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An “Expert Committee for Health Manpower Planning order red viagra line erectile dysfunction treatment supplements, – Inititation of health manpower studies purchase generic red viagra canada erectile dysfunction treatment raleigh nc. Establishment of health science universities in various redesigning of socially useful producive work states and union territories buy red viagra 200mg with amex erectile dysfunction drugs uk. Establishment of health manpower cells at centre and dependence of literacy, social and family welfare in the states. Vocationalization of education at 10 + 2 levels as – Incorporation of health component, with well regards health related fields with appropriate incen- structured pedagogic inputs, in the curriculum for tives, so that good quality paramedical personnel teacher training and education. These three aspects were This would call for appropriate changes in instructional methodology. Occupational therapists, Physiotherapists, Sanitary/ • Health manpower cells should be established at health inspectors, etc. There has been a phenomenal growth of medical should be reorganized so as to be equated with the colleges in the country as reflected in Table 26. The suggested curricular mix should The training of nurses and other categories of health consist of (a) 25 to 30 percent of total instructional personnel was also augmented along with the training time devoted to teaching of languages, humanities, of medical men. This expenditure may be considered educational infrastructure; (b) 70 to 75 percent time wasteful if doctors do not serve the country’s devoted to vocational theory and practice, including population. By this yardstick, 25 percent of the training on the job training, utilizing the existing training infra- of doctors may be a waste. The committee the norm of 1:3500 for doctor: population, ratio suggested that the two years of 10 + 2 course should suggested by the Mudaliar Committee. The doctor be phased into four semesters of which the first two population ratio in India is 1:2222 (45 doctors per lakh should be devoted to a core curriculum common population). The fourth semester should concen- Imbalance exists regards distribution of doctors. Students passing vocational About 68 percent are working in the urban areas and courses should be able to pursue higher courses in only 32 percent in the rural areas. This is so in spite medical or other professional colleges either at the of the fact that 73. For there is imbalance in the distribution of doctors in example, (i) Students taking vocational courses at different states, as seen in Table 26. This imbalance, 10 + 2 level should be eligible to join medical or too, needs corrective measures and these must form their professional course after passing 10 + 2 course part of our future manpower planning. Various policy pronouncements of the as also after 3 to 5 years of work in their chosen Government as well as the plan documents have vocation; (ii) Awards and stipends should be given; constantly stressed that health and medical services (iii) Employment should be facilitated for those quali- will be provided on priority basis to rural and fying the 10 + 2 courses. However, the securing recognition from the empolyment sector for actual pattern of availability of medical and health these courses. Like all other benefits of • A national health manpower policy should be drawn development, those of health services have also gone up in relation to the stated objectives of the national in favor of the affluent urban sections of the society. What we need colleges* admitted qualified today is not to produce more doctors but to deploy them in such a way as to remove the regional and 1947 25 1983 959 urban rural imbalances. It is important that job opportunities should be population in selected countries created in rural areas where the population: doctor ratio Countries No. The concept is manifest in the following is higher than Sri Lanka where, incidentally, the infant definitions: mortality rate is about one-third of that in India. It must • Administration is the direction, coordination and be realized that more doctors do not mean more control of many persons to achieve some purpose health. This point is well illustrated human and material resources to achieve desired in Table 26. It is the systematic ordering branch of public administration which deals with matters of affairs and calculated use of resources, aimed at relating to promotion of health, preventive services, making those things happen which we want to medical care, rehabilitation, development of health happen and simultaneously preventing develop- manpower and medical education and training. It is the purpose of public health administration is to provide marshalling