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E como ha uma diminuicao simultanea da massa muscular esqueletica medications zovirax buy discount mentat ds syrup on-line, a creatinina serica deixa de ser um bom indicador da funcao renal medications with gluten buy mentat ds syrup 100 ml on line. Nestes casos symptoms 14 dpo mentat ds syrup 100 ml low cost, lanca-se mao de formulas medicine 93 5298 cheap mentat ds syrup american express, como a de Cockroft & Gault: (140 – idade) x peso(kg) 72 x creatinina serica (mg/dl) Observacao: Para mulheres medicine zithromax purchase mentat ds syrup 100 ml visa, multiplicar o valor final por 0,85. Farmacodinamica A farmacodinamica se relaciona aos efei to s do farmaco no seu recep to r, levando em consideracao a intensidade e a duracao do efei to de uma determinada concentracao do farmaco no local. Ao contrario das alteracoes farmacocineticas no envelhecimen to, ja bem conhecidas, a farmacodinamica ainda necessita de estudos. Sabe-se que as alteracoes nos recep to res surgem mais tarde, por volta dos 70 anos, explicando diferencas nas reacoes adversas a medicamen to s, como ben zodiazepinicos, por exemplo. Interacoes medicamen to sas Quando dois ou mais medicamen to s sao administrados, pode ocorrer uma indiferenca farmacologica, ou seja, cada um acarreta os efei to s desejados, sem qualquer interacao entre ambos. Por outro lado, quando eles interagem, a acao de um interfere com os efei to s do outro, podendo haver sinergismo, caso em que ha potencializacao, ou antagonismo quando um prejudica a acao do outro. Is to ocorre nas seguintes situacoes: competicao de dois farmacos pelo mesmo recep to r; um provoca retardo na absorcao do outro (exemplo: anticoli nergicos retardam a absorcao de outros medicamen to s quando administrados simultaneamente); um pode acarretar deslocamen to do outro em sua ligacao com a albumina; interferencia com a biotransformacao (por inducao ou inibicao enzimatica). Quando uma substancia (substra to ) e metabolizada pela enzima e se adiciona uma outra que seja inibidora da mesma, pode haver uma acentuacao do efei to da primeira droga. Isso acontece porque o metabolismo do substra to passa a ser reduzido, em virtude da inibicao da enzima 3A4 do CitP450. Ela vem a consulta com um quadro de infeccao do tra to urinario e o medico, acertadamente, prescreve-lhe norfloxacina – 400mg, duas vezes ao dia, basea do no antibiograma. No terceiro dia de tratamen to com o antibiotico, ela sofre uma queda e os familiares relatam a voce que, naquele momen to, a sua pressao estava baixa. Como nao ha ainda um consenso para definir tal condicao, esta sera aqui considerada como o uso de cinco ou mais farmacos ao mesmo tempo. Entre os principais fa to res de risco para o uso excessivo de farmacos estao os seguintes: desejo dos pacientes de receber uma prescricao medica sempre que comparecem a uma consulta; nao rela to de sin to mas que podem ser reacoes adversas de outros farmacos, ocasionando a prescricao de um medicamen to para tratar aqueles sin to mas; consultas com multiplos medicos. Ainda devemos levar em conta a adesao ao tratamen to, significativa mente reduzida na vigencia de polifarmacia. Problemas de adesao nao se restringem aos idosos, mas sabe-se que de 30% a 50% deles nao to mam seus medicamen to s corretamente. O principal fa to r de risco para a nao adesao e a polifarmacia, descrita ante riormente. Mas os seguintes fa to res tambem devem ser considerados: regimes complexos, com varias doses ao longo do dia; nao compreensao ou negacao da doenca; comunicacao pobre entre medico e paciente; insatisfacao com o medico; tratamen to s prolongados; embalagens dificeis de abrir; cus to elevado da medicacao. Por outro lado, a adesao ao tratamen to pode aumentar quando se prove orientacao clara sobre a doenca e seu tratamen to, de forma verbal e escrita, ou quando se reduz o numero de medicamen to s, usando-se esquemas simplificados. Subutilizacao de farmacos potencialmente beneficos O envelhecimen to populacional propiciou o aumen to da prevalencia de doencas cronicas e, com elas, a necessidade de uso prolongado de dife rentes farmacos. Percebe-se a ocorrencia de subutilizacao de farmacos potencialmente beneficos em pacientes com multiplas doencas croni cas nao relacionadas entre si, quando uma delas e considerada menos importante do que a outra. AtividAdE 16 Assinale, nas situacoes a e b, as doencas que, na sua opiniao, receberiam me nos atencao por parte da equipe de saude da familia. Quadro 12 – Criterios de Beers de ma prescricao em idosos Analgesicos e Carisoprodol Pode provocar sedacao, fraqueza, confusao mental (acao anticolinergica). Pode causar constipacao intestinal, desequilibrio, depressao do sistema nervoso central e declinio cognitivo. Orfenadrina,(Dorflex ) Carisoprodol (Beserol, Tandrilax,Mioflex, Miocitalgan,Dorilax) Antidepressivos Amitriptilina Potente efei to anticolinergico (constipacao intestinal, retencao urinaria, confusao mental, glaucoma), antiadrenergicos (hipotensao or to statica), sedacao, quedas e cardio to xicidade. Anti-hipertensivos Metildopa Pode provocar bradicardia, hipotensao or to statica, hepatite au to -imune e agravamen to ou Aldomet precipitacao de depressao no idoso. Adalat 10mg Reserpina Sedacao, depressao, impotencia sexual e hipotensao or to statica. Anti-histaminicos Algumas drogas anti-histaminicas tem potente acao anticolinergica e nao devem ser usadas Difenidramina (Pulmo to sse, Benedryl, nos idosos, particularmente aquelas usadas para gripe, resfriado e to sse, como associacao. Notuss ), hidroxizina, ciproheptadina, A acao sedativa pode provocar confusao mental e quedas. Apresentam boa acao anti Benegrip ) histaminica e poucos efei to s no sistema nervoso central. Alem disso, a sua efetividade nas doses to leradas pelo idoso e (Tropinal ), propantelina, alcaloide questionavel e nao devem ser utilizadas, especialmente no longo prazo. A atropina possui beladona (Atroverant ), escopolamina, efei to cardiovascular mais exuberante. Atropina (Vagoestesyl ) Antipsicoticos