He buy generic zoloft from india depression no energy, therefore cheap zoloft amex depression dsm 5, becomes overworked rural mother cannot carry her healthy 6 months choosy too. Tey constitute 17% of the country’s total and reduction in activity, resulting in obesity. Te under-fves clinic is usually located in a village, a Secondly, common illnesses of this age group—say slum or a labor colony. It is managed by a health worker trained in child health Tirdly, this age period is known for its accelerated and nutrition. She gives nutritional education to the growth and development, warranting regular monitoring. Te services rendered by the clinic are set out in the symbol At times, such clinics also provide low-cost weaning foods for the under-fves clinics (Fig. Te apex of the large triangle represents care in illness by a trained health worker. Te health worker attempts to identify early onset of According to the Biomedical Waste (Management and growth failure and malnutrition through the road-to- Handling) Rules 1995, the biomedical wastes are to be health card, provides supplementary nutrition and handled as per the prescribed procedures. Te incinerators/suitable devices for safe disposal of human aim is to give to the mother all the advice about family anatomical waste (tissues, organs, and body parts), blood planning. Te border across the symbol represents and body fuids and items saturated or dripping with blood health teaching to the mother through posters, charts, and body fuids (Fig. Which of the following is the most appropriate statement in relation to community pediatrics? Health is a state of complete physical, mental and social wellbeing, and not merely an absence of disease or infrmity B. The term, community pediatrics, refers to the practice of pediatrics only outside the hospitals contd... Preventive pediatrics is meant prevention of disease and promotion of physical, mental and social wellbeing of children with the aim of attaining a positive health D. Tertiary prevention: Halting development of disabilities from an established disease 3. True entries about National Family Health Mission include all the following, except: A. Step 1 in management pertains to classifcation of illness according to color-coded charts D. All sick young infants upto two months of age must be assessed of possible bacterial infection/jaundice and diarrhea Answers 1. C Clinical Problem-solving Review 1 An 18-month-old girl, weighing 6 kg, presents with cough and cold for 2 days in a primary health center. On examination she is alert with a respiratory rate of 38/minute but without chest indrawing and temperature of 36. This infant has cough or cold which appear to be consistent with diagnosis of upper respiratory tract infection. When planning vaccination of an unimmunized child we need to keep in mind various vaccine preventive diseases prevalent in that particular age group. Children presenting late for vaccination should be immunized at frst contact (preferably) as the passive immunity derived from maternal antibodies gradually wanes. Indian Academy of Pediatrics has given recommendations for vaccination of unimmunized children (Table 9. India’s national vaccine Policy is guided and rev- of our pediatric population is as yet far from adequate. India is engaged in boosting immunization coverage of children to safeguard them from vaccine preventable diseases through various endeavors. Government of India’s newly launched Indradhanush Mission aims to cover all those children who are unvaccinated or are partially vaccinated against seven vaccine preventable diseases which include diphtheria, whooping cough, tetanus, polio, tuberculosis, measles and hepatitis B, by the end of the year 2020. Immunization has been rightly hailed as “the greatest discovery of the times for pre- several regions/countries now want to adopt or develop vention against infectious diseases”. Vaccination and immunization, though interchangeable Immune response may be: in practice, are not exactly synonymous. It also reduces It is the process of inoculating the antigen (vaccine) carrier state because of production of IgA. It is not the same as seroprotection which is the actual It is mainly IgM type, short-lived, shows revaccination state of protection from infection as a consequence of development of antibodies from seroconversion. Examples: Conjugated Hib, pneumococcal, It is expected to elicit an immune response not Vi typhoid and meningococcal vaccines. Te response is largely humoral Furthermore, immunization may be active or passive. On the other Two terms, vaccine efcacy and vaccine protective- hands, in passive immunization, readymade antibodies ness, need clarifcation. Administration of specifc immunoglobulin or to protect against infection and is epidemiologically nonspecifc normal human immunoglobulin as in case of expressed by the formula: hepatitis A (hep A) and measles provides passive protection Vaccine efcacy = against these viral infectious illnesses. Rate of infection in unvaccinated population In active-passive immunization, both active immuni- Rate of infection in the vaccinated population zation via a vaccine (antigen that stimulates production Vaccine Effectiveness of antibodies) for providing long-term protection and passive immunization via immunoglobulins (preformed Te term, vaccine efectiveness, refers to an ability of the antibodies) for providing immediate protection are given. Preventing hepatitis B (hep