of available labor and materials in order total health services to the people with economy and to gain that which is desired at the lowest cost of efficiency. A good public health administrator is one of people in association to achieve some goal who carries out this task with maximum efficiency and temporarily shared. To forecast and operations and coordinating the efforts of people plan means examining the future and drawing up the working in it. To organize means building up the dual coordination of resources such as money, materials and structure, material and human, of the undertaking. To manpower, to achieve defined objectives with maximum command means maintaining activity among the efficiency. The productiveness of the resources, unifying and harmonising all activity and effort. In 490 management of affairs with the use of well thought out its traditional interpretation, the term ‘management’ principles and practices and rationalized techniques to refers to the activities (and often the group of people), involved in four general functions-planning, organi- • Management is a distinct process consisting of plan- zing resources, leading and controlling or coordinating. Leading includes setting membership groups, taking into consideration the directions for the organization, groups and individuals complex of objectives, limitations and standards and also influences people to follow that direction. Management is nothing but a are primarily responsible for making decisions in the process of making decisions. In a nonprofit organization, the term planning” include setting objectives, outlining activities “management” might refer to all or any of the activities towards achieving these objectives and procuring of the board, executive director and/or program directors. More recent interpretations of management assert “Decisions related to implementation” are that management needs to focus more on leadership concerned with execution of all activities as planned, skills, e. Management is a function not only of those • Management is the creation and control of techno- at the top of the hierarchy. Good health management logical and human environment of an organization means adaptation to the needs of changing situation, in which human skills and capacities of individuals optimum utilization of limited resources, improvement and groups find full scope for their effective use in in the standard and quality of services provided and order to accomplish the objectives for which an maintenance of high staff morale aimed at providing enterprise has been set up. Coordination is defined as the process • Management is the act of securing maximum results by which managers achieve integrated patterns of with a minimum of effort so as to secure maximum prosperity and happiness for both the employer and group and individual effort. To coordinate is to the employees, and give the public the best possible develop unity of action in common purposes. Coordination is often wrongly confused with • Management embraces all duties and functions that cooperation. Cooperation is certainly desirable pertain to the initiation of an enterprise, its financing, between two individuals or organizations and helps the establishment of all major policies, the provision in coordination. It is important to remember that of all necessary equipments, the outlining of the individuals or organizations may cooperate, but do general form of organization under which the not coordinate, on their own. Any degree of enterprise is to operate and the selection of the coordination between the cooperating individuals is coincidental. Staffing, that is, the whole personnel function of bringing in and training the staff and maintaining An organization is a group of people whose activities favorable conditions of work. An organization comes into sions and embodying them in specific and general being when there are persons able to communicate with orders and instructions as also serving as the leader each other, who are willing to contribute action, to of the enterprize. Coordinating, that is, the all important duty of elements of an organization: Purpose, process, interrelating the various parts of the work. Reporting, that is, keeping those, to whom the Efforts have been made during last 100 years to executive is responsible, informed as to what is going improve administrative performance or productivity on, which, thus, includes keeping himself and him and to learn more about human behavior in subordinates informed through records, research organizations.

