By M. Gonzales. Bob Jones University.
Medical information has no place in such a report and must not be included without written consent from the individual concerned discount cytotec 100mcg line. Where an employee consults an airline health professional because of personal problems or symptoms of a clinical nature quality 200 mcg cytotec, such a consultation must conform to the normal rules of medical confidentiality cytotec 100mcg fast delivery. There are circumstances which may be extremely sensitive but which may have serious implications in terms of safety of passengers or other employees generic cytotec 100 mcg amex. Such situations require considerable judgement on the part of the physician who must weigh the rights of the individual against the safety and rights of others. Factual evidence based medical information has to be provided in a concise manner. This may involve the Medical Services liaising with, and working with, other airline departments to collate the required information to pass back to the enquirer or complainant by Customer Relations. Aircraft accident Flying is acknowledged as the safest means of travel, but accidents can and do happen albeit rarely. The airline Medical Services must therefore work with other airline departments to produce an appropriate response to such a crisis. The development of a Crisis Response has to be global and encompass scenarios at locations, which may be very different to the hub from which the airline operates. There are a number of international organisations that make such expertise available to airlines and these are to be recommended. Their assistance at such times to provide logistical and medical manpower is invaluable as no Medical Services will have the resource to do this independently. It is important that accurate medical records, where possible, are kept of all aircrew as these may be required for assistance in identification after an accident. The way the airline and the Medical Services respond to such a crisis can significantly influence the future of the airline. Therefore very close co-operation between local and international medical and emergency organisations is essential and regular training and exercises involving mass casualty situations are essential. In most situations the Medical Services will not be directly involved at the accident scene, but will be expected to care for survivors after discharge from hospital, and for friends and relatives of passengers who arrive at the location in the aftermath. The Medical Services must also be prepared to participate in aviation medical committees and conferences. This allows discussion and exchange of information in a forum of peers and encourages best practice. Other international bodies such as the World Health Organisation are now also keenly interested in aviation and travel medical matters and seek the experience and knowledge of the airline Medical Services. Some also provide an employee dental health service with an extension to dependants or families as well. The level of primary health care provision is influenced by the local facilities and culture. While there is also a fairly large body of literature on in-flight incidents, those incidents are considered as exceptions and should be addressed separately. This approach does not suggest that those incidents should be neglected; however, each incident is different and should be investigated appropriately. When a common problem is identified in a particular type of aircraft, the same rationale applies. It is useful to remember that three different groups share the aircraft environment: the pilots who are healthy and perform sedentary but safety sensitive work, the cabin crew who are healthy and perform fairly intensive physical activities, and the passengers who are sedentary but who can be in any state of health or ill health. Contrary to popular belief, the aircraft cabin is not pressurised to ground level equivalent. For mechanical and economic reasons, it is practically impossible to maintain ground equivalent pressure at high cruising altitudes. The pressurisation schedule was developed to vary between ground level pressure and a maximum equivalent cabin altitude of 2400 meters (8000 feet) depending on the aircraft altitude. Currently most aircraft are pressurised by bleeding air from its engines before the combustion chamber. The pressurisation system draws air from different stages of the compressor, before it enters the combustion chamber, and redirects it to the aircraft cabin. With the assistance of an outflow valve, the pressure is raised and maintained to a predetermined desired level. However, it is possible to have a mechanical malfunction which might allow contaminants into the cabin. This would constitute an incident, as described above, and the mechanical malfunction should be rectified immediately. Returning to the pressurisation schedule, it is worth noting that this approach was accepted many decades ago when all the flights were relatively short, the aircrew were all relatively young and virtually no sick passengers travelled. In other words, the rationale was based on an average healthy young person, whether this person was a passenger or an aircrew member. Demographic and flight profiles have changed significantly over the years, and the current question is whether the original rationale is still valid. The selection of 2400 meters (8000 feet) was based on the oxyhemoglobin dissociation curve which shows that up to that level the hemoglobin oxygen saturation normally remains above ninety percent in the average healthy individual. The reduced oxygen partial pressure creates a mild hypoxia that is well tolerated by healthy individuals. As several body cavities contain gas, these cavities will be affected; the gas expansion will mainly affect the middle ear, the sinuses and the bowels. It also explains why a passenger with an active pneumothorax