B) as well as tetanus is its best Tree factors that infuence vaccine efectiveness are: illustrative examples. Tey can, though duced so that it produces protective antibodies), or passive rarely, become virulent and cause disease per se. Additionally, there are two more types of vaccines— Secondary immune response occurs on reintroduction toxoids and subunit vaccines. Toxoid-based vaccines: Here a modification system responds by producing antibodies immediately. Tetanus z Wound/exposure in 250 units Specifc hyperimmune globulin unimmunized/incompletely immunized subjects. Such a vaccine Subunit vaccines Bacterial—acellular pertussis (aP) needs to be given in several divided doses to cut Viral—hepatitis B (recombinant), infuenza down adverse events. A failure of cold chain may result in inadequate or negli- By stimulation of B cells, subunit vaccines elicit hum- gible protection against the disease despite vaccination. Only IgM antibodies are produced by reports of occurrence of vaccine preventable diseases in pop- these vaccines. Te cold chain equipment consists of: Example: Diarrhea or pneumonia z Idiopathic or unknown: The cause of the adverse event cannot Cold box: Tis can transport large quantities of vaccines be determined. Vaccine carrier: Tis is designed to transport small quantities of vaccine by a vehicle, bicycle or on foot to Adverse events following immunization Box 10. Infrequently, local accelerated reaction, axillary/cervical lymphadenitis (sometime suppurative) not be much encouraged. Tough z Hib: Local erythema, pain, swelling; Infrequently, fever, myalgia, hypersensitivity reactions.
Foam core allows you to build supports so you can use it hands-free purchase zoloft 50 mg visa depression help chat, plus it can be cut to multiple sizes purchase zoloft in united states online anxiety 2 days after drinking. If this occurs and you are aware of why it is occurring, you can accu- rately correct for it. No reﬂector Bouncing Flash (b) If an external fash with a pivoting head is used, one can bounce the light of the ceiling or corners of a room. Tis works nicely in small room like bathrooms that may have refective surfaces or mirrors. Bouncing light will help light the entire room instead of a single subject (see Figure 12. Tis is due Flash bounced off ceiling to the lens being lined up with the subject, so light from (b) the fash passes too high resulting in hot spots on the top and dark spots on the bottom. White foam core is ofen used as a refector to even out the light when working with an on-camera fash. Tey are extremely useful in decreasing shadows, macro Direct flash photography, and shooting into concave objects such as mouths. How to Read a Meter One side of the meter has a plus sign; the other has a minus sign. If the meter is lit at the frst slash on the plus side, it represents +1; the camera settings are one stop overexposed, and Figure 12. If the meter is reading the frst slash on the minus side, the picture is underexposed Ring Flash by one stop and will be too dark. When in focus and assumes that it is a neutral tone to set the shooting into a hole, bring the fash down to the level of exposure. On convex surfaces, the ring fash brings approximately 18% of the light that hits it. Te 18% gray card was example, if you were photographing a face, you would developed to mimic a perfect scene with the tone bal- turn the camera vertically. For example, say the fash on an 18% gray card in any light condition, you are get- is on the right. Because the face is convex, the right side ting the middle exposure between blacks and highlights. Gray now assumes the value of be to put a refector on the lef side to refect the light white, and anything white will be blown out (see Figure back. An external fash may be too high up and will (a) not be able to dissipate while working in a macro set- ting. A ring fash will allow you to get very close and surround your subject with light (see Figure 12. Metering Most cameras have a center-weighted in-camera meter that reads for middle gray. When pointing the camera toward an object and focusing on it, the camera also takes a light reading. Overexposed Overexposed means the picture is too bright or Metering on white washed out. Choose an exposure between the two to get both in the exposure range (see Figure 12. Changing one of the three aforementioned settings may result in changing the others to compensate. Te camera is telling you this is the exposure Metering on White that will give you enough light in your picture; however, W hen metering on white, the camera will make the it does not take into account how much motion blur or white subject the middle value. When changing the shutter speed to 1/60th of a second, for Problems with Metering every stop faster the shutter speed gets, the aperture Metering on white can become problematic. If you meter of their shirt without knowing it, their skin Say the camera meters at a shutter speed of 1/15 will become extremely dark. T e second solution is to If the desired image has both shadows and highlights add more light by turning up the fash output or adding in it and a fll fash is not being used, one may have to ambient light. When the camera is set to day- Daylight light balance while shooting in tungsten light, the light M ost photography will be shot in daylight or with will appear orange in the photograph. Fluorescent Light Tungsten Light Fluorescent lights are the long lights seen in hallways of