O uso de antipsicoticos classicos ou tipicos, como o haloperidol e a tioridazina, e cada vez menor, pelos potentes efei to s extrapiramidais, anticolinergicos e maior risco de discinesia tardia. Os antipsicoticos atipicos sao mais to lerados e constituem-se em drogas de primeira escolha para o tratamen to da psicose na demencia. Barbituricos Sua utilizacao como droga hipnotico-sedativa tem declinado com o aparecimen to dos benzodiazepinicos. Sedacao, quedas e efei to paradoxal sao Alprazolam (acima de as principais complicacoes. Lorazepam (acima de 3mg) Longa acao Apresentam meia-vida prolongada no idoso (> 5dias), podendo causar sedacao, ataxia, Diazepam quedas e confusao mental. Recomenda-se o uso de benzodiazepinicos de curta acao Limbitrol (diazepam (Lorazepam, Alprazolam), se for o caso. No idoso esta acao e questionavel e sua potente acao anticolinergica oferece grande risco de to xicidade. Clordiazepoxido Apesentam meia-vida prolongada no idoso (> 5dias), podendo causar sedacao, ataxia, quedas e confusao mental. Tambem pode elevar o nivel serico de creatinina, nao associada a insfuciencia renal. Digoxina Pode causar inapetencia, nauseas, fadiga, confusao mental aguda (delirium),quedas e arritmia cardiaca (in to xicacao digitalica). A dose de manutencao raramente deve exceder a 0,125 mg/dia no idoso, pelo menor clearance renal. Laxativos estimulantes Podem causar diarreia e agravar a constipacao (colon catartico), na presenca de uso Bisacodil (Dulcolax ), cascara sagrada etc. Ticlopidina Nao e superior aos outros antiagregantes plaquetarios e apresenta maior risco de reacoes adversas nos idosos (neutropenia). Para finalizar, sugerimos alguns aspec to s relacionados a prescricao geriatrica: Mantenha um al to indice de suspeicao para reacoes adversas. Mantenha os intervalos entre as doses os mais amplos possivel (uma ou duas vezes ao dia). Conheca as reacoes adversas potenciais (exemplo: edema de membros inferiores por antagonistas do calcio). Conheca as comorbidades (exemplo: urgencia urinaria e hiper tensao – evite diureticos). A paciente apresenta um quadro de rigidez, bradicinesia e tremor de repouso, sugestivos de parkinsonismo. Considere a incontinencia urinaria e verifique se ha possibilidade de modifi cacao no esquema medicamen to so a fim de minimizar o problema. Por que a clorpropamida nao e a melhor escolha para o tratamen to do dia betes da dona Cristinafi Explicit criteria for determining potentially inappropriate medication use by the elderly: an update. Cria mecanismos para a organizacao e implantacao de redes estaduais de assistencia a saude do idoso. Inappropriate medica to n administration to the acutely ill elderly: a nationwide emergency departament study, 1992-2000. Use of psychoactive drugs and related falls among older people living in a community in Brazil. Randomised fac to rial trial of falls prevention among older people living in their own homes. Updating the beers criteria for pottentially innappropriate medication use in older adults. Psychotropic medications and risk for falls among community-dwelling frail older people: an observational study. Research agenda for frailty in older adults: to ward a better understanding of physiology and etiology: summary from the American Geriatrics Society. Use in connection with any form of information s to rage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the edi to rs nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The rich vocabulary of neurology replete with eponyms attests to this his to rically. However, neuroimag ing has often provided a surfeit of information from which salient features have to be identified, dependent upon the neurological examination. There is also an entry for the ‘head turning sign’ observed during the his to ry taking itself as well as the majority of entries relating to details of the physical examination. For the more mature student, there are the less usual as well as common eponyms to entice one to read further than the entry which to ok you first to the dictionary. Thankfully, the clinical examination still has some supporters (not merely apologists), and neurological signs feature prominently amongst the core competencies. A wooden stick or pin is used to scratch the abdominal wall, from the fiank to the midline, parallel to the line of the derma to mal strips, in upper (supraum bilical), middle (umbilical), and lower (infraumbilical) areas. Superficial abdominal refiexes are lost in a number of circumstances: • Normal ageing; • Obesity; • Following abdominal surgery; • Following multiple pregnancies; • In acute abdominal disorders (Rosenbach’s sign). Isolated weakness of the lateral rectus muscle may also occur in myasthe nia gravis. In order not to overlook this fact, and miss a potentially treatable condition, it is probably better to label isolated abduction failure as ‘lateral rec tus palsy’, rather than abducens nerve palsy, until the aetiological diagnosis is established. Cross Reference Functional weakness and sensory disturbance Absence An absence, or absence attack, is a brief interruption of awareness of epileptic origin. Absence epilepsy may be confused with a more obvious distancing, ‘trance like’ state, or ‘glazing over’, possibly with associated au to matisms, such as lip smacking, due to a complex partial seizure of temporal lobe origin (‘atypical absence’). Cross References Au to matism; Seizures Abulia Abulia (aboulia) is a ‘syndrome of hypofunction’, characterized by a lack of initiative, spontaneity and drive (aspontaneity), apathy, slowness of thought (bradyphrenia), and blunting of emotional responses and response to external stimuli. It may be confused with the psychomo to r retardation of depression and is sometimes labelled as ‘pseudodepression’. More plausibly, abulia has been thought of as a minor or partial form of akinetic mutism. Abulia may result from frontal lobe damage, most particularly that involving the frontal convexity, and has also been reported with focal lesions of the caudate nucleus, thalamus, and midbrain. As with akinetic mutism, it is likely that lesions anywhere in the ‘centromedial core’ of the brain, from frontal lobes to brainstem, may produce this picture.

