By Y. Abe. Pickering University.

Initiatives in Ethiopia cheap 100mg suhagra otc erectile dysfunction doctors in south jersey, such as using irrigation systems order 100mg suhagra impotence versus erectile dysfunction, water harvest technology and drip irrigation, are encouraging steps that need to be strengthened further. Causes of food insecurity Mechanism (how it leads to food insecurity) Rapid population growth A high rate of population growth calls for more food production and the need for ploughing more land. Population may exceed the carrying capacity of the fragile environment in some areas At the household level the food produced from the same plot of land that the household has may not be sufficient. The chances of drought occurring in parts of Ethiopia have increased the probability of food insecurity, especially in the arid and pastoralist areas (northern and eastern parts of Ethiopia) Traditional rain-dependent farming systems Lack of agricultural intensification and low agricultural productivity means that many of those in rural areas remain subsistence producers. Therefore, the large quantity of food at low prices which is essential for economic growth in urban areas is not available Stop reading for a while and think of the causes of food insecurity in your area. Indirect indicators can also give clues to the presence of household food insecurity. These include measuring the percentage of children under five years old who are malnourished and other early warning signs of vulnerability such as low rainfall or the presence of other disasters. One of the most common methods for identifying food-insecure households or regions is to look at the frequency and types of coping strategies. The different types of coping strategies are markers of the severity of conditions, often categorised into four distinct stages of food insecurity. Stage 1: Insurance strategies The first stage of household food insecurity is marked by the initial shortage of food, or inability to provide sufficient quantities of food to all members of the household. Households may have prepared for a food quantity shortfall, as in the case of seasonal production, by storing quantities of grain or owning livestock that can be quickly sold, traded, or used for food (in the case of agricultural societies). These are often referred to as insurance (reserve food crisis), and are not intended to be a main source of income or an integral part of income generation, simply crisis insurance. But, before any assets are sold, changes in diet and frequency of meals per day are the first adaptations undertaken. Rationing of food consumption is a very common response, and is started and planned generally far in advance of selling any assets. The frequency and severity of coping strategies practiced will vary according to the causes of the food shortage (chronic vs. Stage 2: Crisis strategies I The second stage of food insecurity is marked by the sale of assets, specifically non-productive assets. At this point, in the food security crisis, food consumption becomes more important than holding onto assets. Jewellery, goats, chickens, other livestock and any other asset that serves as crisis insurance would be sold. Generally, the assets that are preserved are those related to income generation, such as land, farming equipment, oxen and cattle. In addition to non-productive asset sales, the second stage also sees the onset of loans or credit from merchants (as opposed to family), which also has serious implications for the future security of the household and recovery to their original livelihood systems. At this point, all else has either failed to provide sufficient food quantities or the crisis has prolonged itself into a dire situation. All livestock remaining at this juncture will be sold, all personal items sold, possibly even the sale of housing material, and the pledging and/or sale of land or productive rights. This disposal of all assets ensures current survival, but severely jeopardises the future security (livelihood system) of the household. In the case of natural disasters, such as drought, many assets will be lost involuntarily, specifically livestock succumbing to disease or starvation. When the crisis has reached this stage, famine conditions have essentially set in. Stop reading for a while and think of some of the coping strategies that are used in your community or in another community you know when food insecurity occurs. Stage 4: Distress strategies Stage 4 is the last in the line and represents complete destitution. Permanent migration (either the whole or part of the household) occurs in order to attempt to resettle on suitable land, find wage labour or, more likely, to seek food aid assistance. Individuals are generally too weak to work and simply need food and care to survive. There is a spectrum of situations that may precipitate crises, possibly ranging from normal, seasonally linked low or zero production, to consecutive years of poor production, to natural disasters and armed conflict. Coping strategies need to be seen in context, and in complex emergencies the situation is different from those situations relating to consecutive seasons of crop failure or seasonal dips in the amount of stored food or resources to obtain food. For example, people suffering due to poor agricultural production might slowly move from stage 1 to stage 2 or 3, whereas in acute emergencies, people might be ‘shocked’ directly into strategies of state 3 or 4, due to sudden external forces such as a flood or armed conflict. It is usually measured by summing up the number of foods or food groups consumed over a period of time.

