Padraig S. J. Malone, MCh, FRCSI, FRCS, FEAPU
Decompressive craniectomy in 14 children with severe head injury: clinical results with long-term follow-up and review of the literature muscle relaxant jaw clenching cheap voveran online mastercard. Aggressive physiologic monitoring of pediatric head trauma patients with elevated intracranial pressure muscle relaxant constipation order generic voveran on-line. Efficacy of barbiturates in the treatment of resistant intracranial hypertension in severely headinjured children spasms headache discount voveran generic. Measuring the burden of secondary insults in head-injured patients during intensive care spasms pregnancy after tubal ligation discount voveran 50mg otc. Treatment of acute traumatic brain injury in children with moderate 290 hypothermia improves intracranial hypertension. In 2012, according to the National Trauma Database Registry, 12% of pediatric trauma patients suffered injury to the chest. Although chest trauma is less common in children, it remains an area of concern because it is associated with increased mortality. In fact, chest trauma accounts for up to 14% of trauma-related deaths in the pediatric population, making it second only to blunt head injuries. However, in cases where there is multi-system involvement concomitant with thoracic injuries, such as abdominal or brain injury, mortality drastically increases to nearly 40% to 70%. This makes motor vehicle crashes the number one mechanism of traumatic chest injury in the pediatric population overall. Children are either passengers in traffic accidents or pedestrians struck by motor vehicles. Other less frequent causes include child abuse, high-risk sporting activities, violence, or suicide. It occurs 6 times less frequently than blunt trauma and almost exclusively during the teenage years. Penetrating thoracic trauma usually occurs in isolation and is less frequently associated with other injuries. When dealing with a pediatric trauma patient, childhood thoracic injury should be considered separately from adult chest trauma. In general, thoracic injury patterns are different in children due to anatomic and physiologic differences between children and adults. The pediatric chest wall has increased compliance and ligamentous flexibility, and the mediastinum is more mobile. Ribs and skeletal structures tend to deform and bend, rather than fracture, even when significant compressive force is applied. This pliability allows the transfer of energy to underlying soft-tissues and organs, and may result in intra-thoracic injury without obvious outward signs of damage. In addition, mediastinal blunt injury is less likely in children due to the increased mobility of the mediastinal structures. This increases, however, susceptibility to tension physiology secondary to mechanical displacement of the trachea, superior vena cava, and heart. Thus, pediatric chest trauma should be approached with diligent evaluation and with a high degree of suspicion for life-threatening injuries, even in the absence of substantial physical exam findings. Primary Survey the initial evaluation of a child sustaining thoracic trauma begins with a primary survey, prioritizing airway, breathing, and circulation. In cases where the airway is questionable or the patient has altered mental status, maintenance of a patent airway can be achieved by repositioning the head with a chin lift and jaw thrust to move the mandible anteriorly. In patients with severe head injury, unresponsiveness, or hemodynamic instability, endotracheal intubation with inline cervical spine stabilization is indicated. Once the airway is secure, breath sounds should be evaluated bilaterally to ensure adequate air movement and ventilation. Intravenous access, hemodynamic monitoring, and resuscitation occur simultaneously as the patient is evaluated for life-threatening injuries that may require immediate intervention. Examination for chest injury the chest examination in blunt injury should be approached systematically to ensure injuries are adequately identified. An efficient physical exam begins with a quick visual inspection of the neck and chest in the cephalad to caudad direction. The trachea is checked for midline position and the internal jugular veins are inspected for distention. Any abrasions, 294 contusions, or lacerations are noted as visual surveillance is carried down the chest for obvious signs of external injury. In addition, the chest wall motion is observed for asymmetric chest rise or paradoxical movement with respirations. The exam should then proceed with auscultation of the chest for symmetrical, bilateral breath sounds. Absent or decreased breath sounds are suggestive of a hemothorax or pneumothorax and immediate drainage with tube thoracostomy is indicated if the patient has cardiopulmonary instability. Auscultation is followed by palpation of the neck, clavicles, sternum, and chest wall to assess for any tenderness, skeletal instability, or crepitance. Finally, percussion of the chest for dullness or hyperresonance completes the chest examination. Abnormalities in the chest exam should prompt further investigation with radiological studies for intrathoracic injuries. For penetrating injuries, particular attention should be directed to Zone I of the neck, which is bordered by the cricoid cartilage superiorly and the clavicles inferiorly. This location is the thoracic outlet and is densely occupied by