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Overall, point-of-care coagulation testing is appropriate in a wide range of clinical applications. Although it is still unclear whether the outcome improvements observed compared to routine care are due to the use of point of care or to the increased frequency of testing, the benefits of these management modalities are clear. Despite this clear evidence, the target times used in these clinical arenas stem from historical clinician comfort rather than clear evidence, yet another area requiring future trials. Target ranges reported in 1990 for "typical" patients ranged from 180240 to 220260, with lower ranges for "bleeding" patients (68). There were no differences in bleeding complications across the 3 treatment groups. The role of point-of-care anticoagulation monitoring in arterial and venous thromboembolic disorders. Bedside coagulation monitoring in heparin treated patients with active thromboembolic disease: a coronary care unit experience. Point-ofcare and standard laboratory coagulation testing during cardiovascular surgery: balancing reliability and timeliness. Effect of analytic uncertainty of conventional and point-of-care assays of activated partial thromboplastin time on clinical decisions in heparin therapy. Determination of normal versus abnormal activated partial thromboplastin time and prothrombin time after cardiopulmonary bypass. The diagnostic accuracy of bedside and laboratory coagulation: procedures used to monitor the anticoagulation status of patients treated with heparin. Bedside coagulometry during intravenous heparin therapy after coronary angioplasty. Prospective evaluation and clinical utility of onsite monitoring of coagulation in patients undergoing cardiac operation. Efficacy of a simple intraoperative transfusion algorithm for nonerythrocyte component utilization after cardiopulmonary bypass. On-site coagulation monitoring does not affect hemostatic outcome after cardiac surgery. A randomized, multicenter trial of weight-adjusted intravenous heparin dose titration and point-of-care coagulation monitoring in hospitalized patients with active thromboembolic disease. Clinical outcomes of point-of-care testing in the interventional radiology and invasive cardiology setting. Long-term, low-dose warfarin therapy for the prevention of recurrent venous thromboembolism. Ximelagatran vs warfarin for stroke prevention in patients with nonvalvular atrial fibrillation: a randomized trial. Capillary whole blood monitoring of oral anticoagulants in children in outpatient clinics and the home setting. Point-of-care versus laboratory measurement of the international normalized ratio. Reliability of point-of-care prothrombin time testing in a community clinic: a randomized crossover comparison with hospital laboratory testing. Patient satisfaction with point-of-care international normalized ratio testing and counseling in a community internal medicine practice. Optimal frequency of patient monitoring and intensity of oral anticoagulation therapy in valvular heart disease. Heparin therapy during extracorporeal circulation, I: problems inherent in existing heparin protocols. The role of the activated clotting time in heparin administration and neutralization for cardiopulmonary bypass. Heparin management protocol for cardiopulmonary bypass influences postoperative heparin rebound but not bleeding. The activated coagulation time: suitability for monitoring heparin effect and neutralization during pediatric cardiac surgery. Control of heparinization by activated clotting time during bypass with improved postoperative hemostasis.
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Amphibian and Reptile Parasites Parasites and Disease-causing Organisms Reported from Wisconsin Amphibians and Reptiles Dreux J. Watermolen Bureau of Science Services Wisconsin Department of Natural Resources P. Parasites and disease-causing organisms reported from amphibians and reptiles in Wisconsin Table 2. In particular, the potentially deleterious impacts of widespread infectious diseases on amphibian and reptile populations have garnered increasing attention (Green et al. A report of the "largest mass die-off of amphibians ever recorded in the academic literature" and linked to ranavirus recently appeared in print (Wheelright et al. Chinchar and Waltzek (2014) have identified this organism as an emerging threat to aquaculture. The impact of chytridiomycosis on frog populations has also been reported widely (Skerratt et al. Many host-parasite relationships appear to be relatively innocuous, with some individual hosts harboring large numbers of microorganisms and worms of several different species. The nematode Serpinema microcephalus has been associated with pancreatitis in red-eared sliders (Trachemys scripta elegans) (Wieczorowski 1939, Hidalgo-Vila et al. Pentastomes have been found to infect some rare and endangered species, with infections sometimes leading to death (Riley 1986). Myiasis (infestations by fly larvae that grow inside the host while feeding on its tissue) leading to death is believed to be more widespread in frogs than previously reported (Bolek and Janovy 2004, Wolff et al. In addition, the presence of some parasites may predispose their host to other ailments either by a reduction in general vitality resulting in increased susceptibility or through the introduction of other disease-causing organisms. Other potential pathogens carried by reptiles include the bacteria Aeromonas, Campylobacter, and Mycobacterium, and various zygomycetes and protozoans. The