Ayesha Hasan, MD, FACC
Keeping in view the recent advances pain treatment center london ky aleve 500mg overnight delivery, a new chapter pain treatment center west hartford ct aleve 500mg without prescription, Current Topics in Gynecology has been added dealing with stem cells and therapies joint pain treatment natural buy aleve no prescription. Information regarding different areas of examination situation (theory pain medication for dogs at petsmart cheap aleve 500 mg with visa, viva-voce, clinical and practical examination including video-clips) have been provided through our electronic sources ( Vij (Group Chairman), Mr Ankit Vij (Managing Director) and Dr Sakshi Arora (Chief Development Editor) along with entire team of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, for their professional guidance, suggestion and support in bringing out the enlarged and revised reprint of sixth edition. I do hope this comprehensive textbook of Duttas Gynaecology will continue to be an essential educational resource to the readers as ever. Initially, I was hesitant to proceed with the stupendous task but considering the fact that a compact, comprehensive and practical-oriented fundamental book in gynecology is not available to the undergraduates, I have decided to comply with their request. Extensive diagrams, photographs, and flow-charts (schemes) have been depicted throughout the text to give clarity of the subject. Due attention has been paid to project the fundamental principles and practice of gynecology. But for that, indications, limitations, and principles of techniques of operations have received adequate consideration. The book is thus made invaluable not only to the medical students but also the practising physicians and students of nursing. The author expressed much pleasure all the time to the House Surgeons, Internees and students of Nilratan Sircar Medical College, Calcutta, for the help they have rendered in preparation of the final drafts of the manuscripts, check up of the proofs and compiling the index. Their help is invaluable and unforgettable and without which the book could never have been published. The author wishes to thank Mr Biren Das for his exhaustive number of drawings and flow-charts which enrich the lucidity of the book. The author also thanks Mr Ranjit Sen for preparation of photographs (black and white) depicted throughout the text. In preparing the textbook, the author has utilized the knowledge of number of stalwarts in his profession and consulted many books and publications. The author wishes to express his appreciation and gratitude to all of them including the related authors and publishers. The author still confesses that as a teacher he has learnt a lot from the students and more so while writing this book and as such he could not think to dedicate the book to anyone else than the students of gynecology, past and present. The lower the vulva includes mons veneris, labia majora, portion of the labia minora fuses across the midline to labia minora, clitoris, vestibule and conventionally form a fold of skin known as fourchette. It is, therefore, bounded anteriorly by and the vaginal orifice is the fossa navicularis. It is homologous to the ventral It is the pad of subcutaneous adipose connective tissue aspect of the penis. The of skin and subcutaneous tissue, which form the labia glans is covered by squamous epithelium and is richly majora. The vessels of the clitoris are to form the posterior commissure in front of the anus. Clitoris is an analogue labia majora are covered with squamous epithelium to the penis in the male, but it differs basically in and contain sebaceous glands, sweat glands and hair being entirely separate from the urethra. Beneath the skin, there are dense connective to the undersurface of the symphysis pubis by the tissue and adipose tissue. The labia majora are homologous with the scrotum in the Vestibule is a triangular space bounded anteriorly by male. Labia minora are two thick folds of skin, devoid of fat, on either side just within the labia majora. The paraurethral ducts open either on the virgins and nulliparae, the opening is closed by posterior wall of the urethral orifice or directly into the labia minora but in parous, it may be exposed. The vaginal orifice lies in the posterior end of the hymen is usually ruptured at the consummation of the vestibule and is of varying size and shape. During childbirth, the hymen is extremely lacerated and is later represented by cicatrized nodules of varying sizes, called the carunculae myrtiformes. During sexual excitement, it secretes abundant alkaline mucus which helps in lubrication. Anterosuperior part is supplied by the of the penis and corpus spongiosum in the male. It has got enough power of distensibility as communicating the uterine cavity with the exterior at evident during childbirth. It constitutes the excretory channel for the Walls: Vagina has got an anterior, a posterior, uterine secretion and menstrual blood. The anterior and posterior of copulation and forms the birth canal of parturition. The upper with the levator ani and the lower-third is related with end of vaginal is above the