significant structures that may be potentially injured, including the carotid artery, internal jugular vein, trachea, and esophagus. As visual inspection descends down the chest, the number, location, and character of open wounds should be noted. Sucking chest wounds should be addressed immediately with a three-sided dressing to prevent precipitation of a tension pneumothorax. In cases of missile injury, the wounds should be marked with a radiopaque marker, prior to chest X-ray. Lastly, the neck and chest are palpated for 295 tenderness and subcutaneous emphysema. There is increased risk of intrathoracic damage with penetrating injuries, particularly hemothorax and pneumothorax. There should be a low threshold to perform chest tube thoracostomy, if the clinical situation warrants. The boundaries of the box are the clavicles superiorly, the nipples laterally, and the costal margin inferiorly. As part of the physical exam, the patient should be examined for signs of cardiac tamponade. Additionally, pulsus paradoxus, or a drop in 10mm Hg of arterial pressure with inspiration, may be seen. Sonographic examination should also be done at the bedside to assess for pericardial effusion. Confirmation of cardiac injury or hemodynamic instability warrants emergent thoracotomy. In cases of severe tamponade, pericardiocentesis may be done as a temporizing measure prior to the operating room. Physical exam findings may be non-specific for injuries in this area of the cardiac box. Patients may present with hoarseness, chest wall crepitance, or substernal tenderness. However, the location of the penetration wound and knowledge of the cardiac box may be the only clue to 296 intrathoracic injury. Concern for injuries in this area, regardless of physical exam findings, merits further endoscopic or radiographic evaluation. Chest Radiography Patients who sustain chest trauma should be evaluated with a screening anterior-posterior chest x-ray.
Genetic or other activity manifest in experimental mammals and humans is regarded as being of greater relevance than that in other organisms muscle relaxant spray voveran 50mg visa. The demonstration that an agent or mixture can induce gene and chromosomal mutations in whole mammals indicates that it may have carcinogenic activity spasms prednisone voveran 50mg without prescription, although this activity may not be detectably expressed in any or all species muscle relaxant shot buy cheap voveran online. Relative potency in tests for mutagenicity and related effects is not a reliable indicator of carcinogenic potency muscle relaxant usa order voveran canada. Negative results in tests for mutagenicity in selected tissues from animals treated in vivo provide less weight, partly because they do not exclude the possibility of an effect in tissues other than those examined. Moreover, negative results in short-term tests with genetic end-points cannot be considered to provide evidence to rule out carcinogenicity of agents or mixtures that act through other mechanisms. Factors that may lead to misleading results in short-term tests have been discussed in detail elsewhere (Montesano et al. When available, data relevant to mechanisms of carcinogenesis that do not involve structural changes at the level of the gene are also described. The adequacy of epidemiological studies of reproductive outcome and genetic and related effects in humans is evaluated by the same criteria as are applied to epidemiological studies of cancer. Inadequate studies are generally not summarized: such studies are usually identified by a square-bracketed comment in the preceding text. Exposure to biological agents is described in terms of transmission and prevalence of infection. For each animal species and route of administration, it is stated whether an increased incidence of neoplasms or preneoplastic lesions was observed, and the tumour sites are indicated. If the agent or mixture produced tumours after prenatal exposure or in singledose experiments, this is also indicated. Toxicological information, such as that on cytotoxicity and regeneration, receptor binding and hormonal and immunological effects, and data on kinetics and metabolism in experimental animals are given when considered relevant to the possible mechanism of the carcinogenic action of the agent. The results of tests for genetic and related effects are summarized for whole mammals, cultured mammalian cells and nonmammalian systems. When available, comparisons of such data for humans and for animals, and particularly animals that have developed cancer, are described. Thus, for example, the action of an agent on the expression of relevant genes could be summarized under both the first and second dimensions, even if it were known with reasonable certainty that those effects resulted from genotoxicity. It is recognized that the criteria for these evaluations, described below, cannot encompass all of the factors that may be relevant to an evaluation of carcinogenicity. In considering all of the relevant scientific data, the Working Group may assign the agent, mixture or exposure circumstance to a higher or lower category than a strict interpretation of these criteria would indicate. An evaluation of degree of evidence, whether for a single agent or a mixture, is limited to the materials tested, as defined physically, chemically or biologically. When the agents evaluated are considered by the Working Group to be sufficiently closely