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Transfer patient for management and include affected limb/digit when possible Placeamputatedsectioningauzesoakedwithsaline buy cytotec 200mcg overnight delivery symptoms stomach flu, then inside a plastic bag generic cytotec 200 mcg mastercard medicine used to treat bv. In hip dislocation discount cytotec 100mcg otc symptoms quadriceps tendonitis, the femoral head may lie anterior (10%) or posterior (90%) to the acetabulum. Delay in repair of certain hip fractures or hip dislocation can lead to avascular necrosis of the femoral head. Long-Bone Fractures of the Leg Definition: Long bone fractures of the lower extremity may affect the tibia, fibula, or femur. Have elevated concern for abuse if the child is not yet ambulatory and has a femur fracture or if the history is not consistent with the type of fracture. Knee Injuries Definition: Knee injuries are common and can be accompanied by significant vascular or neurologic injuries. For instance, popliteal artery injuries occur in approximately 35% of knee dislocations. Always check for distal pulses o Failure to re-vascularize the popliteal artery within 6-8 hours leads to approximately 90% amputation rate. Ankle Injuries Definition: Injuries can include ligament injuries, tendon injuries, dislocation or fracture of the tibia, fibula and/or talus. Partial or complete ligament tears are the most common ankle injuries (ankle sprain). Associated proximal tibial and fibular fractures are often seen; therefore careful inspection of the entire leg distal to the knee is very important. The plaster is changed in series, decreasing the plantar flexion and eventually moving toward short-leg casts in a neutral ankle position. Respiratory failure (patient is not able to maintain adequate oxygenation or ventilation) is also a very common cause of death in Rwanda. Start oxygen with non-rebreather mask (bag reservoir) and consider intubation if possible. Is the patient posturing (sitting upright, uncomfortable, with increased work of breathing)? Consider early intubation if the equipment is available in your hospital and the physician is trained on the procedure. More importantly however, is stabilizing the patient until they reach a referral center. Pneumonia Definition: Infection in the lung space that can be caused by a virus, bacteria, and less often a fungus. Consider a Foley catheter in any patient who is ill appearing and be sure urine output is atleastO. Antibiotics: Treatment regimens are typically based on local sensitivities for pathogens. Large studies do not exist for pathogens specific to Rwanda therefore we must use other guidelines to direct our care. If you do transfer to referral hospital, record what antibiotics were given and for how many days so referral specialists know how to guide treatment upon arrival. Results in mediastinal displacement and kinking of the great vessels, which compromises preload and cardiac output and can cause cardiac collapse/death Open pneumothorax (sucking chest wound): due to a direct communication between the pleural space and surrounding atmospheric pressure Signs and symptoms Clinical status and stability of patient is related to size of pneumothorax. Air between the visceral pleural line and chest wall seen as area of black without vascular or lung markings. Pulmonary Edema Definition: The presence of excess fluid in the alveoli, leading to impaired oxygen exchange. Pulmonary edema can result from either high pulmonary capillary pressure from heart failure (cardiogenic) or from non-cardiogenic causes, such as increased capillary leak from inflammation. Many patients with acute hypertensive pulmonary edema may not be fluid overloaded! Studies have shown that it is an inferior vasopressor compared to others (such as norepinephrine) in cardiogenic shock (Debacker, et al), but it is the best option to temporarily increase blood pressure. Counsel family and patient early to decide when appropriate to switch goals of care towards palliation. Transfer to referral center only after discussion with family and consideration of whether there is possibility of recovery. While the two are different and often unrelated processes, their clinical symptoms and treatments are similar. Can present anxious (because of inability to breathe), tachypneic, tachycardic, and with wheezing. Massive hemoptysis is rare but frequently fatal; definitions vary from 100-600 ml of blood over 24 hours. Only consider if prognosis is reasonable and referral facility will be able to obtain useful tests (i. Effusions can be either transudative (caused by changes in the hydrostatic and or osmotic gradient) or exudative (caused by pleural inflammation and increased permeability). If unable to sit, lie patient on affected side with ipsilateral arm above head Use ultrasound to find the largest pocket of fluid and measure distance from skin to fluid. Stop once fluid is aspirated and inject some Lidocaine to anesthetize the parietal pleura. Make sure to turn the stopcock to the off position when removing the syringe to prevent air from entering the pleural space. Can range from occult and insignificant to massive, causing obstructive shock and death. It may originate from an organ located in the chest or be referred from another part of the body. Signs and symptoms History: Ask about the following factors o Duration: Constant (likely not cardiac) vs. Causes Low contractility o Cardiomyopathy o Myocarditis Poor heart filling o Arrhythmias o Mitral stenosis o Pericardial tamponade Other valvular heart disease o Examples include acute mitral regurgitation or aortic regurgitation from acute rheumatic fever or endocarditis Signs and symptoms History o Depends on etiology; may have slowly progressing or acute symptoms o Dyspnea, syncope, weakness, confusion/coma Exam o Low blood pressure alone should not make the diagnosis. These patients are in shock because their heart is not squeezing well (contractility problem). This may need to be reduced with Captopril or nitroglycerin once above pressors have been started and blood pressure is raised. Be aware that this may further lower their blood pressure, therefore, may need to start pressors prior to or just after intubation. Cardiogenic shock secondary to mitral stenosis and rapid heart rate o These patients are in shock because their left ventricle is unable to fill adequately during diastole (preload problem). If they are in rapid atrial fibrillation, defibrillate o If defibrillation does not work, give Amiodarone or Digoxin Amiodarone 150 mg over 10 minutes Digoxin 0. Ischemic heart disease as a cause of heart failure is thought to remain relatively uncommon in Rwanda, particularly in more rural settings. If anything other normal or cardiomyopathy, should be referred for formal echocardiogram (possible candidates for cardiac surgery) Management: Initial approaches to heart failure the same in all patients.