pelvic floor. The upper one-third is related with base of the bladder and the lower two-thirds are with the urethra, the Epithelium lower half of which is firmly embedded with its wall the vaginal epithelium is under the action of sex. Thereafter, up to prepuberty and the middle-third with the anterior rectal wall separated in postmenopause, the epithelium becomes thin, by rectovaginal septum, and the lower-third is separated consisting of few layers only. From puberty till menopause, the vaginal epi Lateral walls thelium is stratified squamous and devoid of any the upper one-third is related with the pelvic cellular gland. The ureter and the uterine artery lie approximately 2 cm intermediate and superficial cells contain glycogen fig. These cells become continuous with those covering the vaginal portion of the cervix and extend up to the squamocolumnar junction at the external os. The superficial cells exfoliate constantly and more so in inflammatory or neoplastic condition. When the epithelium is exposed to the dry external atmosphere, keratinization occurs. Secretion: the vaginal secretion is very small in amount sufficient to make the surface moist. Normally, it may be little excess in mid-menstrual or just prior to menstruation, during pregnancy and during sexual excitement. The secretion is mainly derived from the glands of the cervix, uterus, transudation of the fig. Conversion of glycogen in the exfoliated squamous cells to lactic acid by the Doderleins bacilli is dependent on estrogen. As such, the pH is more towards acidic during child bearing period and ranges between 4 and 5. The pH is highest in upper vagina because of contaminated cervical secretion (alkaline). The vaginal secretion consists of tissue fluid, epithelial debris, some leukocytes (never contains more than an occasional pus cell), electrolytes, proteins, and lactic acid (in a concentration of 0. Apart from Doderleins bacilli, it contains many a pathogenic organism including Cl. It appears again at puberty 8 cm long, 5 cm wide at the fundus and its walls are and disappears after menopause. This acid pH prevents Body or corpus: the body is further divided into growth of the other pathogenic organisms. The body properly is triangular and Blood Supply lies between the openings of the tubes and the isthmus. The with the uterine, (3) middle rectal, and (4) internal uterine tube, round ligament, and ligament of the pudendal.
The fistula y Often pain treatment center dover de order aleve cheap, the bladder mucosa may be visibly prolapsed margin is fixed to the bone kearney pain treatment center cheap aleve 500mg on line. Patient profile: In the developing countries pain diagnostic treatment center sacramento ca order aleve 500mg without prescription, obstetrical fistula being common chronic back pain treatment guidelines purchase aleve without prescription, the patients are Associated clinical features that may be present usually young primiparous with history of difficult in cases of such fistula are: labor or instrumental delivery in recent past. In others, y Secondary amenorrhea of hypothalamic origin it is related with the relevant events. But, sometimes correlation with the related events mentioned in confusion arises in a case of tiny fistula for which the etiology. The confused clinical conditions are stress inconti Leakage of urine following surgical injury occurs nence, ureterovaginal and urethrovaginal fistula. When the methylene blue solution is introduced into the y There is associated pruritus vulvae. At times, there may be varying degrees of vaginal Procedure of Three Swab Test. The methylene blue is instilled into the when the vagina becomes ballooned up by air because bladder through a rubber catheter and the patient is of negative suction. She is then asked 420 TexTbook of GynecoloGy inVesTigaTions imaging studies intravenous urography: for the diagnosis of ureterovaginal fstula. Where to lie down and the swabs are removed for inspection involvement of ureter or intestines are there. Upper most swab soaked Ureterovaginal fstula examination under anesthesia is helpful for with urine but unstained identifcation of small fstulae. It is difficult to collect urine for x Care to be taken to avoid injury to the bladder during culture and sensitivity. Unobstructed outflow tract helps speculum will not serve the purpose because epithelialization, provided the tissue damage is of contamination. Other-wise treatment failure may cause further the ideal time of surgery is after 3 months following devastation. By this time, the general condition improves and local tissues are likely to be free from infection. Either the abdominal or vaginal route may y Urethral involvement is assessed by introducing be approached according to the choice and expertize a metal catheter through external urethral meatus of the surgeon. Preoperative Preparations y Excision (minimal) of the scar tissue round the margins. To introduce ureteric catheter prior to repair Second layer is with interrupted sutures using the to prevent inclusion of the ureteric opening in suture. Saucerization is the closure of a small fistula using interrupted stitches without dissection