related, they may be grouped together for the purpose of a single evaluation of degree of evidence. The Working Group seeks to identify the specific exposure, process or activity which is considered most likely to be responsible for any excess risk. The evaluation is focused as narrowly as the available data on exposure and other aspects permit. The evidence relevant to carcinogenicity from studies in humans is classified into one of the following categories: Sufficient evidence of carcinogenicity: the Working Group considers that a causal relationship has been established between exposure to the agent, mixture or exposure circumstance and human cancer. That is, a positive relationship has been observed between the exposure and cancer in studies in which chance, bias and confounding could be ruled out with reasonable confidence. Limited evidence of carcinogenicity: A positive association has been observed between exposure to the agent, mixture or exposure circumstance and cancer for which a causal interpretation is considered by the Working Group to be credible, but chance, bias or confounding could not be ruled out with reasonable confidence. Inadequate evidence of carcinogenicity: the available studies are of insufficient quality, consistency or statistical power to permit a conclusion regarding the presence or absence of a causal association between exposure and cancer, or no data on cancer in humans are available. Evidence suggesting lack of carcinogenicity: There are several adequate studies covering the full range of levels of exposure that human beings are known to encounter, which are mutually consistent in not showing a positive association between exposure to the agent, mixture or exposure circumstance and any studied cancer at any observed level of exposure. In addition, the possibility of a very small risk at the levels of exposure studied can never be excluded. In some instances, the above categories may be used to classify the degree of evidence related to carcinogenicity in specific organs or tissues. Exceptionally, a single study in one species might be considered to provide sufficient evidence of carcinogenicity when malignant neoplasms occur to an unusual degree with regard to incidence, site, type of tumour or age at onset. Inadequate evidence of carcinogenicity: the studies cannot be interpreted as showing either the presence or absence of a carcinogenic effect because of major qualitative or quantitative limitations, or no data on cancer in experimental animals are available. Evidence suggesting lack of carcinogenicity: Adequate studies involving at least two species are available which show that, within the limits of the tests used, the agent or mixture is not carcinogenic. A conclusion of evidence suggesting lack of carcinogenicity is inevitably limited to the species, tumour sites and levels of exposure studied. The strength of the evidence that any carcinogenic effect observed is due to a particular mechanism is assessed, using terms such as weak, moderate or strong. Then, the Working Group assesses if that particular mechanism is likely to be operative in humans. The strongest indications that a particular mechanism operates in humans come from data on humans or biological specimens obtained from exposed humans. The data may be considered to be especially relevant if they show that the agent in question has caused changes in exposed humans that are on the causal pathway to carcinogenesis. Such data may, however, never become available, because it is at least conceivable that certain compounds may be kept from human use solely on the basis of evidence of their toxicity and/or carcinogenicity in experimental systems. For complex exposures, including occupational and industrial exposures, the chemical composition and the potential contribution of carcinogens known to be present are considered by the Working Group in its overall evaluation of human carcinogenicity. The Working Group also determines the extent to which the materials tested in experimental systems are related to those to which humans are exposed. In addition, when supporting data indicate that other, related compounds for which there is no direct evidence of capacity to induce cancer in humans or in animals may also be carcinogenic, a statement describing the rationale for this conclusion is added to the evaluation narrative; an additional evaluation may be made for this broader group of compounds if the strength of the evidence warrants it. The agent, mixture or exposure circumstance is described according to the wording of one of the following categories, and the designated group is given. The categorization of an agent, mixture or exposure circumstance is a matter of scientific judgement, reflecting the strength of the evidence derived from studies in humans and in experimental animals and from other relevant data. This category is used when there is sufficient evidence of carcinogenicity in humans. Exceptionally, an agent (mixture) may be placed in this category when evidence of carcinogenicity in humans is less than sufficient but there is sufficient evidence of carcinogenicity in experimental animals and strong evidence in exposed humans that the agent (mixture) acts through a relevant mechanism of carcinogenicity. Group 2 this category includes agents, mixtures and exposure circumstances for which, at one extreme, the degree of evidence of carcinogenicity in humans is almost sufficient, as