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In the second case, the complaint of Social and Physical Disability pain does not represent the presence of pain. The role of the doctor in this task may be lim monoamine receptors has been suggested. Page 57 ited to drawing attention to discrepancies and inconsis Painful Scar (1-26) tencies in the history and clinical findings. Xld Systemic Lupus Erythematosis, Systemic Sclerosis and Fibrosclerosis, Polymyositis, and Dermatomyositis Sickle Cell Arthropathy (1-19) (1-27) Code X34. X5c Psoriatic Arthropathy and Other Osteoporosis (1-33) Secondary Arthropathies (1-25) Code Code X32. X8c Page 58 Muscle Spasm (1-34) Signs Extremity weakness and areflexia are essential features of the neuropathy. Back and leg pain are commonly ex Code acerbated by nerve root traction maneuvers such as X37. Cerebrospinal fluid Code shows elevated protein with relatively normal cell count. X8e Usual Course Aching back and extremity pain, sometimes of a severe Guillain-Barre Syndrome (1-36) nature, usually resolves over the first four weeks. Dys esthetic extremity pain persists indefinitely in 5-10% of Definition patients. Acetaminophen or nonsteroidal anti-inflammatory drugs System for mild to moderate pain. Active and passive exercise Deep aching pain involving the low back region, but program. Pad tocks, thighs, and calves is common (> 50%) in the first ding to prevent pressure palsies. Pain may also occur in the shoulder girdle and upper extremity but is less frequent. Complications Beyond the first month, burning tingling extremity pain Persistent weakness and contractures from incomplete occurs in about 25% of patients. Ulnar and peroneal pressure palsies from im Note: While in the Guillain-Barre syndrome weakness mobilization. Peripheral nerve demyelination with secondary axonal Associated Symptoms degeneration. During the acute phase there may be muscle pain and Differential Diagnosis pains of cramps in the extremities associated with mus Pain secondary to neuropathies stimulating Guillain cle tenderness. Constipation can produce lower abdomi Barre syndrome: porphyria, diphtheritic infection, toxic nal and pelvic pain. No par Sudden, usually unilateral, severe brief stabbing recur ticular aggravating factors. Site If medical measures fail, radio-frequency treatment of Strictly limited to the distribution of the Vth nerve; uni the ganglion or microsurgical decompression of the tri lateral in about 95% of the cases. The second, third, and first branches of the Usual Course Vth cranial nerve are involved in the foregoing order of Recurrent bouts over months to years, interspersed with frequency. In patients with multiple sclerosis, there is also an Pathology increased incidence of tic douloureux. Sex Ratio: women When present, always involves the peripheral trigeminal affected perhaps more commonly than men. Impingement on the root by set: after fourth decade, with peak onset in fifth to sev vascular loops, etc. No sensory or reflex deficit detectable by tern: paroxysms may occur at intervals or many times routine neurologic testing. Periodicity is characteristic, with episodes Differential Diagnosis occurring for a few weeks to a month or two, followed Must be differentiated from symptomatic trigeminal by a pain-free interval of months or years and then re neuralgia due to a small tumor such as an epidermoid or currence of another bout. Intensity: extremely severe, small meningioma involving either the root or the gan probably one of the most intense of all acute pains. Sensory and reflex deficits in the face may be detected in a significant proportion of such cases.