effects of parasites may interact in complex ways with environmental conditions and other stressors. The observed relationships between environmental contaminants and parasites have led to the occasional use of parasitological data in environmental monitoring (Overstreet 1997, Marcogliese and Giamberini 2013). It is important to acknowledge that very few individual animals of any species are completely free of parasitic organisms. Knowledge of epidemiology and control techniques appears to be of growing importance, but the literature regarding the parasites of amphibians and reptiles remains widely scattered throughout a variety of sources, often crossing disciplines. Titles of many articles do not indicate that the parasites of Wisconsin species were studied. Sometimes, particularly in older references, authors have failed to indicate the source of their study organisms or the location where their work was performed. As a result, attempts to find information specific to Wisconsin species can pose significant challenges. Even with the availability of modern electronic indexing and abstracting services, presenting a basic host-parasite species list for the state has proven to be a difficult task. The objective of this report, therefore, is to compile and summarize the published information on parasites and disease-causing organisms of Wisconsin amphibians and reptiles in an accessible general reference for use by wildlife health and conservation practitioners. Similar comprehensive catalogs have been prepared for only one other state in our region: Michigan (Muzzall 2005). Methods Parasite records were gleaned from a variety of sources including bibliographies focused on Wisconsin herpetology (Dlutkowski et al. I searched for Wisconsin records in standard references addressing the various parasite taxa (Bychowsky 1957, Petrochenko 1971, Yamaguti 1971, Schell 1985, Riley 1986, Levine 1988, Barta 1991, Anderson 1992, Walters et al. I also searched various electronic databases (Biological Abstracts, Zoological Record, Web of Science, etc. I then reviewed the works cited in each source found for additional likely references. No attempt, however, was made to identify studies addressing viruses, and although several bacteria, fungi, and protoctists are included in the catalog, only limited efforts were made to investigate these groups. Greater focus was placed on helminths and leeches, taxa with which I am more familiar. No effort was made to investigate the freshwater mollusk (Simpsonaias ambigua) larvae that parasitize mudpuppies (and possibly other salamanders), although a record is included as a result of other work. Records of arthropod ectoparasites were noted when they were encountered, but as with mollusks were not a focus of the effort. I made no efforts to sift through the "gray" literature, but included agency reports when I stumbled upon them in the course of my other searching.
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Comparison of latex agglutination, wet preparation, and culture for the detection of Trichomonas vaginalis. Treatment of Trichomonas in pregnancy and adverse outcomes of pregnancy: a subanalysis of a randomized trial in Rakai, Uganda. Use of an immunochromatographic assay for rapid detection of Trichomonas vaginalis in vaginal specimens. Use of spun urine to enhance detection of Trichomonas vaginalis in adolescent women. Trichomonas vaginalis associated with low birth weight and preterm delivery: the Vaginal Infections and Prematurity Study Group. Evaluation of self-collected samples in contrast to practitioner-collected samples for detection of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis by polymerase chain reaction among women living in remote areas. Sexually transmitted infections and increased risk of co-infection with human immunodeficiency virus. A preliminary study on the relationship between Trichomonas vaginalis and cervical cancer in Egyptian women. Prevalence of sexually transmitted diseases and human immunodeficiency virus among women attending prenatal services in Apia, Samoa. Reliability of diagnosing bacterial vaginosis is improved by a standardized method of gram stain interpretation. Gram stain method shows better sensitivity than clinical criteria for detection of bacterial vaginosis in surveillance of pregnancy, low-income women in a clinical setting. Reproducibility of a scoring system for gram stain diagnosis of bacterial vaginosis. Indications for therapy and treatment recommendations for bacterial vaginosis in nonpregnant and pregnant women: a synthesis of data. Association between bacterial vaginosis and preterm delivery of a low-birth-weight infant. Bacterial vaginosis and preterm birth: a prospective community-based cohort study. Costeffectiveness of screening and treatment for bacterial vaginosis in early pregnancy among women at low risk for preterm birth. Evaluation of a new rapid diagnostic kit (FemExam) for bacterial vaginosis in patients with vaginal discharge syndrome in the Gambia. Occult blood is the unexpected presence of nonvisible blood in the stool or other body fluids. A daily loss of 23 mL of blood is generally considered the lower limit for abnormal bleeding that may be indicative of gastrointestinal pathology. Fecal occult blood testing is commonly used in outpatient settings to screen for colorectal neoplasia in asymptomatic individuals. The literature search performed for occult blood testing is seen in Literature Search 60. Colorectal carcinoma has a well-defined natural progression, and survival correlates strongly with