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  • Professor, Department of Clinical Pharmacy, West Virginia University School of Pharmacy
  • Infectious Diseases Clinical Specialist, West Virginia University Medicine, Morgantown, West Virginia

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Clinical Effects the clinical effects of atherosclerosis depend upon the size and type of arteries affected. There is narrowing of the lumen of coronary due to fully developed atheromatous 1. It may occur following invasion of the vessel by infectious agents, or may be induced by non-infectious injuries such as chemical, mechanical, immunologic and radiation injury. It may be found in the vicinity of an infected focus like in tuberculosis, pneumonia, abscesses, etc. Endarteritis obliterans is not a disease entity but a patho Large arteries affected most often are the aorta, renal, logic designation used for non-specific inflammatory mesenteric and carotids, whereas the medium and small response of arteries and arterioles to a variety of irritants. It sized arteries frequently involved are the coronaries, is commonly seen close to the lesions of peptic ulcers of the cerebrals and arteries of the lower limbs. Accordingly, the stomach and duodenum, tuberculous and chronic abscesses symptomatic atherosclerotic disease involves most often the in the lungs, chronic cutaneous ulcers, chronic meningitis, heart, brain, kidneys, small intestine and lower extremities and in post-partum and post-menopausal uterine arteries. The effects pertaining to these organs are described in relevant chapters later while the major effects Grossly, the affected vessels may appear unaltered are listed below (Fig. Microscopically, the obliteration of the lumen is due to ii) Heart?Myocardial infarction, ischaemic heart disease. Miscellaneous vasculitis attached to it, there is minimal or no inflammatory cell infiltrate. There is endarteritis and periarteritis Non-syphilitic Infective Arteritis of the vasa vasorum in the media and adventitia. There is perivascular Various forms of invasions of the artery by bacteria, fungi, infiltrate of plasma cells, lymphocytes and macrophages. Intimal thickenings consist of dense avascular collagen Syphilitic or luetic vascular involvement occurs in all stages that may undergo hyalinisation and calcification. The changes that are found in the syphilitic arteritis are seen the effects of syphilitic aortitis may vary from trivial to within the arterial tissue (syphilitic endarteritis) and in the catastrophic. Manifestations of a) Aortic aneurysm may result from damage to the aortic wall the disease are particularly prominent at two sites?the aorta (page 406). Syphilitic involvement of the important sequela of syphilis but now-a-days rheumatic ascending aorta and the aortic arch is the commonest disease is considered more important cause for this. It occurs in about aortic incompetence results from spread of the syphilitic 80% cases of tertiary syphilis. The lesions diminish in severity in descending thoracic aorta the features distinguishing syphilitic aortitis from aortic and disappear completely at the level of the diaphragm. The opened vessels show intimal surface studded with pearly changes may accompany syphilitic meningitis. These lesions are separated by Grossly, the cerebral vessels are white, rigid and thick wrinkled normal intima, giving it characteristic tree-bark walled. Cut section of the lesion shows more firm and Microscopically, changes of endarteritis and periarteritis fibrous appearance than the atheromatous plaques. There However, superimposed atherosclerotic lesions may be is atrophy of muscle in the media and replacement by present. Sites Ascending aorta, aortic arch; Progressive increase from the arch to abdominal absent below diaphragm aorta, more often at the bifurcation 2. Macroscopy Pearly-white intimal lesions resembling Yellowish-white intimal plaques with fat in the core; tree-bark without fat in the core; ulceration ulceration and calcification in plaques common and calcification often not found 3. Microscopy Endarteritis and periarteritis of vasa Fibrous cap with deeper core containing foam vasorum, perivascular infiltrate of plasma cells, cholesterol clefts and soft lipid cells and lymphocytes 4. However, some vasculitis, more often affecting arterioles, venules and usual clinical features are fever, malaise, weakness, weight capillaries, and hence also termed as small vessel vasculitis. The from many of patients with vasculitis of immunologic origin condition is believed to result from deposition of immune show the presence of following immunologic features: complexes and tumour-related antigens. While most cases of iii) Healed stage?In this stage, the affected arterial wall is immunologic vasculitis have immune complex deposits in markedly thickened due to dense fibrosis. The internal the vessel wall, there are some cases which do not have such elastic lamina is fragmented or lost.

