Mark Corson

A. Abe. Urbana University.

She prepares the duty roster and ensures that the appropriate nursing staff be posted to the various facilities of the department order 60mg alli. They should have ongoing training in emergency procedures discount 60 mg alli, investigations and patient stabilisation cheap 60 mg alli overnight delivery. Further, they should ensure the replacement of all appropriate drugs in the resuscitation cart as well as miscellaneous disposables. Nurses should ensure the working condition of monitors and other electronic equipment and notify malfunction. They are trained in the knowledge and skills to assist medical and nursing personnel in the Emergency Department. They are the leading cause for long-term absence from work (> 2 weeks) in many countries. Their direct and indirect cost is considerable and their management utilizes a significant part of the gross national product of many countries. For the middle aged and elderly, early detection and treatment of osteoporosis and management of rheumatic diseases at an early stage with available agents can significantly reduce the risk of fractures, deformities and associated morbidity and mortality. This in totality justifies the need for developing a program on a district model for Musculo- skeletal disorders in the country. Special provision for providing Calcium and Vitamin D to infants and women of both child bearing age and post menopause for both prophylactic and therapeutic purpose. Management information system for monitoring and evaluation through a structured data base mechanism for gathering information on availability of manpower, logistics, performance and other relevant information pertaining to the programme. Based on the response, necessity of services and willingness of the states/ medical colleges for implementing the program the medical colleges will be selected on priority. The phase-wise inclusion of medical colleges would be as shown below in the table: Medical 2012-13 2013-14 2014-15 2015-16 2016-17 Total Colleges 10 30 35 25 20 120 New 40 70 105 130 150 150* Cumulative th 150* medical colleges include 30 medical colleges that are targeted to be covered in 11 th Plan and 120 new medical colleges proposed to be covered in the 12 Plan. Amputee rehabilitation These institutions will impart training disability prevention, detection and early intervention for undergraduate and post-graduate medical students and other health professionals. General Objectives- 1) To build capacity in the Medical Colleges for providing comprehensive rehabilitation services and to train adequate manpower required at all levels of Health Care Delivery System. To set up an independent Department of Physical Medicine and Rehabilitation in Central / State Governments or Municipal Corporation totaling around 150 colleges. To train medical and rehabilitation professionals in the districts in adequate numbers for providing secondary and tertiary level rehabilitation services. Training programme on Disability Prevention, Detection and Early Intervention at Undergraduate & Postgraduate level for all Medical Officers in the participating District. Provision of Rehabilitation Services in the setting of rehabilitation services in a comprehensive manner so that all clinical departments are involved and thereby to evolve a strategy of continuation of care even in the domiciliary and community set up. Setting up of independent Physical Medicine and Rehabilitation Department in 150 th medical College/Training Institutions during the end of the 12 Five Year Plan. Training of 1000 Medical doctors and allied health professionals in disability assessment and early identification. Develop Linkages and registration of Medical Rehabilitation to impairments and functional limitation arriving out of acute and chronic conditions undertaking treatment at Medical Colleges. Training of Medical Officers in disability assessment and computation for issue of disability certificates. The medical college will have to provide their space and infrastructure for the Department. Given below are the requirements for a well developed department but starting of a departing or its development can be planned according to the sources available and requirement of the facilities in the area. No Name of Post monthly pay Posts Expenditure (Consolidated) 1 Consultant 60000 2 1440000 2 Programme Assistant 30000 1 360000 3 Data Entry Operator 15000 2 360000 Total 130000 6 2160000 222 B. No Name of Post monthly pay Posts Expenditure (Consolidated) 1 Assistant Professor 55000 1 660000 2 Sr. Equipments would be supplied in phased manner as given below- st 1 year of inclusion: Rehabilitation equipment for diagnosis & treatment, Workshop equipments. Apex Institutions (Centre of Excellence) for Medical Rehabilitation- It is proposed to Establish National Centres for Medical Rehabilitation in field of Medical Rehabilitation in 4 different parts of the country either by up-gradation of the existing Institution or by starting new centres in response to scaled up needs of disabled population. Each centre is proposed to have separate unit for above category of disabled and treatment guidelines on the basis of evidence, conduct research, interact with various engineering Institution periodically for designing, manufacturing of aids and appliances, assistive devices and independence devices for physically disabled. Highly trained manpower in rehabilitation in specific areas is the need of the hour considering the fact that there is huge demand in the private sector for experienced rehab personnel. National Blindness Control Program India is committed to reduce the burden of avoidable blindness. The proposal is to modify pattern of assistance to effectively reduce prevalence of blindness and develop infrastructure th and Eye Care services delivery system during 12 Five Year Plan. Focus Areas: 9 Cataract: Cataract is the leading cause of blindness contribution around 62. In spite of all out efforts, there is a backlog of cataract in the country due to various reasons including inadequate eye care infrastructure, ophthalmic manpower. It has, therefore, been proposed to provide assistance for control of Refractive Error. Among the emerging causes of blindness, diabetic retinopathy and glaucoma need special mention. Prevalence of blindness due to glaucoma is estimated to be 4% in persons aged 50 years and above. Multi-Purpose mobile ophthalmic units to be introduced at all the districts level to reach the remote areas not covered by existing facilities and to be involved in all the following activities a. Construction of dedicated Eye units in District Hospitals in North-Eastern States, Bihar, Jharkhand, J&K, Himachal Pradesh, Uttarakhand and few other States where dedicated Operation Theaters are not available as per demand.

On the antecubital fossa and axillary folds order 60mg alli with mastercard, the rash has a linear petechial character referred to as Pastia’s lines (127) buy alli 60mg overnight delivery. Confirmation of the diagnosis is supported by isolation of group A streptococci from the pharynx and serologies (111) buy alli 60mg free shipping. The signs and symptoms evolve over the first 10 days of illness and then gradually resolve spontaneously in most children. Fever for five days or more that does not remit with antibiotics and is often resistant to antipyretics. Changes in the lips and mouth: reddened, dry, or cracked lips; strawberry tongue; diffuse erythema of oral or pharyngeal mucosa 36 Engel et al. Changes in the extremities: erythema of the palms or soles; indurative edema of the hands or feet; desquamation of the skin of the hands, feet, and perineum during convalescence e. Other clinical features include intense irritability (possibly due to cerebral vasculitis), sterile pyuria, and upper respiratory symptoms (130). Treatment with aspirin and intravenous immune globulin has reduced the development and severity of coronary artery aneurysms. Other Causes of Diffuse Erythematous Rashes Streptococcus viridans bacteremia can cause generalized erythema. Enteroviral infections, graft versus host disease, and erythroderma may all present with diffuse erythema (8). The causes of vesiculobullous rashes associated with fever include primary varicella infection, herpes zoster, herpes simplex, small pox, S. Other causes that will not be discussed include folliculitis due to staphylococci, Pseudomonas aeruginosa, and Candida, but these manifestations would not result in admission to a critical care unit. Varicella Zoster Primary infection with varicella (chicken pox) is usually more severe in adults and immunocompromised