of bladder special posTopeRaTiVe caRe from the vagina. Principle of this operation is to produce partial x the patient is advised to pass urine frequently colpocleisis (obliteration of the vagina around the (say 1 hourly) following removal of catheter. Principal steps y Vaginal mucosa is dissected off the bladder wall advice during Discharge around the fistula site. The fistula may become 424 TexTbook of GynecoloGy smaller when the second attempt may be successful. Principles in the Management of In cases of repeated failures, before declaring Gynecological vvF the case as irreparable, it is preferable to have a Detected during operation: To repair immediately second opinion or to consult an urologic surgeon. Ureter Ureters Ureters are Residual fistula left behind following repair involvement are draining draining into of vesicourethrovaginal fistula. A sound or a metal catheter passed defect (urethra through the external urethral meatus when comes out separated from through the communicating urethrovaginal opening the bladder) confirms the diagnosis. This approach is and in 10 percent cases there is post fistula stress also used when ureteroneocystostomy is done or incontinence. Ureteric injury through rare has got considerable nature of Ureteral Injury morbidity. Because of close anatomical association between x Injury by staplers during Laparoscopic surgery. Risk of injury is more where pelvic anatomy is About 75 percent of ureteral injury result from distorted due to presence of any pelvic pathology. Diagnosis:Signs and symptoms are subtle and often x Where it traverses through the musculature of overlooked. The patient has got urge to pass urine and can x Placement of ureteral catheters (preoperative or pass urine normally. This may lead to blind clamping urine from the ureteric orifce of the affected side. The tract of ureterovaginal fstula any important structure at risk of inadvertent is also outlined. Hydronephrosis and retroperitoneal urinomas x To avoid blind clamping of blood vessels. When the ureter is ligated or kinked, gradually increasing ureteric dilatation will be noticed, instead Principles of Ureteric Repair of dye leakage. Ureteral ligation: Deligation immediately DeFiniTion:Abnormal communication between the assessment of viability by blood flow and ureteral rectum and vagina with involuntary escape of flatus peristalsis. Ureteral stenting may be needed if any and/or feces into the vagina is called rectovaginal doubt. Ureteric implantation into the bladder (uretero neocystostomy) must be done without any tension. High mobilization of bladder is needed and bladder dome is sutured to the psoas muscle on that side (psoas hitch). To prevent vesicoureteric reflux, ureter is implanted through submucosal tunnel in the posterior wall of the bladder. Bladder flap procedure (modified Boari-Ocker blad) is an alternative when the ureter is short or the injury is at the level of pelvic brim. The flap is rolled into a tube and the ureter is reimplanted in the submucosal tunnel without tension. It was of moderate size so as to pass a Thermal injury: Depending upon the severity it metal probe through the vagina and it is clearly seen to may need resection and management according to come out through the anus transection. Instrumental injury inficted during destructive may be conducted to facilitate clinical diagnosis operation. Trauma inflicted inadvertently and remains to confirm the site of intestinal fistula. Consciousness about the possible injury of the rectum in gynecologic surgery mentioned and.
Hypersensitivity vasculitis systemic knee pain treatment urdu cheap aleve master card, involving lymphoid organs and other tissues Summary Statement 26: Many drugs pain treatment diverticulitis discount aleve american express, hematopoietic throughout the body pain medication for dogs advil 250mg aleve overnight delivery. Sensitized T cells produce a wide array growth factors groin pain treatment exercises purchase genuine aleve line, cytokines, and interferons are associated with of proinflammatory cytokines that can ultimately lead to vasculitis of skin and visceral organs. It has been suggested there is a marked clinicopatholog the interferons are suspected of causing widespread vascular ical similarity between some late-onset drug reactions and inflammation of skin and visceral organs. A Henoch-Schonlein the drugs involved, the most universally accepted offenders syndrome with cutaneous vasculitis and glomerulonephritis are topical formulations of bacitracin, neomycin, glucocorti 232 may be induced by carbidopa/levodopa. Drug Rash With Eosinophilia and Systemic hyde, ethylenediamine, lanolin, and thimerosal. Pho duced, multiorgan inflammatory response that may be life toallergic dermatitis morphologically resembles allergic con threatening. First described in conjunction with anticonvul tact dermatitis and is caused by such drugs as sulfonamides, sant drug use, it has since been ascribed to a variety of drugs. Phototoxic, non syndrome is mainly associated with aromatic anticonvulsant allergic reactions (eg, erythrosine) are histologically similar drugs and is related to an inherited deficiency