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Other methods of skin closure at caesarean section have been compared in randomised trials. Three of these studies have been mentioned in the Cochrane review of skin closure techniques and the 71;137;139;140 risk of infection, but the analysis only included the results of one study. The study of staples did not evaluate 138 cosmetic outcome, but it found no difference in postoperative pain. The studies are of varying quality, and their power is too low to evaluate the risk of infection. Thus, it is currently not possible to make any conclusions regarding these other skin closure techniques. In conclusion, both objective and subjective measures have to be considered in the evaluation of skin closure techniques for caesarean section. We found subjective and cosmetic outcomes in favour of staples, whereas meta-analyses of previous studies found the use of staples increased the rate of separation. More studies and meta-analyses of skin closure techniques for caesarean section will doubtlessly be published in the future. Until further evidence is available, both staples and sutures can be recommended for skin closure at caesarean section at the discretion of the surgeon. The study found no difference in patient preference for the blunt or sharp technique. Nor 25 Discussion were there any significant differences in pain scores after either technique up to 3 months postoperatively. Pain intensity is the most clinically relevant dimension of the pain experience 122 and should be assessed by unidimensional scales based on self-reporting. Pain scores were generally higher during mobilisation, independent of the fascial opening technique. Under what circumstances pain intensity scores are more precise is unknown, and therefore it was reasonable to measure pain both at rest and during mobilisation. Techniques for fascial incision have previously only been compared in studies where several surgical steps and techniques were investigated at the same time. Thus, it is unknown whether one technique for fascial incision is superior to the other. We hypothesised that the blunt technique would cause less pain (stated in the protocol but not the published article). Thus, in a two-sided sample size estimation, the minimal relevant difference in absolute pain scores should be 2. With a power of 80% and a two-sided significance level of 5%, a trial with each patient as her own control would then require 11 participants. This is confirmed by the confidence intervals of the absolute pain differences, which did not pass the 2. Assuming that the purpose of the study had been to test whether there was equivalence of pain scores caused by the two techniques, we can conclude that the two methods of fascial incision are equivalent. According to the previously mentioned study, the equivalence margin should be 2. Thus the confidence interval of the differences in pain scores should be within this level to be considered equivalent. Differences in pain scores have to be not only statistically significant but 142 also clinically significant. And the equivalence margin corresponds to the clinically relevant difference in absolute pain scores. At all times, the confidence intervals of the absolute pain scores 26 Discussion at rest were within the 2. However, since pain was measured repeatedly and non-equivalence was only shown once for the absolute pain scores, the finding is not relevant. Additionally, the confidence intervals of the pain differences at the other time points were so far from the equivalence margins that it is doubtful that a larger sample size would have changed the results. Postoperative pain is due to nerves traumatised by perioperative injury or compression, constricting 143;144 sutures, or postoperative fibrotic tissue. The clear lack of pain differences between the two techniques could be because the pain from the fascial incision is overshadowed by pain from other surgical steps. And therefore pain would probably not have been the appropriate primary outcome in a study comparing fascial incision techniques after all.


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A woman with a respiratory tract infection should be made aware that the infection can be transmitted not only by droplets but also by contact with contaminated hands and fomites. Therefore, she should practice strict hand hygiene techniques and appropriately handle or dispose of contaminated tissues and any other items that may have come in contact with infectious secretions. If needed, she can wear a surgical mask to reduce the chance of droplet spread to her newborn. Postpartum women who are infected with nonobstetric-related commu nicable diseases should be treated according to the precautions and isolation techniques required by the specific disease. If the required guidelines cannot be followed safely in the obstetric unit, the patient should be transferred to the appropriate unit where such care can be provided. Cohorting During Epidemics ^ During hospital epidemics, a comprehensive program of infection control is required. Even if an intensive investigation is not indicated, the results of the control measures should be evaluated to ensure that they have been effective and that the problem has been resolved. Because many infections become apparent only after newborns leave the hospital, each hospital should establish procedures to be used during a suspected or confirmed epidemic for disease surveillance of recently discharged newborns. Hospital infection-control personnel and appro priate public health officials should be notified promptly about suspected or confirmed epidemics. Newborns with overt infection and those who are colonized with that pathogen should be identified rapidly and placed in cohorts?separate areas where newborns with similar exposure or illness receive care. If rapid identifica tion of these newborns is not possible, separate cohorts should be established for newborns with disease, those who have been exposed, those who have 452 Guidelines for Perinatal Care not been exposed, and those who are newly admitted. The success of cohort programs depends largely on the willingness and ability of nursery and ancil lary personnel to adhere strictly to the cohort system and to follow established infection-control practices. Newborns With Infections the isolation requirements for a newborn who is infected or suspected of being infected depend on the type of infection, the condition of the newborn, the type of care required, the available space and facilities, the ratio of available nurses to patients, and the size and type of the clinical service. Other factors to be considered include the clinical manifestations of the infection, the source and possible modes of its transmission, and the number of colonized or infected newborns. In many instances (notable exceptions are