We carried out a study to evaluate the possibility of using breath methane excretion to indicate lactose malabsorption in field situration cheap cytotec 100mcg online treatment with cold medical term. Hydrogen breath test following a lactose test meal (2g/kg purchase 100 mcg cytotec amex medications known to cause weight gain, maximum 50g) was used as a standard test discount cytotec line medications bad for kidneys. Although there were no significant increments of methane concentration at any time in lactose absorbers, breath methane production increases significantly after 120 minutes in lactose malabsorbers. At 180 minutes breath methane concentration between lactose malabsorbers were significantly different. The sensitivity and specificity, the positive and negative predictive values of methane excretion of more than 3ppm at 180min after lactose ingestion as a diagnostic test for lactose malabsorption had sensitivity of 61. A single breath methane measurement at 3 hours after a lactose test meal may be used as an alternative test for lactose malabsorption. No significant differences were found between the differential sugar ratios of the children who had chronic (90% length-for-age) or acute (80% weight-for-height) malnutrition and those children who were normally nourished according to there classifications. We carried out a study to ascertain the effect of de- worming on recovery of intestinal permeability in 47 children before de-worming, and 2 months, 4 months and 6 months after de-worming. All the subjects have ascaris ova in their stool as 128 Bibliography of Research Findings on Gastrointestinal Diseases in Myanmar demonstrated by initial microscopy. De-worming was carried out using combantrin (pyrental pamoate) 10mg/kg body weight and three days stool collection was carried out to determine the round worms (Ascaris lumbricoies) excreted. No significant correlation was found between worm count and intestinal permeability. Lactulose permeability after de-worming show only minimal decrease (from % excretion 0. However, the rhamnose permeability showed significant increase at 4 months after de- worming (p<0. The result of this study demonstrated that the deworming has positive effect on intestinal permeability and overall improvement was found to begin at 2 months after deworming. However, the significant improvement in trans- cellular permeability was found to take about 4 months to recover after deworming. Dual sugar permeability test using lactulose and L-rhamnose was used to assess, the intestinal mucosal function. All children had marked decrease in L-rhamnose excretion reflecting decrease absorption through enterocytes and villous atrophy. Lactulose excretion was significantly increased in kwashiorkor suggesting increased absorption through paracellular spaces and mucosal damage. We conclude that intestinal permeability is increased in malnutrition and mucosal damage is more evident in kwashiorkor. Significant association of intestinal type with intestinal metaplasia and diffuse type with normal gastric mucosa were noted (p<0. Most intestinal types wer well differentiated, but most diffuse types were poorly differentiated (p<0. These finding support the possible pathogenesis that intestinal type started from intestinal metaplasia in gastric mucosa. Diffuse type tumours arerelatively more in poor differentiation and more aggressive in nature which determine the relatively poor prognosis than intestinal type. As the first pilot study in Myanmar, a total of seventy five cases of neonates and infants admitted during January- December 1991, at the No. Out of seventy five cases screened, a case of 9 day old neonate showed positive rotavirus as the aetiological agent. Fluid and electrolyte replacement is all that is necessary without any need for antibiotics for such cases. Out of 20 cases of oesophageal carcinoma, 5 involved in middle third, 14 involved in lower third and one involved distal half of the oesophagus. A community based study on defecation frequency, stool weight, and consistency was conducted in a cohort of 300 Myanmar children aged 1 to 4 years. Within (9) months of case collection, we found (21) numbers of biopsy proven patients. This may be due to advanced in diagnostic technique and awareness 130 Bibliography of Research Findings on Gastrointestinal Diseases in Myanmar of surgeons and physicians regarding the cases presenting with obstructive jaundice. Although the results can t be generalized because of the small sample size, the present study hightlights the problem of advanced stages of carcinoma pancreas and periampullary carcinoma and confirmed that the stage of the disease is one of the determinants of the outcome of treatment in our country. Because of the advanced stages in these patients, curative resections are not possible. High morbidity and mortality rate within the follow-up period of (3) months which indicates poor prognosis. Lacks of knowledge and health education are the reasons for poor outcome of carcinoma pancreas and periampullary carcinoma patients in our country than others (i. The poor prognosis of these patients emphasise the need to improve the survival rate with considerable efforts in the future. The public health measures influencing the pattern of eating style in daily diet such as fat, meat, coffee, alcohol favours the incidence. At the present, the best way to solve the problem is to give informations about the nature of the disease to the general practitioners and health education to the public. Majority of cases were referred from Liver Unit and Gastrointestinal Tract Medical Unit. So collaboration of the Surgical Unit and other disciplines is required for early case detection and effective treatment. Any patients presenting th th with anorexia, weight loss in their 4 or 5 decades should be screened for malignancy. Author hope the efforts of early detection of carcinoma pancreas patients with the resultant increase in curative resectability rate, better staging incorporation with the radiologist and pathologist will undoubtedly improve the prognosis of carcinoma pancreas and periampullary carcinoma patients in our country in the future. It was hospital based 131 Bibliography of Research Findings on Gastrointestinal Diseases in Myanmar descriptive study. The incidence and severity of diarrhoeal diseases in relation to breast feeding practices and illness were assessed monthly by questionnaires. Incidence of diarrhea was less among those who were exclusively breast-fed compared with those who received non-exclusive breast- feeding (P value=0. The risk of developing dehydration was also reduced in exclusively breast-fed babies, but it is not statistically significant. Most of the mothers who were successful in initiating and maintaining exclusive breast-feeding were low parity, young age and educated and they all attended antenatal care regularly. The study subjects included 100 infants with diarrhoea, aged less than 4 months, admitted to the hospital from June 1997 to May 1998. Of these 48 cases, 28 had some dehydration and 20 had 132 Bibliography of Research Findings on Gastrointestinal Diseases in Myanmar severe dehydration. Exclusive breast-feeding was observed only in the age group <1 and >1- 2 month(s). The association of the severity of dehydration with other types of feedings compared to exclusive breast-feeding was not statistically significant. In this study, most mothers washed their hands with water only after cleansing their children s defaecation, and before and after feeding their children. The severity of dehydration was statistically significant in hand-washing practices when compared to washing with water only and washing with soap and water.

