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Medicalmanagement of Preterm baby of 33 To 34 Weeks with Mild Hyaline Membrane Disease 2659 septicemia Culture Positive Hyperbilirubinemia not requiring ventilatory support medications john frew order bimat 3 ml fast delivery. Medical management of Preterm baby of 33 To 34 Weeks with severe Hyaline Membrane 2660 Disease septicemia Culture Positive Hyperbilirubinemia requiring ventilatory support/ bubble Cpap treatment juvenile rheumatoid arthritis cheap generic bimat canada. Medical management of Preterm baby of 30 To 32 Weeks with severe Hyaline Membrane 2661 Disease septicemia Culture Positive Hyperbilirubinemia requiring Mechanical ventilatory support symptoms 6 weeks purchase bimat 3 ml fast delivery. Medical management of Preterm baby of 33 To 34 Weeks with severe Hyaline Membrane 2662 Disease septicemia Culture Positive Hyperbilirubinemia Patent Ductus Arteriosus requiring Mechanical ventilatory support treatment of gout buy bimat 3ml low price. Medical management of pre-term baby of <30 Weeks Severe Hyaline Membrane Disease 2678 Septicemia Culture Positive treatment zone tonbridge purchase bimat line, Hyperbilirubinemia Patent Ductus Arteriosus requiring Mechanical Ventilation. Phenol, Lignocaine 149 2954 Motor point blocks 2955 Regional nerve blocks 2956 Stellate ganglion block 2957 Coeliac plexus nerve block 2958 Neuraxial blocks B4. Scopies 2962 Arthroscopy diagnostic and therapeutic 2963 Cystoscopy in neurogenic bladder 2964 Proctoscopy E. Advanced interventions 150 2965 intra-thecal pump 2966 Neuro-prosthetic implants 2967 Osseointegration 2968 Stem cell therapy F. Day Care d) Referral criteria: 153 *Situation 2: At Super Specialty Facility in Metro location where higher-end technology is available a) Clinical Diagnosis: b) Investigations: c) Treatment: Standard Operating procedure a. National Programme for Prevention and Control of Deafness Management of Common Ear Conditions 4. National Leprosy Eradication Programme (i) Training Manual for Medical officer (ii) Disability Prevention & Medical Rehabilitation 6. National Vector Borne Disease Control Programme (i) Case Management of Acute Encephalitis Syndrome / J. National Blindness Programme Pre-operative, Operative and Post-operative precautions for Eye Surgery 9. Agenda 1 Welcome and introductions 2 Provisions and benefits of Clinical Establishment Act and Current status in the country 3 Queries of representatives/stakeholders/participants from State. Health Care Support 7 Health Care Support Services Schedule H Services Departments 9. The major assumptions on apportionment of cost are: a) Costs which are directly identified with the surgery b) Costs are apportioned based on time of surgery wherever applicable. This includes of preparation time of one hour, surgery time of 6 hours and cleaning time of one hour. The cost has been appropriately absorbed when the same manpower is used for other procedures/surgeries. Non-Medical Asset cost can be apportioned to Surgeries/ Procedures in the ratio in which the surgery/procedure performed 10. Lab investigations: If the investigations are done in-house, costs such as equipment cost, manpower cost, chemicals and consumables cost etc. If this service is outsourced, then a ratio of utilisation of the lab for the purpose of the Hospital can be taken into the cost pool and allocated on the basis of the number of patients with respect to each of the investigation. If there is a specific 167 arrangement between the service provider and the Hospital, the cost should be taken accordingly and then further allocated to the respective departments/ patients. Since Blood Bank is outsourced in many cases, cost per unit of blood can be considered as cost to the hospital. Average life-time of Non-Medical Assets used in Pharmacy is considered as 5 years. Average life-time of Non-Medical Assets used in Ward can be considered as 5 years. In case of Medical Equipment specific for General Ward, depreciation, power consumption & other maintenance costs for Ward are to be considered. Admission department cost has to be arrived on per admission basis, and this can be considered for the specific procedure/surgery. This has to be considered for the specific surgery based on the number of days stay in Ward. Health Care Administration Overheads: Per day per bed cost for the following supporting service departments has to be computed and these are multiplied by number of days stay and considered as Other Indirect cost for the specific surgery: a. Schedule C Rupees Direct Employees Cost (In 000s) Particulars Procedure Total Super Specialist Specialist Assistant/Attending/Resident Others Total Costs Note: If the nomenclature used is different, please mention the same in brackets. Wherever technicians are dedicated, cost is Man power allocated to that department Number of investigation in each department within the lab. Wherever technicians are dedicated, cost is Man power allocated to that department Number of procedures in each department within radiology. Wherever materials are particular to a machine, cost allocated to procedures from such Consumables machine. Despite the large number of original research studies on carpal tunnel syndrome, considerable uncertainty and even controversy exists in the medical community about its extent and etiology, the contribution of work and non-work risk factors to its development, the criteria used to diagnose it, the outcomes of various treatment methods, and the appropriate strategies for intervention and prevention. The intent of this investigation is to establish a current, valid, clinically important and applicable foundation of peer-reviewed scientific evidence that can be used to make evidence-based decisions about the diagnosis, causation and treatment of carpal tunnel syndrome. Because high quality, clinically relevant research is a small subset of the journal literature and can be difficult to find, the selection of original research studies for consideration in this review was a systematic and deliberate process that involved multiple stages: establishing a research context, executing literature searches, reviewing titles and abstracts, identifying articles for retrieval, and finally selecting, classifying and critically appraising the original research studies that make up the primary evidence base. The carpal compression test and the hand symptom diagram also appear to be useful diagnostic tools. Combinations of independent tests (models) likely perform better diagnostically than do single tests. With the exception of thenar wasting, all clinical diagnostic methods rely on subjective input. Use of electrodiagnostic study findings as the sole diagnostic tool is not recommended: they must be correlated with the history and physical examination. There is ample evidence that the accuracy of the available diagnostic tools is not