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Prevention and treatment of periodontal diseases Medical interventions Non-medical interventions Other interventions • Scaling and polishing of teeth • Oral health education • Make oral health care more accessible • Oral and systemic antibiotics • Nutrition and diet and affordable • Use of mouth washes • Proper methods of oral hygiene maintenance • Improve the socioeconomic and literacy • Gingival and periodontal surgery ·use of toothpaste and tooth brush level of the population ·gingivoplasty discount 100 mg suhagra overnight delivery erectile dysfunction drugs covered by insurance, gingivectomy discount suhagra 100 mg with visa erectile dysfunction in the morning, flap surgery, ·use of inter-proximal cleaning devices such as • Include oral health care in general health mucogingival surgeries, guided tissue interdental brushes, dental floss and water pik, etc. Periodontal m anifestations of system ic in com m unity settings for people with special needs: Preface. It is the m ost com m on cancer in cancers are diagnosed at a very late stage, when treatm ent m en and the fourth m ost com m on cancer in wom en, and not only becom es m ore expensive, but the m orbidity and constitutes 13% –16% of all cancers. The 5- Aetiology year survival rate is 75% for local lesions but only 17% for Direct causes those with distant m etastasis. Since the oral cavity is easily • Tobacco— M any form s of tobacco are used in India— accessible for examination and the cancer is always preceded sm oking (78% ); chewing of betel quid, paan m asala, by som e pre-cancerous lesion or condition such as a white gutka, etc. Increased incidence of • Bacterial infections such as syphilis, and fungal (candi- 8–10 m outh cavity, pharyngeal and laryngeal carcinom as. Dental factors in the genesis Table 7 lists the direct, indirect and distant causes of of squam ous cell carcinom a of the oral cavity. Prevalence of oral subm ucous fibrosis am ong the cashew workers of Kerala, Strategies for prevention and treatm ent of oral cancer are South India. Solar radiation, lip protection, and lip cancer risk in Los Angeles County wom en (California, United 1. The concentration of fluoride in drinking water to teeth, som etim es with structural defects in the enam el such give the point of m inim um caries with m axim um safety. Fluoride water, food and drugs with a high fluoride content, (ii) varnishes— a review of their clinical use, cariostatic m echanism , efficacy and safety. Causes of dental fluorosis Direct Indirect Distant • Exposure to high levels of fluorides: >1 ppm of • Tropical climate·excess ingestion of water • Poor nutritional status·deficiency of fluoride in drinking water and beverages with a high fluoride content vitamin D, calcium and phosphates • Airborne fluoride from industrial pollution (aluminium • Presence of kidney diseases affecting the • Decreased bone phosphatase activity is factories, phosphate fertilizers, glass-manufacturing excretion of fluoride linked to fluoride toxicity industries, ceramic and brick products) • Thyroid and thyrotrophic hormones have a • Fluoride-rich dietary intake·sea food, poultry, grain synergistic effect on fluoridetoxicity and cereal products (especially sorghum), tea, rock salt, green leafy vegetables, etc. Strategies for the prevention of dental fluorosis Primary prevention Secondary prevention Tertiary prevention • Specific guidelines on the use and • Improve the nutritional status, especially of Treat the discoloured/disfigured dentition by appropriate dose levels of fluoride expecting mothers, newborns and children up appropriate aesthetic treatment such as bleaching, supplements, and use of fluoride to the age of 12 years. Equipment, minimum manpower required and approximate cost for medical interventions for oral and dental diseases Medical Equipment/instruments In dental In private clinics* interventions required Time required Personnel Set-up schools (in Rs) (in Rs) Dental check-up Gloves, face mask, 5 minutes Dental surgeon At all levels Nil 100–300 head light, mouth mirror, explorer, tweezers, cotton/ gauze, etc. Dental caries Though not life-threatening, these diseases are often very painful, expensive to treat and cause loss of several m an- Dental caries is a universal disease affecting all geographic days. It has now been recognized that oral and prevalence of dental caries is generally estim ated at the general health are closely interlinked. Periodontal (gum ) ages of 5, 12, 15, 35–44 and 65–74 years for global diseases are found to be closely associated with several