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Another possible factor explaining the lack of consideration for stage is the wide range of countries in which the trials have been undertaken. It is clear, however, that any future research should not neglect consideration of stage. Because of the lack of evidence on treatment efects in patients with diabetes, this will be an important subgroup. This refects the recent survey that highlighted those with diabetes as an important subgroup. This is unsurprising given that there is a noted absence of a standard defnition and classifcation for frozen shoulder. Although potential classifcations for primary and secondary frozen shoulder have been put forward,3 a consensus on the defnition of frozen shoulder is sorely needed to enable the generalisability of further research to be assessed. This should conclude with a consensus on the most appropriate tools to assess shoulder function, both in research and in clinical practice. Based on the available evidence we were unable to structure a simple decision tree, but, given the complex nature of the treatment pathways, future decision-analytic modelling undertaken in this area will need to take into account the nature of any sequential decision-making processes and treatments rather than just a single therapy. This will require tangible evidence of current treatment patterns and resource use in frozen shoulder populations. Tere may be beneft in undertaking an elicitation exercise with a range of health-care professionals to prioritise the interventions to be compared and underpin the design of any future trial. This information is required to enable assessments of cost–utility to be undertaken. Mapping is always a second-best solution to using a preference-based (generic or condition specifc) measure in the frst place, but it is ofen the approach followed for pragmatic reasons and so this remains an important area of research. Tere is also short term beneft for the same population of adding physiotherapy to a single intra-articular steroid injection. This is based on two studies that varied in steroid dose and in whether the injection was guided, making it difcult to determine how the steroid intervention should be delivered. Although neither study explicitly provided information on stage of frozen shoulder, only patients with frozen shoulder of < 6 months’ duration were included, suggesting that these patients were likely to be at the initial painful stage. Based on two studies of physiotherapy that included mobilisation in 8–12 sessions over a 4-week period, it is unclear what is the most efective physiotherapy to provide with injection in terms of content and duration. Suggested research priorities Tere are large gaps in the evidence for the efectiveness and cost-efectiveness of all of the interventions investigated. This should be fully specifed in any future trial and we suggest that it should involve a structured protocol of high-quality education, advice, home exercise and monitoring/support to encourage completion of the home exercises. Research is required to establish whether there is any beneft from having physical therapy alone over and above that of high-quality conservative management. Although there is also a gap in the evidence regarding the efectiveness of distension, in the recent survey of health-care professionals this intervention did not receive as much support as a topic for future research as the other intensive interventions. Contribution of authors Emma Maund contributed to writing the protocol, study selection, data extraction, quality assessment, data analysis and report writing. Dawn Craig contributed to writing the protocol, undertaking the economic analysis and report writing. Sara Suekarran contributed to writing the protocol, study selection, data extraction, quality assessment, data analysis and report writing. Kath Wright developed the search strategies, undertook the searches and wrote the literature search methods section. Stephen Brealey, Laura Dennis, Lorna Goodchild, Nigel Hanchard, Amar Rangan, Gerry Richardson and James Robertson provided clinical and/or methodological input and advice throughout the project and commented on the protocol and drafs of the report. Catriona McDaid was responsible for writing the protocol, contributed to study selection, data extraction, quality assessment, data analysis and report writing and had overall responsibility for co-ordinating the project. Rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Lack of uniformity in diagnostic labeling of shoulder pain: time for a diferent approach.

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Diabetes (prepregnancy and gestational)  Hypertension (prepregnancy, gestational, eclampsia) . Standard Certificate of Live Birth Yes No New Item in 2003 Abnormal Conditions of Newborn. Chief Consultant, Department of Gynecology & Obstetrics, Karnali Province Hospital, Nepal; Professor in Karnali Academy of Health Science, Nepal. Inclusion criteria were primary studies conducted in institutional setting in Bangladesh, India, Nepal and Pakistan and published in the English language. However, this is uneven with very low rates in rural and very high rates in urban settings, the co-existence of ‘Too Little Too Late & Too Much Too Soon’. The challenge is to avoid ‘Too Much Too Soon’ in otherwise healthy urban women and avoid ‘Too Little Too Late’ in women living in remote and rural area and in poor urban women. Nevertheless, it is advanced obstetric care 3-7 which has been gaining popularity in the modern world particularly in urban settings. These include increased risk of abnormal placentation (placenta previa), hysterectomy, 9,10-15 uterine rupture, ectopic pregnancy, stillbirth, preterm birth and miscarriage. The Lancet series (2018) has highlighted many short-term health risks for children born by a caesarean birth, such as allergy, atopy, 9 asthma, alteration of immune development and reduced intestinal gut microbiome diversity. Similarly, other studies showed 12,19 12 20 associations with childhood obesity, asthma and type 1 diabetes. Mesh terms and Key words for ‘caesarean’; ‘cesarean’; C-section’ was combined with the specific country using Boolean operators (and/or). Titles and abstracts of the identified citations were initially scanned for the rates of caesarean sections to assess eligibility. Full text articles of eligible studies were appraised, and relevant data was extracted, and proportions of C sections were reported. After scanning of titles and abstracts we included 43 papers, five were from Bangladesh, 18 from India, 12 from Nepal, and eight were from Pakistan. Rising Caesarean Section Rate in Bangladesh Caesarian sections have become increasingly common in Bangladesh (Table 1) and have increased alarmingly in recent decades. Despite the rising trend of institutional births from 23% in 2010 to 47% in 2016, maternal deaths are still as high as 194 per 100,000 live 24 births. The 60 percentage of institutional birth has increased from 35% in 2011 to 57% in 2016. However, the actual reasons behind this and the wide variations reported across facilities are unclear. The role of midwifery in keeping childbirth normal There is international consensus that midwifery care is the most cost effective way of supporting normal childbirth. Midwives are trained to use minimal intervention but to refer timely when complications arise. Midwifery care can decrease maternal and new-born 83, 84 mortality in low and lower-middle income countries. To ensure positive maternal and newborn health outcomes, high quality intrapartum care, especially through the promotion of 85,86 spontaneous vaginal births with a minimum of medico-technical interventions is central. The outcome of the care for women and newborns around the time of birth in health facilities reflects the evidence-based practices used and the overall quality of services provided. The quality of care during childbirth in health facilities depends on the physical infrastructure, human resources, knowledge, skills and capacity to deal with both normal pregnancies and 87 complications that require prompt, life-saving interventions. There is evidence to suggest that midwives who work in the communities in which they live and are known are most 88 effective at delivering effective care. The Lancet series (2018) highlights the need for multicomponent and locally tailored interventions which address both women’s’ and professionals’ concerns as well as health 90 system and financial factors. The increasing trend in caesarean section rates: Global, Regional and National estimates: 1990-2014. Short-term and long-term effects of caesarean section on the health of women and children. Impact of multiple cesarean deliveries on maternal morbidity: a systematic review. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: systematic review and meta-analysis. Caesarean delivery and subsequent stillbirth or miscarriage: systematic review and meta-analysis. Caesarean delivery and subsequent pregnancy interval: a systematic review and meta-analysis.