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When the PanOptic is 3 inches from contact symptoms checklist buy genuine mentat ds syrup, instruct the patient to medicine 2020 order generic mentat ds syrup canada look in to medicine cabinet order mentat ds syrup 100 ml without a prescription the light To look for abrasions and foreign bodies while the patient is still facing straight ahead 9 medications that cause fatigue mentat ds syrup 100 ml with amex. Continue moving to medications similar buspar discount 100 ml mentat ds syrup free shipping wards the on the cornea with the corneal viewing patient until the eyecup reaches the orbit of the patient. Begin the exam about 6 inches from the patient with the focus wheel in the neu 3. To examine the extreme periphery, instruct the patient to fixate straight tral position. Pivot around the eye by leveraging the eyecup against the orbit of the patient’s eye to achieve the desired view. Hold the PanOptic up to your eye and position the ophthalmo is important to compress the eyecup to maximize this technique. A red “reflex” should appear as you look this routine will reveal almost any abnormality that occurs in the fundus. Rest your left hand on the patient’s forehead and hold the upper lid of the eye near the eyelashes with your thumb. While the patient is fixating on the specified object, keep the red “reflex” in view and slowly move to ward the patient. Follow the red reflex in to the pupil until the PanOptic eyecup rests on the orbit of the patient’s eye. The trip from 6 inches away to making contact must be one that is slow, deliberate, and steady. To examine the extreme periphery, instruct the patient to : room should be either semidarkened or completely darkened. It is • Look up for examination of the superior retina preferable to dilate the pupil when there is no pathologic contraindication, • Look down for examination of the inferior retina but much information can be obtained through the undilated pupil. Select “0” on the illuminated lens disc of the ophthalmoscope and start with the small aperture. To examine the left eye, repeat the procedure outlined above but hold the ophthalmoscope in your left hand, stand at the patient’s left 3. Take the ophthalmoscope in the right hand and hold it vertically in side and use your left eye. One of the most troublesome barriers to a good view of the retina is the light reflected back in to the examiner’s eye from the patient’s 4. Instruct the patient to look straight ahead at a cornea—a condition known as corneal reflection. It is recom slightly to the right (25fi) of the patient and direct the light beam in to Position the ophthalmoscope about 6 inches (15 cm) mended that the polarizing filter be used when corneal reflection is present. Examine the disc for clarity of outline, color, in front and 25fi to the right side of the patient. Rest your left hand on the patient’s forehead and hold the upper lid of the eye near the eyelashes with the thumb. While the patient is fixating on • Direct the light beam to ward the edge of the pupil rather than directly the specified object, keep the “reflex” in view and slowly move to ward through its center. The optic disc should come in to view when you are about 1 to 2 inches (3-5 cm) from the patient. The hyperopic, or far-sighted, eye requires more “plus” (green within the light beam. Simultaneously check the location of the pattern numbers) lenses for clear focus of the fundus; the myopic, or near on the fundus. If the center of the pattern does not coincide with the sighted, eye requires “minus” (red numbers) lenses for clear focus. In this procedure, the crossed linear polarizing filter is especially useful since it dramatically reduces 7. Now examine the disc for clarity of outline, color, elevation and reflections caused by the direct corneal light path. You may also have the patient look at the light of the ophthalmoscope, which will au to matically By selecting the +15 lens in the scope and looking at the pupil as in place the macula in full view. Look for abnormalities in the macula a fundus examination [2 inches (5 cm) distance from the patient], area. One can also easily detect lens opacities by looking at the pupil through the +6 lens setting at a distance of 6 inches (15 cm) from the patient. In the same manner, vitreous opacities can be detected by having the patient look up and down, to the right and to the left. Any vitreous opacities will be seen moving across the pupillary area as the eye changes position or comes back to the primary position. Incus When a patient complains of ear pain, examination of the ear is Endolymphatic Malleus Duct and Sac indicated to differentiate whether the patient’s disorder is an ear infection or a disorder originating in adjacent structures, such as the tempomandibular joint, the teeth or the to nsils. As the only window in to the middle ear, the appearance and behavior of the tympanic membrane offer valuable information about possible Cochlea disease within the middle ear. Epitympanic Recess Fortunately, the ear provides easy access for examining and diagnosing disorders of the complex and interrelated ear, nose and throat system. The Welch Allyn o to scope, when used Outer correctly, is the single most important diagnostic to ol available Ear to the practitioner for determining whether the ear is the source of the patient’s complaint. External Ear Canal O to scopy is one of the primary methods a practitioner uses for diagnosing patient complaints for the entire ear-nose-throat complex. Use of a well-designed o to scope which provides illumi nation, magnification and air pressure capability for checking Tympanic Membrane tympanic membrane mobility is, therefore, essential, allowing the practitioner to view the ear canal and, in particular, the Eustachian tympanic membrane with clarity. Tube Tympanic Cavity the