the stage of the tumor. Screening can change the overall prognosis and outcome in patients with early disease. Participants were asked to submit 6 guaiac-impregnated paper slides (slides contained 2 smears from each of 3 consecutive stools). Dietary restrictions, such as avoidance of aspirin, red meat, and vitamin C, were in place but were not verified. All volunteers with positive results were encouraged to obtain a full examination and colonoscopy. The results in the biennial group were not significant after 13 years; however, after an 18-year follow-up, the mortality reduction in the biennial group was statistically significant, at 21% (6). The European studies were similar in design to the Minnesota study, with a few exceptions. Participants received the original Hemoccult home test kit (single slide rather than triple slides), with instructions from their primary care physician. The specimens were shipped to the medical center and results analyzed without rehydration by 1 of 3 investigators. Further delineation in this study illustrated that the mortality reduction was most pronounced in patients with lesions above the sigmoid colon (10). The conclusions in the 3 randomized trials were similar, although the magnitude of mortality reduction differed.
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Vishnu Rao Consultant, Department of Infectious diseases, Yashoda hospital, Hyderabad 3. Trauma, underlying skin lesions and spread from adjacent infections such as osteomyelitis can lead to the development of cellulitis. The distinctive features of erysipelas are well defined indurated margins, particularly along the naso-labial fold, rapid progression and intense pain. Early and aggressive surgical debridement and treatment with appropriate antibiotics are important to reduce mortality. Gentle probing is performed with a blunt instrument or index finger and if the tissue dissects with minimal resistance, then probe test is considered to be positive. Staphylococcus aureus, Enterobacter species, Streptococcus species, Pseudomonas species, gram negative bacilli. Typical signs and symptoms of infection like fever, swelling, and tenderness are uncommon. Investigations directed towards identification of systemic illness like blood sugars, renal and liver function tests should be done. However, X-ray finding will be positive in the majority of patients with chronic osteomyelitis. In case the patient is currently on antibiotics which appear to be ineffective it is advisable to discontinue for 1-2 weeks if possible. Swab cultures and sinus tract cultures may be unreliable Container: Sterile screw-capped container / sterile swabs in the screw capped tubes A swab from wounds: (generally discouraged as they often grow skin colonizers) -Collect swabs only when tissue or aspirate cannot be obtained. Blood cultures should be obtained for all suspected cases of septic arthritis before starting antibiotics. Sonication of the prosthetic implant will detect biofilm organisms &improve microbiological yield especially in patients with prior receipt of antimicrobials. Each episode of treatment failure leads to significant tissue damage and loss of functional integrity. The cure is defined as long-term, pain free functional joint/limb with complete eradication of infection. The most important consideration in the management of bone & joint infections is the presence of biofilm associated with implants and prosthesis. The implications of biofilm formation are: Antibiotic penetration into biofilm is poor Antibiotics that penetrate may not act on biofilm organisms (non-replicating, stationary phase) Biofilm organisms are protected from immune processes like phagocytosis Biofilm organisms can acquire resistance patterns from one another Hence, the antimicrobial regimen used to treat B&J infections should have the following properties: a. Drugs with biofilm activity (penetration into biofilm, action against biofilm organisms) d. If ongoing/ recent receipt of empiric antimicrobials, surgery may be deferred for 2 weeks (antibiotic-free interval), to increase diagnostic yield in a stable patient. Initial management includes resuscitation and stabilization based on the clinical condition followed by clinical evaluation, imaging and investigations to establish the diagnosis. Supportive care should be continued and then therapy narrowed based on the results of investigations. Unlike the western world, Group B Streptococcus and Listeria are not reported as common causes of neonatal meningitis in India. Influenzae and meningococcus are uniformly susceptible to the 3rd generation cephalopsorins. If the delay is expected the samples should be kept at room temperature and never refrigerated. Molecular tests have enhanced sensitivity as compared to cultures and can be requested if available. Therefore it is acceptable to at least give one dose prior to the antibiotic in suspected meningitis. The etiology depends on local epidemiology but commonly includes multi drug / extremely drug resistant gram negative pathogens including Acinetobacter, Pseudomonas, Klebsiella and Staphylococcus aureus/ epidermidis. Diagnosis is a challenge since sensorial obtundation (a cardinal symptom of meningitis) may be due to the underlying disease/ surgery. The patients are frequently on antibiotics and hence microbial isolation rates are low. Empirical therapy depends on local flora but usually includes high dose meropenem with vancomycin. For carbapenem resistant pathogens, intraventricular / intrathecal therapy with colistin/ polymyxin B/ aminoglycosides is indicated.