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Fecal microbiota transplantation for fulminant Clostridium difficile infection in an allogeneic stem cell transplant patient. Fecal bacteriotherapy for relapsing Clostridium difficile infection in a child: a proposed treatment protocol. Colonoscopic fecal microbiota transplant for recurrent Clostridium difficile infection in a child. Fecal transplant for recurrent Clostridium difficile infection in children with and without inflammatory bowel disease. Fecal microbiota transplant for relapsing Clostridium difficile infection using a frozen inoculum from unrelated donors: a randomized, open-label, controlled pilot study. What Is the Value of a Food and Drug Administration Investigational New Drug for Fecal Microbiota Transplantation in Clostridium difficile Infection? Guidance for Industry: Enforcement Policy Regarding Investigational New Drug Requirements for Use of Fecal Microbiota for Transplantation to Treat Clostridium difficile Infection Not Responsive to Standard Therapies, 2013. Guidance on preparing an investigational new drug application for fecal microbiota transplantation studies. Fecal Microbiota Transplantation: A Practical Update for the Infectious Disease Specialist. Fecal Microbial Transplantation in a One-Year-Old Girl with Early Onset Colitis Caution Advised. Safety, tolerability, and clinical response after fecal transplantation in children and young adults with ulcerative colitis. Unrelated o Household versus non-household ▪ Volunteer donor o Age-matched : yes, no, or unknown o Gender-matched: yes, no, or unknown. Modified human stool (filtered/processed and/or enhanced) o OpenBiome ▪ Batch/Lot number o Other stool bank o Specify bank o Batch/Lot number. Oral ingestion: capsule o Fresh capsule o Frozen capsule o Lyophilized capsule o Number of capsules used. Had any fevers, vomiting, diarrhea or other symptoms of infection within the past 4 weeks? Had sexual contact with a prostitute or anyone else who takes money or drugs as payment for sex? Had sexual contact with anyone who has hemophilia or has used clotting factor concentrates? Female donors: Had sexual contact with a male who has ever had sexual contact with another male (male donors circle “I am male)? Yes No List location/time spent: From 1980 through 1996, 24. Did you spend time that adds up to three (3) months or more in the United Kingdom? Male donors: had sexual contact with another male, even once (female donors circle “I am female”)? Do you have any autoimmune diseases (for example: Rheumatoid arthritis, Multiple Sclerosis, Lupus) Yes No If yes, please list: 42. Specific Aims By collecting and characterizing the microbiomes of these samples, we aim to expand knowledge to help optimize practice in the transplantation of fecal microbiota or other gut‐related microbiota products. Background and Significance the gut microbiome functions in a symbiotic relationship with the human body at a level of complexity akin to an organ or tissue. Recent advancements in genome sequencing technology have been used to identify the tremendous diversity of these microorganisms, opening a new frontier for research into the role of the gut microbiome in health and disease. It is now well appreciated that intestinal microbiota constitute a microbial “organ” that is integral to overall host physiology, including pivotal roles in metabolism and immune system function. Initial investigations have demonstrated that alterations in the gut microbiome (dysbiosis) may play a role in a number of gastrointestinal and non‐gastrointestinal disorders. Upon consenting to enroll in the registry, individuals will be given the opportunity to also enroll in this biorepository sub-study, after explanation of the biorepository and providing an additional signature on the registry informed consent. The Knight lab at University of California San Diego will perform microbiome data analysis in accordance with the methods of the American Gut Project which may include amplicon sequencing, metagenomics, metabolomics, and proteomics.