well as those for which, at the other extreme, there are no human data but for which there is evidence of carcinogenicity in experimental animals. Agents, mixtures and exposure circumstances are assigned to either group 2A (probably carcinogenic to humans) or group 2B (possibly carcinogenic to humans) on the basis of epidemiological and experimental evidence of carcinogenicity and other relevant data. The exposure circumstance entails exposures that are probably carcinogenic to humans. This category is used when there is limited evidence of carcinogenicity in humans and sufficient evidence of carcinogenicity in experimental animals. In some cases, an agent (mixture) may be classified in this category when there is inadequate evidence of carcinogenicity in humans, sufficient evidence of carcinogenicity in experimental animals and strong evidence that the carcinogenesis is mediated by a mechanism that also operates in humans. Exceptionally, an agent, mixture or exposure circumstance may be classified in this category solely on the basis of limited evidence of carcinogenicity in humans. The exposure circumstance entails exposures that are possibly carcinogenic to humans. This category is used for agents, mixtures and exposure circumstances for which there is limited evidence of carcinogenicity in humans and less than sufficient evidence of carcinogenicity in experimental animals. It may also be used when there is inadequate evidence of carcinogenicity in humans but there is sufficient evidence of carcinogenicity in experimental animals. In some instances, an agent, mixture or exposure circumstance for which there is inadequate evidence of carcinogenicity in humans but limited evidence of carcinogenicity in experimental animals together with supporting evidence from other relevant data may be placed in this group.
Subclavian vein has higher insertion-related complications like pneumothorax muscle relaxant spray cheap voveran online, hemothorax spasms and pain under right rib cage discount 50mg voveran with visa, subclavian artery injury spasms from catheter order voveran 50mg on line, brachial plexus injury muscle relaxant examples purchase generic voveran line, and a higher risk of developing subclavian vein stenosis. Femoral vein lies medial to artery (5 mm in infants and toddler, 10 mm in adolescents and adults). An alternative landmark for puncture is halfway between the sternal notch and tip of the mastoid process. After hitting the clavicle, glide the cannula close to under surface of the clavicle. After entering space between clavicle and first rib, advance cannula directed aiming at the suprasternal notch. Injury to adjacent structures like brachial plexus, trachea, and recurrent laryngeal nerve. Delayed complications include thrombosis, infection, vascular stricture, and A-V fistula. Late catheter dysfunction may occur due to fibrin sleeves, mural thrombosis, central vein stenosis, thrombosis, or stricture and due to catheter fragment in circulation. Contraindications to this procedure include recent abdominal surgery or trauma, extensive intra-abdominal adhesions, necrotizing enterocolitis, a large intra-abdominal mass, diaphragmatic hernia, ventriculoperitoneal shunt, and prune belly syndrome. Insertion of this catheter (percutaneously with the help of a guide wire and a peel-away sheath) may be done at the bedside. The catheter insertion can also be done by a surgeon in the operating room (peritoneoscopic/laparoscopic/open method). The use of bicarbonate as a buffer in the dialysate results in better correction of acidosis, lower lactate levels, and improved hemodynamic stability. Heparin, insulin, and potassium can be added to bicarbonate-based fiuid, if required. Vasudevan Dialysis Maintenance doses of potassium, calcium, and magnesium can be infused intravenously. Identify the midpoint of the line joining the umbilicus to the pubic symphysis or in a neonate on a paramedian line a little lateral to rectus sheath. Make a stab skin incision and insert the catheter with stylet perpendicular to the abdominal wall with a twisting motion. Withdraw the stylet gradually, simultaneously advancing the catheter toward the opposite pelvic cavity. Attach the connecting set to the catheter and run in dialysate fiuid to confirm free fiow. Monitoring: Maintain pulse, blood pressure, and intake/output hourly charts; serum electrolytes and blood sugar every 8 h and blood urea and creatinine every 24 h. Watch changes in appearance of returning peritoneal fiuid (infection, blood, fibrin threads). Flush, reposition, or remove and reinsert catheter Pericatheter leak During insertion of catheter ensure that all holes are intraperitoneal. Try small fi ll volumes Abdominal pain during infiow May be because of peritonitis, cold dialysate fiuid, hypertonic solution, or excessive fill volume Hypokalemia, hypernatremia, Regular monitoring and appropriate correction hyperglycemia Respiratory embarrassment Because of overdistention of abdomen or pleural effusion. Decrease dwell volumes Peritonitis Manifests as abdominal pain and cloudy peritoneal fiuid containing more than 100 cells/mm3, predominantly neutrophils (>50 %). Start initial treatment with broadspectrum antibiotics covering both gram-positive and gramnegative organisms until availability of gram stain or culture report Bowel perforation Manifests with watery diarrhea and fecal material in dialysate effiuent. With proper needle placement, the