neonatal varicella zoster virus infection or epidemics of bacterial infection), infected newborns do not need to be placed in a separate room, if certain criteria are met. Physical separation with assignment of separate health care personnel for each area is best. These guidelines outline transmission-based precautions for patients who are infected or colonized with pathogens that are spread by airborne, droplet, or contact routes. Forced-air incubators filter incoming air, but they do not filter the air that is discharged from the incubator into the nursery. Therefore, they are satisfactory for limited protective isolation of infants, but they should not be relied on to prevent transmission of microorganisms from infected infants to others. Cohorting of children infected with the same pathogen is acceptable if a single-patient room is not available, a distance of more than 3 feet between patients can be maintained, and precautions are observed between all contacts with different patients in the room. When an isolation room is deemed necessary (eg, for patients with highly contagious infections), blinds, windows, and other structural items must allow for ease of regular room cleaning. Contact precautions should be observed when treating patients with viral respiratory infection, gastroenteritis, cutaneous infections, or draining lesions or abscesses that cannot be contained adequately by a dressing. All person nel should use gowns and disposable gloves when providing direct patient care. Contaminated items should be properly discarded, and gowns and gloves should be discarded before leaving the room. The environment may be heav ily contaminated with the infecting microorganism, and these organisms often are transmitted on the hands of personnel to other neonates. If more than one 454 Guidelines for Perinatal Care neonate is infected, a cohort approach should be taken (see also Cohorting During Epidemics earlier in this chapter). Standard precautions provide adequate isolation for most congenital infections, with two exceptions: 1) congenital rubella, which requires droplet isolation, and 2) suspected herpetic infection, which requires contact isolation. Many viruses, such as respiratory syncytial virus, coxsackie viruses, or echoviruses, spread rapidly among infants and personnel in a nurs ery. Because infants may shed selected viruses after their clinical illness has been resolved, they can be reservoirs of infection. It is believed that the entero viruses and respiratory syncytial virus are transmitted predominantly by direct or indirect contact by the hands of personnel that become contaminated with virus-containing secretions or with contaminated environmental surfaces or fomites.

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Diets high in antioxidants and lycopene that include many fruits and vegetables. Some vitamins may modify the effect of chemical carcinogenesis such as vitamin A (which promotes the differentiation of epithelial tissues), vitamin C (which blocks the formation of N-nitrosocarcinogens from nitrites and secondary amines), and vitamin E (which is a free radical scavenger). In general, these agents are more effective for cancer prevention when consumed in the diet rather than being taken in supplement form. Breast, endometrial, colon, prostate, lung, melanoma, and stomach have an increased risk of development in first-degree relatives. This cluster may be due to hereditary factors, shared exposures to environmental carcinogens, chance associations, or a combination of all three. Nonpolyposis colorectal cancer with an increased incidence of other cancers, including endometrial, ovarian, breast, stomach, small intestine, pancreatic, urinary tract, and biliary tract that is associated with an autosomal dominant pattern of predisposition. A familial cancer syndrome with an autosomal dominant pattern of inheritance leading to a varied spectrum of mesenchymal and epithelial tumors, and multiple primary neoplasms in children and young adults. P53, sometimes called guardian of the genome, is a gene that is very important in preventing damaged cells from duplicating themselves. Enzymes, hormones, and oncofetal antigens that are associated with particular tumors. These markers are sometimes present on the cell surface or secreted by the malignant cells and can be detected in the bloodstream or by staining tissue samples. The markers reflect the presence of the tumor and sometimes also the quantity of the tumor or tumor burden. Many cancers do not produce tumor markers, and tumors known to produce markers may sometimes fail to do so, particularly if they are very poorly differentiated. To follow the effects of therapy on tumor burden and in detecting recurrent disease after initial therapy. A glycoprotein normally secreted by the trophoblastic epithelium of the placenta that is used as a sensitive and specific marker for germ cell tumors of the testes and ovary and extragonadal presentations of these tumors. Tumor markers are generally nonspecific and can be elevated in a variety of conditions. Tumor markers are used to assist in diagnosis and therapy in patients suspected to have malignancy by clinical parameters. Nausea and vomiting are the most common immediate effects and may vary in presence and degree with the type of drug. Some medications, such as cisplatin, are very emetogenic, whereas others, like fludarabine, are less likely to cause emesis. When myelosuppression occurs, leukopenia predisposes to acute and serious infections; thrombocytopenia predisposes to bleeding; and anemia may worsen symptoms from other problems, such as chronic obstructive pulmonary disease and atherosclerotic cardiovascular disease. Doxorubicin (Adriamycin) and other drugs of the anthracycline class, which cause a progressive loss of cardiac muscle cells. In previously normal hearts, toxicity is dose-related and does not become clinically important until a total dose of approximately 450 mg/m2 of doxorubicin is administered. In patients with already compromised cardiac function, toxicity may occur at lower dosages. With cardiac radionuclide gated wall motion studies (multiple-gated acquisition scans) or echocardiograms measuring ejection fraction. Neoadjuvant therapy means treatment such as chemotherapy or hormones before definitive surgery or radiotherapy. Patients given neoadjuvant therapy often have large or fixed tumors, and the goal is to shrink these tumors to make subsequent surgical removal or radiation therapy easier and more complete. Adjuvant chemotherapy and/or radiotherapy are administered after an operation to eradicate possible micrometastatic disease and, therefore, prevent recurrence. Radiosensitization by these compounds may be mediated by a variety of poorly understood mechanisms. Radiation sensitizers likely have effects on the induction and/or repair of radiation-induced damage.