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Some vaccines contain purifed bacterial polysaccharides conjugated chemically to immunobiologically active proteins (eg, tetanus toxoid, nontoxic variant of mutant diphtheria toxin, meningococcal outer membrane protein complex). Viruses and bacteria in inactivated, subunit, and conjugate vaccine preparations are not capable of replicat ing in the host; therefore, these vaccines must contain a suffcient antigen content to stimulate a desired response. In the case of conjugate polysaccharide vaccines, the protein linkage between the polysaccharide and the protein enhances vaccine immuno genicity. Maintenance of long-lasting immunity with inactivated viral or bacterial vaccines and toxoid vaccines may require periodic administration of booster doses. Although inacti vated vaccines may not elicit the range of immunologic response provided by live-atten uated agents, effcacy of licensed inactivated vaccines is high. For example, an injected inactivated viral vaccine may evoke suffcient serum antibody or cell-mediated immunity but evoke only minimal mucosal antibody in the form of secretory immunoglobulin (Ig) A. Mucosal protection after administration of inactivated vaccines generally is inferior to mucosal immunity induced by live-attenuated vaccines. Nonetheless, the demonstrated effcacy for such vaccines against invasive infection is high. Bacterial polysaccharide con jugate vaccines (eg, Haemophilus infuenzae type b and pneumococcal conjugate vaccines) reduce nasopharyngeal colonization through exudated IgG. Viruses and bacteria in inac tivated vaccines cannot replicate in or be excreted by the vaccine recipient as infectious agents and, thus, do not present the same safety concerns for immunosuppressed vaccin ees or contacts of vaccinees as might live-attenuated vaccines. Recommendations for dose, vaccine storage and handling (see Vaccine Handling and Storage, p 16), route and technique of administration (see Vaccine Administration, p 20), and immunization schedules should be followed for predictable, effective immunization (see also disease-specifc chapters in Section 3). Adherence to recommended guidelines is criti cal to the success of immunization practices. Major constitu ents, including cell line derivation or animal derivatives, as relevant, are listed in package inserts. Sometimes multiple vaccines, each made by a different manufacturer, are licensed for similar indications and use. When this is the case, physicians should be aware that such products may have different active and/or inert ingredients. Some vaccines consist of a single antigen that is a highly defned constituent (eg, tetanus or diphtheria toxoid). Other vaccines consist of multiple antigens, which can vary substantially in chemical composition and number (eg, acellular pertussis components, Haemophilus infuenzae type b, and pneu mococcal and meningococcal products). Carrier proteins of proven immunologic potential (eg, tetanus toxoid, nontoxic variant of diphtheria toxin, meningococcal outer membrane pro tein complex), when chemically bound to less immunogenic polysaccharide antigens (eg, H infuenzae type b, meningococcal and pneumococcal polysaccharides), enhance the type and magnitude of immune responses, particularly in children younger than 2 years of age, who have immature immune systems. Sterile water for injection or saline solution is used commonly as a vaccine vehicle or suspending fuid. Some vaccine products use a complex tissue culture fuid, which may contain proteins or other constituents derived from the medium and biological system in which the vaccine is produced (eg, egg antigens, gelatin, or cell culture-derived antigens). Some vaccines and immune globulin preparations contain added substances (eg, preservatives or stabi lizers) or residual materials from the manufacturing process (eg, antibiotic agents or other chemicals, including trace amounts of thimerosal). Allergic reactions may occur if the recipient is sensitive to one or more of these additives. Whenever feasible, these reactions should be anticipated by screening the potential vaccinee for known severe allergy to specifc vaccine components. Standardized forms are available to assist clini cians in screening for allergies and other potential contraindications to immunization ( Thimerosal has been the most commonly used preservative in vac cines, added to multidose vaccine vials specifcally to kill or inhibit growth of micro organisms. All routinely recommended vaccines for infants and children in the United States are available only as thimerosal-free formulations or contain only trace amounts of thimerosal, with the exception of some inactivated infuenza vaccines. Institute of Medicine safety reviews regarding thimerosal-containing vaccines as well as vaccines and autism are available 1 ( An aluminum salt commonly is used in varying amounts to increase immu nogenicity and to prolong the stimulatory effect, particularly for vaccines containing inactivated microorganisms or their products (eg, hepatitis B vaccine and diphtheria and tetanus toxoids). Vaccine Handling and Storage Vaccines should be transported and stored at recommended temperatures. Inattention to vaccine handling and storage conditions can contribute to vaccine failure. Vaccines licensed for refrigerator storage should be stored at 35°F–46°F (2°C–8°C).