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Clinical features • It most often occurs in middle-aged women with a history of recurrent urinary tract infections buy red viagra 200 mg lowest price diabetic with erectile dysfunction icd 9 code. Renal stones are formed either due to Patients with calcium oxalate supersaturation of urine (constituent concentration exceeding the solubility) or defciency stone are advised to maintain a of crystal formation inhibitors like pyrophosphate 200mg red viagra for sale erectile dysfunction drugs from himalaya, diphosphonate purchase 200mg red viagra overnight delivery erectile dysfunction emedicine, citrate, osteopontin and low sodium, low protein but nephrocalcin. Renal stones Calcium oxalate Uric acid Magnesium Cystine ammonium phosphate Struvite (triple) stone: Coffn lid • Most common • Seen with hyper- • Also called “stru- • Due to genetic Q stoneQ. Concept Stones are usually unilateral (80% of patients) and are deposited in renal pelvis and Reasons why low calcium bladder. If the developing stone takes the shape of the pelvicalyceal system, it is called is avoided in patients with calcium oxalate are: staghorn calculi. Clinical symptoms include hematuria, urinary obstruction, renal colic (if they pass • Low calcium diet increases into the ureters) and increased chances of infection. Most of the renal stones are managed risk of stone formation by reducing calcium in the surgically. Q White cell casts Are suggestive of interstitial injury and may be seen in interstitial nephritis. Q Broad granular casts Arise in the dilated tubules of enlarged nephrons that have undergone compensatory hypertrophy in response to reduced renal mass i. Q 450 Kidney and Urinary Bladder Pigmented muddy brown granular casts Are suggestive of ischemic or nephrotoxic injury i. Denys-Drash syndrome It is characterized by gonadal dysgenesis (male pseudohermaphroditism) and early-onset nephropathy leading to renal failure. The characteristic glomerular lesion in these patients is a diffuse mesangial sclerosis. In addition to Wilms’ tumors these individuals are also at increased risk for developing germ-cell tumors called gonadoblastomas. Beckwith-Wiedemann syndrome Concept It characterized by enlargement of body organs (organomegaly), macroglossia, hemihypertrophy, Anaplasia is an indicator of omphalocele and abnormal large cells in adrenal cortex (adrenal cytomegaly). The genetic locus adverse prognosis because involved in these patients is in band p15. In addition to Wilms’ it is associated with p53 gene tumors patients with Beckwith-Wiedemann syndrome are also at increased risk for developing mutation and resistance to anti- hepatoblastoma, adrenocortical tumors, rhabdomyosarcomas and pancreatic tumors. Microscopically, Wilms tumors are characterized by the classic triphasic combination of blastemal, stromal, and epithelial cell types (immature glomeruli and tubules) seen in majority of lesions. The tumor usually presents as a large abdominal mass, which may extend across the midline and down into the pelvis. The patient may also present with fever and abdominal pain, with hematuria, or rarely, with intestinal obstruction as a result of pressure from the tumor. The prognosis for Wilms tumor is generally very good, and excellent results are obtained with a combination of nephrectomy and chemotherapy. Males are more frequently affected (M:F ratio is 2 to 3:1) in the Cerebellar hemangioblastoma th + Bilateral renal cell cancer + age group of 6-7 decade. Clinical features include the classical triadQ of hematuria (earliest and most common symptomQ; usually intermittent), palpable mass and fank pain. Infammation of urinary bladder is called cystitis and it is more common in females as compared to males. Hemorrhagic cystitis: Due to cytotoxic antitumor drugs like cyclophosphamide and Adenovirus. Dysuria - Painful or burning sensation or urination This triad may be associated with fever and malaise. Special cystitis Hunner ulcer Malacoplakia • Painful chronic cystitis associated • Chronic bacterial cystitis having presence of soft, with hemorrhagic infammation yellow mucosal plaques. The commonest histological variant is the transitional cell tumors (urothelial tumors). Risk factors of urinary bladder cancers Transitional cell cancers Squamous cell cancer Adenocarcinoma • Cigarette smokingQ. The prognostic markers include grade of tumor, presence of lamina propria invasion and associated carcinoma in situ. The worst prognosis is associated with tumor invading the muscularis mucosa (detrusor muscle)Q. A 28 year old man has lenticonus and end stage renal and creatinine with hematuria. His maternal uncle also died of the same demonstrate markedly enlarged kidneys with irregular illness. Which one of the following is not associated with adult polycystic kidney disease? Podocytes are seen in: interactions (a) Proximal convoluted tubule (c) Intracranial berry aneurysm may be present (b) Distal convoluted tubule (d) Tricuspid valve prolapse (c) Collecting tubule of the kidney 3. Which of the following