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This epidemic increase is even encountered in some developing countries [Belizan et al 1999; Khawaja et al. Reasons behind the high cesarean delivery rates in some developing countries are generally unclear [Wylie & Mirza, 2008]. Poor healthcare access, underdeveloped healthcare infrastructure, geographical inaccessibility, cultural mistrust, poverty, and paucity of human health resources are barriers to providing cesarean deliveries to all women who need them [Dumont et al. Large ecological studies in West Africa emphasized this gap by demonstrating increased maternal mortality in settings with a lower percentage of births supervised by a skilled attendant, fewer deliveries performed in-hospital, or a smaller proportion of deliveries performed by cesarean section. Increased access to these services correlated with lower maternal mortality rate [Ronsmans et al, 2003]. Mali is the 3rd poorest nation in the world, with an estimated maternal mortality ratio between 464 and 830 deaths per 100,000 live births [Chou et al, 2010; Samake et al, 2007]. In 1990, the Mali Ministry of Health developed a healthcare initiative focusing on the maternal and child health. Among the key elements of the Malian healthcare system, is the clear distinction between the three levels of care provision: primary (community health centres), secondary (district referral health centres) and tertiary care (hospitals). Pregnant women are initially supposed to book at the community health centres (which is the entry point of the healthcare system) with a primary care midwife or obstetric nurse for care provision during pregnancy, birth and the puerperium. These community health centres have the pivotal role of patients selection based on risk assessment. One important innovation of this new policy was the establishment of a referral system for perinatal complications in 1994. To ensure that referral takes place in an optimal fashion, guidelines for consultation and collaboration between community health centres, district referral health centres and hospital have been formulated in the Perinatality Module and in the Standard, Options and Procedures for Reproductive Health Services Manual. In these documents, all professional groups involved in maternity care agreed on the indications for consultation and referral according to the level of care. The main obstetric emergency encountered was cephalopelvic disproportion and its complications. Cesarean delivery was the main obstetric procedure used to deal with these complications. Lowering of financial barriers to increase access to this major obstetric intervention was one of the strategies of the organisation of the referral system in Mali. To date, there have not been any in-depth evaluations of cesarean delivery in Mali since the inception of this program. Poor data capture of most population health indicators have called into question the reliability of cesarean delivery reports for other developing countries [Stanton et al, 2005; Holtz and Stanton, 2007]. This paper aims to assess the trends of cesarean delivery at the Point G national hospital in Bamako, Mali over a period of 2 decades. We explore the impact of sociodemographic, Determining Factors of Cesarean Delivery Trends in Developing Countries: Lessons from Point G National Hospital (Bamako Mali) 163 obstetric, and systemic determinants on cesarean delivery rates. Results are discussed in relation to current medical literature available for developing countries and lessons for improvement of current health systems are highlighted. This hospital provides emergency obstetric services for women referred from other health centers, as well as prenatal care and delivery services for women from urban and rural areas surrounding Bamako. The catchments population in Bamako grew rapidly from 658,275 in 1987 to 1,016,296 in 1998. Many patients referred to Point G hospital reside in rural areas surrounding Bamako. Thus, rates of early access to care and facility-based delivery among patients at Point G hospital may be lower than those found among residents of Bamako. Among the major events that influenced obstetric admission at Point G hospital, is the National Perinatality Program implemented in 1994, which included organization of a referral system between primary health structures and district referral centers. Access to cesarean delivery was the cornerstone of this organization which improved transport and designed schemes to lower its cost for women in needs. This referral system has been shown to increase access to emergency obstetric care and decrease maternal mortality in rural Mali [Fournier et al, 2009], though its impact on maternal deaths at an urban tertiary care center is unknown. Between 1998 and 2000, an audit of near-miss events was undertaken to improve delivery services. The obstetrics and gynecology service of Point G teaching hospital was equipped with 1 labor ward containing 3 delivery tables, 30 beds, and a single operating room for scheduled surgeries as well as emergent surgeries from 1985 to 1994. At Point G National Hospital the general surgery and urology services also provided care during delivery mainly to those women requiring cesarean delivery.