patient should not experience pain or resistance to filling the cavity with fiuid. These foods have greater than 250 mg of potassium per serving and should be avoided or eaten in very small portions if a low-potassium diet is prescribed Grains Whole-grain breads, wheat bran, granola and granola bars, barley, ragi, wheat fi our All pulses All leafy vegetables such as amaranth, coriander leaves, drumstick leaves, spinach, potato, sweet potato, yam, drumstick, green papaya, sword beans Milk, fi sh especially sardines Nuts such as cashew nuts, almonds; oilseeds such as peanuts Condiments and spices, jaggery Fruits such as sweet lime, mango, banana, chikoo, apricots, dates, figs, melons, oranges, pears Brown sugar, coffee, cocoa powder, chocolate Beverages Sports drinks, instant breakfast mix, soy milk Snack foods/sweets Peanut butter (2 tablespoons), nuts or seeds (1 oz), fig cookies, chocolate (1. Vasudevan Dairy products Milk and milk products, buttermilk, yogurt Proteins (3-oz serving) clams, sardines, scallops, lobster, whitefish, salmon (and most other fish), ground beef, sirloin steak (and most other beef products), pinto beans, kidney beans, black beans, navy beans (and most other peas and beans, serving size fi cup) Soups Salt-free soups and low-sodium bouillon cubes, unsalted broth Condiments Imitation bacon bits, salt, or salt substitutes (avoid completely) 17. Soak the vegetables for at least 2 h in unsalted warm water (approximately 10 parts water to 1 part vegetables). Cook vegetables as desired, using a large amount of unsalted water (approximately 5 parts water to 1 part vegetables). Cereals such as ragi, whole bengal, gram (chana), moth beans (matki), red beans, soybeans, horse gram 2. Oilseeds such as dry coconut, sesame seeds, mustard seeds, asafoetida, dry cloves, coriander and cumin seeds, poppy seeds 4. Moderate sources of phosphorus are bengal gram, chick pea, cowpea, and red beans 3. Almond, cashew nuts, sesame seeds, mustard seeds, pistachio, cumin seeds, poppy seeds 4. Use canola, soybean, or saffiower oils or other unsaturated oils, in place of solid fats during food preparation. Use fresh vegetables and fruits and serve at every meal; be careful with added sugar and sauces. Remove the skin from poultry before eating; use only lean cuts of meat and reduced-fat meat products. I 5 Birth G 10 H 4 T 8 3 6 2 Ib kg Birth Published May 30, 2000 (modified 4/20//01. Group A received the left Yang-Monti ileal ureter-ureteral anastomosis; group B received the left Yang-Monti ileal ureterbladder anastomosis. The length of the incision and the operation time of the two groups were compared. Results: the remaining 11 miniature pigs had no urinary fistula or intestinal fistula. The narrowest diameter of group A was larger than that of group B; no contrast agent was returned to the upper urinary tract in the two groups. Histological examination showed that the transitional epithelium and columnar epithelial mucosa in group A were not close together; the intestinal villi are slightly atrophied and shortened. Conclusions: Compared with the Yang-Monti ileal ureteral anastomosis, the Yang-Monti ileal ureterbladder anastomosis is simpler, more reliable, and less complication. Background With the widespread development of urological endoscopic surgery, iatrogenic injury has become one [1] of the most common causes of ureteral injury, and the incidence of long-term ureteral injury is increasing. The most serious complication of ureteroscopy is ureteral avulsion, with an incidence of 0. Most cases of lower ureteral avulsion are treated with ureteral bladder replantation. However, multiple operations cause adhesions and stenosis in the lower ureter, poor blood supply to the ureter, difficulty in healing postoperatively, scarring, and result in a ureter with a small diameter and thin wall, which is not conducive to anastomosis. The Yang-Monti technique for ileal ureteral reconstruction is used in clinical practice and has good 3 [6-8] curative effects. The characteristics of this method are that the alternative ureteral tube diameter is the same as that of the original ureter, the intestinal tube is short, the diameter of the replacement tube is small, and the intestinal tube is saved. In addition, the absorptive and secretive functions of the intestinal segment used in ureteral reconstruction are decreased because the absorbent surface area is limited and the mucous production is decreased, preventing occlusion of the lumen and postoperative metabolic abnormalities. Order 50 mg voveran visa. Muscle Relaxant. Article 42 The internment or placing in assigned residence of protected persons may be V spasms kidney stones trusted voveran 50 mg. Grounds for ordered only if the security of the Detaining Power makes it absolutely necessary esophageal spasms xanax buy generic voveran 50 mg on-line. Procedure shall be entitled to have such action reconsidered as soon as possible by an appropriate court or administrative board designated by the Detaining Power for that purpose spasms homeopathy right side order voveran 50 mg with mastercard. If the internment or placing in assigned residence is maintained spasms 7 weeks pregnant generic 50 mg voveran fast delivery, the court or administrative board shall periodically, and at least twice yearly, give consideration to his or her case, with a view to the favourable amendment of the initial decision, if circumstances permit. Unless the protected