m onitoring of trends and international com parisons. The serious system ic illnesses such as cardiovascular and prevalence is expressed in term s of point prevalence pulm onary diseases, stroke, low birth-weight babies and (percentage of population affected at any given point in preterm labour. In India, different caries, (ii) periodontal diseases, (iii) dentofacial anom alies investigators have studied various age groups, which can and m alocclusion, (iv) edentulousness (tooth loss), (v) oral be broadly classified as below 12 years, above 12 years, cancer, (vi) m axillofacial and dental injuries, and (vii) above 30 years and above 60 years (Tables 12–15). Periodontal diseases affect the supporting structures of Therefore, there is no uniform ity in data on the prevalence teeth, i. M ore advanced periodontal disease with pocket Table 17 docum ents only som e studies, and highlights form ation and bone loss, which could ultim ately lead to totally incoherent data. M oreover, m ost of the studies have tooth loss if not treated properly, m ay affect 40% –45% of been conducted on the child population, in whom periodontal the population. The major vary from m ild to severe, causing aesthetic and functional dentofacial deform ity is cleft lip and palate, which is seen problem s, and m ay also predispose to dental caries, in 1. Prevalence of dentofacial anomalies and malocclusion Author and year State Place Age group (years) Prevalence (%) Shourie 1952 Punjab Punjab 13–16 50 Guaba et al. Tooth loss (edentulousness) studies) Age group (years) Number of missing teeth Edentulousness (%) Incidence (%) 60–64 8. Tooth loss increases with advancing age (Table Data available from a field survey in Gujarat, H aryana 20). Loss of the teeth results in decreased m asticatory and Delhi are presented in Tables 22, 23 and 24, respectively. Distribution of fluoride analysis of ground water samples from different States of India Number of Fluoride Fluoride Fluoride Maximum fluoride States water samples <1. Distribution of fluoride analysis of ground water samples from different States of India Number of Fluoride Fluoride Fluoride Maximum fluoride States water samples <1. Incidence of dental fluorosis in two villages in Haryana Drinking water fluoride Incidence of dental Village level (mg/L) fluorosis (%) Sotai 1. Sponsored by the Task Force on Safe Drinking Water, Government of India, 2003) Oral cancer N ational Cancer Registries in M um bai and Chennai for the period 1988–92 is shown in Tables 28 and 29, In India, the incidence of oral cancer is the highest in the respectively. O verall, the incidence per 100,000 m ost im portant of all prem alignant lesions is oral population is 29 for males and 14. Given the large population of India, the paan m asala and gutka by persons of all age groups, actual num ber of cases of oral cancer is gigantic. The prevalence of oral cancer reported by Population- 1994 5961 Bihar, Gujarat, Himachal Pradesh and Maharashtra 1995 6794 Bihar, Gujarat and West Bengal based Cancer Registries is given in Table 27.

Strategies and communication skills for clinicians  Exclude misunderstanding or inadequate information  Determine whether denial requires management  Explore emotional background to fears  Provide information tailored to the needs of the patient and clarify goals of care  Be aware of cultural and religious issues  Monitor the shifting sand of denial as the disease progresses  Aim to increase a person’s self esteem discount suhagra 100mg erectile dysfunction treatment himalaya, dignity purchase suhagra 100 mg otc erectile dysfunction symptoms age, moral and life meaning (Greer 1992; Watson et al 1984; Erbil et al 1996; Schofield et al 2003) Useful Link for communication skills in cancer care: http://pro. Other Programmes to Support Cancer Patients Travel2Care scheme This scheme helps patients who are suffering from genuine financial hardship with travel costs due to travelling to a cancer centre. Care to drive programme Care to Drive is a volunteer-led transport initiative in which the Irish Cancer Society recruits and trains volunteers to drive patients to and from their chemotherapy appointments. Tax relief can also be claimed back on travelling costs for insured cancer patients. Dengue Fever 1 Introduction Dengue has a wide spectrum of clinical presentations, often with unpredictable clinical evolution and outcome. Reported case fatality rates are approximately 1%, but in India, Indonesia and Myanmar, focal outbreaks away from the urban areas have reported case- fatality rates of 3-5%. To observe for the following Danger signs