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Future workers should check the original sources to avoid perpetuating any such errors. Structure of the Catalog the catalog consists of two tables that summarize the available literature. Table 1 (pages 5-24) lists parasite species by taxonomic group and provides a host list for each parasite. Parasites are listed to the lowest taxonomic unit possible and nomenclature appears here as it did in the original work, with only minimal attempts to address the past complexities of parasite taxonomy and the resulting synonyms. In cases where I was able to update parasite nomenclature, the species name as reported in the original source(s) usually follows the updated name in parentheses. It should be recognized, however, that review of the validity of the published names was well beyond the scope of current efforts. The bewildering diversity of protoctists has led to continuous debate about organismal names and classification schemes. Parasite location within/on the host (anatomical habitat) is indicated in parentheses when this information has been included in the sources. Entries in Table 1 are presented in the following format: Parasite Species (Name in Original Source, if Updated by Me) Host Species (Anatomical Habitat) Literature Citation(s) Since this is not a taxonomic work and for the sake of simplicity, I omitted the author and year of description associated with genus-species names for both parasites and hosts. Table 2 (pages 25-36) provides a checklist of Wisconsin amphibians and reptiles along with their reported parasites. Amphibian and reptile nomenclature follows Casper and Anton (2013), with species names listed alphabetically by order. Although included in Table 1, nonnative host species reported from captive settings in the state are omitted from this table. County of occurrence is provided when this information has been included in the reference. As in Table 1, each entry is followed by a citation to the relevant literature source(s). A short "Discussion" section follows these tables and presents observations and summary conclusions derived from a cursory analysis of the records contained in the tables. Table 3 in this section (page 38) lists host species for which I was unable to find any published parasite records from Wisconsin. All references cited in the tables are listed together in the "Literature Cited" section that follows the discussion. Finally, Appendix A concludes the catalog by providing a list of references that specifically address parasites of Wisconsin amphibians and reptiles. Notes 4 Amphibian and Reptile Parasites Catalog of the Parasites and Disease-causing Organisms Table 1. Parasites and disease-causing organisms reported from amphibians and reptiles in Wisconsin. The location of the parasite infestation within/on the host is indicated in parentheses following the host name. Bacteria Aeromonadaceae Aeromonas hydrophila ("red-leg" disease) Lithobates pipiens (unspecified) Dent and Schuellein 1950 Lithobates pipiens (unspecified) Hine et al. Lithobates pipiens (blood) Heller 1973 Lankesterellidae Lankesterella minima Lithobates pipiens (erythrocyte) Levine and Nye 1977 Lankesterella sp. Lithobates pipiens (unspecified) Heller 1974 Plasmodiidae Haemoproteus metchinikovi Chrysemys picta (unspecified) De Giusti and Batten 1951 Graptemys geographica (unspecified) De Giusti and Batten 1951 3 Protoctista: Ciliophora Nyctotheridae Nyctotherus cordiformis Hyla chrysoscelis (small intestine, large intestine) Bolek and Coggins 1998a Pseudacris triseriata (small intestine, large intestine) Bolek and Coggins 1998a Nyctotherus sp. Hyla chrysoscelis (small intestine, large intestine) Bolek and Coggins 1998a Unidentified opalinids Lithobates pipiens (large intestine) Hine et al. Lithobates pipiens (unspecified) Williams and Taft 1980 Clinostomidae Clinostomum sp. Lithobates clamitans (eustachian tubes, pharynx, stomach) Sutherland 2005 Diplostomatidae Alaria arisaemoides Lithobates pipiens (between thigh muscles, under sternum) Hofer and Johnson 1970 Alaria marcianae Lithobates pipiens (between thigh muscles, under sternum) Hofer and Johnson 1970 Lithobates pipiens (small intestine, parenchyma, liver 6) Schaefer and Etges 1969 Alaria mustelae Lithobates pipiens (between thigh muscles, under sternum) Hofer and Johnson 1970 Lithobates sylvaticus (body cavity, rectal area) Yoder and Coggins 1996 Pseudacris crucifer (body cavity, rectal area) Yoder and Coggins 1996 Pseudacris crucifer (leg musculature) Yoder and Coggins 2007 Alaria sp. Anaxyrus americanus (leg muscles, body cavity) Bolek and Coggins 2003 Lithobates clamitans (unspecified) Hartson et al. Anaxyrus americanus (bladder) Bolek and Coggins 2000 Lithobates pipiens (bladder) Burton 1966 Phyllodistomum americanum Ambystoma laterale (urinary bladder) Yoder and Coggins 2007 Ambystoma tigrinum (bladder) Coggins and Sajdak 1982 Ambystoma tigrinum (urinary bladder) Tiekotter and Coggins 1982 Phyllodistomum coatneyi Ambystoma maculatum (bladder) Meserve 1941, 1943 Haematoloechidae 7 Haematoloechus complexus Lithobates clamitans (unspecified, most likely lungs) Bolek and Janovy 2007b Haematoloechus longiplexus Lithobates clamitans (unspecified, most likely lungs) Williams and Taft 1980 Haematoloechus medioplexus Lithobates pipiens (lungs) Burton 1967 Lithobates pipiens (lungs) Kennedy 1981 Lithobates pipiens (lungs) Leon-Regagnon and Brooks 2003 Lithobates sylvaticus (unspecified) Williams and Taft 1980 Haematoloechus parviplexus Lithobates clamitans (unspecified, most likely lungs) Schell 1965 Lithobates clamitans (unspecified, most likely lungs) Williams and Taft 1980 Lithobates clamitans (unspecified, most likely lungs) Bolek and Janovy 2007a Haematoloechus varioplexus (as Pneumonoeces similiplexus by Cort 1915a and Cort 1915b) Anaxyrus americanus (lungs) Bolek and Coggins 2003 Lithobates clamitans (unspecified, most likely lungs) Williams and Taft 1980 Lithobates clamitans (lungs) Bolek and Coggins 2001 Lithobates clamitans (lung) Yoder et al.