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However, prompt management with vasoactive drugs should be performed if dysrhythmias persist. An indwelling urinary catheter is used in almost all women undergoing cesarean delivery [64]. A urinary catheter helps avoid overdistention of the bladder during and after surgery. In cases of hypovolemia and/or oliguria, a collection system that allows precise measurement of urine volume should be used. In regard to central invasive hemodynamic monitoring, there is insufficient literature to examine whether pulmonary artery catheterization or minimally invasive methods to evaluate cardiac output (pulse-wave analysis methods) are associated with improved maternal, fetal, or neonatal outcomes in women with pregnancy-related hypertensive disorders [65]. Additionally, there is an important lack of evidence regarding the management of obstetric patients with central venous catheterization. However, the routine use of pulmonary artery catheterization, pulse-wave analysis methods to evaluate cardiac output or central venous does not reduce maternal complications in severely preeclamptic women [6]. The most important preventive measure is to ensure left uterine displacement so as to avoid the supine hypotensive syndrome [66]. Prehydration or preloading is not necessarily an effective measure to prevent hypotension and several strategies of prehydration have been used elsewhere [67-69]. Some studies have found a smaller incidence of hypotension in the prehydrated patients as compared with the control (no prehydrated) patients. However, the total amount of fluid and vasoconstrictors, and the severity of the hypotension usually not differ between groups [67-69]. Nevertheless, neonatal outcomes, as measured by Apgar score and umbilical cord blood gas and pH measurements, are improved when the parturient is prehydrated [70]. Although there are some conflicting findings, the literature still supports the use of intravenous fluid preloading for spinal anesthesia since it seems to reduce the frequency of maternal hypotension when compared with no fluid preloading. Of note, though fluid preloading 80 Cesarean Delivery reduces the frequency of maternal hypotension, initiation of spinal anesthesia should not be delayed to administer a fixed volume of intravenous fluid. Future studies should address the use of colloids in the obstetric setting in order to demonstrate efficacy and safety. The literature is equivocal regarding the relative frequency of patients with breakthrough hypotension when infusions of ephedrine are compared with phenylephrine; however, lower umbilical cord pH values are reported after ephedrine administration as compared to the alpha1-agonist phenylephrine. Although recent data indicates that alpha1-agonists are more effective to avoid hypotension following spinal anesthesia for cesarean delivery, ephedrine is acceptable for treating hypotension during neuraxial anesthesia. Therefore, intravenous ephedrine and phenylephrine are both acceptable drugs for treating hypotension during neuraxial (spinal or epidural) anesthesia. In the absence of maternal bradycardia, phenylephrine may be preferable because of improved fetal acid-base status in uncomplicated pregnancies. Of note, some countries routinely use metaraminol as an alpha1-agonist instead of phenylephrine in the obstetric setting without significant adverse events. Of note, prophylactic intravenous ephedrine or phenylephrine before spinal anesthetic placement has been studied to prevent hypotension, and is generally not recommended because of the risk of reactive hypertension [71,72]. In addition, the literature is insufficient to evaluate spinal opioids compared with parenteral opioids. However, there is sufficient evidence that neuraxial opioids improve postoperative analgesia and maternal satisfaction. Therefore, we can argue that, for postoperative analgesia after neuraxial anesthesia for cesarean delivery, neuraxial opioids are preferred over intermittent injections of parenteral opioids [6]. Studies are equivocal regarding doses regimen, especially for epidural opioids (morphine). In spinal anesthesia for cesarean delivery, morphine doses are usually between 60 and 100? However, controversy exists and new studies regarding efficacy and adverse effects are warranted. Evidence-Based Obstetric Anesthesia: An Update on Anesthesia for Cesarean Delivery 81 4. The authors found that the early consumption (within 4 to 8 hours) was associated with a shorter time to return of bowel sounds and a shorter hospital stay. No differences were reported in nausea and vomiting, abdominal distention, time to bowel activity, paralytic ileus, or need for analgesia. There are no differences in the incidence of urinary retention after general anesthesia and epidural anesthesia following cesarean delivery [74].