Tungsten light is a household light bulb (the old round public buildings. Knowing where the light falls on the Kelvin scale will help control the look and feel of the photograph. Overalls are an overview of the scene and its surround- More advanced cameras will let you type this number ings. Tese photos acclimate the viewer to the scene and into the custom white balance to get the correct color what is around it. Some cameras can photograph a white Before shooting overalls, a photo identifer must be area and automatically adjust the white balance. Tis may be a sheet of paper with the dece- Almost all cameras, including point-and-shoots, dent’s claim number and personal information or a card have a white balance menu that can be changed. Tis will help both you and others viewing the images identify which case they are Scene Photography looking at. T e purpose of overall photographs is to answer the Scene photography can be quite complex. Tey do not always the street sign closest to you or the milepost marker on the ofer much natural light when they are indoors nor a lot highway. Tis will show the environment themselves shooting photos with one hand so they can around the body. In low-light situa- inate any possible doubt as to the placement of the body at tions, this can lead to a number of problems with motion the scene and the surrounding environment. Proper scene blur and getting the photographs needed for the medical photography can change the way people perceive an inci- examiner to do a proper investigation. T e best way to dent; therefore, it is paramount to carefully and thoroughly approach any forensic photography is to have a set plan document a scene using photography (see Figure 12. Tis plan should consist of a shot list that can be broken down into three parts: Overall photographs Midrange photographs Close-range photographs Tese three categories will assure that everything needed for an investigation is covered. Overshooting can be just as confusing to people who are not at the scene as under- shooting. It should be consistent from scene to scene, with only slight variations tailored Figure 12. No matter what view a picture is taken from, you always want a view looking back to where you entered. Te body will be seen at autopsy the next day but the scene will not be; therefore, it is important to show the body in the scene and its surrounding environment. From Each Wall Te second way to photograph a room 35mm close up 50mm lens from distance is from each fat wall straight out. When shooting these photos, step back as far as possible until the building flls the frame. Using Tripods and Monopods Te composition should always fll the frame, taking care to omit as much extraneous information as possible.
In either case buy discount zoloft 100 mg on-line bipolar depression in adolescents, ventricular stimulation must produce block in the slow pathway (concealed) buy generic zoloft 100mg on-line clinical depression symptoms yahoo, conduction up the fast pathway, with subsequent recovery of the slow pathway in time to accept antegrade conduction over it to initiate the ventricular echo, and sustained tachycardia. With ventricular extrastimuli, the initial site of delay and/or block is in the His–Purkinje system. Even when conduction proceeds retrogradely over the His–Purkinje system, because of delay in the His–Purkinje system, the S1-H2 or V1-H2 remains constant. Following cessation of pacing, atypical A-V nodal reentry begins with a long R-P interval following the last paced complex. Note that antegrade conduction (A-H) is faster than retrograde conduction (H-A) in the reentrant circuit. Ventricular pacing at 260 msec is shown on the left with 1:1 conduction up the fast pathway. On cessation of pacing following retrograde conduction up the fast pathway, conduction goes down the slow pathway, leading to typical A-V nodal reentry. Transient infra-His block is observed with resumption of 1:1 conduction with bundle branch block. The ventricles are paced at 400 msec, and a ventricular extrastimulus is delivered at 280 msec. The relatively rapid retrograde conduction up the fast pathway is followed by antegrade conduction over the slow pathway, with a markedly prolonged A-H interval exceeding 400 msec and over the slow pathway to initiate A-V nodal reentry. Retrograde conduction proceeds up the fast pathway without prolonged retrograde conduction. As mentioned, this is easier to achieve with ventricular pacing than ventricular extrastimuli. The H-A interval over the slow pathway at initiation of the tachycardia is much longer than the H-A interval during the tachycardia because of concealment into the slow pathway by the initial conduction over the fast pathway. During a basic drive of 400 msec (S1-S1), a premature stimulus (S2) is delivered at 340 msec. With S2, the impulse conducts retrogradely up the fast pathway with essentially no delay and also goes up the slow pathway with a markedly prolonged H-A interval to initiate the tachycardia as it returns down the fast pathway. When pacing is turned off, atypical A-V nodal reentry is present, having been initiated from the seventh stimulus. Therefore, the eighth stimulus is a fusion between the first beat of atypical A-V nodal reentry and ventricular pacing. This can be evaluated by using the maximum rates of 1:1 antegrade and retrograde conduction as indices of antegrade slow pathway refractoriness and retrograde fast pathway refractoriness. Although