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Women who are younger than 15, older than 49, or who are pregnant at the start of the simulation, are assumed not to be using any contraceptive method. For these women, we relied on data from other studies to determine relative rates of contraceptive usage. Based on the data presented by Burgard , rates of contraceptive usage are specified separately for each race and for each of three age groups (15-24, 25-34 and 35-49). The odds ratios in the first row are set to 1, since this corresponds to the baseline category in Table 3. The odds ratios in the second and third rows are estimated based on logistic regression models fitted by Burgard . However, as the Burgard analysis excluded women who had never been married and never had a child, it cannot be used to estimate the odds ratios in the final row. MacPhail et al  report that in sexually active women aged 15-24, marital status was not significantly associated with modern contraceptive usage after controlling for other factors (such as sexual activity and previous children). It is therefore assumed that the odds ratio for unmarried, never-pregnant women is the same as that for married, never-pregnant women. MacPhail et al  report that in sexually active women aged 15-24, women who were sexually active in the last month were 1. It is assumed that in women who are not sexually experienced, contraceptive usage is rare. Based on these data, we assume that the rate of contraceptive usage in women aged 15-49, who are not yet sexually experienced, is 3%. It is also consistent with a study of users of injectable contraceptives in 10 South African clinics, of whom only 0. Consistent with other studies, these data suggest a high rate of injectable contraception use among black South African women , and relatively low rates among white women. The use of female sterilization is strongly related to age and previous childbearing. In women who are assigned to contraception use at baseline, but who are not assigned to use of injectable contraception, it is assumed that a certain proportion has been sterilized. This proportion is set to zero in women who have never had children, and is assumed to depend on age among those women who have had children. Since the latter survey is more nationally representative, we have used these data in setting the model assumptions about the fraction of non-injectable contraceptive users who are sterilized. In both analyses, women were only included if either ever pregnant or ever married (but women who were currently pregnant were excluded). In panel (b), the analysis is further limited to the subset of women who reported using injectables, the pill or sterilization. The model therefore assumes that the rates of sterilization (expressed as a multiple of those in 1997) decline linearly from 1. In women aged 15-19, who were not previously pregnant but have previously used hormonal contraception, and who do not use condoms with their new partner, this probability is set to 0. The baseline values are adjusted as follows: · For women who have had a previous child, the odds of initiation of hormonal contraception is multiplied by 2. In another analysis of data from the Eastern Cape (a mainly black African population), the odds ratio was 1. The assumption of a bigger effect of prior pregnancy on contraceptive uptake among coloured and black 19 · · · · · women when compared to white women is consistent with relatively low rates of teenage pregnancy among white South Africans  and the observation that many black South African women only begin to use hormonal contraception after their first birth [31, 40]. The previously-specified probabilities are assumed to apply in women whose highest educational attainment is grade 10. For each additional grade passed, the odds of initiating contraception is assumed to increase by a factor of 1. This is higher than the odds ratios estimated in various regression models fitted to South African data sources [28, 35, 38] because the regression models are applied to cross-sectional data, whereas we are interested in modelling the effect of education on the incidence of contraceptive use. The previously specified baseline probabilities are assumed to apply to women who have average fecundability (fecundability value of 1). This means that a woman who is infertile is assumed not to adopt hormonal contraception. If women use condoms with their new sexual partner, it is assumed that there is a reduced probability that they will also use hormonal contraception. Several studies have shown a significant negative association between condom use and use of nonbarrier contraceptive methods. Although there have been a number of other South African studies, they are generally of limited value because they report only univariate associations between condoms and non-barrier methods.