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This technique is efective in showing the inner surface of blood vessels, but, unlike Doppler methods (see below), it provides no information about fow velocity (Fig. The 3D data collected (left, image 3) can provide 2D sections in diferent planes (right, images 1, 2 and 4) Fig. This technique gives a clear delineation of the inner surface of the vessel (++ measures the outer diameter of the aorta) Doppler techniques In these techniques, theDoppler efect(see above) is used to provide further information in various ways, as discussed below. Continuous wave Doppler The transducer consists of two crystals, one permanently emitting ultrasound and the other receiving all the echoes. No information is provided about the distance of the refector(s), but high fow velocities can be measured (Fig. Pulsed wave Doppler In this technique, ultrasound is emitted in very short pulses. All echoes arriving at the transducer between the pulses in a certain time interval (termed the gate) are registered and analysed (Fig. When the Doppler frequency is higher than the pulse repetition frequency, high velocities are displayed as low velocities in the opposite direction (spectral Doppler) or in the wrong colour (colour Doppler). This phenomenon is known as ‘aliasing’ and is directly comparable to the efect seen in movies where car wheels rotating above a certain speed appear to be turning backward. A correct display is possible only for Doppler frequencies within the range ± one half the pulse repetition frequency, known as the Nyquist limit. As a consequence, Doppler examination of higher velocities requires lower ultrasound frequencies and a high pulse repetition frequency, whereas low velocities can be analysed with higher frequencies, which allow better resolution. The gate is adjusted to the distance of the vessel and the echoes within the gate are analysed (the Doppler angle α is 55° in this example) Spectral Doppler The fow of blood cells in vessels is uneven, being faster in the centre. Doppler analysis, therefore, shows a spectrum of diferent velocities towards or away from the transducer, observed as a range of frequencies. Flow towards the transducer is positive (above the baseline), while fow away is negative (below the baseline). The number of signals for each velocity determines the brightness of the corresponding point on the screen. The spectral Doppler 16 approach combined with the B-scan technique is called the duplex technique. The B-scan shows the location of the vessel being examined and the angle between it and the ultrasound beam, referred to as the Doppler angle. This angle should always be less than 60°, and if possible around 30°, to obtain acceptable results. The combination of B-scan with colour Doppler and spectral Doppler is called the triplex technique (Fig. The lower part of the image shows the spectrum of the velocities over time (two cycles). Note the diferent velocities: peak velocity in systole (Vpeak), maximal velocity over time (Vmax, white plot), most frequent velocity (Vmode, black plot) and average velocity (Vmean) Additionally, the cross-section of the vessel can be determined from the image. The velocity curves in a Doppler display yield indirect information about the blood fow and about the resistance of the vessel to fow. Highly resistant arteries show very low fow or even no fow in late diastole, whereas less resistant arteries show higher rates of end-diastolic fow. Indices that are independent of the Doppler angle can be calculated to characterize the fow in the vessels, showing the relation between the systolic peak velocity (Vmax) and the minimal end-diastolic fow (Vmin). The grade of the stenosis (St) (as a percentage) can be estimated from the calculated average fow velocity before (V1) and within (V2) the stenotic section of the vessel using the formula: V1 St 100(1) V (1. The echoes arising from stationary refectors and scatterers are displayed as grey-scale pixels to form the B-scan image. The echoes from moving scatterers are analysed by the Doppler technique separately in a selected window and are displayed in the same image as colour-coded pixels (Fig. The disadvantages of colour Doppler are the angle dependence and aliasing artefacts. The echoes from moving targets (blood cells) within the window are colour-coded and depicted here in black (see also Fig. In general, it is up to fve times more sensitive in detecting blood fow than colour Doppler, being in particular more sensitive to slow blood fow in small vessels; however, it gives no information about the direction of fow. Terefore, contrast agents administered intravenously into the systemic circulation were initially used to obtain stronger signals from blood fow. Tese agents are microbubbles, which are more or less stabilized or encapsulated gas bubbles, and are somewhat smaller than red blood cells.