very good. A variety of contributing etiological factors and conditions can affect the median nerve in the carpal tunnel. Genetic predisposition may play a major role in the causation of carpal tunnel syndrome. While several studies in the evidence base reported risk of carpal tunnel syndrome associated with job tasks that require exposure to forceful repetitive wrist motion, others did not demonstrate that association. It has by no means entered the mainstream of medical thought and its applicability to clinical medicine is not clear at this point. Bilateral carpal tunnel syndrome should prompt a review for systemic medical conditions that may cause peripheral neuropathy. Neither study showed a statistical difference in benefit between the two procedures. This relief may be temporary, and limited by the risk of repeated steroid injections into the carpal tunnel. Oral steroids may also provide a measure of symptom relief, though this is a less common approach for most clinicians, and has additional risks. In such cases, expedited medical and surgical assessment is required due to the risk of progressive and permanent neurological damage. In the vast majority of cases, electrophysiological testing 11 should be performed prior to surgery to confirm the diagnosis. Surgical treatment is usually only offered to electrophysiologically confirmed cases with no underlying reversible disorder. The patient should undergo a thorough re-examination and repeat electrodiagnostic assessment to rule out other, less common causes of peripheral neuropathy. Following surgery, most patients can return to light hand use following the removal of sutures, but may not tolerate the use of tools that require a power grip for an average of six to eight weeks. Increased pressure on the median nerve in the carpal tunnel can result in progressive sensory and motor disturbances in parts of the hand innervated by this nerve, leading to pain and loss of function. Despite the large number of original research studies on carpal tunnel syndrome, controversy persists among physicians about its extent and etiology, the contribution of work and non-work risk factors to its development, the criteria used to diagnose it, the outcomes of various treatment methods, and the appropriate strategies for intervention and prevention (Sluiter 2001). Confusion in the general public is compounded by the dubious quality of the information about carpal tunnel syndrome found in the popular media and on the World Wide Web: as the Internet is a main source of medical information for patients, it is likely many are misinformed about 1 carpal tunnel syndrome (Beredjiklian 2000). The intent of this investigation is to establish a current, valid, clinically important, and applicable foundation of peer-reviewed scientific evidence that can be used to make evidence-based decisions about the diagnosis, causation, and treatment of carpal tunnel syndrome. The research team selected the criteria for retrieving articles and including studies, critically appraised the scientific evidence on the diagnosis, causation and treatment of carpal tunnel syndrome, and formulated evidence-based answers to the research questions. We confined ourselves to the science base and the conclusions that the science could bear: policy considerations were not a part of our mandate and were not addressed in our deliberations. This report is based on information that was collected between January and September, 2003. More than 90% (36/39) of the articles that met our inclusion criteria (and were therefore included in our primary evidence base) were published after this date. Research questions this background paper systematically evaluates the scope and quality of the available scientific evidence on diagnosis, causation and treatment of carpal tunnel syndrome to answer 24 research questions. Questions 1-6 address diagnosis of carpal tunnel syndrome, questions 7 17 address causation of carpal tunnel syndrome, and questions 18-24 address treatment of carpal tunnel syndrome. Together, the 24 research questions (found in Figure 1) define the scope of the background paper. Items not addressed by the research questions are beyond the scope of this document. It is in these sections of the report that the 24 research questions are answered. What indicators suggest that a patient can reasonably be expected to return to work following a course of conservative therapy or surgery Is there a role for pre and post operative electrodiagnostic testing in assessing work return, recurrence or prognosis Definition, classification and characterization of carpal tunnel syndrome Carpal tunnel syndrome arises from the intermittent or continuous compression or entrapment of the median nerve as it passes through the carpal tunnel from the wrist to the hand. However, when such diseases affect the worker, they may be work-related in a number of ways: they may be partially caused by adverse working conditions; they may be aggravated, accelerated or exacerbated by workplace exposures; and they may impair working capacity. Dimensions of the problem: occurrence and distribution While carpal tunnel syndrome is believed be a common clinical condition, its prevalence and incidence in general and working populations have not been reliably established by epidemiological studies. There are a number of caveats with respect to the interpretation of epidemiological data on carpal tunnel syndrome. For example: • Variable diagnostic criteria and lack of agreement on a gold standard for diagnosis of carpal tunnel syndrome have a significant impact on any statistic of prevalence. In work-related diseases, in contrast, the work environment and the performance of work contribute significantly, but as one of a number of factors, to the causation of a multifactorial disease. Occupational diseases therefore stand at one end of the spectrum of work-relatedness, where the relationship to specific causative factors at work has been fully established and the factors concerned can be identified, measured, and eventually controlled. General population survey data do not and cannot distinguish cases of carpal tunnel syndrome that may be associated with work from those not likely to be associated with work in the study populations. The data include work and non-work-related cases of carpal tunnel syndrome without distinction. Rates derived from these general population sources cannot be considered in any sense equivalent to rates for background, reference, or unexposed groups. Carpal tunnel syndrome in general populations A general 1997 health survey in southern Sweden found that 354 responders (prevalence 14. Nerve conduction testing showed median neuropathy at the carpal tunnel in 120 symptomatic subjects (prevalence 4. On clinical examination, 94 symptomatic subjects were diagnosed as having clinically certain carpal tunnel syndrome (prevalence 3.