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The group I allergens are of major importance in that by skin testing and histamine release buy cheap cytotec 200mcg medicine for yeast infection, 90% to 95% of grass pollen allergic patients react on testing ( 75) discount cytotec 100 mcg on-line treatment 3 phases malnourished children. Profilin discount generic cytotec canada treatment keratosis pilaris, a compound involved in actin polymerization, has been described as a component of several tree pollens ( 77). Despite 84% identity, the predicted secondary structures suggest they may not be cross-reactive ( 78). Only about 20% of grass pollen sensitive patients appear to be skin test reactive to these allergens. Analysis of the cloned Kentucky bluegrass allergen, Poa p 9, has suggested the existence of a family of related genes. Among the group V allergens, the most work has been done with the timothy grass allergens Phl p 5a and Phl p 5b. Other group V allergens have been isolated from a number of temperate grasses, including Dactylis glomerata (orchard grass). The Dac g 5b allergen also has been cloned and coded for a fusion protein that was recognized by IgE antibodies in six of eight samples of atopic sera tested. This suggests that Dac g 5b may be a major allergen, but it has not been completely characterized ( 82). The most recent major grass pollen to be identified, Lol p 11, appears to be a member of a novel allergen family (83). No sequence homology with known grass pollen allergens was found, but it does have 32% homology with soybean trypsin inhibitor ( 83). This allergen reacted with IgE from over 65% of grass-pollen positive sera tested. Lol p 11 appears to share some sequences with allergens from olive pollen, as well as tomato pollen. A strategy to take advantage of the extensive cross-reactivity between species using recombinant allergens has been studied. A mixture of Phl p 1, Phl p 2, Phl p 5, and Bet v 2 (birch profilin) accounted for 59% of grass-specific IgE ( 85). The Lol p extracts reacted with 80% of the IgE, whereas the recombinant Phl p reacted with 57% of the IgE (86). This transgenic ryegrass pollen maintained its fertility, but had a significant decrease in its IgE binding capacity compared with normal pollen. This creates the possibility of genetic engineering of less allergenic grasses ( 87). Tree Pollen Antigens There seems to be a higher degree of specificity to skin testing with individual tree pollen extracts compared with grass pollens because pollens of individual tree species may contain unique allergens. Despite this observation, several amino acid homologies and antigenic cross-reactivities have been noted. A major birch-pollen allergen, Bet v 1, has been isolated by a combination chromatographic technique. Monoclonal antibodies directed against this allergen have simplified the purification process ( 88). There is considerable (80%) amino acid homology between Bet v 1 and other group I tree allergens ( 2). Bet v 1 is the birch tree allergen that cross-reacts with a low-molecular-weight apple allergen, a discovery that helps to explain the association between birch sensitivity and oral apple sensitivity ( 90). Further investigations by the same workers extend this cross-reactivity to include pear, celery, carrot, and potato allergens. Most of the 20 patients tested had birch-specific serum IgE (anti Bet v 1 and anti Bet v 2) that cross-reacted to these fruits and vegetables. Bet v 2 has been cloned and identified as profilin, a compound responsible for actin polymerization in eukaryotes. There is approximately 33% amino acid homology between the human and birch profilin molecules ( 77). Bet v 3 and Bet v 4 have both been cloned and further described as calcium binding molecules ( 91,92). Recombinant Bet v 5 appears to have sequence homology with isoflavone reductase, but the biochemical function remains unknown ( 93). It reacts with IgE from 20% of birch allergic patients and has been identified as a cyclophilin ( 94). A major allergen has been isolated from the Japanese cedar, which contributes the most important group of pollens causing allergy in Japan. This allergen, designated Cry j 1, was initially separated by a combination of chromatographic techniques. Four subfractions were found to be antigenically and allergenically identical (95). There is some amino acid homology between Cry j 1 and Amb a 1 and 2, but the significance of this is unclear. Allergens from mountain cedar (Juniperus ashei) are important in the United States. The major allergen, Jun a 1, has a 96% homology with Cry j 1 and with Japanese cypress (Chamaecyparis obtusa) (97). In 1726, Sir John Floyer noted asthma in patients who had just visited a wine cellar; in 1873, Blackley suggested that Chaetomium and Penicillium were associated with asthma attacks; and in 1924, van Leeuwen noted the relationship of climate to asthma and found a correlation between the appearance of fungal spores in the atmosphere and attacks of asthma ( 99). Over the next 10 years, case reports appeared attributing the source of fungal allergies to the home or to occupational settings. In the 1930s, Prince and associates ( 100) and Feinberg (101) reported that outdoor air was a significant source of fungal spores and demonstrated that many of their patients had positive skin test reactivity to fungal extracts. More alarming is the association noted between elevated Alternaria airborne spore concentrations and risk of respiratory arrests in Alternaria-sensitive individuals ( 102). Initially, fungal sensitivity was equated to skin test reactivity, but more direct evidence for the role of fungal sensitivity in asthma has been presented by inhalation challenge studies by Licorish and co-workers ( 103). In addition to