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Homoeopathy and veterinary attitudes, British Homoeopathic journal, Volume 83, Issue 4, October 1994, Page 232 Kayne S. Warner Books, New York (1996) British Homoeopathic journal, Volume 86, Issue 2, April 1997, Pages 117-119 Kayne S. Homeopathy in Cuba, British Homoeopathic journal, Volume 89, Issue 2, April 2000, Pages 99-100 Kayne, S. Homoeopathy in sports medicine: Br Hom J 1992; 81: 142–147, Complementary Therapies in Medicine, Volume 1, Issue 1, January 1993, Page 57 Kayne S. Drug nanocrystals of poorly soluble drugs produced by high pressure homogenisation. Homoeopathic versus Conventional Treatment of Children with Eczema: A comparative Cohort Study. Stabilization of Amorphous Calcium Carbonate in Inorganic Silica-Rich Environments J. The case of chiropractic and homeopathy Social Science & Medicine, Volume 63, Issue 10, November 2006, Pages 2617-2627 K Kelner, M. European Medicine: A Résumé of Medical Progress During the Eighteenth and Nineteenth Centuries Medical Library and Historical Journal. Cost Effectiveness of Natural Health Products: A Systematic Review of Randomized Clinical Trials Evid Based Complement Alternat Med. Fractionating Nanosilver: Importance for Determining Toxicity to Aquatic Test Organisms. Metrology of Airborne and Liquid-Borne Nanoparticles: Current Status and Future Needs. Comment on “The defining role of structure (including epitaxy) in the plausibility of homeopathy” Homeopathy, Volume 97, Issue 1, January 2008, Pages 44-45 Kerssens, J. The evidenced-based approach to treating podiatric conditions with Marigold therapy and homeopathy European Journal of Integrative Medicine, Volume 1, Supplement 1, November 2008,Pages 21-22 Khan H. Observation of Extra-High Depolarized Light Scattering Spectra from Gold Nanorods. Mice as a model for homeopathy research Homeopathy, Volume 98, Issue 4, October 2009, Pages 267-279 Khuda-Bukhsh, A. Can Homeopathic Arsenic Remedy Combat Arsenic Poisoning in Humans Exposed to Groundwater Arsenic Contamination? A follow-up study on the efficiacy of the homeopathic remedy Arsenicum album in Volunteers living in high risk arsenic contaminated areas. Condurango 30C Induces Epigenetic Modification of Lung Cancer-specific Tumour Suppressor Genes via Demethylation. In Vivo Modulation of Dendritic Cells by Engineered Materials: Towards New Cancer Vaccines. Role of cell cycle on the cellular uptake and dilution of nanoparticles in a cell population. Size Control of Silica Nanoparticles and Their Surface Treatment for Fabrication of Dental Nanocomposites. Multifaceted interactions between adaptive immunity and the central nervous system. Homeopathic trial design in influenza treatment, Homeopathy, Volume 99, Issue 1, January 2010, Pages 69-75 Kirkwood, J. Practicing classical homeopathy in a headache clinic of a major public hospital in Athens,Greece. British Homoeopathic journal, Volume 89, Supplement 1, July 2000, Pages S1-S2 Kleijnen, J. Searches for controlled trials of homoeopathy, ascorbic acid for common cold and ginkgo biloba for cerebral insufficiency and intermittent claudication. Comparison of homeopathic globules prepared from high and ultra-high dilutions of various starting materials by ultraviolet light spectroscopy. Differences in Median Ultraviolet Light Transmissions of Serial Homeopathic Dilutions of Copper Sulfate, Hypericum perforatum, and Sulfur.

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Several different studies have demonstrated that motor activity level or onset of motor activity is altered in patients with impingement or glenohumeral instability. Diminished serratus anterior activity has been documented in throwers with unstable shoulders and swimmers with impinge ment. Delayed onset of serratus anterior activity in overhead reaching has been demonstrated in swimmers with impingement. Diminished scapular movement, particularly in posterior tilting and superior translation, has been associated with rotator cuff impingement symptoms. Scapular dyskinesia describes abnormal or atypical movement of the scapula during normal active motion tasks, such as reaching overhead. Similar terms used in the literature include abnormal scapulohumeral rhythm, scapular winging, and scapular dysrhythmia. According to Warner, 64% of patients diagnosed with an unstable glenohumeral joint present with some form of scapular dyskinesia, while all patients with impingement demonstrated some degree of scapular dyskinesia. Scapular pathology should be suspected of any overhead athlete or patient who presents with pain in the shoulder region, regardless of the patient’s age. Current research suggests little league baseball players as young as 10 years old present with increased upward scapular rotation compared with nonathletic children of the same age. It is not clear whether the scapula dyskinesis is primary or secondary to shoulder pathology. The general consensus is that deficiency of the scapular musculature, particularly the serratus anterior and trapezius, is often involved. The deficiency may be simple weakness, tightness, or a com pensatory motor pattern developed in response to pain. Congenital deformities such as scoliosis or Sprengel’s deformity may cause scapular dyskinesis. Also called Eulenburg’s deformity, Sprengel’s deformity is failure of the scapula to descend during normal development. Typically it is seen in infancy or early childhood as a prominent lump in the web of the neck. The scapula often is hypoplastic, abnormally shaped, and malrotated so that the superomedial angle is curved anteriorly into the supraclavicular region and the inferior angle abuts the thoracic spine. Associated musculoskeletal deformities such as scoliosis, rib abnormalities, Klippel-Feil syndrome, and spina bifida are common. It is a severe form of scapular dyskinesis associated with overuse syndrome and fatigue. Abnormal