is associated with adult (d) Bowman’s capsule polycystic kidney disease? Adult polycystic kidney disease is inherited by: (a) Berry aneurysms of Circle of Willis (a) Autosomal dominant (b) Saccular aneurysms of aorta (b) Autosomal recessive (c) Fusiform aneurysms of aorta (c) X-linked (d) Leutic aneurysms (d) Mitochondrial 4. In a specimen of kidney, fbrinoid necrosis is seen and (b) Kimmelstein-Wilson lesion onion peel appearance is also present. Urinary examination (a) Rapidly progressive glomerulonephritis reveals grade 3 proteinuria and the presence of hyaline (b) Alport syndrome and fatty casts. Which (c) Goodpasture’s syndrome of the following statements about her condition is true? Which of the following is not true about Berger’s (d) Fibrillary glomerulopathy disease? In Wegener’s granulomatosis, kidney has which of the biochemical examinations showed hypoalbuminemia following lesions? Which of the following is a feature of Collapsing (minimal change disease) was diagnosed. Visceral leishmaniasis causes (Karnataka 2005) (b) Selective proteinuria (a) Membranous glomerulonephritis (c) IgG deposition in mesangium (d) Common in the age group of 2-9 years (b) Mesangioproliferative glomerulonephritis (c) Focal segmental glomerulonephritis 69. Histological hallmark of rapidly progressive (c) Cresenteric glomerulonephritis glomerulonephritis is (Karnataka 2004) (d) Alport syndrome (a) Crescents in most of the glomeruli 70. A 60-year-old man develops oliguria and peripheral (c) IgA nephropathy edema over a period of weeks. Urinalysis reveals (d) Crescentic glomerulonephritis hematuria and proteinuria; examination of the 78. On electron microscopy, in most of the cases, urinary sediment reveals red cell casts. An old man from a village Ram Khilavan has (c) Hypertensive nephropathy progressively increasing back pain for last 6 months. He (d) Lupus nephritis also had repeated bouts respiratory tract infections with 83. He form of nephrotic syndrome that does not respond to ignored these thinking they are associated with his age. Which of the However, he then notices the development of an edema following histological diagnoses will most likely be on his lower limbs.

Initial recession of the antagonist muscle decreases the tension pulling the globe away from the resected muscle and makes it easier to bring the resected muscle to the insertion site and to tie the sutures on the resected muscle purchase 200 mg red viagra mastercard impotence high blood pressure. When performing surgery on an oblique muscle and rectus muscle of the same eye buy discount red viagra online impotence at 17, on which muscle do you operate first? The oblique muscles are more difficult to identify and isolate on the muscle hook than the recti order red viagra erectile dysfunction protocol book scam. Strabismus surgery creates swelling of Tenon’s capsule and bleeding, which can obscure the view and make identification of the oblique muscles difficult. Therefore, it is preferable to operate on the oblique muscles first, when Tenon’s capsule and the tissues surrounding the oblique muscles are the least swollen and distorted. There should be no difficulty in isolating the correct rectus muscle, even in the presence of significant bleeding and swelling of Tenon’s capsule associated with oblique muscle surgery. A spatulated needle, which has cutting surfaces on the side, decreases the risk of perforating the globe. Various techniques of placing and tying scleral sutures allow the muscle to be moved forward or backward during the immediate postoperative period. If a patient has an immediate overcorrection or undercorrection, the muscle can be moved to improve the alignment. Some surgeons do not perform adjustable suture surgery, citing the fact that the correction seen immediately after strabismus surgery is variable and may not be indicative of the long-term result. Others use adjustable sutures in cases in which the results of strabismus surgery are difficult to predict, such as reoperations and restrictive or paralytic strabismus. A transposition procedure usually involves the placement of either part or the entire tendon of the adjacent recti muscles to the insertion of the palsied or underacting muscle. For instance, in double-elevator palsy the tendon of the lateral and medial recti may be sutured to the nasal and temporal borders of the superior rectus insertion. A transposition procedure is the procedure of choice when the function of one or more recti muscles is severely limited, as with third-nerve, sixth-nerve, or double-elevator palsy. In cases of oblique muscle overaction, the appropriate oblique muscle should be weakened. Weakening of the inferior oblique muscles corrects a V pattern, whereas weakening of the superior oblique muscles corrects an A pattern (Fig. In patients