of epoxide to photoallergic inflammatory responses. First de nephritis, and leukocytosis with atypical lymphocytes and scribed in conjunction with anticonvulsant drug use, it has eosinophils may be part of the syndrome. These multiorgan reactions ing this syndrome have varied in the literature, with various may be induced by phenytoin, carbamazepine, or phenobar terms preferred by some authors, including phenytoin hyper bital, and cross-reactivity may occur among all aromatic sensitivity syndrome, drug hypersensitivity syndrome, drug anticonvulsants that produce toxic arene oxide metabolites induced hypersensitivity syndrome, and drug-induced de Treatment involves removing the offending agent, and layed multiorgan hypersensitivity syndrome. Relapses have larged lymph nodes at least 2 sites, involvement of at least 1 occurred after tapering of corticosteroids. Pulmonary Drug Hypersensitivity other drug allergic reactions in that the reaction develops Summary Statement 29: Pulmonary manifestations of al later, usually 2 to 8 weeks after therapy is started; symptoms lergic drug reactions include anaphylaxis, lupuslike reactions, may worsen after the drug therapy is discontinued; and symp alveolar or interstitial pneumonitis, noncardiogenic pulmo toms may persist for weeks or even months after the drug nary edema, and granulomatous vasculitis (ie, Churg-Strauss therapy has been discontinued. Biopsy-proven eosinophilic pneumonia may occur intermediates may mediate the abnormal lymphocyte re after use of sulfonamides, penicillin, and para-aminosalicylic sponses. Patchy pneumonitis, pleuritis, and pleural effusion may valproic acid or gabapentin is rare. It appears fibrotic changes are caused by certain cytotoxic drugs, such to result from an inherited deficiency of epoxide hydrolase, as bisulphan, cyclophosphamide, and bleomycin. Acute pul an enzyme required for the metabolism of arene oxide inter monary reactions produced by other fibrogenic drugs, such as mediates produced during hepatic metabolism of aromatic methotrexate, procarbazine, and melphalan, are similar to anticonvulsant drugs. It is characterized by fever, a maculo those of nitrofurantoin pneumonitis and therefore appear to papular rash, and generalized lymphadenopathy, resembling be mediated by hypersensitivity mechanisms. Drugs most commonly associated with cu done, propoxyphene, or hydrochlorothiazide. Early treat hepatitis occurs after sensitization to para-aminosalicylic ment of erythema multiforme minor with systemic cortico acid, sulfonamides, and phenothiazines. Herbal agents, such as black cohosh and dai whereas drugs in the moderate risk category included quin saiko-to, may trigger autoimmune hepatitis. Whether these olones, carbamazepine, phenytoin, valproic acid, and glu drugs or herbs unmask or induce autoimmune hepatitis or 264 cocorticosteroids. Rarely, vancomycin may induce several cause drug-induced hepatitis with accompanying autoim forms of bullous skin disease. There are no generally available blistering disorder characterized by IgA deposition beneath diagnostic methods to distinguish between hepatic immuno the basement membrane. Biopsy with direct immunofluores allergic and toxic reactions due to drugs, such as itraconazole. As described Summary Statement 34: Erythema multiforme minor is a under the Physical Examination section (section V), target cell-mediated hypersensitivity reaction associated with vi and bullous lesions primarily involving the extremities and ruses, other infectious agents, and drugs. Liver, kidney, and lungs may be involved singly or in Summary Statement 36: Use of systemic corticosteroids for combination. As soon as the diagnosis is established, use of treatment of erythema multiforme major or Stevens-Johnson the suspected drug should be stopped immediately. Toxic Epidermal Necrolysis with high-dose intravenous immunoglobulin is controversial. It is manifested by pleomorphic widespread areas of confluent erythema followed by epider cutaneous eruptions; at times bullous and target lesions are mal necrosis and detachment with severe mucosal involve also characteristic. Significant loss of skin equivalent to a third-degree minor may develop in the radiation field of oncologic patients burn occurs. Glucocorticosteroids are contraindicated in this receiving phenytoin for prophylaxis of seizures caused by condition, which must be managed in a burn unit. The latter are caused by such drugs as dence of an antibody-mediated basis for this reaction. In vitro tests for toxic metabolites have confirmed a valently to a T-cell receptor, which may lead to an immune lack of cross-reactivity between cefaclor and other cephalo response via interaction with a major histocompatibility com sporins. In this scenario, no sensitization is required tions to cefaclor and cefprozil may not need to avoid other because there is direct stimulation of memory and effector T cells, analogous to the concept of superantigens. Immunologic Nephropathy classifying drug reactions is by predilection for various tissue Summary Statement 41: Immunologically mediated ne and organ systems. Cutaneous drug reactivity represents the phropathies may