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In the context of the large population and demographic transition, the total numbers are estimated to more than treble in the next 35 years, reaching over six million by 2040. The joint family system - the traditional support system for frail elderly people - is crumbling because of the migration of the younger generation to the cities in search of better prospects. The women who traditionally took on the role of caregivers are also working and cannot spend as much time caring for the elderly. Dementia is considered as a normal part of ageing and is not perceived as requiring medical care. Thus primary health-care physicians rarely see this condition in their clinical work. Private medical care (which includes home visits) is preferred and this leads to a higher out-of-pocket cost for dementia care. More than 80% of carers are female and around 50% are spouses who are themselves quite old. In this project, a flexible, stepped-care intervention was adopted to empower the carers with knowledge and skills to manage the person with dementia at home. The intervention was implemented by locally trained home care advisers under supervision. This not only helped in decreasing the stress of looking after a person with dementia, but also helped the caregivers to manage behavioural problems and thus reduced the number of deaths in the intervention group. There is a need to make dementia a public health priority and create a network of home care advisers to provide supportive and educational interventions for the family caregivers through the primary health-care system in India. Social and economic changes have disrupted this system, however, especially by young people moving into the towns and leaving the old people to cope on their own. In 2005 there were only about 77 psychiatrists and three occupational therapists in the country. There are no specialist services for the elderly (geriatric or psychogeriatric services, meals on wheels, respite care or drop-in centres) and few nursing homes. Usually record-keeping, accountability and political will are poor, so that many elderly people who retire do not receive their benefits. Recently the Federal Government has introduced a contributory pension scheme, but in the past elderly people found it difficult to learn about and access their entitlements. A national policy on elderly care was published in 2003, and a National Implementation Plan is now under way, but is being piloted only among certain Federal civil servants. Assessing the extent of dementia among this huge, varied and shifting population is not easy, but what little research has been done suggests prevalence rates for dementia may be low. Interest in the mental health of elderly Nigerians is only just beginning: for example in the past three years, old-age mental health clinics have been established at two universities. The term is also applied to a large group of Research conditions characterized by common symptoms Education and training called "epileptic seizures", which may occur in the Partnerships within and beyond the health system context of a brain insult that can be systemic, toxic or metabolic. These events (called provoked or acute Conclusions and recommendations symptomatic seizures) are presumed to be an acute manifestation of the insult and may not recur when the underlying cause has been removed or the acute phase has elapsed. Epilepsy has been defined as "a disorder of the brain characterized by an enduring predisposition to generate epileptic seizures, and by the neurobiological, cognitive, psychological and social consequences of this condition. The definition of epilepsy requires the occurrence of at least one epileptic seizure" (1). An epileptic seizure is defined as "a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain" (1). These definitions recognize that a diagnosis of epilepsy implies the existence of a persistent epileptogenic abnormality that is present whether seizures occur or not, as well as that there may be consequences of this persistent abnormality other than the occurrence of seizures that can cause continuous disability between seizure occurrence (interictally). Because it is often difficult to identify definitively an enduring predisposition to generate epileptic seizures, a common operational definition of epilepsy is the occurrence of two or more non-provoked epileptic seizures more than 24 hours apart. Differential diagnosis of transient events that could represent epileptic seizures involves first determining that the events are epileptic, then distinguishing between provoked epileptic seizures and a chronic epileptic condition. Febrile seizures in infants and young children and withdrawal seizures in alcoholics are common examples of provoked seizures that do not require a diagnosis of epilepsy. If seizures are recurrent, it is next necessary to search for an underlying treatable cause. If such a cause cannot be found, or if it is treated and seizures persist, then treatment of seizures is guided by diagnosis of the specific seizure type(s), and syndrome if present (see Box 3. Etiology and risk factors Epileptic conditions are multifactorial disorders, and it is useful to discuss three important factors. Anyone with a functioning brain is capable of having a seizure; however, seizures occur more easily in some people than in others.