examination instructions that follow this section use the Welch Allyn o to scope, which incorporates many features that aid Stapes in achieving an accurate, thorough examination. Welch Allyn’s traditional diagnostic is fastened securely and patient’s ear canal. Apply Adults 4 mm or 5 mm light transmission provides a 360fi ring of light without visual positive and negative air pressure Traditional obstruction or specular reflection. This distal light results in and view tympanic membrane Children 3 mm or 4 mm O to scope glare-free viewing and an easier examination. A focusing wheel, conveniently located on each side of the o to scope and the back eyepiece, is available to the the first type of speculum is reusable and made of lightweight, durable practitioner for adjusting the focal length. KleenSpec tips are made of non to xic When examining tympanic membrane mobility, the plastic and are available in two sizes: 2. The third type of speculum, available for traditional Welch Allyn o to scopes, is SofSpec. SofSpec fits snugly in to the the Welch Allyn MacroView o to scope features external ear canal. These specula are available in three sizes: 3 mm, 5 mm, a unique specula attachment and removal design, and 7 mm and may be cleaned or sterilized by conventional methods. After the examination is complete, the tip can be released from the o to scope For improved seal and comfort during pneumatic o to scopy, the by turning the TipGrip counterclockwise or by simply twisting off the tip SofSeal™ can be placed on the end of either a disposable or reusable with one hand, as is the technique with traditional o to scope models. The first way is to hold the o to scope like a hammer by gripping the to p of the power handle between your thumb and forefinger, close to the light source. You can conveniently hold the bulb of the pneumatic attachment between the palm of the same hand and the power handle. It is recommended that you extend the middle and ring finger outward so they come in to contact with the person’s cheek. This way, any sudden flinch by the patient will not cause the o to scope to be jammed in to the ear canal. The o to scope can also be held like a pencil, between the thumb and the forefinger, with the ulnar aspect of the hand resting firmly but gently against the patient’s cheek. If the patient turns or moves, the o to scope will move in unison with the patient’s head. It is very important that the o to scope be held correctly, particularly when examining children. A sudden movement by the patient could cause the skin on the inside of the ear canal to be pierced by the end of the speculum. It may be necessary to adjust the line of sight and the position of the speculum to get a complete view of the entire ear canal and all areas of the tympanic membrane. If the tympanic membrane or desired area in view is not in focus, the practitioner has the option to adjust the focal length of the optics system of the MacroView o to scope. Gently palpate the pinna to either side of the focusing wheel or on the back eyepiece of the o to scope. To shorten the focal length or zoom in, rotate the focusing wheel to wards the smaller dashes on the side of the o to scope. Inspect the entrance to the ear canal for debris or pus, which might interfere or zoom out, rotate the focusing wheel to wards the longer dashes. Choose the largest speculum that can comfortably be inserted in to the ear removed from the o to scope. TipGrip feature (MacroView only) by rotating the TipGrip counter For adults, this is accomplished by retracting the pinna upwards and backwards. For children, this is accomplished by retracting the pinna horizontally backwards. The handle of the malleus is seen extending downwards and backwards, ending at the apex of the It is the pneumatic capability and insuffla to r attach triangular “cone of reflected light. Gently squeezing the insuffla to r attachment produces small changes in the air pressure of the canal. By observing the relative movements of the tympanic membrane in response to the induced changes in pressure, the practitioner can obtain valuable diagnostic information about the mobility of the tympanic membrane. The pneumatic o to scope may the introduction of a speculum in to the external audi to ry canal also be useful in distinguishing between a thin atrophic intact may cause a reflex dilatation of the circumferential and manubrial tympanic membrane adherent to the medial wall of the middle blood vessels supplying the tympanic membrane. This procedure provides a simple method for Following a prolonged examination of the ear or in a crying child, determining tympanic membrane mobility and is of value in this vasodilatation may produce an appearance mimicking that of the recognition of many middle ear disorders. Exos to ses in the ear canal are more often multiple than single and are usually bilateral. They are usually asymp to matic, extremely slow growing and seldom enlarge sufficiently to occlude the meatus. Multiple exos to ses appear to result from the prolonged stimulation of the bony external canal with cold water and are consequently seen more commonly in persons who swim frequently. In this case, a large piece of sponge rubber was cream colored, thickish debris which may have a fluffy appear removed. In adults, a forgotten piece of cot to n wool is frequently ance due to the presence of tiny mycelia. The foreign body or an unsuccessful attempt to remove caused by Aspergillus niger, it may be possible to identify the tiny it can both product secondary otitis externa or damage to the grayish-black conidiophores. In young children, it is sometimes is often inflamed and granular from invasion by fungal mycelia. In the early stages of acute otitis media, the tympanic the skin of the ear canal is painful, infected and swollen, and it membrane varies according to the stage of the disease. There is tympanic membrane is retracted and pink with dilatation of the often a considerable amount of keratin debris in the canal which manubrial and circumferential vessels.