present as interstitial nephritis (such as with most common form of restricted tissue responsiveness to methicillin) or as membranous glomerulonephritis (eg, gold, drugs. The pulmonary system is also recognized as a favorite penicillamine, and allopurinol). Other individ the major example of drug-induced immunologic ne ual tissue responses to drugs include cytotoxic effects on phropathy is an interstitial nephritis induced by large doses of blood components and hypersensitivity sequelae in liver, benzylpenicillin, methicillin, or sulfonamides. Some drugs, however, induce tion to symptoms of tubular dysfunction, these patients dem heterogeneous immune responses and tissue manifestations. Allergic reactions to peptides and antibiotic are less likely to sensitize compared with high-dose proteins are most often mediated by either IgE antibodies or prolonged parenteral administration of the same drug. Such reactions may also be quent repetitive courses of therapy are also more likely to mixed. In specific situations, the process may culminate in a sensitize, which accounts for the high prevalence of sensiti multisystem, vasculitic disease of small and medium blood zation in patients with cystic fibrosis. Although immune responses induced by carbohy Host factors and concurrent medical illnesses are signifi drate agents are infrequent, anaphylaxis has been described cant risk factors. In the case of penicillin, allergic reactions after topical exposure to carboxymethycellulose. The parent compound itself is not immunogenic to have a 35% higher incidence of adverse cutaneous reac tions to drugs than men. Metabolism of drugs by women developing reactions to radiocontrast media was 20 fold greater than for men. In addition, patients with certain genetic A subset of patients shows a marked tendency to react to clinically unrelated drugs, especially antibiotics. Com and structural complexity are often associated with increased pared with monosensitive patients, many of these patients immunogenicity, at least as far as humoral-mediated hyper show evidence of circulating histamine-releasing factors, as assessed by autologous serum skin tests. Large-molecular-weight agents, such as to the underlying immunologic abnormalities or the fact that proteins and some polysaccharides, may be immunogenic and such patients are exposed more often to drugs. On the other hand, specific structural moieties in non presence of an atopic diathesis (allergic rhinitis, allergic protein medicinal chemicals are often critical determinants in asthma, and/or atopic dermatitis) predisposes patients to a inducing drug hypersensitivity. How these particular struc higher rate of allergic reactions to proteins (eg, latex) but not tures (eg, lactam rings of penicillins and cephalosporins) to low-molecular-weight agents. Cu (C) taneous manifestations are the most common presentation for the first question facing the physician in the evaluation of drug allergic reactions. Numerous cutaneous diagnosis of unpredictable (type B) drug reactions is based on reaction patterns have been reported in drug allergy, includ a number of clinical criteria: ing exanthems, urticaria, angioedema, acne, bullous erup 1) the symptoms and physical findings are compatible with tions, fixed drug eruptions, erythema multiforme, lupus ery an unpredictable (type B) drug reaction; thematosus, photosensitivity, psoriasis, purpura, vasculitis, 2) There is a temporal relationship between administration of pruritus, and life-threatening cutaneous reactions, such as the drug and an adverse event. Patients may develop drug Stevens-Johnson syndrome, toxic epidermal necrolysis, exfo reactions after discontinuation of use of the drug. Drug-induced exanthems typically involve the trunk place either in utero or via breast milk.
Biosafety practices require laboratory access to be limited when work is in progress pain evaluation and treatment center tulsa ok aleve 250 mg on line. Biosecurity practices ensure that access to the laboratory facility and biological materials are limited and controlled as necessary pain treatment with laser order aleve uk. An inventory or material management process for control and tracking of biological stocks or other sensitive materials is also a component of both programs pain treatment center colorado springs discount aleve 500mg with mastercard. For biosafety swedish edmonds pain treatment center order aleve 250mg line, the shipment of infectious biological materials must adhere to safe packaging, containment and appropriate transport procedures, while biosecurity ensures that transfers are controlled, tracked and Principles of Laboratory Biosecurity 105 documented commensurate with the potential risks. Both programs must engage laboratory personnel in the development of practices and procedures that fulfll the biosafety and biosecurity program objectives but that do not hinder research or clinical/diagnostic activities. The success of both of these programs hinges on a laboratory culture that understands and accepts the rationale for biosafety and biosecurity programs and the corresponding management oversight. In some cases, biosecurity practices may