IgE-mediated reactions, sensitization to certain fungi, especially Aspergillus, can lead to hypersensitivity pneumonitis ( 104). Although fungal spores are thought to be the causative agents in atopic disorders, other particles that become airborne (including mycelial fragments) also may harbor allergenic activity. Alternaria is an important allergenic fungus and has been associated with significant episodes of respiratory distress. Among the Alternaria species, A alternata has been the subject of the most research. The Alt a 1 allergen is rich in carbohydrates, and glycosylation of proteins may be necessary for allergenic activity (107). Alt a 1 can induce positive intradermal test results at extremely low concentrations (6 pg/mL) in Alternaria-sensitive subjects. Interestingly, the fungus Stemphyllium shares at least 10 antigens with Alternaria and an allergen immunochemically identical to Alt a 1 (110). Commercial Alternaria extracts contain widely varying amounts of Alt a 1, underscoring the need for improved methods of standardization (111). There is also evidence of further cross-reactivity with Saccharomyces and Candida (114).

Prevalence of cocaine use and its impact on asthma exacerbation in an urban population generic cytotec 200 mcg without prescription treatment 3rd degree av block. Rapid-onset asthma attack: a prospective cohort study about characteristics and response to emergency department treatment buy generic cytotec line treatment norovirus. Mechanisms of hypoxemia in patients with status asthmaticus requiring mechanical ventilation buy discount cytotec 200mcg on-line medicine pictures. Arterial blood gases and pulmonary function testing in acute bronchial asthma: predicting patient outcomes. Airway obstruction and ventilation perfusion relationships in acute severe asthma. Serial relationships between ventilation perfusion inequality and spirometry in acute severe asthma requiring hospitalization. Assessment of the patient with acute asthma in the emergency department: a factor analytic study. The application of an asthma severity index in patients with potentially fatal asthma. A cohort analysis of excess mortality in asthma and the use of inhaled beta-agonists. Cardiac dysrhythmias during the treatment of acute asthma: a comparison of two treatment regimens by a double blind protocol. The effects of deep inhalation on maximal expiratory flow during intensive treatment of spontaneous asthmatic episodes. Cardiorespiratory arrest following peak expiratory flow measurement during attack of asthma. Emergency room treatment of asthma: relationships among therapeutic combinations, severity of obstruction and time course of response. Early prediction of poor response in acute asthma patients in the emergency department. Failure of peak expiratory flow rate to predict hospital admission in acute asthma. Continuous intravenous terbutaline infusions for adult patients with status asthmaticus. Routine chest radiographs in exacerbations of acute obstructive pulmonary disease. A pilot study of steroid therapy after emergency department treatment of acute asthma: is a taper needed? Comparison of intramuscular triamcinolone and oral prednisone in the outpatient treatment of acute asthma: a randomized controlled trial. Ventilation perfusion mismatching in acute severe asthma: effects of salbutamol and 100% oxygen. Continuous versus intermittent nebulization of salbutamol in acute severe asthma: a randomized, controlled trial. Effect of outpatient treatment of asthma with beta agonists on the response to sympathomimetics in an emergency room. Comparison of intermittent and continuously nebulized albuterol for treatment of asthma in an urban emergency department. Continuous versus intermittent albuterol nebulization in the treatment of acute asthma. Beta-adrenoceptor responses to high doses of inhaled salbutamol in patients with bronchial asthma. Cardiovascular safety of high doses of inhaled fenoterol and albuterol in acute severe asthma. Isoetharine versus albuterol for acute asthma: greater immediate effect, but more side effects. Improved bronchodilation with levalbuterol compared with racemic albuterol in patients with asthma. A randomized, placebo-controlled study to evaluate the role of salmeterol in the in-hospital management of asthma. Emergency department treatment of severe asthma: metered-dose inhaler plus holding chamber is equivalent in effectiveness to nebulizer. A comparison of albuterol administered by metered dose inhaler (and holding chamber) or wet nebulizer in acute asthma. Efficacy of albuterol administered by nebulizer versus spacer device in children with acute asthma. Treatment of acute asthma: is combination therapy with sympathomimetics and methylxanthines indicated? Comparison of nebulized terbutaline and subcutaneous epinephrine in the treatment of acute asthma. Inhaled salbutamol (albuterol) vs injected epinephrine in the treatment of acute asthma in children. Epinephrine improves expiratory airflow rates in patients with asthma who do not respond to inhaled metaproterenol sulfate. Comparison of intravenous and nebulised salbutamol in initial treatment of severe asthma. Comparison of salbutamol given intravenously and by intermittent positive-pressure breathing in life-threatening asthma. Nebulized versus intravenous albuterol in hypercapnic acute asthma: a multicenter, double-blind, randomized study. A controlled study of the effects of single doses of hydrocortisone on the resolution of acute attacks of asthma. Corticosteroids in the emergency department therapy of acute asthma: an evidence-based evaluation. Early administration of hydrocortisone in the emergency room treatment of acute asthma: a controlled clinical trial. A controlled trial of methylprednisolone in the emergency treatment of acute asthma. Rapid improvement of peak flow in asthmatic patients treated with parenteral methylprednisolone in the emergency department: a randomized controlled study. Effectiveness of steroid therapy in acute exacerbations of asthma: a meta-analysis. Controlled trial of oral prednisone in the emergency room treatment of children with acute asthma. A randomized comparison of 100-mg vs 500-mg dose of methylprednisolone in the treatment of acute asthma. A double-blind, randomized clinical trial of methylprednisolone in status asthmaticus. Effectiveness and safety of inhaled corticosteroids in controlling acute asthma attacks in children who were treated in the emergency department: a controlled comparative study with oral prednisone.