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The World Federation for Mental Health set the workplace as its focus for two consecu tive World Mental Health Days in 2000 and 2001 symptoms 2016 flu discount generic mentat ds syrup uk. This action identified the workplace and the role of employers as key entry points for promoting mental health and creating healthy environments medicine 1975 lyrics order 100 ml mentat ds syrup with mastercard. This represents a broad view of the role of work for mental health and well-being conventional medicine generic mentat ds syrup 100 ml free shipping. Not only does it identify the role of conditions within the workplace but also the importance of meaningful employment itself for positive mental health medications migraine headaches buy mentat ds syrup online from canada. As described in earlier chapters symptoms 8dpiui mentat ds syrup 100 ml with mastercard, social and econo mic disadvantage is linked to higher prevalence of mental illness (Desjarlias & Kleinman, 1997). The mental health of employees is essential for both their well being and for the effective operation of the organization. The most significant research in this area is in the context of how the organization of work can induce stress that in turn affects both health and productivity. The scientific evidence on stress, health and performance has concentrated on two paradigms: the Demand/Control Model (Karasek & Theorell, 1990) the Effort/Reward Imbalance Model (Siegrist, 1996). The essence of these models is that to o much demand coupled with to o little job control and to o much effort coupled with to o little reward are stressors complicit in the produc tion of numerous types of illness and injury. These harms range from the common cold to cancer and include injuries such as repetitive strains and back problems. Increasingly, it appears that both pairs of conditions are likely to co-exist in the same workplaces. The framework calls for the concept of the healthy workplace to be an integral component of the busi ness place and for: a broad-based commitment of workers and management in all stages; a partnership which permits all participants to address a full range of issues; targeting of health issues which are a priority of workers; researchers to act as technical resources and facilita to rs. Results from the programme have demonstrated how the meaningful involvement of staff in decision-making about their own health and welfare at work leads to higher levels of satisfaction and reduced stress levels. Work offers opportunities to engage in the civil and eco nomic life of a community (Pavis, Platt & Hubbard, 2002). Economic fac to rs directly affect mental health in both developed and developing countries. For example, the banking and credit sec to r has an enormous impact on the mental health of communities. Selling off farms to repay loans not only takes away the livelihood of individuals but also results in loss of identity and family cohesion. The mechanisms by which micro-credit and income generation schemes have an impact on mental health are detailed in Chapter 14. The past 30 years have seen significant workplace health improvements in some countries in res pect of physical and to xic hazards, and workplace health promotion initiatives that have helped to encourage healthier behaviours by individuals. However, the situation in many low income coun tries remains severe in the face of human rights abuses such as forced labour and child labour. These abuses require a range of political and social interventions beyond the workplace as well as within (see Chapter 7). Even in affluent countries the social and psychological demands of work are increasing. These demands arise from managerial decisions that in turn are constrained by the wider economic, political, social and political environment (Polanyi et al. Even within the workplace, successful promotion of mental health must extend beyond the tra ditional boundaries of occupational health and individually focused health promotion strategies. Neither the provision of a safe physical environment nor the promotion of a healthy lifestyle is sufficient. It is now time to : tackle the bigger, more controversial task of creating healthier workplaces that can create the working conditions necessary for good health. This will require the difficult task of striving to balance economic strength, social equity and for survival over the lon ger term, environmental sustainability (Polanyi et al. Such a move in no way negates the need for occupational health strategies or workplace health promotion programmes but rather calls for a greater emphasis than there is at present on orga nizational and societal determinants of worker health. A more comprehensive approach incorpo rating inter-related strategies is required. Employers who provide safe and supportive work envi ronments for all their staff can do more than prevent stress and injury: they can provide mentally healthy environments which will promote mental health and potentially improve performance and productivity (McKernon, Allen & Money, 2002). Promoting health and mental health in the workplace has developed as a priority from evidence that employers who attend to their responsibilities to be good employers and provide supportive work environments have reduced absenteeism, less workplace stress, fewer accidents, less staff turnover and higher performance. It emphasizes that effective practice involves partnerships between employers and staff. In its development phase, the Foundation market-tested the content and format of the to olkit. This consultative process drew on the wisdom and practices of the private sec to r partners, identifying that employers wanted practical and helpful to ols that improved productivity. This process also enabled employers to see that a mentally healthy organization was also potentially a more enjoyable and profitable one. The consultative process will hopefully contribute to relevance and sustainability of the resource and the partnerships. Alongside the resource, tailored training programmes and employer forums are expanding the programme of activity in response to employer feed back. The following table outlines some of views on mental health of staff and employers. At the indi vidual level, participants can discover and develop skills, increase their self-esteem, build social networks and improve the sense of control over their lives. In the case of young people, involvement in creative activity can result in improved academic achievement, school retention rates and levels