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In this way medicine 5277 discount bimat online american express, over time medicine effexor purchase bimat in india, the Joint Commission will develop a compendium of recommended practices that will improve patient safety symptoms 6 year molars buy online bimat. Patient Safety Principles the College and the American Academy of Pediatrics also have a long-standing commitment to medications quit smoking purchase cheap bimat line patient safety and quality medicine encyclopedia order 3 ml bimat with visa. To improve patient care and reduce medical errors, they encourage all health care providers to promote the follow ing four principles in all practice settings, which are discussed in the following paragraphs: 1. Improve communication Culture of Patient Safety A culture of patient safety continuously evolves and should be the framework for every effort to reduce medical errors. Patient safety focuses on systems of 68 Guidelines for Perinatal Care care, not individuals. Confidential reporting and analysis of errors and near misses will reveal areas that require remediation to provide improved patient safety. State and federal laws may have an effect on the level of confidentiality and the manner of reporting. A culture of patient safety starts at the top with strong leadership that provides the necessary human and financial resources to achieve patient safety. Additionally, a culture of safety recognizes the importance of team function in optimizing individual performance. A culture of patient safety fosters open communication and welcomes input from team members at every level. Care must be taken to ensure that hierarchical systems do not hamper free com munication among physicians. Competing clinical demands, interruptions, and distractions are inherent in clinical practice. It requires specific effort to ensure that issues are understood and that meaningful information is trans ferred. Certain clinical communications should be verified, such as reading back medication orders. Safe Medication Practices Medication errors are one of the most common types of preventable adverse events. Automated systems for prescribing and dispensing medication can greatly reduce these errors, but there are many low technical support solutions that can be implemented rapidly with minimal cost, such as the following: • Improve the legibility of written orders. Reduce the Likelihood of Surgical Errors the College and the American Academy of Pediatrics, along with other spe cialty societies and other organizations, have endorsed the Joint Commission’s Quality Improvement and Patient SafetyCare of the Newborn 6969 Universal Protocol to Prevent Wrong Site, Wrong Procedure, and Wrong Patient Surgery. The Joint Commission now requires this protocol as part of a preoperative time out, which involves all members of the operating room team, including the patient (see “Bibliography” in this chapter). In obstetrics, the time out process does not need to be limited to patient identification and planned procedure, but also may provide an opportunity to ensure the comple tion of other patient safety or clinical recommendations, such as administra tion of antibiotics before cesarean delivery, communication of critical neonatal information with pediatricians or the possible need for and availability of blood products, or at the completion of vaginal delivery to ensure the absence of retained vaginal sponges. Communication Physicians should be aware that complete and accurate communication of med ical information is critical in reducing preventable medical errors. Improving communication skills merits the same attention as improving clinical skills. According to information gathered from the Joint Commission, in collecting sentinel event information, the most common cause of preventable adverse outcomes is communication error. Optimal communication to improve patient safety has many dimensions including the following: • Communication with the patient and the family • Communication among all those caring for the patient • Availability of information necessary for coordination of care Physician–Patient Communication. The key to a good physician–patient rela tionship is the ability to listen, explain, and empathize. This is particularly important if the patient is under stress, which negatively affects her ability to grasp important messages. Preventive Services Task Force defines shared decision making as a process in which both the patient and physician share information, participate in the decision-making process, and agree on a course of action (see “Bibliography” in this chapter). Another factor potentially limiting communication is health literacy, which is unrelated to level of education or social status. In order to have a meaning ful discussion with an individual about her health care, it is imperative that one recognize and address the patient’s level of understanding and knowledge. A very important part of physician–patient communication is when and how to disclose medical errors. The Joint Commission requires that accredited hospitals inform patients of adverse events. They should be informed that the factors involved in the injury will be investigated so that steps can be taken to reduce the likelihood of similar injury to other patients. Improving the disclosure process through policies, programmatic training, and available resources will enhance patient satisfaction, strengthen the physician–patient relationship, potentially decrease litigation, and most importantly promote higher quality health care. Physician-to-physician handoff of patient information is one of the most important factors to focus on to prevent discontinuity of care, eliminate preventable errors, and provide a safe patient environment. Inaccurate information and missing clinical data can result in serious medical errors and patient injury. Physician Fatigue and Patient Safety Individuals who are tired are more likely to make mistakes. Reducing fatigue may improve patient care and safety as well as improve a health care provider’s Quality Improvement and Patient SafetyCare of the Newborn 7171 performance satisfaction and increase communication. Although there are no current guidelines placing any limits on the volume of deliveries and procedures performed by a single physician or the length of time physicians may be on call and still perform procedures, it is imperative that physicians recognize their limitations caused by fatigue. Recovery from a period of insufficient