persons concerned object, the Detaining Power shall, as rapidly as possible, give the Protecting Power the names of any protected persons who have been interned or subjected to assigned residence, or who have been released from internment or assigned residence. The decisions of the courts or boards mentioned in the frst paragraph of the present Article shall also, subject to the same conditions, be notifed as rapidly as possible to the Protecting Power. Refugees the Detaining Power shall not treat as enemy aliens exclusively on the basis of their nationality de jure of an enemy State, refugees who do not, in fact, enjoy the protection of any government. If protected persons are transferred under such circumstances, responsibility for the application of the present Convention rests on the Power accepting them, while they are in its custody. Nevertheless, if that Power falls to carry out the provisions of the present Convention in any important respect, the Power by which the protected persons were transferred shall, upon being so notifed by the Protecting Power, take efective measures to correct the situation or shall request the return of the protected persons. In no circumstances shall a protected person be transferred to a country where he or she may have reason to fear persecution for his or her political opinions or religious beliefs. The provisions of this Article do not constitute an obstacle to the extradition, in pursuance of extradition treaties concluded before the outbreak of hostilities, of protected persons accused of ofences against ordinary criminal law. Article 46 Cancellation In so far as they have not been previously withdrawn, restrictive measures of restrictive taken regarding protected persons shall be cancelled as soon as possible afer measures the close of hostilities. Restrictive measures afecting their property shall be cancelled, in accordance with the law of the Detaining Power, as soon as possible afer the close of hostilities. Article 49 Individual or mass forcible transfers, as well as deportations of protected perDeportations, sons from occupied territory to the territory of the Occupying Power or to that transfers, of any other country, occupied or not, are prohibited, regardless of their motive. Such evacuations may not involve the displacement of protected persons outside the bounds of the occupied territory except when for material reasons it is impossible to avoid such displacement. Persons thus evacuated shall be transferred back to their homes as soon as hostilities in the area in question have ceased. The Occupying Power undertaking such transfers or evacuations shall ensure, to the greatest practicable extent, that proper accommodation is provided to receive the protected persons, that the removals are efected in satisfactory conditions of hygiene, health, safety and nutrition, and that members of the same family are not separated. The Protecting Power shall be informed of any transfers and evacuations as soon as they have taken place. The Occupying Power shall not detain protected persons in an area particularly exposed to the dangers of war unless the security of the population or imperative military reasons so demand. The Occupying Power shall not deport or transfer parts of its own civilian population into the territory it occupies. Article 50 The Occupying Power shall, with the co-operation of the national and local Children authorities, facilitate the proper working of all institutions devoted to the care and education of children. The Occupying Power shall take all necessary steps to facilitate the identifcation of children and the registration of their parentage. It may not, in any case, change their personal status, nor enlist them in formations or organizations subordinate to it. A special section of the Bureau set up in accordance with Article 136 shall be responsible for taking all necessary steps to identify children whose identity is in doubt. Particulars of their parents or other near relatives should always be recorded if available. The Occupying Power shall not hinder the application of any preferential measures in regard to food, medical care and protection against the efects of war, which may have been adopted prior to the occupation in favour of children under ffeen years, expectant mothers, and mothers of children under seven years. The Occupying Power may not compel protected persons to serve in its Labour armed or auxiliary forces. No pressure or propaganda which aims at securing voluntary enlistment is permitted. The Occupying Power may not compel protected persons to work unless they are over eighteen years of age, and then only on work which is necessary either for the needs of the army of occupation, or for the public utility services, or for the feeding, sheltering, clothing, transportation or health of the population of the occupied country. Protected persons may not be compelled to undertake any work which would involve them in the obligation of taking part in military operations. The Occupying Power may not compel protected persons to employ forcible means to ensure the security of the installations where they are performing compulsory labour. The work shall be carried out only in the occupied territory where the persons whose services have been requisitioned are. Every such person shall, so far as possible, be kept in his usual place of employment. Workers shall be paid a fair wage and the work shall be