patients. Although it can be seen year-round, the highest incidence of infection occurs in the winter and spring. The disease presents with a prodrome of fever and malaise one to two days prior to the outbreak of the rash. A characteristic of primary varicella is that lesions in all stages may be present at one time (8). Patients often have a prodrome of fever, malaise, headaches, and dysesthesias that precede the vesicular eruption by several days (139). The characteristic rash usually affects a single dermatome and begins as an erythematous maculopapular eruption that quickly evolves into a vesicular rash (Fig. The lesions then dry and crust over in 7 to 10 days, with resolution in 14 to 21 days (112). Both immunocompetent and immunocompromised patients can have complications from herpes zoster; however, the risk is greater for immunocompromised patients (147). Complications of herpes zoster include herpes zoster ophthalmicus (140,148), acute retinal Fever and Rash in Critical Care 37 Figure 8 Lower abdomen of a patient with a herpes zoster outbreak due to varicella zoster virus. The diagnosis of primary varicella infection and herpes zoster is often made clinically. The World Health Organization declared that smallpox had been eradicated from the world in 1980 as a result of global vaccination (156,157). With the threat of bioterrorism, there is still a remote possibility that this entity would be part of the differential diagnosis of a vesicular rash. Smallpox usually spreads by respiratory droplets, but infected clothing or bedding can also spread disease (158). The pox virus can survive longer at lower temperatures and low levels of humidity (159,160). After a 12-day incubation period, smallpox infection presents with a prodromal phase of acute onset of fever (often >408C), headaches, and backaches (158). A macular rash develops and progresses to vesicles and then pustules over one to two weeks (161). The rash appears on the face, oral mucosa, and arms first but then gradually involves the whole body. The pustules are 4 to 6 mm in diameter and remain for five to eight days, after which time, they umbilicate and crust. In the United States, almost nobody under the age of 30 years has been vaccinated; therefore, this group is largely susceptible to infection. The diagnosis of smallpox is based on the presence of a characteristic rash that is centrifugal in distribution. Laboratory confirmation of a smallpox outbreak requires vesicular or pustular fluid collection by someone who is immunized. Herpes Simplex Herpes simplex virus type 1 (herpes labialis) commonly causes vesicular lesions of the oral mucosa (163). The illness is characterized by the sudden appearance of multiple, often painful, vesicular lesions on an erythematous base. Recurrent infections in the immunocompetent host are usually shorter than the primary infection. Aside from vesicular eruptions on mucous membranes, the infection can cause keratitis, acute retinal necrosis, hepatitis, esophagitis, pneumonitis, and neurological syndromes (163–172). Herpes simplex virus type 1 can cause sporadic cases of encephalitis characterized by rapid onset of fever, headache, seizures, focal neurological signs, and impaired mental function. Bacteremia can lead to metastatic complications, such as endocarditis and arthritis.

Infections (for which the offending antibiotic may have been prescribed) purchase alli 60mg without prescription, including pneumococcal order alli 60 mg online, mycoplasmal buy alli 60mg with amex, and staphylococcal infections can cause a similar rash. Stevens–Johnson syndrome can evolve into toxic epidermal necrolysis; mortality of this condition is 30% (62). Sulfonamides are the antibiotics most often associated with toxic epidermal necrolysis. Although the benefits of corticosteroid therapy are unproven, these products are often used for treatment. Severe cases have been associated with angioedema, hypotension, chest pain, and rarely, severe cardiac toxicity and death (20). Incidence may be as high as 47% in patients and is substantially higher in human volunteers (64). One study documented a dose-related increase in circulating histamine concentrations that correlated with the severity of the reaction (65). Histamine antagonists may abort the syndrome in patients who require 548 Granowitz