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Lobbying and negotiation was undertaken by all project sites, and local evaluation data was used to present a case for sustainability following the conclusion of the implementation period. Three projects teams were still awaiting the outcome of their funding submission / business case to their respective organisation (although services were continuing to some extent nonetheless). This coincided with the trainees completing their competency assessments so it is anticipated the project outcomes, particularly in relation to patient throughput, should increase. Opportunities to increase scope of practice, ongoing competency assessment and continual service development will continue to be explored. In addition to ensuring sustainability through continuation of the funding for service, ongoing funding of 0. Progress towards developing a team of Advanced Musculoskeletal Physiotherapists willing and able to work across sites and multiple clinics is also being made. Temporary funds were allocated from within the health service to continue the additional In-Scope Physiotherapist role for a further six months. The professional development pathway resources can be utilised for further candidates in the In-Scope Physiotherapist role. The service is identical to that of the project period, 7 days per week, a daily 7. Ongoing dissemination efforts from project teams were evident throughout the implementation and evaluation phases, although at a reduced volume. Sustaining the change effort required ongoing communication and the decrease in dissemination activity in the latter stages of the project suggested that project teams needed to invest more energy in regular dissemination activities throughout the life of the project and particularly towards the conclusion of the project, when project achievements can be disseminated. A presentation to staff within the organisation was the most common method of dissemination employed. Physiotherapists in the Emergency Department Sub-Project Final Report Page 96 the purpose of approximately three quarters of total dissemination activities was capacity building and sustainability (which included information shared with project stakeholders, such as steering committee members, management and staff of participating services, and groups or individuals in the local community to support the capacity building and sustainability aspects of the project). The primary audience for most activities were the staff of the respective organisation (including staff and directors of emergency and physiotherapy departments) to improve organisational engagement and assist change management. A number of activities had a broader audience including the local community and state and national audiences. For example, several conference presentations were made throughout the implementation phase including at the Emergency Management Conference, the Australian Physiotherapy Association National Conference, 10th National Allied Health Conference and Health Workforce Australia Conference. Project teams also had plans to submit more abstracts to relevant conferences and manuscripts for publication in peer reviewed journals in the future. The vast majority of activities resulted in someone who heard about the project following up to seek more information, suggesting that interest was generated among some audience members, and providing some indication of successful dissemination. Nonetheless, demonstrating early wins is difficult and usually requires sustained implementation. This climate of limited resources also led to managers having to balance the implementation of the initiative with multiple organisational demands. Project teams that maintained a high level of investment in project management best positioned their projects for sustainability. A receptive context for change within organisations includes factors such as a need for change, a supportive culture conducive to innovation, managerial support, leadership, appropriate infrastructure and resources, and engagement of key stakeholders. In conclusion, the availability of additional funding was the single most important determinant of sustainability for most project teams. Physiotherapists in the Emergency Department Sub-Project Final Report Page 98 7 Prospects for wider implementation the starting point for decision-making around wider implementation of any innovation is the extent and quality of the available evidence of effectiveness. It is summarised in four reviews of the literature, supplemented by a few more recent studies. Only four papers met 6 the inclusion criteria for the review: one literature review and three primary studies. The authors concluded that: Despite the lack of methodological rigor of the studies reviewed, findings provide consistent, albeit low grade, evidence that for patients with musculoskeletal disorders, [expanded scope of practice physiotherapy] care may be as beneficial (or more so) than usual care by physicians in terms of diagnostic accuracy, treatment effectiveness, use of healthcare resources, economic costs and patient satisfaction. It did not add materially to the findings of the two more relevant reviews described above. Findings which showed equivalent care between the two groups in each study are not included in the table. There was, however, a notable absence of findings to demonstrate improvements in clinical outcomes. Although some studies have shown equivalent or improved efficiency with an expanded scope of practice physiotherapy model, safety and quality outcomes have not been demonstrated to date. If the innovation is relatively complex, it helps if it can be broken down and implemented in stages.