retrograde fast-pathway characteristics determine if reentry can occur, slow-pathway conduction time determines when it will occur. Thus, the “critical A-H” concept depends on fast-pathway recovery at a given A2-H2 interval. When echoes do not occur as soon as the impulse blocks in the fast pathway and goes down the slow pathway, concealed conduction into the fast pathway by A2 may be present, requiring a critical A-H for recovery. This can mimic a primary impairment of V-A fast-pathway conduction as the determinant of reentry. One can recognize the likely presence of concealment if the A-H interval not producing an echo exceeds the shortest cycle length of 1:1 retrograde conduction up the fast pathway. In addition, as noted earlier in the chapter (and to be discussed later) A-V nodal tachycardia can occur with block to the atrium; retrograde fast pathway is present but not manifested by atrial activation. The A-H interval may be a useful marker in predicting the capability of rapid V-A conduction. In fact, the shorter the A-H interval, the shorter the antegrade refractory period of the fast pathway, the shorter the cycle length at which block is produced in the fast pathway, and the shorter the cycle length at which 1:1 V-A conduction is maintained. He was trying to determine the limiting factor for tachycardia rate while we were analyzing factors controlling the tachycardia rate. It is our impression that retrograde slow-pathway conduction is the major determinant inducing this arrhythmia. Antegrade fast- pathway conduction is usually rapid enough and refractoriness is short enough to accept and conduct antegradely the impulse that has conducted retrogradely over the slow pathway. Multiple breakthroughs were considered to be present when two or more activation times along the His bundle catheter within 5 msec of each other were separated by two later sites, or when one or more sites on the His bundle catheter and any other catheter (i. From these heterogenous activation patterns, the wave of atrial activation subsequently spreads cephalad and laterally to depolarize the remainder of the right and left atria. In general, the shorter the H-A interval, the more likely the earliest atrial activation is recorded in the His bundle electrograms. As the H-A interval prolongs, the earliest activation moves closer to the base of the triangle of Koch or in the coronary sinus. Of importance is the recognition that identification of an “earliest” site of atrial activation does not mean that atrial activation is sequential from that site. One or two recordings are also obtained at the posterior triangle of Koch at the “slow pathway” area. Broad is defined by simultaneous (within 5 msec) activation of three or more adjacent sites. Left and middle show multiple breakthrough patterns (two or more separate sites activated within 5 msec) or a single breakthrough (one early site at any location). Nonuniform anisotropy is responsible for age-related slowing of atrioventricular nodal reentrant tachycardia. The P wave sometimes begins so early that it gives the appearance of a Q wave in the inferior leads. This is most likely to occur when there is delay between the reentrant circuit and the ventricles. In the former case retrograde activation takes place during the H-V interval, and in the latter case retrograde atrial activation begins before the His deflection. The rapid retrograde atrial activation occurs because, as discussed previously, the retrograde limb of the reentrant circuit is the fast beta pathway. In such cases atrial mapping as well as a variety of different responses to ventricular stimulation can help determine whether a bypass tract or atrial tachycardia is present (see following discussion of concealed bypass tracts and atrial tachycardia). We have noted a greater incidence of atypical R-P relationships and multiple tachycardias in patients postablation. Thus the apex and base of the triangle of Koch demonstrate multiple breakthroughs. During ventricular pacing on the right, atrial activation is single and sequential. If the turnaround site of the reentrant circuit incorporated one of the bundle branches, then bundle branch block or impaired conduction in that proximal bundle branch could alter the tachycardia. An additional 85 developed ≥5 consecutive complexes manifesting bundle branch block either following induction by ventricular stimulation (19 patients) or, more commonly, following resumption of 1:1 conduction to the ventricles after a period of block below the tachycardia circuit (66/103 patients; see following discussion entitled “Requirement of the Atrium and Ventricle”). At the onset of bundle branch block, if the H-V interval is prolonged, an increase in the V-V interval equal to the increment in the H-V interval can occur; however, the following V-V time would be shortened by the same amount. During this transition, the A-A and H-H intervals generally remain constant, although if aberration occurs at the onset of the tachycardia, some oscillation of all electrograms can be observed, with some slight slowing prior to resumption of 1:1 conduction. Thus, it is safest to analyze the effects of bundle branch block after induction of the arrhythmia when the tachycardia is stabilized.