sleep generally requires at least two or three full nights of adequate uninterrupted sleep. The following recom mendations adapted from the National Highway Traffic Safety Administration guidelines offer some guidance that may assist obstetric and neonatal care pro viders in achieving a balance between work schedules and continuity of patient care: • Arrange work schedules to take advantage of circadian influences. If a 2-hour nap cannot be scheduled, sleep no more than 45 minutes to avoid deep sleep and difficulty with arousal. Individual practitioners and group practices should examine their sleeping habits and work schedules to ensure an optimal balance between fatigue and continuity of patient care. Although there may be an economic effect of such considerations, patient safety should take precedence. Drills and Simulator Training the principle that standardized care can result in safe care applies to emergen cies as well as to routine care. Thus, each service should consider a protocol for management of common emergencies. This training may use a sophisticated simulated environment, but it also may use the everyday workspace in a mock event. Protocols also can be reinforced by being prominently displayed as post ers, pocket cards, or other aids. Emergencies occur in a specific physical setting and may involve a group of nurses, physicians, and other health care providers attempting to respond. By conducting a drill in a realistic simulator or in the actual patient care setting, issues related to the physical environment become obvious. Emergency drills also allow physicians and others to practice principles of effective communication in a crisis. Many aspects of the medical environment work against effective communication, including the often hierarchical hospital structure, and the nature of the training, work setting, and the different educa tional backgrounds and levels of understanding of the health care team. It requires that there be a team leader coordinating the response, but it also should empower all members of the team to share informa tion. By practicing together, barriers hindering communication and teamwork can be overcome. Effective drills may lead to improved standardization of response, health care provider satisfaction, and patient outcomes. Simulator training also may be beneficial with respect to identifying com mon clinical errors made during emergencies and correcting those deficiencies. Although this is promising, there are limited data to suggest that improved proficiency with simulation models correlates with increased proficiency during actual emergencies. The March of Dimes recommends that these patient handoffs be face-to-face, structured, uninterrupted, and provide opportunity for clarification of information between participants. Standardized verbal tools, electronic tools, or both are important aids in this process. Teams including obstetric care providers can be used to practice simulated high-risk events in labor and delivery. Becoming a high reliability organi zation: operational advice for hospital leaders. Quality Improvement and Patient SafetyCare of the Newborn 7575 National Transportation Safety Board. Introduction to the Universal Protocol for preventing wrong site, wrong procedure, and wrong person surgery. Society of Obstetricians and Gynaecologists of Canada; Healthcare Insurance Reciprocal of Canada. Chapter 4 Maternal and Neonatal Interhospital Transfer ^ the primary goal of regionalized perinatal care is for women and neonates at high risk to receive care in facilities that provide the required level of special ized care. Neonates born to women transported during the antepartum period have better survival rates and decreased risks of long-term sequelae than those transferred after birth. Delivery in a center providing high level neonatal care offers availability of pediatric subspecialists for early diagnosis and treatment of life-threatening conditions. Because all hospitals cannot provide all levels of perinatal and neonatal care, interhospital transport of pregnant women and neonates is an essential component of a regionalized perinatal health care system. Both facilities and professionals providing health care to pregnant women need to understand their obligations under federal and state law. The Emer gency Medical Treatment and Labor Act defines the responsibilities of both transferring and receiving facilities and practitioners. Federal law requires all Medicare-participating hospitals to provide an appropriate medical screening examination for any individual seeking medical treatment at an emergency department to determine whether the patient has an emergency medical condi tion (Appendix G). However, there have been misinterpretations of these laws that have been barriers to optimal health care. For example, the medical condition of a woman having contrac tions is not considered an emergency if there is adequate time for her safe trans fer before delivery or if the transfer will not pose a threat to the health or safety of the woman or the fetus. Maternal and neonatal transport programs are typically considered separately because they each have particular characteristics, requirements, and are generally overseen by their respective specialists. Maternal Transport Maternal transport refers to the transport of a pregnant woman during the antepartum period or intrapartum period for special care of the woman, the neonate, or both. Occasionally, the same system is used to transport a postpar tum woman so that the mother can either be with her baby or receive a higher level of care for severe postpartum complications. Depending on the severity of the maternal illness, a team from the receiving hospital may go to the referring hospital to pick up the patient, or the patient may be sent by one-way ambu lance from the referring hospital to the receiving hospital. All attempts should be made to ensure that women and infants at high risk receive care in a facility that provides the required level of specialized obstetric and newborn care. Formal transfer agreements should be in place that clearly outline the responsibilities of each facility. Neonatal Transport the interhospital transfer of a newborn infant who requires specialized or intensive care generally proceeds according to one of the following approaches: • A team is sent from one hospital, often a regional center, to the referring hospital to evaluate and stabilize the infant at the referring hospital and then transfer the infant to the team’s hospital.