proportionate to their physical and intellectual capacities. The legislation in force in the occupied country concerning working conditions, and safeguards as regards, in particular, such matters as wages, hours of work, equipment, preliminary training and compensation for occupational accidents and diseases, shall be applicable to the protected persons assigned to the work referred to in this Article. In no case shall requisition of labour lead to a mobilization of workers in an organization of a military or semi-military character. All measures aiming at creating unemployment or at restricting the opportunities ofered to workers in an occupied territory, in order to induce them to work for the Occupying Power, are prohibited. Article 53 Any destruction by the Occupying Power of real or personal property belongProhibited ing individually or collectively to private persons, or to the State, or to other destruction public authorities, or to social or co-operative organizations, is prohibited, except where such destruction is rendered absolutely necessary by military operations. Article 54 The Occupying Power may not alter the status of public ofcials or judges in Judges the occupied territories, or in any way apply sanctions to or take any measand public ures of coercion or discrimination against them, should they abstain from ofcials fulflling their functions for reasons of conscience. This prohibition does not prejudice the application of the second paragraph of Article 51. It does not afect the right of the Occupying Power to remove public ofcials from their posts. Article 55 To the fullest extent of the means available to it, the Occupying Power has the Food and duty of ensuring the food and medical supplies of the population; it should, in medical particular, bring in the necessary foodstufs, medical stores and other articles supplies if the resources of the occupied territory are inadequate. Subject to the provisions of other international Conventions, the Occupying Power shall make arrangements to ensure that fair value is paid for any requisitioned goods. The Protecting Power shall, at any time, be at liberty to verify the state of the food and medical supplies in occupied territories, except where temporary restrictions are made necessary by imperative military requirements. If new hospitals are set up in occupied territory and if the competent organs of the occupied State are not operating there, the occupying authorities shall, if necessary, grant them the recognition provided for in Article 18. In similar circumstances, the occupying authorities shall also grant recognition to hospital personnel and transport vehicles under the provisions of Articles 20 and 21. In adopting measures of health and hygiene and in their implementation, the Occupying Power shall take into consideration the moral and ethical susceptibilities of the population of the occupied territory. Article 57 Requisition The Occupying Power may requisition civilian hospitals only temporarily and of hospitals only in cases of urgent necessity for the care of military wounded and sick, and then on condition that suitable arrangements are made in due time for the care and treatment of the patients and for the needs of the civilian population for hospital accommodation. The material and stores of civilian hospitals cannot be requisitioned so long as they are necessary for the needs of the civilian population. Article 58 Spiritual The Occupying Power shall permit ministers of religion to give spiritual asassistance sistance to the members of their religious communities. The Occupying Power shall also accept consignments of books and articles required for religious needs and shall facilitate their distribution in occupied territory. Article 59 Relief If the whole or part of the population of an occupied territory is inadequately I. Collective supplied, the Occupying Power shall agree to relief schemes on behalf of the relief said population, and shall facilitate them by all the means at its disposal. Such schemes, which may be undertaken either by States or by impartial humanitarian organizations such as the International Committee of the Red Cross, shall consist, in particular, of the provision of consignments of foodstufs, medical supplies and clothing. A Power granting free passage to consignments on their way to territory occupied by an adverse Party to the confict shall, however, have the right to search the consignments, to regulate their passage according to prescribed times and routes, and to be reasonably satisfed through the Protecting Power that these consignments are to be used for the relief of the needy population and are not to be used for the beneft of the Occupying Power. The Occupying Power shall in no bilities of the way whatsoever divert relief consignments from the purpose for which they Occupying are intended, except in cases of urgent necessity, in the interests of the populaPower tion of the occupied territory and with the consent of the Protecting Power. This duty may also be delegated, by agreement between the Occupying Power and the Protecting Power, to a neutral Power, to the International Committee of the Red Cross or to any other impartial humanitarian body. Such consignments shall be exempt in occupied territory from all charges, taxes or customs duties unless these are necessary in the interests of the economy of the territory.
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