and Brown vancomycin and who continue to have red man syndrome despite slow administration of the drug (63,66). Both may be associated with redness, heat, tenderness and a “cord” at the peripheral catheter site. Therapy for the former is removal of the catheter and appropriate antibacterial agents, while the latter is treated with catheter removal and moist heat. Presence of lymphangitic streaking or purulent drainage from the catheter site generally indicates infection. Antibiotics most likely to cause phlebitis include potassium penicillin, cephalosporins, vancomycin, streptogramins, and amphotericin B. Although routine audiography has been promulgated for some hospitalized patients given potentially ototoxic drugs (67), in practice such testing is not routinely employed. Therefore, the clinician must recognize the circumstances that could result in ototoxicity and take steps to decrease its likelihood. Erythromycin and azithromycin can cause bilateral hearing loss and/or labyrinthine dysfunction that is usually reversible within two weeks of discontinuating the agent (68,69). These complications are dose- related and usually occur in the presence of renal and/or hepatic dysfunction (71). A prospective study in patients with pneumonia documented sensorineural hearing loss in approximately 25% of patients treated with 4 g of erythromycin daily, while no patients who received lesser doses or control agents developed this condition (68). Aminoglycosides cause ototoxicity or vestibular dysfunction in 10% to 22% of patients and it can be permanent (24,72). Cumulative dose is important and clinicians should be wary of administering repeated courses of aminoglyco- sides. Use of an early vancomycin preparation was associated with sensorineural hearing loss (76). Other Neurotoxicities Antibiotics can also occasionally cause peripheral nerve or acute central nervous system dysfunction (e. Most peripheral neuropathies occur with prolonged administration of selected antibiotics (e. Hallucinations, twitching, and seizures can be caused by penicillin, imipenem/cilastatin, ciprofloxacin, and rarely by other b-lactam antibiotics (78,79). Seizures may be the result of b-lactams interfering with the function of the inhibitory neurotransmitter g-aminobutyric acid (80). Intravenous aqueous penicillin G may cause central nervous system toxicity when normal-sized adults are given more than 20 to 50 million units per day (78). Patients with abnormal renal function, hyponatremia, or preexisting brain lesions can experience neuro- toxicity at lower doses. The maximum recommended dose of imipenem-cilastatin in adults with normal renal function is 4 g/day. Animal studies confirm that neurotoxicity with imipenem/cilastatin may be noted at substantially lower blood levels than with other b-lactams (80). Our practice has been to virtually never employ imipenem/cilastatin in doses of >2 g/day unless treating Pseudomonas aeruginosa infections. Seizures have not been noted in more than two decades of regular use at the authors’ institution. Fluoroquinolone use has been associated with central nervous system adverse effects including headache and seizures in 1% to 2% of recipients (83). Hallucinations, slurred speech, Adverse Reactions to Antibiotics in Critical Care 549 and confusion have been noted; these generally resolve rapidly once the offending agent is discontinued. The presence of an underlying nervous system disorder may predispose to neurotoxicity. Serotonin syndrome is due to impaired serotonin metabolism and is characterized by agitation, neuromuscular hyperactivity, fever, hypotension and even death. Although linezolid itself does not cause serotonin syndrome, combining this drug with other monoamine oxidase inhibitors can result in toxicity. A small percentage (<5%) of patients on selective serotonin reuptake inhibitors who are given linezolid develop serotonin syndrome (84–88). If it is necessary to start linezolid in a patient requiring a selective serotonin reuptake inhibitor, the patient should be watched for signs of serotonin syndrome and the responsible medications promptly discontinued if signs develop. Neuromuscular blockade has been reported with aminoglycosides (78) and polymyxins. Clinical presentation is acute paralysis and apnea that develop soon after drug administration.