scapular movement or scapular dyskinesis can be observed during static or dynamic activities. Several clinical methods of measurement exist; one of the most common is the lateral scapular slide test, which measures the distance between T8 and the inferior angle of the scapula in three positions: (1) arm at side, (2) hands on waist, and (3) arms abducted to 90 degrees with maximal internal rotation. Intra-tester and inter-tester reliability measurements of this test have been reported at 0. Differences in vertical height between the affected and unaffected scapula should also be assessed to determine abnormal tilting or protraction. A bubble goniometer is used to determine vertical height differences between superomedial borders of the affected and unaffected scapula in centimeters. The first step is to perform a complete neuromuscular examination of the shoulder girdle and cervical region. Based on the findings, tight structures need to be stretched and weak structures 368 the Shoulder need to be strengthened. Strengthen the scapular protractors with resistance exercises that emphasize scapular protraction that activates the serratus anterior without overactivating the upper trapezius. One of the most important treatments is education about proper posture and typical movement of the scapula. Biofeedback techniques, such as mirrors, verbal cueing, tactile cueing, and video monitoring during exercises, are helpful for the patient to visualize the trunk and scapula. The patient benefits by observing the trunk and scapula during exercises in order to learn how to voluntarily control scapular musculature.

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Red cells have a mean lifespan product of Embden-Meyerhof pathway, as occurs in anaemia of 120 days, after which red cell metabolism gradually and hypoxia, causes decreased affinity of HbA for oxygen. The destroyed This, in turn, results in enhanced supply of oxygen to the red cells are removed mainly by the macrophages of the tissue. The haemoglobin tetramer can bind up to four molecules of oxygen in the iron containing sites of the haem molecules. Newborn infants have higher via plasma transferrin to marrow erythroblasts, and haemoglobin level and, therefore, 15 g/dl is taken as the protoporphyrin which is broken down to bilirubin. Bilirubin lower limit at birth, whereas at 3 months the normal lower circulates to the liver where it is conjugated to its level is 9. Globin Pathophysiology of Anaemia chains are broken down to amino acids and reused for protein synthesis in the body. Subnormal level of haemoglobin causes lowered oxygen carrying capacity of the blood. In adults, the lower extreme of the redistribution of blood flow to maintain the cerebral blood supply. Eventually, however, tissue hypoxia develops causing impaired functions of the affected tissues. The degree of functional impairment of individual tissues is variable depending upon their oxygen requirements. Clinical Features of Anaemia the haemoglobin level at which symptoms and signs of anaemia develop depends upon 4 main factors: 1. The speed of onset of anaemia: Rapidly progressive anaemia causes more symptoms than anaemia of slow-onset as there is less time for physiologic adaptation. The severity of anaemia: Mild anaemia produces no symptoms or signs but a rapidly developing severe anaemia (haemoglobin below 6. The age of the patient: the young patients due to good cardiovascular compensation tolerate anaemia quite well as compared to the elderly. The elderly patients develop cardiac and cerebral symptoms more prominently due to associated cardiovascular disease. As a result, oxyhaemoglobin is dissociated more readily to release free oxygen for cellular use, causing a shift of the oxyhaemoglobin dissociation curve to the right. In symptomatic cases of anaemia, the presenting features are: tiredness, easy fatiguability, generalised muscular weakness, lethargy and headache. In older patients, there may be symptoms of cardiac failure, angina pectoris, intermittent claudication, confusion and visual disturbances. Pallor is the most common and characteristic sign evaluated in an area where there is neither Rouleaux which may be seen in the mucous membranes, conjunctivae formation nor so thin as to cause red cell distortion. The following be present with tachycardia, collapsing pulse, cardiomegaly, abnormalities in erythroid series of cells are particularly midsystolic flow murmur, dyspnoea on exertion, and in the looked for in a blood smear: case of elderly, congestive heart failure. Increased variation in size of the red cell is giddiness, headache, tinnitus, drowsiness, numbness and termed anisocytosis. Anisocytosis may be due to the presence tingling sensations of the hands and feet. Menstrual disturbances such as other causes are aplastic anaemia, other dyserythropoietic amenorrhoea and menorrhagia and loss of libido are some anaemias, chronic liver disease and in conditions with of the manifestations involving the reproductive system in increased erythropoiesis. They may also result from trating capacity of the kidney may occur in severe anaemia. The nature In addition to the general features, specific signs may be of the abnormal shape determines the cause of anaemia. After obtaining the full medical history pertaining to different Normally, the intensity of pink staining of haemoglobin in a general and specific signs and symptoms, the patient is Romanowsky-stained blood smear gradually decreases from examined for evidence of anaemia. It may develop either from in the retina, atrophy of the papillae of the tongue, rectal lowered haemoglobin content. A number of changes are associated with compensatory increase in erythropoietic A. These are as under: investigation in any suspected case of anaemia is to carry i) Polychromasia is defined as the red cells having more than out a haemoglobin estimation.