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In individual cases a healthcare professional may, after careful consideration, decide not to follow a guideline if it is deemed to be in the best interests of the woman and her baby. It may not be appreciated that at the time caesarean deliveries were performed with a vertical incision in the uterus and that the lower segment transverse incision was not popularised until the 1920s. The consensus in clinical practice remains once a vertical incision on the uterine body at the time of a prior section, always a repeat caesarean. The authors concluded that a trial of labour after prior caesarean was associated with a greater perinatal risk than elective repeat caesarean, although absolute risks were low. Searches were confined to the titles of English language articles published between August 2001 and July 2011. Relevant meta-analyses, systematic reviews, intervention and observational studies were sought. Interestingly, there is evidence of inconsistencies between national guidelines (Foureur et al, 2010; Bujold, 2010). The accurate dating of the pregnancy may help avoid unnecessary induction of labour, for example for postdates, and thus any risks associated with oxytocic agents for induction may be avoided. All women with a previous caesarean section should also have an ultrasound examination before 32 weeks gestation for placental localisation because they have an increased risk of placenta praevia, and less commonly of placenta accreta. The risk of placenta accreta increases with the number of previous caesareans (Silver et al, 2006; Solheim et al, 2011). If abnormal placental localisation is diagnosed before delivery this facilitates advanced planning to ensure that both a senior obstetrician and anaesthetist are available for delivery and that adequate blood is cross-matched. It also gives an opportunity to prepare the woman and her family for the possibility of peripartum hysterectomy if intraoperative haemorrhage cannot be controlled. The Programme has commissioned a separate guideline for the management of placenta accreta. The views of the woman should be sought, including her plans for future pregnancies. Any plans for delivery should be recorded in the notes by the senior obstetrician on the mutual understanding that the clinical circumstances can change as pregnancy advances. It is also preferable that any request for tubal ligation is discussed and recorded early in the pregnancy because the acquisition of informed consent for sterilisation is problematic if deferred until delivery is imminent. There are two types of rupture; complete rupture involves the full thickness of the uterine wall and incomplete rupture occurs when the visceral peritoneum remains intact. It is important to make this distinction because there are significant differences between the two in terms of clinical presentation and complication rates. Complete rupture usually presents as a dramatic emergency, which is potentially life-threatening for both mother and baby. It is also possible that asymptomatic scar dehiscence can occur with a vaginal delivery but remain undiagnosed. Thus, it is recommended that the term uterine dehiscence is reserved for an incomplete uterine rupture. The different rates may be explained by different methodological designs and definitions of scar rupture. Comparisons are also hindered by limitations in coding and verification (Foureur et al, 2010). Particular attention should be paid to the details of the previous delivery and/or labour. With increasing migration of women, the previous records may be unavailable and additional caution should be exercised in cases where these details are unknown. There is evidence that women with a previous scar on the body of the uterus may experience a rupture antepartum (Turner, 2002). However, rupture of a previous low transverse incision is usually diagnosed intrapartum or postpartum. Thus, women with a previous vertical scar on the body of the uterus may require hospitalisation in the third trimester for observation, particularly if they present with abdominal pain or signs of impending labour. There is a consensus that women with a previous vertical incision on the uterine body should be delivered by an elective repeat section (Turner, 2002). Due to the risk of antepartum rupture, consideration should also be given to administering corticosteroids to mature the fetal lungs and to delivering the baby before 39 weeks gestation. This may be achieved successfully with an abdominal monitor with recourse to fetal scalp electrode where loss of contact is present.

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Sultan K et al: the nature of inflammatory bowel disease in patients with 0 Postprandial pain coexistent colonic diverticulosis. Along with the epidemic of obesity, diverticulosis is now seen even among young adults such as this young woman. Both obesity and diverticulosis are related to a diet high in fat and low in fiber, and both are more common among inactive individuals. There is a pericolic abscess due to the perforated diverticulum, but the rectum is spared. This amount of free intraperitoneal air is unusual as the omentum usually walls off the perforated diverticulum. Mesenteric vein becomes contaminated with resulting from perforation of colonic diverticula. Kechagias A et al: the role of C-reactive protein in the prediction of the narrowing clinical severity of acute diverticulitis. Diverticulitis has become more common in younger individuals as part of the obesity and metabolic syndrome epidemic. Numerous diverticula and pericolonic stranding were better seen on other sections. At surgery, the fistula was determined to be due to diverticulitis that had infected the scar from the hysterectomy. Low acuity, but persistent diverticulitis is a relatively common cause of portal thrombophlebitis and liver abscess. It has a fat-density core and a contrast-enhanced rim, with inflammation of the adjacent mesenteric fat. The lesion has a thin, enhanced capsule, and there is a thin linear density in its center? Omental infarction may have a similar presentation but usually appears as a larger "ball of dirty fat. Similar findings can result from "dropped" gallstones, but this patient had an intact gallbladder. The sigmoid is folded back upon itself, and the apposed walls of the redundant sigmoid colon? The dilated colonic segments upstream from the volvulus may be easier to distinguish on coronal sections. Selcuk Atamanalp S: Treatment for ileosigmoid knotting: a single-center 0 Compound volvulus experience of 74 patients. Meyer F et al: Unusual "twister"-like appearance of a sigmoid volvulus on computed tomography. The base of the cecum is directed toward the upper quadrant, and the ileocecal valve? Vrablik V et al: [Pseudoobstruction syndrome of the large intestine 0 Orthopedic surgical procedures (1% of patients develop (endoscopic therapy). The colonic distention persisted all the way to the rectum, although the descending colon? Complaints of abdominal pain and distention led to this supine film showing massive distention of the colon. At surgery, the cecum was twisted on its mesentery (cecal volvulus) with ischemic necrosis of its wall. Note the low position of the rectum and anus relative to the ischial tuberosities. At surgery there were several lacerations of small bowel, and the descending colon had a "degloving" injury with active bleeding. Bortolin M et al: Primary repair or fecal diversion for colorectal injuries after thickness laceration blast: a medical review. Epub ahead of print, 2009 0 Insertion of foreign objects into rectum may result in 5. The outer rim of the "Mexican hat" is the head of the polyp, while the inner ring is the stalk.