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The vertical lines in each muscle fiber identify the relative spacing of its striations. Each contraction knot identifies a segment to muscle fiber experiencing maximal contracture of its sarcomeres. The sarcomeres within these contraction knots are markedly shorter and wider than the sarcomeres of the neighboring normal muscle fibers. In fibers with these contraction knots (note the lower three individual knots), the sarcomeres on the part of the muscle fiber that extends beyond both ends of the contraction knot are elongated and narrow compared with normal sarcomeres. At the top of this enlarged view is a pair of contraction knots separated by an interval of empty sarcolemma between them that is devoid of contractile elements. This configuration suggests that the sustained maximal tension of the contractile elements in an individual contraction knot could have caused mechanical failure of the contractile elements in the middle of the knot. If that happened, the two halves would retract, leaving an interval of empty sarcolemma between them. In patients, the central TrP would feel nodular as compared to the adjacent muscle tissue because it contains numerous "swollen" contraction knots that take up additional space and are much more firm and tense than uninvolved muscle fibers. As for the taut band, both ends of these affected muscle fibers would be maximally stretched out and "taut," producing the palpable taut band. This was conservatively treated with rest, soft diet, and anti-inflammatory medications. Severe symptoms subsided, but the patient continued to complain of persistent "aching of the left jaw. Active range of motion of the mandible had increased from 41 to 47 mm, and the joint was nontender to palpation. Trigger points in this part of the masseter muscle have also been reported to cause unilateral tinnitus55 and accounted for the high-pitched sound the patient complained of with clenching. Treatment must be directed at rehabilitating the masseter muscle and not at the asymptomatic joint. Figure 8-33 Deep layer, upper part of the masseter muscle refers pain to the temporomandibular joint area and ear. Systematic fingertip examination of suspected muscles and their contralateral counterparts, looking for taut bands and focal tenderness, is essential. Depending on the muscle, the tip of the index finger should be used for flat palpation or the index finger and thumb for pincer-type palpation (Figure 8-35). Once a TrP is found, 2 to 4 kg/cm2 of pressure should be applied for 6 to 10 seconds to elicit the referred pain pattern, if any. If uncertainty exists, specific TrP therapies, such as "spray and stretch" or TrP injections, described below, may be used diagnostically. All head and neck muscles should be routinely examined in patients with a persistent pain complaint. Therapeutic techniques such as "spray and stretch," voluntary contract- 344 Endodontics A B Figure 8-35 Muscle palpation for myofascial trigger points. A, "Flat" fingertip palpation of masseter muscle looking for taut bands and focal tenderness characteristic of myofascial trigger points. The flat palpation technique is also useful for temporalis, suboccipital, medial pterygoid, and upper back muscles. B, "Pincer" palpation of the deep clavicular head of the sternocleidomastoid muscle. Myofascial TrP therapists are especially adept at TrP examination, spray and stretch, and TrP pressure release techniques. Perpetuating factors most commonly include mechanical factors that place an increased load on the muscles. Teaching patients good posture and body mechanics will go a long way in reducing referred pain from myofascial TrPs, especially in the head and neck region. Simple stress management and relaxation skills are invaluable in controlling involuntary muscle tension if this is a problem.