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Others danced in front of it discount cytotec 100 mcg with mastercard symptoms gluten intolerance, and the wall had to be repainted frequently because so many viewers tried to touch and hug it cytotec 100mcg on-line medicine yoga. They can also help decrease the amount of staff turnover by making the workplace less stressful order cytotec 100mcg on line medicine 2020. So there are economic benefts to having an arts program but the value of the Arts and Medicine Institute is much greater than that, Fattorini says. Photo by Cleveland Clinic Photography Below: Docents lead tours of the Cleveland Clinic art collection several times per week. Patients suffering from memory loss and their caregivers enjoy a special tour program monthly. Photo by Jim Lang Community Partnership for Arts and Culture 14 Creative Minds in Medicine the intersection of arts and health What is the Arts and Health Intersection? From writing poetry or playing music with friends to taking photos or experiencing theater, arts and culture serve as outlets for individual learning, expression and creativity. Participation in arts and culture has been shown to yield positive cognitive, social and behavioral outcomes for human development and for overall quality of life throughout the human lifespan. Because of its ability to span both personal and public spheres in varying degrees, arts and culture participation can yield far-reaching results. At another level, the paintings can be developed into public murals that call attention to areas or issues in need of improvement. Even further, the paintings can become an exhibition that rallies the broader community, encouraging it to take actions that address neighborhood challenges. In this way, a multifaceted view of impact is critical to develop a full understanding of the ways in which arts and culture infuence the human condition on a personal and global scale. In a similar way, an inquiry into the nature of the arts and culture / health and human services intersection (referred to hereafter as the arts and health intersection, for simplicity) requires4 a multifaceted approach. In this general sense, the terms arts and health can be ambiguous because their defnitions are dependent on the manner through which they intersect. Defnitions are ultimately determined by who is participating in the arts and health intersection, where the intersection takes place and what the intersection s goals are. Clinical outcomes in physical and mental health, improved health and human services delivery and personal enjoyment of arts and culture all exist on the continuum of this creative intersection. Artistic practice commonly challenges convention, organically develops new methods and accepts subjective outcomes, while protocols for health practice and clinical outcome measurement demand greater rigidity. In these ways, arts and culture have the10 ability to span multiple disciplines and be applied through a wide range of methods. This ability makes arts and culture interventions useful in responding to the unique needs and concerns of individuals that arise in multiple healthcare situations. Arts and Health in Cleveland Cleveland is fortunate to be home to world-class sets of healthcare and cultural institutions. Meanwhile, Cleveland s arts and culture institutions have multiplied in number and discipline, expanded in size and reputation, and become renowned attractions for both local and international audiences. The Framework of this White Paper While Cleveland is known for the strength of its arts and culture and health and human services sectors, the intersections of those sectors are still being explored and developed. This white paper examines the concept of such intersections with a brief historical perspective on the development of the feld. The organization of subsequent chapters is based on a number of examples of real-life programs and practices illustrating the many ways in which arts and culture contribute to healthcare practice and human services delivery:11 Arts integration in healthcare environments. Community Partnership for Arts and Culture 16 Creative Minds in Medicine Arts and health integration with community development, public health and human services. In the following chapters, these categories will be defned more fully and will highlight key examples of arts and health collaborations that are happening in Cleveland. The fnal sections of this paper will introduce best practices and policy recommendations to further strengthen Cleveland s arts and health intersections in the future. The Historical Development of the Arts and Health Field I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon s knife or the chemist s drug. They have worked to apply scientifc methods in light of and sometimes in spite of the cultural conditions of the period and location in which they work. The patient-centric approach with its stronger15 connection to the social sciences has emerged more recently, following a period