Characterization of endocardial electrophysiological substrate in patients with nonischemic cardiomyopathy and monomorphic ventricular tachycardia buy cheap zoloft depressing kik names. Percutaneous pericardial instrumentation for endo-epicardial mapping of previously failed ablations discount zoloft 50 mg mastercard depression job burnout. Endocardial and epicardial radiofrequency ablation of ventricular tachycardia associated with dilated cardiomyopathy: the importance of low-voltage scars. Electroanatomic substrate and ablation outcome for suspected epicardial ventricular tachycardia in left ventricular nonischemic cardiomyopathy. Catheter ablation of ventricular epicardial tissue: a comparison of standard and cooled-tip radiofrequency energy. Endocardial unipolar voltage mapping to detect epicardial ventricular tachycardia substrate in patients with nonischemic left ventricular cardiomyopathy. Endocardial ablation to eliminate epicardial arrhythmia substrate in scar-related ventricular tachycardia. Outcome of ventricular tachycardia ablation in patients with nonischemic cardiomyopathy: the impact of noninducibility. Apical ventricular tachycardia morphology in left ventricular nonischemic cardiomyopathy predicts poor transplant-free survival. Isolated septal substrate for ventricular tachycardia in nonischemic dilated cardiomyopathy: incidence, characterization, and implications. Catheter ablation of ventricular arrhythmia in nonischemic cardiomyopathy: anteroseptal versus inferolateral scar sub-types. Catheter ablation of ventricular tachycardia in patients with right ventricular dysplasia: identification of target sites by entrainment mapping techniques. Entrainment mapping and radiofrequency catheter ablation of ventricular tachycardia in right ventricular dysplasia. Electroanatomic substrate and outcome of catheter ablative therapy for ventricular tachycardia in setting of right ventricular cardiomyopathy. Ablation of ventricular arrhythmias in arrhythmogenic right ventricular dysplasia/cardiomyopathy: arrhythmia-free survival after endo-epicardial substrate based mapping and ablation. Three-dimensional electroanatomic voltage mapping increases accuracy of diagnosing arrhythmogenic right ventricular cardiomyopathy/dysplasia. Cardiac sarcoidosis mimicking arrhythmogenic right ventricular cardiomyopathy/dysplasia: the renaissance of endomyocardial biopsy? Long-term efficacy of catheter ablation of ventricular tachycardia in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy. Epicardial substrate and outcome with epicardial ablation of ventricular tachycardia in arrhythmogenic right ventricular cardiomyopathy/dysplasia. Outcomes of catheter ablation of ventricular tachycardia in arrhythmogenic right ventricular dysplasia/cardiomyopathy. Role of purkinje conducting system in triggering of idiopathic ventricular fibrillation. Reversal of cardiomyopathy in patients with repetitive monomorphic ventricular ectopy originating from the right ventricular outflow tract. Radiofrequency ablation of frequent, idiopathic premature ventricular complexes: comparison with a control group without intervention. Relationship between burden of premature ventricular complexes and left ventricular function. Repetitive monomorphic tachycardia from the left ventricular outflow tract: electrocardiographic patterns consistent with a left ventricular site of origin. Radiofrequency catheter ablation as a cure for idiopathic tachycardia of both left and right ventricular origin. Long-term results of catheter ablation of idiopathic right ventricular tachycardia. Radiofrequency catheter ablation of ventricular tachycardia in patients without structural heart disease. Identification of distinct electrocardiographic patterns from the basal left ventricle: distinguishing medial and lateral sites of origin in patients with idiopathic ventricular tachycardia. The v(2) transition ratio: a new electrocardiographic criterion for distinguishing left from right ventricular outflow tract tachycardia origin. Ventricular tachycardias arising from the aortic sinus of valsalva: an under-recognized variant of left outflow tract ventricular tachycardia. Ablation of ventricular arrhythmias arising near the anterior epicardial veins from the left sinus of valsalva region: ecg features, anatomic distance, and outcome. Idiopathic sustained left ventricular tachycardia: clinical and electrophysiologic characteristics. Spectrum of electrophysiologic and electropharmacologic characteristics of verapamil- sensitive ventricular tachycardia in patients without structural heart disease. Radiofrequency catheter ablation of idiopathic left ventricular tachycardia guided by a purkinje potential. Significance of late diastolic potential preceding purkinje potential in verapamil- sensitive idiopathic left ventricular tachycardia. Idiopathic fascicular left ventricular tachycardia: linear ablation lesion strategy for noninducible or nonsustained tachycardia. Catheter ablation of subeicardial ventricular tachycardia using electroanatomic mapping. A method of treating macroreentrant ventricular tachycardia attributed to bundle branch reentry. Treatment of macroreentrant ventricular tachycardia with radiofrequency ablation of the right bundle branch. Bundle branch reentrant tachycardia treated by transvenous catheter ablation of the right bundle branch. Cure of interfascicular reentrant ventricular tachycardia by ablation of the anterior fascicle of the left bundle branch. Surgical correction of recurrent sustained ventricular tachycardia following complete repair of tetralogy of Fallot. Radiofrequency catheter ablation of right ventricular