of self-esteem and reduced drug and alcohol consumption and juvenile offending (Heath & Soep, 1998). Community-based arts activity can also make a considerable contribution to community health, development and renewal (Williams, 1997). Taiho is a collective of Maori women who use a combination of theatre and Maori processes to investigate local issues through the retelling in dramatic form of people’s s to ries. The Hokianga, where Taiho is based, is one of the poorest and remotest regions in New Zealand, with a high proportion of young Maori and unemploy ment rates in some areas of over 50%. O’Connor and colleagues (2003) suggest the power of working with s to ries with Maori is that, like most colonized and oppressed groups, they are more accus to med to their s to ries being systematically suppressed. Taiho theatre uses existing forums, including local iwi (tribe) sporting and cultural events and family reunion days on local marae (traditional meeting houses), and works in mental health facilities that operate within Maori models of healing. The layers of partnership relationships in the project are instructive in understanding the links between policy, par tnership and theatre process in mental health promotion. Government policies to counter stigma and discrimination associated with mental illness led to funding of the national Project to Counter Stigma and Discrimination Associated with Mental Illness. Government priorities aimed at redu cing economic and social disparities for Maori also provided funding opportunities. In the series of theatre events staged by Taiho, the community explored their own s to ries and reflected on their needs and possible solutions. Government policies of ”fixing mental health and Maori issues” became a process by which those who lived the s to ries attempted to understand how to better live with them. The Mental Health Foundation concluded that the way the Company worked meant it was seen as part of the community, rather than as an agent from outside that brought theatre to the community, and that this was one of its strengths. They publicly reflect the values, beliefs, diversity, aspirations and identity of the people who live there. Public spaces have the power to uplift, chal lenge, inspire, celebrate and unite (City of Yarra, 2003). In a public housing estate in Melbourne, Australia, the Public Housing Estate Arts Committee (made up of resident and community members) oversees an arts and environ ment project managed by local government. Planning for the project began in 2001 and has, over time, embraced many of the estate’s 2400 residents. Residents have been consul ted at each stage of the project and their aspirations for the area continue to be included and implemented where possible. The new space is attracting people to participate in workshops (practical and cultural); see films, performance and art exhibitions; rehearse for theatrical performances; and design floats for arts festivals. Residents are taking a leading role in the transformation of the car park from a disused urban site to a creative space. As well as mosaic designs on the floor, murals have been painted by an Indigenous mural painting group that includes residents. New and improved lighting has also been installed, along with sculptural works, and fern gardens have been planted in the light wells. It is a safe and friendly place where residents and people from the local communities can meet and organize events. The appointment of a part-time cultural officer (funded by Government) is likely to be a further boost to the area. Other mental health outcomes include the creation of social connections, drawing people out of their flats and in to their community and thus brea king down residents’ sense of isolation. This partnership of local government and state government departments, combined with local community groups, has resulted in creative actions to achieve the transformation of a public space. The dual outcomes of improved mental health from the collaborative practice and the creation of a space that will continue to provide opportunities for connection and creativity breaks new ground in what can be achieved from intersec to ral collaboration. Durable structures that support planning and deci sion-making, such as local committees, councils and voluntary agencies, are key fac to rs in succes sful alliances and partnerships for health promotion (Gillies, 1997). In this context, the arts, in par ticular theatre arts, have traditionally been used in mental health promotion for two purposes: as events attached to the beginning or end of a campaign or project to give it media attention and as a communication strategy to convey a health message in a way that engages an audience. This latter strategy is particularly suited to low income countries, where there may be few resources but a long his to ry of s to ry-telling and education through drama and songs. More recently, the community development aspect of arts-based programmes has been highlighted. This involves such processes as groups being supported to determine their own s to ries and communicate them through music, song, dance and theatre. These more participa to ry and democratic forms of theatre process are being incorporated in to health promotion strategies to create dialogic relationships and partnerships between health promoters and the communities they work within (O’Connor et al. Mental health outcomes include increased self-esteem, social inclusion and sense of well-being (Matarasso, 1997). Two effective arts-based mental health promotion programmes are described in case studies 20. Globally, the use of theatre in health activities is accepted as an important and culturally appro priate contribu to r to engagement of communities in the process of articulating their health con cerns. This practice provides opportunities to gain insight in to the lived experiences of individuals and communities and facilitates understanding and healing. It also provides access for a wider audience because literacy skills are not prerequisites to engage in the activities. Community involvement Community development strategies have been the corners to ne of primary health care. This approach gives primacy to the development of collaborative relationships with communities that are respectful of their needs and priorities. That is, in activities between different sec to rs, agencies and communities, the process of negotiation and action is an integral part of relationship building – a process that can enhance the mental health and well-being of participants.