of stricter emphasis on disease-based, standardized treatment in the vein of natural sciences methodology. Expressive arts therapies have been recognized since ancient times for their utility as treatments for a host of ailments and both Aristotle and Plato wrote of the healing infuence of music on behavior and health. During the moral therapy or humane-treatment movement of the late 19th and early 20th centuries, art and music were incorporated into the treatment of mental illness. Such practices18 continued as the formal integration of arts and health progressed during the period of the frst and second World Wars. During this time, the value of the visual arts in raising public awareness about infectious diseases gained greater prominence through the design of posters. Thayer Gaston professionalized the music therapy feld with his research demonstrating the impact of music on health and supporting the development of educational programs. In 1950, the National Association for Music Therapy was founded21 and became one of the frst expressive arts therapy organizations to codify its operations, set educational standards, and conduct and disseminate research. During the Works Progress Administration s Federal Art Project, art teachers were hired to work with psychiatric patients. These led in the 1970s to the art therapy feld dividing into two24 approaches: The frst views the process of art-making in and of itself as a therapeutic practice; the other, art psychotherapy, regards art-making as a way for patients to express their emotions symbolically and for therapists to interpret their patients mental conditions. Hospital Audiences was a key contributor to the development of one of the frst arts programs in a hospital, a performance series at Duke University Medical Center. It is an alliance of professional creative arts therapies associations who are working together to further the use of the arts as therapeutic modalities while collaborating on education, research, and advocacy. Percent- for-art programs, which devote a set percent of a project s cost to support the incorporation of arts and culture, also helped jumpstart some early hospital art programs. Whatever the type of facility, design considerations are typically focused on creating environments that welcome patients and their families, ease navigation Key Benefts to destinations and facilitate positive general wellness and therapeutic outcomes. Florence Nightingale,36 the founder of modern nursing, was one of the earliest practitioners of medicine that tied a patient s In patients, research has demonstrated arts and environment to his or her health results. However, this view has shifted as the healthcare industry has focused greater attention Improved communications with patients and on how facilities might create supportive or healing other staff environments for patients. The industry increasingly Less work-related injuries recognizes that design helps to create spaces Reduction in medical errors conducive to recovery by giving patients a degree of Higher productivity control over their environment, encouraging social Lower levels of stress interaction as a means of support, and providing Higher rates of job satisfaction them with access to nature and other positive distractions. Such outcomes yield faster recovery times for patients and increase staff effciency, both of which yield cost savings for healthcare institutions. In the43 following sections, this chapter will explore the effects that arts and culture create in healthcare environments from two key viewpoints: the infusion of works of art and performances into healthcare spaces; and the specifc role the design feld plays in healthcare environments from structural, aesthetic and practical viewpoints. Locally,44 the Cleveland Clinic Arts and Medicine Institute resulted from work that began in 1983 when the hospital formed an Aesthetics Committee to oversee art and design considerations in Cleveland Clinic facilities.

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Aetiology Investigations Previously purchase cytotec on line amex medications routes, chronic osteomyelitis resulted from poorly r The X-ray nding may take 2 3 weeks to develop order 200 mcg cytotec with amex 7 medications that can cause incontinence. It now occurs more fre- raised periostium is an early sign that may be seen quentlyinpost-traumaticosteomyelitis discount 100mcg cytotec otc medical treatment. With healing there is sclerosis and seques- Pathophysiology trated bone fragments may be visible. Blood cultures are positive in the bone may remain dormant for years giving rise to 50%. Clinical features The clinical course is typically ongoing chronic pain Management r and low-grade fever following an episode of acute os- Surgical drainage should be used if there is a subpe- teomyelitis. There may be pus discharging through a si- riosteal abscess, if systemic upset is refractory to an- nus. However, if the pus is retained within the bone or tibiotic treatment or if there is suspected adjacent join the sinus becomes obstructed, rising pressure leads to an involvement. Par- enteral treatment is often required for a prolonged period (2 4 weeks) prior to a long course of oral an- Investigations tibiotics to ensure eradication. Theperiostiummayberaisedwithunderlying with a third-generation cephalosporin to cover for new bone formation. Management r Adequate analgesia is essential and may be improved Discharging sinuses require dressing, and if an abscess with splints to immobilise the limb (which also helps persists despite antibiotic therapy it should be incised to avoid contractures). Prolonged combined parenteral antibiotics to reduce associated muscle disuse atrophy and to are required. In early stages the joint space is