tachycardia late after repair of congenital heart defects. Prevention of ventricular fibrillation episodes in Brugada syndrome by catheter ablation over the anterior right ventricular outflow tract epicardium. Surgical coronary revascularization in survivors of prehospital cardiac arrest: its effect on inducible ventricular arrhythmias and long-term survival. Management of patients with ventricular tachyarrhythmias: does an optimal therapy exist? Reentry as a cause of ventricular tachycardia in patients with chronic ischemic heart disease: electrophysiologic and anatomic correlation. Endocardial mapping by simultaneous recording of endocardial electrograms during cardiac surgery for ventricular aneurysm. Endocardial mapping of ventricular tachycardia in the intact human ventricle: evidence for reentrant mechanisms. Electrogram patterns predicting successful catheter ablation of ventricular tachycardia.
Te Te process of rehabilitation involves: discriminated girl child generic zoloft 50mg with visa anxiety 1-10 scale, if she manages to survive discount 25 mg zoloft amex depression and bipolar support alliance, grows Restoration of function (medical rehabilitation), up to show discrimination to her female children. Tis Restoration of capacity to earn livelihood (vocational vicious cycle goes on and on and is hard to break. Tis Restoration of personal dignity and confdence will eventually have a positive bearing on the status of the (psychological rehabilitation). Every year, 18–24 September is observed Naturally, multitudes of subdisciplines are required to as girl child week throughout India. Services for the handicapped must incorporate thera- Discrimination against the girl child begins even before peutics, education, and social and emotional support to her birth. Nothing short of community participation can having roaring business, ofering amniocentesis and make these services efective. Te areas of community ultrasound facilities for fnding the unborn baby’s sex participation include: and indirectly instigating abortion of the female fetus. Te Case reporting and referral to the rehabilitative services, practice attracts clients from all socioeconomic groups, Raising funds for maintenance of these services, even if the money has to be begged or borrowed. Te Now, there is a legal ban on abortion of female community needs to ofer employment opportunities in fetus following sex-determination tests. Tere truly is an unholy nexus between the parents, their advisers, sex- determination clinics and abortionists. Nutritional Status On an average, nutritional status of the girl child is poorer than that of the boy. She is provided less amount of food which again is of inferior quality as compared to a boy. Often, it is a practice to postpone onset of puberty in a young girl by restricting her food intake so that parents can buy sufcient time to arrange dowry and a suitable groom for her. In resource-limitied Morbidity and Mortality communities, household responsibilities keep millions of girls out of school. Educational Status Girl Street Child Educating the girls is hailed as the best investment a nation Te girl street child is much worse than her boy counterpart. Yet, education of girls in India She is harassed, sexually abused and often pushed into presents a sordid picture. Many parents do not wish to allow girls Tere should be no discrimination on the basis of sex. A total ban on female feticide in all States and Union Territories needs to be implemented strictly. Girl Child Abuse and Neglect Awareness of importance of various aspects of the girl child, e. She is denied very survival, local languages, posters/cartoons at prominent parts adequate food intake, education, health care, etc. She is brought up to be submissive and docile, playing second of localities, television/radio skits, and street plays, fddle to the brother. Her attitudes are molded in such a discussions/seminars by local bodies at all levels to manner that she herself gets gravely biased against her ensure participation at grassroots level. When she becomes a mother, her treatment Education of girls should be the priority—free to daughters and daughters-in-law becomes a refection of education of all girls upto secondary school level in this unhealthy bias. Girl Child Laborer Improvement of nutritional status—midday school In India alone, there are around eight million working meal program should be introduced in the municipal female children. A special supplement- ation program should be designed for the severely malnourished children. First is the and implemented, especially in regard to sexual forethought which means to anticipate the possible risk to exploitation. Second is time in order to watch the child and his Motivation of adoption of girl children and especially activities. It should be impart- Handicapped and socially deprived girls should be ed to the parents, school teachers and grown-up children. Majority of accidents also be made compulsory for car riders—the driver and the are preventable. Accidents are undoubtedly among the chief causes of Children must not travel in the front seat of the car. Tough in India and other Every crossing and every vehicle must have frst-aid developing countries, the priority health problems are facilities and every driver must be familiar with frst-aid diarrheal disease, malnutrition and infections, accidents administration before being issued a license. Te remedial Accidents may be