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C Extraction of large specimens E the gases used for pneumoperitoneum D Poor vision have high water content treatment h pylori order bimat 3 ml with visa. Which of the following are complications associated with creating Pneumoperitoneum pneumoperitoneum What are the desired characteristics A Bleeding of the gas used to medicine quiz buy discount bimat 3 ml on-line provide B Bowel injuries pneumoperitoneum in laparoscopic C Gas dissection within the abdominal wall surgery Which of the following are gases used B Bipolar diathermy/combinations (Ligasure) to medicine reminder alarm buy 3ml bimat otc provide pneumoperitoneum What parameters are taken into D Nitrous oxide account while using laparoscopic E Argon symptoms nasal polyps generic 3ml bimat free shipping. B Age A Hyperthermia C Left/right side dominance B Acidosis D Number of errors C Cardiac arrhythmias E Depth (3D) perception medications safe while breastfeeding purchase bimat 3ml overnight delivery. Which of the following are suture loop advantages of robotic surgery to the C By suturing surgeon D Applying pressure from a Foley catheter A Better visualisation (higher balloon magnification) and stereoscopic views E Diathermy. B Greater precision due to elimination of hand tremor Electrosurgery in C Improved manoeuvring due to ‘robotic laparoscopic surgery wrist’ with seven degrees of freedom 15. Which of the following statements D Ergonomic environment are true in relation to the risks E Reduced costs. Which of the following statements A the majority occur following the use regarding robotic surgery are true D Specialities that use microsurgery will E Bipolar diathermy is equally dangerous. A Inadvertent touching or grasping of A Better ergonomic operating positions tissue during current application B Reduces the need for assistants B Direct coupling C Guidance from experienced surgeons C Insulation breaks not physically present in the operating D Direct sparking theatre E Current passage to bowel from recently D Shorter operating time coagulated tissue. A By applying upwards and lateral pressure with the trochar itself 138 Extended matching questions 1. The nurses observe that the dressings are getting soaked with blood despite repeated changing. The laparoscopist could not visualise any structures in the peritoneal cavity as the view had a ‘red-out’. The abdomen was distended and the end of the telescope was covered with blood despite repeated cleaning. It detects different levels of brightness and adjusts for the best image possible. A, B, D the other advantages are reduction in wound pain and wound-related problems, such as wound dehiscence, bleeding, herniation and nerve entrapment. A, B, C, E the other limitations are reliance on remote vision and operating, dependence on hand-eye feedback and reliance on new techniques. The set-up costs and some operating costs can also be higher, although some of this is recovered by reduced length of hospital stay. B, C, D the gas used to provide pneumoperitoneum should not be combustible or a supporter of combustion, as this will cause fire with the use of diathermy. B, C, D, E the other complications include hypothermia and referred shoulder-tip pain. The most common method employed by general surgeons is the ‘open method’, where the layers of the abdominal wall are incised under direct vision. A Hasson trochar or a similar blunt-tip trochar is employed in the open technique. The usual intraperitoneal pressure employed is between 12 and 14 mmHg and rarely exceeds 15 mmHg. Increased pressures risk affecting tissue microcirculation similar to compartment syndrome. The temperature of the gas used to provide pneumoperitoneum is 21 C and hence can cause hypothermia. A, B, C, D, E the procedure for creating a pneumoperitoneum can be associated with potential major risks, and hence utmost care needs to be employed. Risks can be reduced by avoiding a blind puncture and 140 taking extra care in difficult cases, such as those who have had previous operations. Gas dissection within the abdominal wall can be avoided by confirming, without doubt, placement in the peritoneal cavity before starting insufflation and closely observing correlation between pressures generated and the volumes of gas insufflated. The abdomen is opened without delay and expert help sought, if needed, to repair the damage. It is safer but presently more expensive methods, such as bipolar diathermy and ultrasonic energy sources, are being more widely used and are likely to become the mainstay in future. A, C, D, E the other parameters include completing the task successfully and the paths taken by instruments during the activities. A, B, C, D A robot is a mechanical device that performs automated physical tasks according to direct human supervision, a predefined programme or a set of general guidelines using artificial intelligence techniques. This has been primarily employed in the form of automated camera systems and tele-manipulator systems, thus creating a human-machine interface. These systems are, however, still not widely available apart from being expensive. A, B, C, D these systems offer advantages to the surgeons by reducing the need for assistants and providing better ergonomic operating positions. They also enable experienced guidance to be provided by surgeons not physically present in the operating theatre. A, B, C It is believed that robotic surgery will be more widely used in future but their use is currently limited by cost and availability. A, B, C, D, E Despite drawbacks, robotic surgery still has potential advantages and is expected to be more widely used in future. A, B, C, D, E Considerable bleeding can occur if the falciform ligament is impaled with the substernal trochar or if one of the epigastric arteries is injured. They are often not recognised at the time of operation and patients may present 3–7 days after injury with complaints of fever and abdominal pain. Bipolar 141 diathermy is safer than monopolar diathermy and is preferred, especially in anatomically crowded areas. The important safety measures include attainment of a perfect visual image, avoiding excessive current application, meticulous attention to insulation and using alternative safer energy sources. It is a technique whereby the peritoneal cavity is entered endoscopically via a natural orifice and the surgery carried out using specialised endoscopic technology and techniques. Minimising potential contamination of the peritoneum and the ability to carry out a safe closure of the peritoneal entry