confict with biosafety practices, requiring personnel and management to devise policies that accommodate both sets of objectives. Standard biosafety practice requires that signage be posted on laboratory doors to alert people to the hazards that may be present within the laboratory. The biohazard sign normally includes the name of the agent, specifc hazards associated with the use or handling of the agent and contact information for the investigator. Therefore, biosafety and biosecurity considerations must be balanced and proportional to the identifed risks when developing institutional policies. Designing a biosecurity program that does not jeopardize laboratory operations or interfere with the conduct of research requires a familiarity with microbiology and the materials that require protection. Protecting pathogens and other sensitive biological materials while preserving the free exchange of research materials and information may present signifcant institutional challenges. Therefore, a combination or tiered approach to protecting biological materials, commensurate with the identifed risks, often provides the best resolution to conficts that may arise. However, in the absence of legal requirements for a biosecurity program, the health and safety of laboratory personnel and the surrounding environment should take precedence over biosecurity concerns. Risk Management Methodology A risk management methodology can be used to identify the need for a biosecurity program. A risk management approach to laboratory biosecurity 1) establishes which, if any, agents require biosecurity measures to prevent loss, theft, diversion, or intentional misuse, and 2) ensures that the protective measures provided, and the costs associated with that protection, are proportional to the risk. The need for a biosecurity program should be based on the possible impact of the theft, loss, diversion, or intentional misuse of the materials, recognizing that different agents and toxins will pose different levels of risk. Biosecurity policies and procedures should not seek to protect against every conceivable risk. The risks need to be identifed, prioritized and resources allocated based on that prioritization. Risk management methodology takes into consideration available institutional resources and the risk tolerance of the institution. Development of a biosecurity program should be a collaborative process involving all stakeholders. The stakeholders include but are not limited to: senior management; scientifc staff; human resource offcials; information technology staff; and safety, security and engineering offcials. The involvement of organizations and/or personnel responsible for a facilitys overall security is critical because many potential biosecurity measures may already be in place as part of an existing safety or security program. This coordinated approach is critical in ensuring that the biosecurity program provides reasonable, timely and cost-effective solutions addressing the identifed security risks without unduly affecting the scientifc or business enterprise or provision of clinical and/or diagnostic services. The need for a biosecurity program should refect sound risk management practices based on a site-specifc risk assessment. A biosecurity risk assessment should analyze the probability and consequences of loss, theft and potential misuse of pathogens and toxins. Example Guidance: A Biosecurity Risk Assessment and Management Process Different models exist regarding biosecurity risk assessment. Most models share common components such as asset identifcation, threat, vulnerability and mitigation. What follows is one example of how a biosecurity risk assessment may be conducted. In this example, the entire risk assessment and risk management process may be divided into fve main steps, each of which can be further subdivided: 1) identify and prioritize biologicals and/or toxins; 2) identify and prioritize the adversary/threat to biologicals and/or toxins; 3) analyze the risk of specifc security scenarios; 4) design and develop an overall risk management program; and 5) regularly evaluate the institutions risk posture and protection objectives. Step 1: Identify and Prioritize Biological Materials Identify the biological materials that exist at the institution, form of the material, location and quantities, including non-replicating materials. Principles of Laboratory Biosecurity 107 At this point, an institution may fnd that none of its biologic materials merit the development and implementation of a separate biosecurity program or the existing security at the facility is adequate. Step 2: Identify and Prioritize the Threat to Biological Materials Identify the types of "Insiders" who may pose a threat to the biologic materials at the institution. Step 3: Analyze the Risk of Specifc Security Scenarios Develop a list of possible biosecurity scenarios, or undesired events that could occur at the institution (each scenario is a combination of an agent, an adversary, and an action). Step 4: Develop an Overall Risk Management Program Management commits to oversight, implementation, training and maintenance of the biosecurity