with no oblique muscle dysfunction, the horizontal recti are supraplaced or infraplaced. The medial recti are displaced toward the point of the A or V pattern, whereas the lateral recti are moved in the opposite direction. For example, to treat a V pattern esotropia without oblique muscle overaction, the medial recti are recessed and infraplaced (moved inferiorly) by half of the tendon width. In Brown’s syndrome, a congenitally short or tight superior oblique tendon creates a mechanical restriction of elevation when the eye is in adduction, as confirmed at surgery with forced duction testing. Brown’s syndrome is treated surgically by superior oblique tenotomy, recession, or a tendon expander. Hypertropia in primary gaze or abnormal head position (face-turn or chin-up position). In strabismus surgery in patients with Duane’s syndrome, is it better to recess or resect? Infection may take the form of cellulitis, subconjunctival abscess, or endophthalmitis. Cellulitis is most common with an estimated incidence between 1 case in 1000 and 1 case in 1900 surgeries. Suspected cellulitis requires prompt treatment with systemic antibiotics as well as careful examination to make certain that the patient does not develop endophthalmitis. What are the signs and symptoms of endophthalmitis after pediatric strabismus surgery? The signs of endophthalmitis typically appear 1–4 days after surgery and include lethargy, asymmetric eye redness, eyelid swelling, and fever. Patients who develop endophthalmitis experience an increase in eyelid swelling and redness during the postoperative period rather than a decrease, as expected during a normal postoperative course. What should you do if you suspect that you perforated the globe when passing the scleral suture? If a scleral perforation is suspected, indirect ophthalmoscopy should be performed in the operating room at completion of the strabismus surgery. If a retinal perforation is seen on ophthalmoscopy, retinal consultation or repeat examinations with the indirect ophthalmoscope are indicated. Whereas some surgeons advocate treatment with cryotherapy or indirect laser, others simply observe the patient. The incidence of retinal detachment after scleral perforation is believed to be low. At the same time, cryotherapy may increase the incidence of retinal detachment by stimulating vitreous changes. In patients predisposed to retinal detachment (for example, high myopes), however, serious consideration should be given to treatment of a retinal perforation at the time of strabismus surgery. Some strabismus surgeons believe that scleral perforation increases the risk of endophthalmitis and therefore recommend sub-Tenon’s injection of prophylactic antibiotics if the globe is perforated. While operating on a rectus muscle it is possible to mistakenly engage only the capsule on the suture. After the muscle is reattached to the eye, it may slip back within its capsule, which results in further weakening of the muscle and consecutive deviation. For instance, if a slipped muscle occurred in recessing a medial rectus muscle for esotropia, exotropia and limited adduction will develop in the involved eye over time. In placing the suture through the muscle, make locking bites on either end of the muscle. Locking bites should be made by placing the suture through the muscle perpendicular to its insertion, engaging the tendon, rather than tangentially. If an accidental opening is made in the portion of Tenon’s capsule that separates the orbital fat from sclera, orbital fat may be pressed through the opening and adhere to the globe. The orbital fat comes forward around the equator of the globe to within 10 mm of the limbus. They penetrate the sclera at the muscle’s insertion site, contributing significantly to the blood supply of the anterior segment. In standard strabismus surgery the anterior ciliary vessels are cut when the rectus muscle is disinserted. It is also possible to dissect the anterior ciliary vessels from the rectus muscle and preserve them. Surgery to preserve the anterior ciliary vessels is performed only when the risk of anterior segment ischemia is high, such as in older patients with cardiovascular disease or patients with a history of previous rectus muscle surgery. The eyes oscillate repetitively and typically symmetrically as well, in a to-and-fro horizontal direction with a fast jerk in a consistent direction in respect to orbital coordinates. Often the nystagmus is exclusively vertical, other cases are purely torsional, and occasional cases are a mixture of all three. As the head of a drowsy student slowly falls to one side, often a head jerk brings the head back to an upright position. Oscillopsia occurs when the efferent copied nerve impulses do not match the motor nerve impulses or if there is a nonadaptive change.