people who are blind or visually at the present rate of 1 order kamagra oral jelly 100mg overnight delivery erectile dysfunction foods. Early impaired, in particular, those who are blind because of diagnosis and prompt treatment are essential in all these infectious causes. Eye camps, base hospitals and tertiary care of people who are blind or visually impaired due to centers, all have to play an important role. Institution of glaucoma screening in to adapt the current strategies of prevention and care high risk groups would bring these cases to notice and in order to take into account these demographic and prompt treatment can be instituted. Mass chemoprophylaxis programs are Primary prevention can be undertaken at two levels: extremely useful in trachoma (tetracycline) and onchocerciasis (ivermectin). Health Disability limitation and rehabilitation are not as cost promotion strategies protect the individual by preventing effective as strategies aimed at eye health promotion, specific protection, early diagnosis and treatment. Various activities of the program include and other supplies are also procured centrally. Assistance establishment of Regional Institute of Ophthalmology, for fixed facilities from central government. Other assistance The goal is to reduce the prevalence of blindness from • Drugs and consumables for cataract surgery @ Rs 1. Training of District Program Managers is being World Bank assistance: A World Bank assisted carried out for 2 weeks. The District Blindness Control cataract blindness control project is under Society concept aims at decentralization to the district implementation since 1994 to 95. The principal area of work of the crores was allocated for the year 1994 to 95, Rs. A midterm review of the project was undertaken during 1998 to assess the progress. Setting up strategies and targets for disease control Golden Jubilee year of the India’s independence a 2. Planning human resource needs and development special program for organizing Mega Eye Camps in 3. This would include problems than those identified under the minimum tribal or geographically difficult areas. About 3 lakhs additional The five diseases identified for global elimination cataract operations were performed during these two include: weeks. Children who cannot read the 6/9 line with any eye Targets have been set up for each of the component diseases for the next 20 years. Surveillance activities carried out under 382 collaborating centers, work with country-based teams to various vertical diseases control program, viz, program support the implementation of strategies developed. Syndromic: Diagnosis made on the basis of To establish a decentralized district-based surveillance symptoms/clinical pattern by paramedical personnel system for communicable and noncommunicable and members of the community based on broad diseases, to provide data for monitoring progress of categories of presentation. Presumptive: Diagnosis made on typical history and Definition of Surveillance clinical examination by Medical Officer. Confirmed: Clinical diagnosis by Medical Officer and/ interpretation of health data essential to planning, or positive laboratory identification. Surveillance helps to keep a close watch on health events occurring in the Considering the disease burden in the community, avai- community and provides information so that effective lability of public health response, special considerations action can be taken timely. It provide data (who, where, and international commitments following diseases were when do they get the diseases and why? Organizational structure: District Surveillance Units The disease conditions that are included in the core at the District level and State Surveillance Unit at the list and state specific list of the surveillance program will State level implement the Project. Feed back in the incidence of the disease and can trigger action report should also be provided on the quality of data for outbreak investigation. It also helps in officer will perform specific additional analysis required diagnosis of cases for case management and feed for each disease. However, at the periphery only back of laboratory reports on a case to the reporting frequency tables are necessary and this will be units. This facilitates identification of new agents and automated by the use of computers. The analyzed changes in the behavior of microorganisms especially reports need to be sent to the stakeholders at different in relation to susceptibility to anti-microbials. Surveys give reliable • Assist in allocation of resources epidemiological information, however it is difficult to • Mobilization of public support for health programs conduct and are relatively expensive. Every disease needs a basic number of cases in order This provides information on magnitude, distribution to sustain the transmission to other vulnerable in the and possible cause of outbreak. When the trigger levels are crossed for communicable diseases Collection and Transmission of Data appropriate responses has to be made. Details are given The health workers or village level volunteers collects in the District Operations Manuals for the project. Each sentinel site will record selected disease conditions by prior agreement but will send regular Though global childhood mortality rates continued weekly report including zero reporting. Often the nutritional and immunization status of all sick infants sick children present with combination of signs and and children. They are also through prompt recognition of all coexisting conditions, assessed for the major symptom of “diarrhea” and rapid and effective treatment based on standard case breastfeeding. All sick children age 2 months up to management and prevention of illness by improving 5 years must be examined for “general danger nutrition including breastfeeding, and vaccination in signs” which indicate the need for immediate referral 1 week to 5 years age group children. Only a appropriate combined treatment of all major illnesses, limited number of carefully selected clinical signs are strengthens the counseling of caretakers and the used, based on evidence of their sensitivity and provision of preventive services, and speeds up the specificity to detect disease. It also aims at improving considering the conditions and realities of first-level the quality of care at the referral level also. Following are significance of the color strategy with additional component of newborn care for code of illness: 0 to 7 days age and renamed as Integrated – Conditions under red color (or pink) indicate Management of Neonatal and Childhood Illness severe illness. Ministry of Health and Family Welfare, Govt of India: Health workers or paramedical worker are supposed Annual Report 1999-2000. Conference of Central Council for Health and Family Welfare, management chart to provide care to the sick children Govt. Global initiative for the Elimination of Avoidable in community and at routine home visits for new borns. Ministry of Health and Family Welfare, Government of and may die within a few hours or days. Integrated Management of of the reasons why young infants have to be managed Neonatal and Childhood Illness: Training Module for differently. However, the topic of food and nutrition must be There is an inseparable association between nutrition discussed separately because it represents an interesting and health. In different situations, nutrition may act as interplay of all the three factors and cannot belong an environmental, host or agent factor influencing exclusively to any one of the above three sections. The present chapter is organized into the following eight parts: Food and Nutrition as Environment 1.

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