site are the main technical challenges. Laparoscopy complications 1G Port-site recurrence is a potential problem after laparoscopic surgery for malignancies. The incidence is fortunately low due to increased awareness and taking precautions such as using wound protectors and endobags for specimen retrieval. This could be due to diathermy injury, which is frequently out of sight and not recognised. This should hence be suspected in any patient presenting with signs of peritonitis a few days after the operation. The bleeding from epigastric arteries or the vessels in the falciform ligament can cause significant bleeding. Lateral ports made using bladeless trochars, which are muscle splitting, and not cutting, may be associated with a lower risk of hernia formation. Laparoscopic/robotic nomenclatures 1C Advances in optic technology including high-definition images have greatly contributed to developments in laparoscopic surgery. This provides several benefits for the surgeon, such as higher magnification with better stereoscopic views, elimination of hand tremors, greater precision, improved manoeuvring due to the ‘robotic wrist’, which allows seven degrees of freedom, ability to carry out complex and large external movements in a limited space, and a better ergonomic environment. B Clinical diagnosis is very obvious B Abdominal surgical wounds may C Hip and knee replacement surgery are compromise postoperative respiratory high risk function. Which of the following statements with E Oliguria is defined as urinary output of regard to postoperative vomiting are less than 0. A Inadequate analgesia can be a cause of Postoperative shortness of postoperative vomiting. B All abdominal operations must routinely breath have a nasogastric tube inserted 2. C Myocardial infarction D Chest infection Postoperative oliguria E Pneumothorax. Which of the following statements with regard to postoperative oliguria are Postoperative hypotension false After an anterior resection, which of A the commonest cause is inadequate the following conditions are causes of fluid replacement. A Postoperative bleeding C Patients undergoing an operation for B Myocardial infarction obstructive jaundice are particularly C Epidural anaesthesia or excessive susceptible. Postoperative pyrexia A Atelectasis B Urinary tract infection C Subphrenic abscess D Wound infection Choose and match the correct diagnosis with each of the scenarios below: 1 A 75-year-old patient underwent a right hemicolectomy. He was tachypnoeic, centrally cyanosed, with his ala nasi moving with every attempt at breathing. The chest wall movement was restricted on the right with reduced breath sounds on that side. He is unwell with a fever of 40 C, with rigors and pain in his right shoulder tip. There is oedema of the skin in the right upper quadrant and no air entry in the right lung base. On the day he was due to go home, 10 days later, he developed pyrexia with rigors. Postoperative confusion A Electrolyte disorder B Pneumonia C Septic shock D Alcohol withdrawal Choose and match the correct diagnosis with each of the scenarios below: 1 A 70-year-old patient underwent a transurethral resection of his prostate 2 days ago. He was due to go home on the second postoperative day when he became confused and disorientated. He underwent a left hemicolectomy with end colostomy and a Hartmann’s closure of the 145 distal stump. From the second postoperative day, he has been very confused, with laboured breathing and an oxygen saturation of 89 per cent on the pulse oximeter. Postoperative renal failure A Hepatorenal syndrome B Nephrotoxin C Septic shock D Postrenal iatrogenic cause Choose and match the correct diagnosis with each of the scenarios below: 1 A 60-year-old man underwent a right hemicolectomy for carcinoma of the caecum. In the past, at the age of 30, he underwent a left nephrectomy for trauma from a motorcycle accident. He sustained fracture shaft of femur, fracture-dislocation of elbow, renal contusion and blunt abdominal trauma. The injuries have been appropriately treated – open reduction and fixation of the orthopaedic injuries and conservative management of soft tissue injuries. While on the ward, over 2 days his urinary output has dropped, he is acidotic and his serum electrolytes show features of early renal failure.

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A proposed mechanism of action for the effects of Quercetin is a cytoprotective effect mediated by antioxidant properties symptoms nausea fatigue buy cheapest bimat and bimat, stimulation of prostaglandin and inhibition of leukotriene production symptoms 16 dpo buy bimat in india, events that reinforce the defensive compounds of the gastrointestinal wall (Alarcon de la Lastra et al medications and mothers milk 2016 generic bimat 3ml without prescription. In this study medicine x topol 2015 discount bimat online mastercard, Ethnopharmacology as Current Strategy in the Search of Novel Anti-Ulcerogenic Drugs: Case of a Brazilian Medicinal Plant (Maytenus ilicifolia Mart treatment 31st october purchase bimat 3 ml online. Reissek) 389 intraperitoneal administration of quercetin, rutin and kaempferol reduced tissue erosion in a dose-dependent manner (25-50 mg/kg), while naringin reduced gastric damage only at high dose levels (200-400 mg/kg) and flavone was inactive. The influence of flavonoids on gastric acid secretion, mucosal prostaglandin production and H. All flavonoids tested also inhibited the gastric proton pump (H+/K+), however, no inhibitory action was observed on the formation of prostaglandin E. Thus, was possible concluded that due to low toxicity of flavonoids and the effective gastroprotective properties described (antisecretory action, stimulation of prostaglandins, inhibition of H. They exhibit haemolytic properties and are highly toxic in direct contact with the blood stream. According to the structure of the aglycone or sapogenin two forms of saponin are recognized, the steroidal and triterpenoid type, the latter form being found in high concentrations in many plant species (Samuelsson, 1992; Borrelli & Izzo, 2000). Antiulcer activity of several plant species containing high amounts of Saponins has been continuously indicated in different experimental ulcer models. The main species investigated in ethnopharmacological studies are shown in Table 3. Was previously demonstrated that liquorice root contains about 2%-12% of glycyrrhizic acid and the seeds of the horse-chestnut up to 13% of aescin (Newall et al. Among these, saponins isolated from the rhizome of Panax japonicus and the