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In addition, the dryness of the dressing promotes an environment that is conducive only to cell death. As stated previously, moist healing is much preferred and is the standard of care. Additionally, the cotton fibers of the dressing are often left behind in the wound and create a foreign body response. Enzymatic debridement involves the application of a commercially prepared proteolytic enzyme to necrotic tissue to aid in removal. A variety of products are available and include such agents as collagenase, papain, urea, and fibrinolysin. Enzymes are generally used in conjunction with moist wound healing for the best results. Certain pharmaceutical antibacterial preparations, which contain silver or other heavy metals, can interfere with enzyme activity. Care should therefore be taken in combining the two types of therapy in a single treatment. Synthetic dressings, when appropriately used, can trap endogenous enzymes and other beneficial agents in the wound and Wound Healing and Management 241 provide for adequate debridement. Though effective, autolytic debridement may take longer to debride a wound than the use of commercial enzyme preparations or more invasive forms of debridement. Any agent strong enough to kill bacteria on an inanimate object has the potential to disrupt healing. Some of the more common agents that have unfortunately persisted in the wound care arena include hydrogen peroxide, acetic acid, sodium hypochlorite solution (Dakin’s solution), and povidone-iodine. All of these substances, when used at standard clinical strength, have been demonstrated to cause the death of fibroblasts in vitro. Dakin’s solution, for instance, could be applied over necrotic tissue to soften the tissue and aid in debridement. Likewise, acetic acid could be used to help address localized colonization of Pseudomonas. In general, however, both agents should be discontinued as soon as the desired results are achieved and not simply used as a moistening agent for gauze. What is the primary difference in the clinical presentation of venous and arterial ulcers? Although both types of ulcers may occur at varying points along the leg, venous ulcers typically are located over the medial malleolar area. Venous ulcers often are associated with lower extremity swelling and generally are quite moist. Brownish staining of the skin caused by the pigment hemosiderin, which is released by lysed red blood cells, suggests a venous ulcer. Patients with venous insufficiency ulcers generally complain of pain after prolonged standing and report relief of pain with leg elevation. Arterial or ischemic ulcers, on the other hand, are noted most often on the distal aspects of the feet but may occur more proximally, depending on the occluded artery. Signs frequently associated with ischemic ulcers include a loss of hair on the extremity, poor capillary refill in the toes, and brittle nails. Patients with ischemic ulcers complain of pain whenever the leg is elevated and frequently hang the leg dependently to reduce symptoms. The most commonly used classification system for pressure ulcers is the Shea scale, which categorizes ulcers according to the degree of tissue involvement from partial to full-thickness dermal erosion. Stage 2—A partial-thickness lesion with a break in the skin and loss of epidermis. Stage 3—A full-thickness lesion with dermal involvement (no penetration of fascia). Stage 4—A full-thickness lesion involving the dermis, fascia, and, to varying degrees, underlying muscles, bones, and joints 10. Reverse-staging implies that as an ulcer heals it moves to the next least involved stage of healing. For example, a stage 4 ulcer would be said to reverse to stage 3, then stage 2, and finally stage 1.


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  • https://www.myesr.org/sites/default/files/ESR_2016_ESR-EuropeanTrainingCurriculum_LEVEL_I%2BII_Edition_March_2016.pdf
  • https://books.google.com/books?id=KzzdCwAAQBAJ&pg=PA1144&lpg=PA1144&dq=Laryngeal+Cancer+.pdf&source=bl&ots=tnCO8aHwET&sig=ACfU3U1AYy4Qb7JepGhTqCoTZhx9zlbyqw&hl=en