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The range of frequencies heard is about 20 feet medications xl generic mentat ds syrup 100 ml mastercard, whereas the whispered available may be fixed at octave or half octave Examination of the Ear 37 intervals between 64 and 8 medicine for stomach pain purchase mentat ds syrup visa,192 cycles/sec (if trap medicine administration buy mentat ds syrup 100 ml on-line, cough-drop symptoms of strep throat discount mentat ds syrup 100 ml mastercard, etc treatment bladder infection purchase discount mentat ds syrup on-line. Whispered voice is Helmoltz scale is used) or there may be conti used at the end of normal expiration and is nued sweep between 0 and 10,000 cycles/sec. The so calibrated that at zero for each selected other ear being masked by the finger on tragus frequency a person with normal hearing can or rubbing the non-test ear with a piece of just hear the test to ne. The distance at which the patient can As sound at a level of 60 dB or more can be hear the conversational and whisper voice in heard in the untested ear, it is advisable to use a reasonably quiet surrounding are noted. Masking is essential distance is reduced for whisper voice in high when there is considerable difference in the frequency loss than for conversational voice. The value of the pure to ne audiometer test Tuning Fork Tests depends upon the following: Tuning forks provide a simple, easy and i. The following tests are Each ear should be tested separately for all commonly in use: frequencies (usually 7) with masking of untested ear when necessary. The fork is struck gently on the elbow, knee cap, hypothenar eminence or a rubber pad and Voice Tests held in such a way so that the prongs vibrate Speech tests though less accurate are simple against the ear in line with the external canal and easily understandable to the patient. The air conversational and whispered voice tests are conduction of the sound is compared with conducted in reasonably quiet surroundings. To test the bone conduction, the material for speech tests may be spondee the foot piece of the fork is placed on the words or numbers. The patient is asked to indicate which bic words having an equal stress on both of the two is louder or where he hears for the syllables like arm-chair, to othbrush, mouse longer time. But in reality, this is false as he is hearing this bone conducted sound across the skull through the normal ear. In these cases, the test is repeated by masking the normal ear while testing the affected ear. Normally air conduction is better than bone conduction, which is called Rinne’s Weber’s Test positive. In patients with sensorineural A vibrating tuning fork is held either on the deafness, both air and bone conduction of vertex, root of nose or on the upper incisor sound are diminished but air conduction teeth (Fig. This is equally on both the sides, in the centre of the called Reduced Rinne’s positive. A Weber’s centralised and is found in normal patient with severe unilateral sensori persons or may occur in patients having Table 5. If the examiner also does not hear the than the other, then it is called Weber’s sound of the fork when the patient has lateralised to that particular side. Weber’s s to pped hearing it, then absolute bone test gets lateralised to the deaf ear in con conduction is regarded as normal. The of bone conduction in presence of air conduc hearing of the examiner is considered to be tion. The vibrating fork is held on the bone conduction test but without occluding mas to id of the patient, closing the external the external audi to ry canal. The fork is then transferred by the examiner to his own mas to id closing Plain X-rays of the temporal bone help in the external meatus. The absolute bone determining the extent of middle ear and conduction of the patient is thus compared mas to id disease, the condition of the ossicles with that of the examiner. If the examiner still hears the vibration of with the film and the direction of the beam is the fork, when the patient has s to pped 25-35° fron to -occipital (Figs 5. The scanner has a diagnostic cells and thus helps in determination of accuracy of 98 per cent and the great advant the posterior extent of the pneumatisa age is that it is noninvasive and the radiation tion. Aditus, attic and antrum are demon pictures in a wider range of densities than the strated. It clearly pin the external audi to ry canal and tympanic points pathology like tumours, intracranial cavity are obscured by the bony labyrinth. The view is taken mainly to seen following the injection of an iodised demonstrate following structures: contrast material in the patient. Pin-pointing of the pathological spots demonstrates both petrosa on the same film facilitates in accurate surgery. The ossicles are shown clearly within a radio-opaque dye may be done for eusta the external audi to ry canal. This test was invented by Dye injected in to the middle ear deter Hounsfield who received the Nobel prize for mines the patency of the tube as well as helps 42 Textbook of Ear, Nose and Throat Diseases in assessing eustachian tube function by 4. The nuclei are aligned in a Cranial Nerves strong magnetic field and a radiofrequency pulse applied. After this pulse is removed, the the fifth cranial nerve is tested by eliciting the nuclei return to their original orientation emit corneal reflex. The image is cot to n wisp and normal brisk closure of the created by specially encoding the emitted eyes occurs. The sagittal, coronal and even oblique Nystagmus is the rhythmic oscilla to ry move sections can be taken to find the exact ment of the eyes and has two components, extent and location of the tumour. Examination of the Ear 43 Second degree nystagmus: Also present field of vision in various directions. If the labyrinth is irritated on one side, Under anaesthesia, the quick component spontaneous nystagmus occurs to wards that is eliminated and only the slow or vestibular side and when the labyrinth is destroyed, the movement takes place and results in conjugate nystagmus occurs to wards the opposite side. The function of the vestibular system may In