program. Elements of a Biosecurity Program Many facilities may determine that existing safety and security programs provide adequate mitigation for the security concerns identifed through biosecurity risk assessment. This section offers examples and suggestions for components of a biosecurity program should the risk assessment reveal that further protections may be warranted. Program components should be site-specifc and based upon organizational threat/vulnerability assessment and as determined appropriate by facility management. Elements discussed below should be implemented, as needed, based upon the risk assessment process. They should not be construed as "minimum requirements" or "minimum standards" for a biosecurity program. Program Management If a biosecurity plan is implemented, institutional management must support the biosecurity program. Appropriate authority must be delegated for implementation and the necessary resources provided to assure program goals are being met. An organizational structure for the biosecurity program that clearly defnes the chain of command, roles, and responsibilities should be distributed to the staff. Program management should ensure that biosecurity plans are created, exercised, and revised as needed. The biosecurity program should be integrated into relevant institutional policies and plans. An evaluation of the physical security measures should include a thorough review of the building and premises, the laboratories, and biological material storage areas. Many requirements for a biosecurity plan may already exist in a facilitys overall security plan. Access should be limited to authorized and designated employees based on the need to enter sensitive areas. Methods for limiting access could be as simple as locking doors or having a card key system in place. Evaluations of the levels of access should consider all facets of the laboratorys operations and programs. The need for entry by visitors, laboratory workers, management offcials, students, cleaning/ maintenance staff, and emergency response personnel should be considered. Personnel Management Personnel management includes identifying the roles and responsibilities for employees who handle, use, store and transport dangerous pathogens and/or other important assets. The effectiveness of a biosecurity program against identifed threats depends, frst and foremost, on the integrity of those individuals who have access to pathogens, toxins, sensitive information and/or other assets. Employee screening policies and procedures are used to help evaluate these individuals. Policies should be developed for personnel and visitor identifcation, visitor management, access procedures, and reporting of security incidents. Inventory and Accountability Material accountability procedures should be established to track the inventory, storage, use, transfer and destruction of dangerous biological materials and assets when no longer needed.
Male and female pelves (singular sciatica pain treatment exercise purchase aleve line, pelvis) differ considerably in size and shape but share the same basic structures pain treatment hemorrhoids order aleve master card. Some of the differences are attributable to the function of the female pelvis during childbearing pain treatment for uti buy aleve visa. The female pelvis not only supports the enlarged uterus as the fetus matures but also provides a large opening to allow the infant to pass through during birth pain medication for dogs human buy aleve 250mg overnight delivery. Even so, female and male pelves are divided into the (10) ilium, (11) ischium, and (12) pubis. These three bones are fused together in the adult to form a single bone called the innominate (hip) bone. The bladder is located behind the (13) symphysis pubis; the rectum is in the curve of the (14) sacrum and (15) coccyx. In the female, the uterus, fallopian tubes, ovaries, and vagina are located between the bladder and the rectum. The lower limbs support the complete weight of the erect body and are subjected to exceptional stresses, especially in running or jumping. To accommodate for these types of forces, the lower limb bones are stronger and thicker than comparable bones of the upper limbs. The difference between the upper and lower limb bones is that the lighter bones of the upper limbs are adapted for mobility and flexibility; the massive bones of the lower limbs are specialized for stability and weight bearing. The seven (19) tarsals (ankle bones) resemble metacarpals (wrist bones) in structure. Lastly, the bones of the foot include the (20) metatarsals, which consists of five small long bones numbered 1 to 5 beginning with the great toe on the medial side of the foot, and the much smaller (21) phalanges (toes). Joints or Articulations To allow for body movements, bones must have points where they meet (articulate). Some are freely movable (diarthroses), others are only slightly movable (amphiarthroses), and the remaining are totally immovable (synarthroses). The ends of the bones that comprise these joints are encased in a sleevelike extension of the periosteum called the joint capsule. In most synovial joints, the capsule