classifed into the following fve measures in this behalf can be in the form of improvement of categories: housing, safe storage of drugs and poisons, improvement of 1. Accidents requiring medical intervention: Drowning, roads and proper placement of electric points, etc. Accidents requiring surgical intervention/obser- portation and in the hospital emergency room. Accidents involving eyes: Bow and arrow, gulli-danda, It is advisable to provide trafc constables, a two way freworks (anar), stone throwing, broom stick and walkie-talkie to speed up the process of medical help. Road/trafc accidents: Reversing car, careless road Te spectrum of child maltreatment encompasses acts of crossing, playing in streets with vehicular trafc, abuse or commission and acts of omission or neglect/lack allowing children to stand in a car, or, still worse, to sit of appropriate action by a caretaker, resulting in adverse in driver’s lap. Te following factors 146 contribute to higher incidence of such maltreatment in For the Children groups living in poverty: Essential newborn care Enhanced number of crises in their lives in the form of Exclusive breastfeeding unemployment, overcrowding and disease. Immunization Limited reach to social and economic resources for Appropriate management of acute respiratory infection support during times of stress. Here, therefore, the focus in z National Malaria Eradication Program z National Family Welfare/Planning Program an integrated manner is on main causes of morbidity and z National Tuberculosis Control Program mortality as also the overall health of the child. Improvement of case management skills of health pro- z National Program for Prevention of Visual Impairment and viders through provisions of locally adapted guidelines Control of Blindness and training activities to promote their use. Provision of essential drug supplies required for z 20-Point Program efective case management of childhood illness. Optimization of family and community practices in rel- z National Diabetic Control Program ation to child health, particularly care-seeking behavior. Major Components Steps of Management Improvement in case-management skills of health Step 1: Check-up to identify the illness staf through appropriate guidelines. Step 2: Classifcation of illness according to color- Improvement in the overall health system. Such a focus on hospitals is the outcome as emergency (requiring urgent intervention and of inappropriate health care practices that have developed emergency measures). Show mothers how to breastfeed, and how to maintain Only a limited number of carefully-selected clinical lactation even if they should be separated from their infants. Give newborn infants no food or drink other than breast milk, the signs, the child is assigned to color-coded classifcation, unless medically indicated. Give no artifcial teats or pacifers (also called dummies or Guidelines address most but not all health problems. Foster the establishment of breastfeeding support groups and drugs and encourage active participation of caretakers refer mothers to them on discharge from the hospital or clinic. Infectious diseases, Intestinal parasitic (both protozoal and helminthic) infestations, Dental caries, Skin diseases, Fig. Te philosophy behind this new Promotion of positive health strategy is that hospitals set the standards for primary care Prevention of disease and act as the major providers and trendsetters, thereby Timely diagnosis, treatment and follow-up infuencing the behavior of the health providers and Health education to inculcate awareness about good the community.
During the harvesting of fat proven zoloft 25mg depression questionnaire pdf, the inﬁltration of wetting The technique described below has the advantage of being solution is minimized in order to obtain fat of maximal solid- simple and safe purchase 100mg zoloft mastercard depression symptoms loss of balance. Autologous fat into all the operative sites is minimized in order to facilitate grafting has been used successfully for replacement for vol- intraoperative evaluation of the contour, as fat is aspirated or ume deﬁciency in various body sites including the abdomen, added. General anesthesia is used in patients with more thighs, hips, waists, buttocks, arms, breasts, and knees. The use of minimal wet- Certain anatomical conditions tend to promote better fat ting solution also reduces the chance of overresection. These conditions include absence of dense subcu- The fat is collected by pouring it directly from the patient taneous scarring, preservation of good quality of the skin, end of the liposuction tubing, or by an interposed sterile gentle slope in the area of indentation, and abundance of sub- specimen trap (Fig. To optimize the quality of the fat used cutaneous fatty tissue in and around the area of depression. If the fat is dilute or if the amount is small, a centrifuge or absorbent gauze can be used to concentrate the fat. Direct inspection of the body and inspection of photographs com- Prior to fat grafting in areas where there is dense subcutane- plement each other to render the most accurate preoperative ous scarring and adhesion, a blunt-tipped cannula without drawing. Some defects are better seen on photographs than suction may be passed beneath the area of depression to with direct inspection of the patient. Different lighting techniques may reveal different Fat is injected with a small blunt-tipped cannula with an