fruit of Kochia scoparia (with about 20% of saponins) showed significant gastro-protective properties by inhibiting the amount and severity of ulcerative lesions (Matsuda et al. Furthemore, oleanolic acid oligoglycosides extracted from the same plants showed antiulcer effects on ethanol and indomethacin-induced gastric damage. Aescin, a mixture of saponins encoutered in the seeds of Aesculus hippocastanum, has been shown to possess a marked antiulcer property (Marhuenda et al. For this compound, the gastroprotective effect has been associated with an inhibition of gastric acid and pepsinogen secretion. However, in a model of gastric ulceration ethanol-inducedm aescin was also effective in preventing gastric lesions (Marhuenda et al. Reissek) 391 Scarabaeoidea Panax binnatifidus rhizome isolated saponin psychological stress Theaceae Camellia sinensis seed methanolic extract ethanol Table 3. In a general context, the current information indicate that the antiulcer protective activities of the saponins are not due to inhibition of gastric acid secretion but probably due to activation of mucous membrane protective factors (Borrelli & Izzo, 2000). Tannins are by definition phenol compound with sufficiently high molecular weight and different chemical structures occurring in medicinal and food plants that are utilized world wide. This phytochemical presents several remarkable biological and pharmacological activities and an important meaning for human health. Tannins are used in medicine primarily because of their astringent properties, which are due to the fact that they react with the proteins of the layers of tissue with which they come into contact (Samuelsson, 1992; Borrelli & Izzo, 2000). Moreover, the used of tannins against peptic ulcer, diarrhea and as an antidote in poisoning by heavy metals are described in medical literature. Several plants with anti-ulcer activity containing high levels of tannins are showed in Table 4. In a previous investigation, a crude extract of Linderae umbellatae exhibited a marked anti peptic and antiulcerogenic activity (Ezaki et al. In this study, condensed tannins such as (+)-catechin, (-)-epicatechin, proanthocyanidin, cinnamtannin B1 and D1 (monomers, dimers, trimers and tetramers) have been isolated and their anti-peptic and anti-ulcer activity confirmed in experimental models of gastric lesions induced by pylorus-ligation in rats and stress in mice. Significant biological differences were observed between the chemicals structures of tannins. Monomers and dimers, did not presented inhibitory activity on peptic activity in vitro, while trimers exhibited higher inhibition of peptic activity compared to tetramers. In mice with pylorus ligation, trimers and tetramers markedly reduced the peptic activity of gastric juice. Furthermore, monomers and dimers slightly suppressed the peptic activity in this experimental model (Ezaki et al. As monomers and dimers proved to be inactive in vitro, it is possible that their activity is not related to the direct inhibition of pepsin in vivo, but mainly related to influence on the secretion mechanism of pepsin. This phytochemicals are known to coat the outermost layer of the mucosa and to render it less permeable and more resistant to chemical and mechanical injury or irritation (Asuzu & Onu, 1990; Borrelli & Izzo, 2000). In another hand, high concentrations of tannins often cause coagulation of the proteins of the deeper layer of the mucosa, resulting in inflammation, diarrhea and vomiting. The discovery of the inhibitory effects of tannins on lipid peroxidation in rat liver mitochondria and microsomes was followed by the uncovering of several effects related to improving the several gastrointestinal symptoms, activity that may be related to inhibition of lipoxygenase products related to metabolism of arachidonic acid (Okuda, 2005; Borrelli & Izzo, 2000). In addition, gastroprotective protective effects are related to antioxidant, vasoconstricting and antihemorrhagic properties of tannins (Borrelli & Izzo, 2000), which has also been linked to inhibition of H. Screening of the constituents from Maytenus ilicifolia with anti-ulcerogenic activity the beneficial medicinal effects of plant materials typically result from the secondary products present in the plant, and usually are not attributed to a single compound but a combination of the metabolites. In an extensive literature review, was identified, in quantitative terms, that the gastroprotective properties of crude drugs plant-based are attributed mainly to the presence of flavonoids, being found about 53 flavonoid compounds with antiulcer activity (Mota et al. However, currently there are sufficient evidence that in crude vegetables preparations the gastroprotective effects are also deeply influenced by other phytochemicals such as alkaloids, saponins and tannins. Therefore, efforts should be directed towards isolation and characterization of the active principles and elucidation of the relationship between structure and activity, followed by attempts for modulation of its activity potential by chemical modification. Furthermore, detailed analysis of the active constituents of natural drugs should be directed towards clinical relevance and to maintain indispensable reproducible quality in biological evaluation. The ethnopharmacology constitutes an important and reliable method in bioprospecting of phytochemicals with anti-ulcer activity. The case of the discovery of the gastroprotective activity of Maytenus ilicifolia constitutes an appropriate example that clearly demonstrates the important role of ethnopharmacology in elucidating the pharmacological basis that is associated with a large part of traditional knowledge about medicinal plants and that waiting to be discovered. Reissek belongs to the Celastraceae, a pantropical family native to southern Brazil, Paraguay, Uruguay, and northern Argentina. The plant is a small medicinal evergreen shrub that grows to a height of five meters bearing leaves and berries that resemble holly and is popularly known as “espinheira santa” (holy spine), “cancerosa”, “cangorosa”, “maiteno” and “espinheira divina” (divine spine) (Cordeiro et al. Maytenus ilicifolia is widely used as a traditional medicine in many countries of South America and its leaves are traditionally used as a remedy for gastrointestinal diseases, including dyspepsia and gastric ulcers (Leite et al. They are found in the local commerce as capsules, powders, dried leaves, or as aqueous or aqueous-alcoholic preparations. Has been showed that its aqueous extract causes