is strengthened by ligaments that lash the bones together, providing additional strength to the joint capsule. The ends of each of the bones are covered with a smooth layer of cartilage that serves as a cushion. Medical Word Elements this section introduces combining forms, suffixes, and prefixes related to the musculoskeletal system. In todays medical practice, however, the orthopedist treats musculoskeletal disorders and associated structures in persons of all ages. Repeated motion, disease, trauma, and aging affect joints as well as muscles and tendons. Overall, disorders of the musculoskele tal system are more likely to be caused by injury than disease. For diagnosis, treatment, and management of musculoskeletal disorders, the medical services of a specialist may be warranted. Orthopedics is the branch of medicine concerned with the prevention, diagnosis, care, and treatment of musculoskeletal disorders. These professionals employ medical, physical, and surgical methods to restore func tion that has been lost as a result of musculoskeletal injury or disease. Another physician who specializes in treating joint disease is the rheumatologist. Bone Disorders Disorders involving the bones include fractures, infections, osteoporosis, and spinal curva tures. An (2) open, or compound, fracture involves a broken bone and an external wound that leads to the site of fracture. A (3) complicated fracture is one in which a broken bone has injured some internal organ, such as when a broken rib pierces a lung. An (5) impacted fracture occurs when the bone is broken and one end is wedged into the interior of the other bone. An (6) incom plete fracture is when the line of fracture does not include the whole bone. A (7) greenstick fracture occurs when one side of a long bone is broken and the other side is bent. It occurs in children because their bones contain more collagen than adult bones and tend to splinter rather than break completely. A (8) Colles fracture, a break at the lower end of the radius, occurs just above the wrist. It causes displacement of the hand and usually occurs as a result of flexing a hand to cushion a fall. A hairline fracture is a minor fracture in which all portions of the bone are in perfect alignment. The fracture is seen on radiographic examination as a very thin hairline between the two segments but not extending entirely through the bone. Pathological (spontaneous) fractures are usually caused by a disease process such as a neoplasm or osteoporosis. Some fractures need to be immobilized to ensure that bones unite soundly in a suitable position. In most cases this is achieved with bandages, casts, traction, or a fixation device. Certain fractures, particularly those with bone fragments, require surgery to reposition and fix bones securely, so that surrounding tissues heal. In addition to promoting healing, immobilization prevents further injury and reduces pain. For instance, the long bones of the arms usually mend twice as fast as those of the legs. Age also plays an impor tant role in bone fracture healing rate; older patients require more time for healing. In addi tion, an adequate blood supply to the injured area and the nutritive state of the individual are crucial to the healing process. The disease usually begins with local trauma to the bone causing a blood clot (hematoma). Bacteria from an acute infec tion in another area of the body find their way to the injured bone and establish the infection. Most bone infections are more difficult to effectively treat than soft tissue infections. With early treatment, prognosis for acute osteomyelitis is good; prognosis for the chronic form of the disease is poor. Paget disease, also known as osteitis deformans, is a chronic inflammation of bones, resulting in thickening and softening of bones. It can occur in any bone but most commonly affects the long bones of the legs, the lower spine, the pelvis, and the skull. Although a variety of causes have been proposed, a slow virus (not yet isolated) is currently thought to be the most likely cause. Osteoporosis Osteoporosis is a common metabolic bone disorder in the elderly, particularly in post menopausal women and especially women older than age 60. Among the many causes of osteoporosis are disturbances of protein metab olism, protein deficiency, disuse of bones due to prolonged periods of immobilization, estro gen deficiencies associated with menopause, a diet lacking vitamins or calcium, and long-term administration of high doses of corticosteroids. Patients with osteoporosis commonly complain of bone pain, typically in the back, which may be caused by repeated microscopic fractures. Deformity associated with osteoporosis is usually the result of pathological fractures. Spinal Curvatures Any persistent, abnormal deviation of the vertebral column from its normal position may cause a spinal curvature. Scoliosis, or C-shaped curva ture of the spine, may be congenital, caused by chronic poor posture during childhood while the vertebrae are still growing, or the result of one leg being longer than the other. Aleve 500 mg sale. Bone Cancer Second Edition Primary Bone Cancers and Bone Metastases. |