information about the contour irregularities. A blunt-tipped cannula is can be very informative and easy to reproduce for postopera- preferred because it is less likely to cause bleeding during fat tive comparison (see Case 2 after). A sharp needle offers the advantage of more pre- Areas of maximal depression, areas of maximal protuber- cise and effective fat deposition, especially in densely ﬁbrotic ance, and adjacent transition zones are indicated with skin areas or in the superﬁcial layer of the skin. The markings Sometimes, the surgeon can identify the original incision should also reﬂect the differences in the amount of fat that through which the overresection was performed. Digital photographs The fat is injected in small increments, in multiple passes, with the surgical markings are produced for intraoperative and at multiple depths. The path of the fat injection may be Lipoﬁlling and Correction of Postliposuction Deformities 391 parallel or crisscross as needed. Fat injection may be carried out as the reversal process of fat extraction in liposuction. During the injection, frequent visual inspection of progressive changes in the contour and skin pinch test provide additional means of assessing the adequacy of fat replacement. The aim of the corrective surgery is to create a smooth contour while the patient is on the operating table. Postoperatively, compression garment is not used in order to prevent any pressure and distortion in the fat-grafted areas. Postoperative manual massage is applied when there is ﬁrm- ness, which may result from large amount of fat deposition. The results of surgical correction of postliposuction con- tour irregularities using corrective liposuction and autolo- gous fat grafting are presented in the following sections. Cases are presented in the following areas: abdomen, waist, hips, inner, outer thighs, and knees. Transitional zone from the areas of maximal indentation to the areas of maximal protuberance was left without markings (Fig. Sixteen months after the corrective surgery, the abdomi- nal contour was improved (Figs. Subsequently, the patient requested and received minor additional liposuc- tion to reduce the periumbilical fullness. She presented with postliposuc- tion contour irregularities of the abdomen and the waist. Her condition consisted of a large area of indentation in the right lower abdomen and multiple areas of indentation and pro- tuberance in the mid- and upper abdomen. Another preoperative photograph was taken without any ﬂash, the only source of light being ceiling ﬂuores- cent light. This picture revealed the indentation in the right upper quadrant and upper mid-abdomen more distinctly than the photo taken with ﬂash (Fig. In the preoperative markings, the solid black areas indi- cate areas to receive autologous fat grafting. One hundred thirty cc was injected into the supraumbilical and upper abdominal areas. The donor sites of the fat consisted of the abdomen, suprapubic area, and the posterior iliac crest areas (Fig. The postoperative course was noted for swelling and sub- cutaneous ﬁrmness in the right lower quadrant area, which responded to massage and time. There was improvement in the appearance of the entire abdomen 14 months postopera- tively (Figs. The sharp indentation in the right upper quadrant required additional liposuction and autologous fat injection 14 months and 6 years after the initial corrective procedures. The pre- and postoperative results obtained fol- lowing the two minor procedures are shown (Figs. Over 6 years and 3 months time period, there is an improvement in the blotchy, discolored appearance of her Fig. A series of tunnels were made markings indicate areas of fat removal in the distal lateral Lipoﬁlling and Correction of Postliposuction Deformities 395 Fig. The area of maximal indentation and the transitional zones are indicated by solid and shaded red color, respectively (Fig. The right lateral mid-thigh was treated with 97 cm3 of fat, which entirely came from the abdomen. At 1 year follow-up, the indentations in the mid-lateral thigh and the hip were improved (Fig. Case 4 This 55-year-old woman presented with multiple areas of postliposuction contour irregularities including bilateral posterior iliac regions, lateral thighs, and the lateral hip areas. Her surgical correction consisted of liposuction around the areas of indentation and autologous fat grafting (Figs. The amount of fat grafting to each area is as follows: 60 cm3 each to the right and left posterior iliac crest areas, 110 cm3 to the left lateral hip, 95 cm3 to the left upper lateral thigh, and 95 cm3 to the right upper lateral thighs (Figs. Two years and 4 months after the corrective proce- dure, the indentation in the right and left iliac crest areas and the left lateral hip and upper thighs was improved as seen in the posterior and lateral views (Figs. Case 5 This 46-year-old woman developed postliposuction contour irregularities in multiple sites including the buttocks, Fig. Liposuction was performed in the upper thighs, medial knees, and anterior superior knees. The fat was injected into the right anterior thigh (23 cm3), right and left mid-medial thighs (10 and 50 cm3), and abdomen (25 cm ). The fat was injected in the right and left posterior lateral thighs (90 and 100 cm ), 3 gluteal folds (40 and 20 cm3), and the calves (25 and 28 cm ). The recipient areas were pretunneled before the fat was injected with a blunt-tipped cannula (Figs.