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Hilar lymphangiectatic cysts more pronounced due to marked thickening of tubular 3. Glomerular diseases encompass a large and clinically A number of clinical syndromes are recognised in significant group of renal diseases. It is convenient to classify nephritic and nephrotic syndromes; glomerular diseases into 2 broad groups: acute and chronic renal failure; I. Primary glomerulonephritis in which the glomeruli are the asymptomatic proteinuria and haematuria. The haematuria is generally slight giving the urine smoky classifications of different types of glomerulonephiritis have appearance and erythrocytes are detectable by microscopy been described, but most widely accepted classification is or by chemical testing for haemoglobin. Appearance of red based on clinical presentation and pathologic changes in the cell casts is another classical feature of acute nephritic glomeruli given in Table 22. Hypertension is variable depending upon the severity the clinical presentation of glomerular disease is quite of the glomerular disease but is generally mild. Oedema in nephritic syndrome is usually mild and present in varying combinations depending upon the results from sodium and water retention (page 97). Minimal change disease pathogenesis; it is characterised by findings of massive 4. Amyloidosis (page 82) increased glomerular permeability to plasma proteins, excess 4. Polyarteritis nodosa (page 402) of protein is filtered out exceeding the capacity of tubules 5. Cryoglobulinaemia proteinuria unexpectedly in a patient may be unrelated to renal disease. Association of asymptomatic the concentration of other proteins in the plasma such as haematuria, hypertension or impaired renal function with immunoglobulins, clotting factors and antithrombin may fall asymptomatic proteinuria should raise strong suspicion of rendering these patients more vulnerable to infections and underlying glomerulonephritis. Oedema in nephrotic syndrome appears due to fall in microscopic haematuria is common in children and young colloid osmotic pressure consequent upon hypo albuminaemia. Nephrotic oedema is usually peripheral but in children facial oedema may be more I. IgA nephropathy of massive protein synthesis in response to heavy urinary protein loss, also causes increased synthesis of lipoproteins. Bee stings, snake bite, poison ivy platelet aggregation and altered levels of protein C and S. Mechanism of Oedema Na+ and water retention vvvvv plasma osmotic pressure, Na+ and water retention 5. Hypercoagulability Absent Present adolescents and has many diverse causes such as diseases sis of some forms of glomerular diseases in human beings of the glomerulus, renal interstitium, calyceal system, ureter, (Table 22. Majority of cases of in patterns that closely resemble those of experimental glomerular disease result from deposits of immune models. The consequences of injury at different sites within complexes (antigen-antibody complexes). The immune the glomerulus in various glomerular diseases can be complexes are represented by irregular or granular glomer assessed when compared with the normal physiologic role ular deposits of immunoglobulins (IgG, IgM and IgA) and of the main cells involved i. There is evidence to suggest that cell-mediated i) Exclusive mesangial deposits are characterised by very mild immune reactions in the form of delayed type hypersensiti form of glomerular disease. Component Physiologic Function Consequence of Injury Related Glomerular Disease 1. It shows three patterns of irregular or granu lar glomerular deposits in immune-complex disease. Classic experimental model of in situ immune complex result from circulating immune complexes. These deposits are detected stimulate cytotoxicity, recruitment of more leucocytes and by immunofluorescence microscopy or by electron fibrogenesis. Deposits of C3 are associated with the early mediators of immunologic glomerular injury operating in components C1, C2 and C4 which are evidence of classic man and in experimental models. But in alternate following: pathway activation, there is decreased serum C3 level, decreased serum levels of factor B and properdin, normal 1. Neutrophils can mediate glomerular to increased deposition of mesangial matrix and proliferation 665 injury by activation of complement as well as by release of of mesangial cells, endothelial and epithelial cell injury, and proteases, arachidonic acid metabolites and oxygen-derived eventually to progressive glomerulosclerosis and end-stage free radicals. Features of individual types Accumulation of mononuclear phagocytes is considered an are described below and a summary of major forms of important constituent of hypercellularity in these forms of primary glomerulonephritis is given in Table 22.