and report immediately for hospital admission • Bleeding: - red spots or patches on the skin - bleeding from nose or gums - vomiting blood - black-coloured stools - heavy menstruation/vaginal bleeding • Frequent vomiting • Severe abdominal pain • Drowsiness, mental confusion or seizures • Pale, cold or clammy hands and feet • Difficulty in breathing Out -patient laboratory monitoring- as indicated • Haematocrit • White cell count • Platelet count 5. If not tolerated, start intravenous isotonic fluid therapy with or without dextrose at maintenance. If the haematocrit remains the same, continue with the same rate for another 2–4 hours and reassess. If the vital signs/haematocrit is worsening increase the fluid rate and refer immediately. Start with 5–7 ml/kg/hour for 1–2 hours, then reduce to 3–5 ml/kg/hr for 2–4 hours, and then reduce to 2–3 ml/kg/hr or less according to the clinical response. If the haematocrit remains the same or rises only minimally, continue with the same rate (2–3 ml/kg/hr) for another 2–4 hours. If the vital signs are worsening and haematocrit is rising rapidly, increase the rate to 5–10 ml/kg/hour for 1–2 hours. Reassess the clinical status, repeat the haematocrit and review fluid infusion rates accordingly. Reduce intravenous fluids gradually when the rate of plasma leakage decreases towards the end of the critical phase. This is indicated by urine output and/or oral fluid intake that is/are adequate, or haematocrit decreasing below the baseline value in a stable patient. Parameters that should be monitored include hourly vital signs and peripheral perfusion. Internal bleeding is difficult to recognize in the presence of haemo-concentration. First correct the component of shock according to standard guidelines with early use of packed cell transfusion. Further infusion of large volumes of intravenous fluids will lead only to a poor outcome. If the patient remains in shock and the haematocrit is elevated, repeated small boluses of a colloid solution may help. Secondly, dextrose is rapidly metabolized resulting in a hypotonic solution that is inappropriate for shock correction. Consider in severe shock  Aim for ≈ 20% fall in haematocrit and adjust fluid rate downwards to avoid overload  Aim for minimal acceptable urine output (0. Flow Chart 1-Volume replacement flow chart for a patient with Severe (1) Dengue and a >20% increase in haematocrit. It results into significant morbidity ; affects precious growing period of a child, parental working days & possible negligence of other family members & also incurs formidable burden on scarce resources if treated improperly or inadequately. However, with the widespread availability of radioimaging techniques , fibrinolytic agents, safe & effective surgical procedures ( open or thoracoscopy ) the recent data is leading to more focused management guidelines though optimal management is still controversial (22). It could be localised or free collection of purulent material in pleural space as a result of combination of inoculation of bacteria & culture medium of pleural fluid. Stage 2 or Fibrinopurulent or Transitional phase ( 3 to 21 days ): There is deposition of fibrin in the pleural space leading to septations & formation of loculations. The presence of septations (fibrinous strands 17 in pleural fluid )doesn’t necessarily mean fluid doesn’t flow freely, although separate loculations will not communicate with each other. These solid fibrous or leather like peels may prevent lung re- expansion ( “trapped lung” ), impair lung function & create a persistent pleural space with potential for infection. It achieves debridement of fibrinous pyogenic material, breakdown of loculations, and drainage of pus from the pleural cavity under direct vision. Decortication involves an open posterolateral thoracotomy and excision of the thick fibrous pleural rind with evacuation of pyogenic material. It is a longer and more complicated procedure leaving a larger linear scar along the rib line. The reported rate of empyema thoracis complicating community acquired pneumonia is said to be 27% in children(21). The prevalence of small parapneumonic effusions is difficult to estimate (and often undetected )& they are unlikely to be reported in case series. Since Staph aureus is the most common organism responsible in our country improving hygienic conditions especially during hot & humid conditions of the year ie April to August will bring down in general incidence & severity of staph infections. Improvement in dental/oral hygiene as it is a welknown predisposing factor for development of aspiration pneumonia.