preserved, but later there is narrowing and ir- Tuberculous bone infection regularity with bone erosion and calcication within adjacent soft tissue. Incidence Patients with tuberculosis have a 5% lifetime risk of Management developing bone disease. Chemotherapy with combination anti-tuberculous agents for 12 18 months (see page 105). Rest and trac- tion may be useful; if the articular surfaces are damaged, Age arthrodesis or joint replacement may be required. Geography Septic arthritis Major illness in developing countries, with increasing Denition incidence in the developed world. Aetiology Tuberculous osteomyelitis is usually due to haematoge- Aetiology nous spread from a primary focus in the lungs or gas- Joint infection arises most commonly from haematoge- trointestinal tract (see pages 105 and 154). Other mechanisms include local trauma or creased the incidence of tuberculosis and tuberculous an adjacent infective focus such as osteomyelitis. The patient complains of pain and later swelling due to Pathophysiology pus collection. Muscle spasm and wasting occur with Bacteriaareinitiallyfoundinthesynovialmembranebut limitation of movement and rigidity. Cytokine-mediated losis, pain may be mild and presentation delayed until inammationandariseinintra-articularpressurefollow thereisavisibleabscessorvertebralcollapsecausingpain the spread of bacteria. Erosion of the articular cartilage results from the In previously healthy children and adults, penicillin release of proteolytic enzymes from neutrophils within (Streptococcus cover) and ucloxacillin (Staphylococ- the inammatory exudate. A third-generation cephalosporin enzymes can result in chondrocyte and bone damage. If the hip The classical features of septic arthritis are a red, hot, is infected it should be held abducted and 30 exed. Overall the Drainage of pus and arthroscopic joint washout under knee is the most commonly affected joint, but hips are anaesthesia can be performed. There may be evidence of the r Surgical drainage may be indicated if the infection source of infection such as a urinary tract infection, skin does not resolve with appropriate antibiotics or if per- orrespiratoryinfection. Arthroscopic pro- immobilised in the position that maximises the intra- cedures allow visualisation of the interior of the joint, articular volume (e. Movement of the joint r Surgerymayalsoberequiredfortheremovalofforeign is very painful and often prevented by pain and muscle bodies or infected prosthetic material. Complications r If treatmentisdelayedthereisseverearticulardestruc- Prognosis tion, which may heal by brosis with permanent re- Outcome is related to immune status of the host, viru- striction of movement, deformity or bony union. In Staphylococcal infections r In children extensive destruction of the epiphysis may involvement of multiple joints carries a signicant mor- occur causing growth disturbance and deformity. Investigations r X-ray of the affected joint may show widening of joint Osteoarthritis spaceandsofttissueswellingbutareoflittlediagnostic value. Blood cultures should be taken and may be pos- of ageing, osteoarthritis is now considered to be a joint itive in a third of cases. The damage seen in osteoarthritis is initiated by trauma, which may be a single event or repeated microtrauma. There is resultant increased The rst radiological nding is narrowing of the joint proliferation and activity of chondrocytes under the in- space. In weight-bearing joints narrowing is maximal uence of monocyte-derived growth peptides. As the process of osteoarthritis has begun a number of factors cartilage is worn away, friction causes the exposed sub- are involved in the continued disease process: chondral bone to become sclerotic (subarticular bony r Mechanical forces can be causative, preventative or sclerosis). Later ndings include bony collapse and r Proteases that are involved with cartilage degradation. Itallowsalterationof tors occur in a genetically susceptible individual setting the muscle use, the contact areas and the blood dy- up a sustained inammatory response. It is of most use in younger r Twin studies demonstrate a signicantly higher con- patients with a good range of movement and rela- cordance in monozygotic compared with dizygotic tive preservation of the intra-articular cartilage. Hip and knee replace- difference diminishes after the menopause reinforcing ments are the most successful; however, there is a the possibility of a role for sex hormones. Sixty per mal range of movement is difcult to achieve and centofpatientswhodeveloprheumatoidarthritishave the prostheses are prone to failure. There are some genetically inherited disorders with early onset os- Pathophysiology r Tcells: Antibody-mediated activation of T cells trig- teoarthritis, which have a much worse prognosis. Cytokine cascades result in a com- Rheumatoid arthritis bination of angiogenesis and cellular inux, leading to transformation of the synovium with the ability to in- Denition vade cartilage and connective tissue. The transformed Rheumatoid arthritis is a chronic multisystem, inam- synovium may also activate osteoclast-mediated bone matory disorder with a characteristic symmetrical pol- erosion. Age r Rheumatoid factors are autoantibodies to the Fc por- Peak age of onset 30 55 years. It is r There is often associated muscle weakness and gen- thought that they provoke further inammation and eralised osteopenia due to immobility, which may be activate the complement system. Clinical features (extra-articular) r Long-standing inammation and effusion distends See Fig. The overall result is joint instability and continued use leads to joint deformity. Investigations r r Blood: Anaemia (usually normochromic normo- Afteravariableperiod,synovialinammationmaybe- come quiescent.