Slightly higher hair follicular counts were observed in females of all ethnic groups (Fig order alli 60mg without a prescription. Familiarity with the differences in qualitative and quantitative information provided by the plane of the scalp biopsy specimen is important in the successful interpretation of horizontal sections alli 60mg on line. The terminal hair follicle penetrates deep into the dermis extending into the subcu- taneous tissue discount alli 60 mg amex. In the vertical plane of section the terminal hair follicle consists of a permanent upper segment of follicular infundibulum and isthmus, and an impermanent lower segment of the hair follicle consisting of the lower follicle and root (bulb) (Fig. Infundibulum The infundibulum opens from the epidermal surface and ends at the entry of the sebaceous duct into the hair follicle. The infundibulum is lined with a keratinized skin surface epithelium that contains a granular layer and basket weave keratin (Fig. Hence proliferation of the infundibulum gives rise to the epidermoid inclusion cyst (folliculo-infundibular cyst). The hair shaft is contained within the infundibulum and has no attachment to the isthmus or the infun- dibulum, allowing freedom of movement. Isthmus The isthmus extends down from the opening of the sebaceous duct and ends at the “bulge” where the arrector pili muscle inserts into the follicle. It is lined by the trichilemmal keratin that is characterized by an eosinophilic compact keratin material, devoid of a granular layer. The inner root sheath crumbles and disappears in the mid-isthmus of the upper follicle (Fig. There it is replaced by trichilemmal keratin formed by the outer root sheath or trichilemma. The hair follicle consists of infundibulum that ends at the sebaceous duct, an isthmus ending at the insertion of the arrector pili muscle, and lower follicle and hair root (bulb). The dilating follicular opening is surrounded by external root sheath lined by skin surface epidermis with granular layer and basket weave keratin (hematoxylin and eosin stain, 200x). External root sheath is lined with skin surface epidermis with a granular layer (hematoxylin and eosin stain, 400x). Trichilemmal keratin lines the upper isthmus extending to the level of entry of the sebaceous duct at the base of the infundibulum (Fig. The bulge area is located in the inferior portion of the isthmus near the insertion of the arrector pili muscle. The bulge contains stem cells that are slow cycling and when activated gives rise to transit amplifying cells that can differentiate into hair follicle (15). Hair Bulb The follicular root consists of the hair bulb, which is found in the deepest portion of the hair follicle and surrounds the dermal papilla (Figs. The bulb contains undifferentiated, actively dividing hair matrix cells that extend to the widest diameter of the hair bulb known as the critical line of Auber. Hair matrix cells around this central area produce elongated cortical cells, which stream upward to form the developing hair shaft. Higher up in the keratogenous zone, these cells become compacted into hard keratin. The outer fringe of matrix cells forms the hair cuticle and the surrounding inner root sheath. The hair cuticle invests the hair fiber with six to ten overlapping layers of cuticle cells. The dermal papilla enveloped by the hair matrix cells contains fibroblasts, collagen bun- dles, fibronectin, glycosaminoglycans, and small blood vessels. The volume of the dermal papilla cells dictates the size of the hair shaft and induces formation of hair follicle (24). Next is the outer root sheath, followed by the inner root sheath comprising Henle’s layer, Huxley’s layer and the cuticle of the inner root sheath. The central developing hair shaft is largely comprised of hair cortex invested by its cuticle and surrounding the medulla. Outer Root Sheath The outer root sheath, or trichilemma, has no granular layer and is glycogen rich, accounting for the pale cytoplasm. It appears at the base of the bulb as a thin lining becoming thicker as it extends upward to the level of the isthmus where it shows trichilemmal keratinization (Figs. The outer root sheath is covered by the hyaline or vitreous membrane, which is continuous with epidermal basement membrane surrounding the dermal papilla. Folds or corrugations of the hyaline membrane are sometimes seen projecting into the underlying trichilemmal layer. The hyaline membrane is surrounded by the fibrous dermal sheath of the hair follicle, which is continuous with the dermal papilla at the base of the hair bulb. Inner Root Sheath The inner root sheath starts from mid-isthmus extending to the base of the bulb. It expands and thickens as it continues upward (left) and is replaced at the level of the isthmus where it shows trichilemmel keratinization (right). Henle’s layer keratinizes first with the appearance of trichohya- line granules near the hair bulb, forming a distinct pinkish keratinized band higher up from the bulb (Fig. The cuticle of the inner root sheath is the next to keratinize, synchronizing with keratinization of the cuticle of the hair shaft (Fig. Finally, trichohyaline granules appear in Huxley’s layer, signaling impending keratinization (Fig. Keratinization of the inner root sheath is completed halfway up the lower follicle. The keratinized inner root sheath occupies the upper half of the lower follicle (Fig. The inner root sheath is surrounded by one or more layers of cells of the outer root sheath or trichilemma. The potential space between inner and outer root sheaths is named the companion layer and it allows the inner root sheath to slide upward over the outer root sheath during hair growth.