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However 100 mg suhagra visa erectile dysfunction medication names, some authorities believe that a change to a macrolide or clindamycin is more effective for endocarditis prophylaxis generic 100 mg suhagra with visa impotence injections medications. Summary Infective endocarditis remains a significant cause (many times unsus- pected) of cardiovascular morbidity and mortality. Although there are no data from controlled studies to support the use of antibiotic prophylaxis to prevent infective endocarditis, it remains the accepted medical/dental standard of care. Clearly, antibiotics have been shown to be able to prevent bacteraemia following dental extraction. Fur- thermore, proper laboratory facilities and clinical acumen are re- quired to reduce the occurrence of this complication of rheumatic heart disease. American Heart Association Committee on the Prevention of Rheumatic Fever, Endocarditis and Kawasaki Disease. Recommendations for prevention, diagnosis and treatment of infective endocarditis. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Prospects for a streptococcal vaccine Early attempts at human immunization Attempts to prevent group A streptococcal infections by immuniza- tion date back to the early years of the twentieth century (1–4). Efforts to develop a vaccine against group A strep- tococci were placed on a firmer scientific footing with the recognition that the principal virulence factor of group A streptococci was M- protein, a streptococcal wall constituent (5), and that opsonic anti- bodies to M-protein protected animals from lethal challenge. Such antibodies persisted for many years in humans (6) and appeared to be the basis of acquired type-specific immunity (7). Nevertheless, at- tempts to develop a safe and effective M-protein vaccine encountered considerable difficulties because of the multiplicity of M-protein sero- types (and genotypes), the toxicity of early M-protein preparations, and the immunological cross-reactivity between M-protein and hu- man tissues, including heart tissue (8) and synovium (9). M-protein vaccines in the era of molecular biology Although our knowledge of the structure and function of M-protein has advanced considerably in recent years (11–15), M-protein pre- parations used in vaccines are still not free of epitopes that elicit immunological cross-reactivity with other human tissues. Antibodies against M-proteins, for example, cross-react with alpha-helical human proteins, such as tropomyosin, myosin and vimentin. Primary struc- ture data have revealed that M-proteins of rheumatogenic streptococ- cal serotypes, such as serotypes 5, 6, 18 and 19, share similar sequences within their B-repeats, and it is likely that such sequences are responsible for eliciting antibodies that cross-react with epitopes in the heart, brain and joints (16). Most of the cross-reactive M- protein epitopes appear to be located in the B-repeats, the A-B flanking regions, or the B-C flanking regions, all of which are some distance from the type-specific N-terminal epitopes (16–18). In contrast, antibodies raised against synthetic N-terminal peptides that correspond to the hypervariable portions of M-protein serotypes 5, 6 and 24 are opsonic, but do not cross-react with human tissue (17– 19). Further studies have shown that peptide fragments of M- 106 proteins, incorporated into multivalent constructs as hybrid proteins or as individual peptides linked in tandem to unrelated carrier pro- teins, elicited opsonic and mouse-protective antibodies against mul- tiple serotypes, but did not evoke heart-reactive antibodies (20, 21). These estimates were based on sero- type distribution data from economically developed western coun- tries, and such a vaccine might need to be reconstituted, based on prevalent local strains. Current studies are directed toward utilizing commensal gram-positive bacteria as vaccine vectors (22–23). One of these is C5a peptidase, an enzyme that cleaves the human chemotactic factor, C5a, and thus interferes with the influx of polymorphonuclear neutrophils at the sites of inflammation (24). Intranasal immunization of mice with a defective form of the streptococcal C5a peptidase reduced the colo- nizing potential of several different streptococcal M-serotypes (25). A second potential vaccine target is streptococcal pyrogenic exotoxin B (SpeB), a cysteine protease that is present in virtually all group A streptococci. Mice passively or actively immunized with the cysteine protease lived longer than non-immunized animals after infection with group A streptococci (26). Epidemiological considerations Once a safe and effective streptococcal vaccine is available many practical issues would need to be addressed. Other issues, such as cost, route of administration, number and frequency of required doses, potential side-effects, stability of the material under field conditions, and dura- bility of immunity, would all influence the usefulness of any vaccine. The most promising approaches are M-protein-based, including those using multivalent type-specific vaccines, and those directed at non-type-specific, highly conserved portions of the molecule. Success in developing vaccines may be achieved in the next 5–10 years, but this success would have to contend with important questions about the safest, most economical and most efficacious way in which to employ them, as well as their cost-effectiveness in a variety of epidemilogic and socio-economic conditions. A review of past attempts and present concepts of producing streptococcal immunity in humans. Intravenous vaccination with hemolytic streptococci: its influence on the incidence of rheumatic fever in children. Persistence of type-specific antibodies in man following infection with group A streptococci. Epitopes of group A streptococcal M protein shared with antigens of articular cartilage and synovium. Rheumatic fever: a model for the pathological consequences of microbial-host mimicry. Streptococcal M protein: alpha-helical coiled-coil structure and arrangement on the cell surface. Alternate complement pathway activation by group A streptococci: role of M-protein. Inhibition of alternative complement pathway opsonization by group A streptococcal M protein.