labyrinthine nystagmus there is a slow be evaluated by stimulating the labyrinth and component of vestibular origin and a quick noting the change in its response. Each nystagmus may be produced by the following labyrinth tries to deviate the eyes slowly to tests. When the cerebral cortex In this test the labyrinth is stimulated by the becomes aware of this deviation, it brings in changes in temperature. This is done by effect the correcting reflex, thus bringing the irrigating the external audi to ry canal with hot eyes quickly back to the original position. This is done because the anterior the vestibular nystagmus is fine, always end of the horizontal semicircular canal is horizontal and does not last for more than six about 30o higher than its posterior end. The patient’s head is kept steady and the endolymph and thus the labyrinth is he is asked to follow the direction of the finger stimulated. Nystagmus occurs and its tip of the examiner, which is moved across the duration nystagmus is compared on both 44 Textbook of Ear, Nose and Throat Diseases sides. Normally the nystagmus persists for intensity nystagmus, which may not be visible about two minutes. Caloric test with Dundas-Grant apparatus In Bithermal caloric test (differential caloric test) or patients with perforation of the tympanic Fitzgerald and Hallpike test this test is done by membrane water cannot be injected in to the irrigating the external audi to ry canal with external canal. In such patients the Dundas water having a temperature 7o above body Grant metallic coil is used. Ethyl chloride is temperature (44oC) and 7o below body tem sprayed over the coil and air is passed by perature (30oC). Rotation Test Cold stimulation produces nystagmus the patient is placed on a revolving Barany’s to wards the opposite side and hot stimulation chair which is rotated at the rate of ten revolu produces nystagmus to wards the same side. The chair is then suddenly the duration of nystagmus is measured on s to pped and the postrotational nystagmus both sides. Both labyrinths are stimulated at the the average time, it is called canal paresis same time, hence the test is not of much (hypoactive). This is due to the Op to kinetic Test loss of to nus elements and commonly occurs to wards the normal ear. A white rotating drum with black vertical lines Nystagmus may be observed unaided or is used. The drum rotates on a horizontal with the help of Frenzel’s glasses worn by the plane. The patient is seated at a distance of 3 patient to prevent optic fixation and provide feet from the drum. Characteristic tracings are seen in peripheral and central vestibular disorders, Fig. This technique allows the recording the vertical lines on the drum to either side. It the drum is s to pped and eyes are examined provides a base line record and subsequent for nystagmus. In central vestibular lesions, allows the evaluation of other parameters of the nystagmus of one side is suppressed. An electric diminished by o to to xic drugs like strep field exists between the cornea (electrically to mycin, neomycin, etc. The electrodes are placed lateral to each eye Normal frequency but reduced amplitude and on the forehead between the eyes. Eye tracking tests: In this test eye move Past Pointing ments in response to a visual pendular the patient has a sensation of objects turning simulus are recorded which normally away from him which, he voluntarily attempts produces a sinusoidal curve. This dal curve is always due to central lesions effect is due to presence of vertigo. It is a rotation test to assess the vestibular function by utilising minimal stimuli. Positional nystagmus can be induced by plac A special turning chair is used in which the ing the patient’s head in different positions. The patient is taken backwards for Subthreshold acceleration is given to the about 10 seconds, if the nystagmus appears, turning chair and maintained till every the position is maintained for 30 seconds. This is repeated at different veloci period, direction, duration and fatiguability. The duration of after-sensation and after Fine, horizontal, fatiguable nystagmus occurs nystagmus are recorded on a logarithm scale. Rota to ry or horizon to rota to ry the test is based on the fact that the nystagmus which is nonfatiguable is seen in cupulae of the semicircular canals respond to central lesions. Angular acceleration which Romberg’s test when maintained for 20 sec is sufficient to evoke a just recordable nystagmus is known this test is conducted by asking the patient to as threshold. In case of the central lesion the patient swings or fall to wards the direction of the Craniocorpography provides a rapid graphi quick component. The basis of craniocorpo test considers walking deviation and lateral graphy is the Unterberger test, established as balance of the patient and provides more the most sensitive method for accurate clinical explicit information allowing better discrimi studies of the spinal vestibular system. The cases of absent pinna can be given a prosthesis or treated by plastic reconstruction using moulded rib cartilage. Accessory Auricles these present as small elevations of skin often containing the cartilage, just in front of the tragus or the helix (Fig. This is an inherited condi tion and is homologus to the tip of the ear in mammals. Preauricular Sinus Bat Ear these are blind tracks lined by squamous this deformity consists of an abnormal epithelium occurring in the region of the protrusion of the pinna with absence of the auricle, usually near the tragus and root of the antihelix. These arise because of incomplete fusion require surgery, the aim is to create an anti of the tubercles during development (Fig. These have an upper opening in the floor of Anomalies of the External Audi to ry Canal the external audi to ry meatus and the lower opening behind the angle of jaw at the ante the congenital abnormalities of the external rior border of sternomas to id. The Dermoid Cysts malformed external canal is usually filled with these may occasionally occur in relation to dense bone, sometimes cartilage and dense the pinna.

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