This is due to new insights into the pathophysiology of sinusitis buy discount cytotec on-line symptoms zinc poisoning, advances in rhinoscopy (nasal endoscopy) generic cytotec 200 mcg with mastercard symptoms 2 days before period, improved radiographic imaging cheap cytotec 100 mcg symptoms of pneumonia, and availability of antibiotics ( 1). Technical advances in endoscopic instrumentation have defined a new era in the office diagnosis and surgical management of sinusitis, permitting an unprecedented level of precision. Understanding the indications as well as the technical limitations of diagnostic and therapeutic rhinoscopy is now essential for practitioners who manage chronic sinusitis. Hirschman performed the first fiberoptic nasal examination using a modified cystoscope ( 2). Messerklinger of Graz began to use this technology for systematic nasal airway evaluation. He reported that primary inflammatory processes in the lateral nasal wall, particularly in the middle meatus, result in secondary disease in the maxillary and frontal sinuses ( 2). Messerklinger found that small anatomic variations or even minimal inflammatory activity in this area could result in significant disease of the adjacent sinuses as a result of impaired ventilation and drainage. With this observation, he used endoscopes to develop a surgical approach to relieve the obstruction in such a way that normal sinus physiology was preserved. Specifically, he demonstrated that even limited surgical procedures directed toward the osteomeatal complex and the anterior ethmoid air cells could relieve obstruction of drainage from the frontal and maxillary sinuses. This philosophy was markedly different from the ablative sinus procedures advocated in the past, such as Caldwell-Luc, in that cilia and sinus mucosal function were preserved. The ethmoid sinus develops into a labyrinth of 3 to 15 small air cells; however, the other sinuses exist as a single bony cavity on each side of the facial skeleton. The ethmoid and maxillary sinuses are present at birth and can be imaged in infancy. The frontal sinuses develop anatomically by 12 months and can be evaluated radiographically at 4 to 6 years. Sphenoid sinuses develop by the age of 3 but cannot be imaged until a child is 9 or 10 years of age. The point at which mucosal outpouching occurs persists as the sinus ostium, through which the sinus drains ( 3). Diagnostic rhinoscopy offers a wealth of information regarding the distribution of inflammatory foci within the sinonasal labyrinth and the associated anatomic variations that may impair physiologic sinus drainage. It is usually performed in an office setting with the aid of topical decongestants and topical anesthesia. It is essentially an extension of the physical examination that helps confirm the diagnosis, gain insight into the pathophysiologic factors at work, and guide medical or surgical therapy. The principles of diagnostic and therapeutic rhinoscopy are based on a firm understanding of the anatomy and physiology of the nose and sinuses (Fig. The lateral nasal walls are each flanked by three turbinate bones, designated the superior, middle, and inferior turbinates. The region under each turbinate is known respectively as the superior, middle, and inferior meatus. The frontal, maxillary, and anterior ethmoid sinuses drain on the lateral nasal wall in a region within the middle meatus, known as the osteomeatal complex. This is an anatomically narrow space where even minimal mucosal disease can result in impairment of drainage from any of these sinuses. The sphenoid sinus drains into a region known as the sphenoethmoidal recess, which lies at the junction of the sphenoid and ethmoid bones in the posterior superior nasal cavity. The nasolacrimal duct courses anteriorly to the maxillary sinus ostium and drains into the inferior meatus. The ethmoid bone is the most important component of the osteomeatal complex and lateral nasal wall. It is a T-shaped structure, of which the horizontal portion forms the cribriform plate of the skull base. The vertical part forms most of the lateral nasal wall and consists of the superior and middle turbinates, as well as the ethmoid sinus labyrinth. A collection of anterior ethmoid air cells forms a bulla, which is suspended from the remainder of the ethmoid bone, and hangs just superiorly to the opening of the infundibulum into the meatus. The drainage duct for the frontal sinus courses inferiorly such that its ostium lies anterior and medial to the anteriormost ethmoid air cell. Therefore, the main components of the osteomeatal complex are the maxillary sinus ostium/infundibulum, the anterior ethmoid cells/bulla, and the frontal recess. The infundibulum and frontal recess exist as narrow clefts; thus, it is possible that minimal inflammation of the adjacent ethmoidal mucosa can result in secondary obstruction of the maxillary and frontal sinuses. The paranasal sinuses are lined by pseudostratified-ciliated columnar epithelium, over which lays a thin blanket of mucus. The cilia beat in a predetermined direction such that the mucous layer is directed toward the natural ostium and into the appropriate meatus of the nasal airway. This is the process by which microbial organisms and debris are cleared from the sinuses ( 4). This principle of mucociliary flow is analogous to the mucociliary elevator described for the tracheobronchial tree. The maxillary ostium and infundibulum are located superior and medial to the sinus cavity itself. Therefore, mucociliary in the maxillary sinus must overcome the tendency for mucus to pool in dependent areas of the sinus. Antrostomies placed in dependent portions of the sinus are not effective because they interfere with normal sinus physiology. Pathophysiology of Chronic Sinusitis The American Academy of Otolaryngology Head and Neck Surgery Task Force on Rhinosinusitis defines sinusitis as a condition manifested by an inflammatory response involving the following: the mucous membranes (possibly including the neuroepithelium) of the nasal cavity and paranasal sinuses, fluids within these cavities, and/or underlying bone ( 5). Rhinosinusitis, rather than sinusitis, is the more appropriate term, because sinus inflammation is often preceded by rhinitis and rarely occurs without coexisting rhinitis. Primary inflammation of the nasal membranes, specifically in the region of the osteomeatal complex, results in impaired sinus drainage and bacterial superinfection, resulting in further inflammation ( Fig. In most patients, a variety of host and environmental factors serve to precipitate initial inflammatory changes. Host factors include systemic processes such as allergic and immunologic conditions, various genetic disorders (e. Host variations in sinonasal anatomy also occur, predisposing some to ostial obstruction with even minimal degrees of mucosal inflammation. Neoplasms of the nose and maxilla and nasal polyps also may cause anatomic obstruction. The pathophysiology of chronic sinusitis can be influenced by sinonasal anatomy, infection, and allergic/immunologic disorders. Rhinoscopy can provide significant insight into the relative importance of these elements in an individual patient. The infectious, allergic, and immunologic elements of chronic sinusitis are typically subjected to intense pharmacologic treatment.