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Once the articular cartilage is eroded there is tremendous muscle spasm and all movements are restricted buy 100 mg suhagra with visa erectile dysfunction which doctor to consult. Because of the destruction of the articular cartilage the joint space on X-ray looks diminished buy cheap suhagra 100mg on line erectile dysfunction medicine. When the lesion is osseous it involves the subchondral bone which also leads to erosion of the cartilage. The lesion may start from the epiphysis in children or may be metaphyseal in origin. When the disease begins to heal, fibrosis occurs across the joint leading to a fibrous ankylosis. Prolonged muscle spasm may lead to subluxation or dislocation of the joint causing further deformity and shortening. If sinus has formed, secondary infection may be superimposed on the tuberculous infection. Fibrous ankylosis may be converted into bony ankylosis either due to complete healing or new bone formation due to superadded pyogenic infection. Radiologically, in bony ankylosis the trabeculae are seen to be crossing the joint line. The child complains of pain in the joint, aggravated by movement, and often wakes ‘up at night because muscle spasm gets reduced and causes pain. Low- grade fever, loss of weight and appetite are some of the symptoms of generalized toxemia usually seen. A negative test may rarely be seen in severe or disseminated disease or in an immunocompromised patient. Lytic lesion and periosteal reaction are seen, although latter is much more prominent in pyogenic infection. Joint space decreases due to cartilage erosion and lytic lesions are seen in the epiphyseal area. The radiological signs of a healing lesion are absence of rarefaction and bony ankylosis. The culture and sensitivity tests for various anti fuberculosis drugs also help in giving appropriate chemotherapy in resistant cases or cases of multi-drug resistant tuberculosis; which are seen quite frequently in today’s clinical practice. It recommended that it should be practiced in all diagnostic centres of our country, even for suspected vertebral tuberculosis. Biopsy from the bone or synovium can provide an early diagnosis for timely starting the treatment and preventing damage to the joint. Biopsy from a cystic lesion in bone or from synovium is more likely to be positive. Some other investigations may include: sputum smear examination and culture, routine urine examination for isolation of tubercie bacilli and an intravenous pyelogram for ruling out pulmonary and genitourinary lesions, respectively. Eradication of the disease and preservation of function are important both in osseous and joint diseases. In case of joints, joint mobility and stability are also the early goals to be achieved. In case the articular cartilage is eroded the joint becomes unsalvageable in terms of function, mobility and stability. In such a situation the aim of treatment is to achieve a sound bony ankylosis which is painless and gives stability, although the patient will not have movements at that joint. General rest and local rest to the specific bone and joint are essential parts of the treatment. However, in cases where the articular surface is not involved a judicious blend of rest and mobilization exercises have to be resorted for restoration of function. However, in case of persistently draining sinuses which are secondarily infected, suitable broad spectrum antibiotics have to be given. About 15% of patients do not respond to chemotherapy alone if the lesion contains much caseation and sequestra. In such situations excision of the diseased focus not only removes the diseased toxic material but also increases vascularity and allows the anti-tuberculosis drugs to reach the site of the lesion. A standard drug regimen is given which includes rifampicin, pyrazinamide, ethambutol, isoniazid, and in some cases even streptomycin. The latter is useful because it kills the rapidly multiplying extracellular tubercle bacilli in the lungs for the initial six months. After two clinically and radiologically, pyrazinamide is stopped and isoniazed, rifampicin and ethambutol are continued for one year. In some cases therapy may be required for 18 months for complete healing of the lesion. In case the infection is suspected to be with multidrug resistant ofloxacin, capreomycin, kanamycin, etc.

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