significant reduction in the number of gastric ulcers induced by both indomethacin and cold-restraint stress in rats. This protection was similar 394 Peptic Ulcer Disease to that observed with cimetidine, a well known histamine H2 receptor antagonist. Chemical constituents obtained from this plant extracts with solvents of different polarities are terpenoids, flavonoids, tannins and polysaccharides (Leite et al. In this study, several phytochemicals were identified in crud extract of Maytenus ilicifolia and apparently polyphenols and flavonoids were the main compounds linked to gastroprotective effects evidenced. Thus, results of these studies suggested that a number of active constituents might be present in crude extract to control ulcerative lesions. However, of the major bioactive component of Maytenus ilicifolia that offers antiulcer effects remained still not well understood. In a previous study, Baggio and collaborators reported the potent in vivo gastroprotective properties of a flavonoid-rich fraction separated from the leaves of Maytenus ilicifolia, Maytenus ilicifolia, containing epicatechin (3. Aiming to further the investigation on the bioactive constituents from Maytenus ilicifolia leaves, Leite et al. Finally, high performance liquid chromatography analyses of aqueous extract and its chromatographic fractions were carried out, aiming at establishing a correlation between gastroprotective effect and chemical composition. In this study, fractionation of aqueous extract led to 5 fractions containing different flavonoids such as the tri-flavonoid glycosides mauritianin, trifolin, hyperin, epi catechin, a tetra-glycoside kaempferol derivate and the monosaccharide galactitol. These fractions were evaluated in rats for their effects on gastric secretion volume and pH in a model of pylorus ligation. Considering the results of the study it was possible to conclude that only fractions containing mauritianin and tetra-glycoside kaempferol derivate caused significant increase of gastric volume and pH, thus indicating that these glycosides play an important role on the gastroprotective effect of Maytenus ilicifolia leaves. Compounds identified in the other fractions had a less important contribution to gastroprotective effect since they have not disclosed significant activity on gastric volume and pH of rats. Gastric mucus is believed to play an important role in the defensive mechanism against gastric ulceration. The protective effect of mucus as an active barrier may be attributed to the glycoproteins, which have the property of holding water in the interstices, thus obstructing the diffusion of hydrogen ions. Stress has been shown to decrease the amount of mucus adhering to the gastric mucosa (Jorge et al. Hence, increase in synthesis of mucus, according to results obtained in this study with Maytenus ilicifolia, is consistent to those found by some authors (Bravo et al. Because of mucosa protection, extracts of Maytenus ilicifolia may represent an important clinical alternative in antiulcerogenic therapeutic, though, further studies are needed to Ethnopharmacology as Current Strategy in the Search of Novel Anti-Ulcerogenic Drugs: Case of a Brazilian Medicinal Plant (Maytenus ilicifolia Mart. Reissek) 395 evaluate the real usefulness of this extract in the prevention and treatment of peptic ulcers. Thus, the screening of the constituents from Maytenus ilicifolia with antiulcer activity used in this study, clearly illustrate as a phytochemical investigation directed by an ethnopharmacologycal approach can be of great value in the search for compounds with potential use for the development of new and more efficient drugs used in management of ulcerative diseases and others health disorders. The occurrence of tetra-glycosylated flavonoids in this specie afford a valuable chemical marker for the quality control of the Brazilian Maytenus marketed as phytomedicines. Phytochemicals identified in a lyophilized aqueous extract of Maytenus ilicifolia leaves. Conclusion Currently, there is a positive trend in favor of traditional, complementar and integrative therapies both in scientific research and health care. Furthermore, in recent decades has been observed strengthening of approaches related to health care such as ethnopharmacology, reverse pharmacology, phytotherapy, systems biology and personalized medicine. Ethnopharmacology has already played recognized importance in the discovery of plants with medicinal potential and in the development of natural health care practices, and is likely to play more significant role in the years to come. It would not be surprising to see that the use of herbal medicines will be gradually accepted in the main stream of conventional medicine. Due to acceptance that the diversity of chemical substances found in vegetable materials may have different biological effects of interest with potential 396 Peptic Ulcer Disease applications in many different health conditions, it is believe that there will be a growing trend in the use of novel natural products and development of chemical libraries based on these products in drug discovery campaigns. Plant resources have proved to be an important source for the discovery of new substances with antiulcer potential. Researches in this area have been targeted for both the isolation of active principles, such as to obtain standardized extracts. Polyphenolic compounds, including flavonoids, have been the subject of increasing interest since in vitro and in vivo biological assays indicated that flavonoids can mediate a range of mechanisms related to anticancer, antitumor, and anti-oxidant activities, among other. The contribution of the flavonoids to the dietary intake of polyphenolics compounds is considerable. In fact, cereals, legume seeds, fruits, wine, and tea contain significant amounts of flavonoids and their derivatives. In Brazil, studies of the species Maytenus ilicifolia have advanced considerably, reinforcing the use in folk medicine, where preparations from the leaves of this species are used as an antiulcer treatment. This species is part of the cast of the Brazilian Pharmacopoeia, being the phenolic constituents used as chemical markers. In Maytenus ilicifolia the 3-O-glycosides of quercetin and kaempferol are the most common group of flavonoids. It is known that the sugar moiety is an important factor for the bioavailability of the flavonoid derivatives. Evaluation of the gastric antiulcerogenic effects of solanum nigrum, brassica oleracea and ocimum basilicum in rats.

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