could not be accepted for air travel in a commercial aircraft. The reduced total pressure could also have an impact on evolved gas, hence the restrictions for flying after diving. There are two main types of ventilation system: one provides one hundred percent fresh air at all times. As the air coming out of the engine is extremely hot, it is passed through an air conditioning unit before it enters the cabin. This air then passes through the outflow valve and is replaced by fresh air coming from outside and the air conditioning unit. The other type of ventilation system provides a ratio of fresh air and recirculated air. In this case, the air leaving the air conditioning unit is directed to a mixing unit where it meets air coming from the cabin. Before entering the mixing unit, the air from the cabin passes through a particulate filter. A proportion of it is exhausted through the outflow valve and the rest passes back to the mixing unit where the cycle continues. In the current commercial fleet, the ratio of fresh air to recirculated air is usually about 50:50. While there has been and still are some questions about recirculated air, it is well accepted by ventilation experts that one hundred per cent fresh air at all times is not necessary. Indeed, nearly all commercial buildings in the last four decades have been supplied with recirculated air. In other words, if the ventilation system is adequate, recirculated air is totally acceptable. In fact, from a comfort standpoint, one clear advantage of air recirculation in aircraft is the somewhat higher degree of relative humidity. However, to summarise the current body of knowledge, aircraft cabin air quality during normal operation is perfectly acceptable and often better than other well accepted indoor environments. The transmission of diseases by biological contaminants has attracted much media attention. The research to date does not report a significant risk when the ventilation system functions normally. Even in aircraft with air recirculation, the biological air quality remains perfectly acceptable. As in any other public transport or public places, the proximity to a contagious person can be a factor in transmission; however, the aircraft ventilation system has not been implicated as a factor in disease transmission. In most modern aircraft the air flow is mainly laminar, from top to bottom and not from front to back or back to front. Therefore, in a suspected case of disease transmission on an aircraft, the Public Health authorities do not necessarily have to contact all the passengers, as only those in the immediate vicinity may be at risk (Link: www. Furthermore, what is a comfortable range for a sedentary person (passenger) may be too warm for a physically active one (cabin crew).
Death rates from coronary heart disease fell steadily across the birth weight distribution such that rates at the higher end of the distribution were roughly half those at the lower end  cheap 100mcg cytotec with visa. Findings from the Swedish cohort study buy cheap cytotec 200mcg on line, which followed up 14 purchase 100 mcg cytotec otc,611 babies cytotec 100 mcg without prescription, also supported the inverse association between cardiovascular disease and birth weight . The associations of birth weight with these diseases were independent of lifestyle risk factors, including smoking and alcohol intake, and of socio-economic status. The developmental origins model of disease pathogenesis is supported by biological evidence from animal experiments. These have shown that alteration of maternal diet during pregnancy can modify offspring physiological processes, and that these modiﬁcations are lasting rather than transient . Such a phenomenon is an example of phenotypic plasticity where a genotype can give rise to different physiological or morphological states depending on the prevailing environmental conditions during development. Studies in experimental animals have made it clear that the long-term effects of early life nutrition act through developmental changes to organs and tissues such as the pancreas, liver, kidneys, skeletal muscle and adipose tissue. Newborn size (equivalent to birth weight in human studies) is frequently used as an indicator of the intra-uterine experience, because it is easy to measure, but can only be a crude proxy of these changes at tissue level. Animal experiments have shown that overfeeding mothers with high fat or high energy diets, leading to maternal diabetes and obesity, will increase insulin resistance, diabetes and cardiovascular changes in their offspring [7,8]. Recently, there has been accumulating evidence that paternal diet, body composition and health can also affect the health of the offspring . Low birth weight, an indicator of poor nutrition in utero, is associated with higher infant mortality, poorer educational outcomes in childhood and poorer long term health . Social, psychological and occupational exposures during infancy, childhood and adult life will modify risk of ill health and disease. Maternal Nutrition Observational evidence of a link between early life and later disease has led to an interest in maternal inﬂuences on the development of the fetus. A girl or woman’s nutritional status before and during pregnancy inﬂuences outcomes both for her pregnancy and for the developing fetus . It also has a strong inﬂuence on risk of pre-term delivery and impaired growth and development in utero and after birth. Recent studies have shown that prenatal exposure to gestational diabetes could lead to epigenetic alterations that increase the risk of type 2 diabetes later in life. In India, for example, ﬁndings of the Pune maternal nutrition study suggest that micronutrient deﬁciencies (such as vitamin B12) can also lead to low birth weight and an increased risk of later diabetes . Healthcare 2017, 5, 14 4 of 12 Maternal undernutrition is usually caused by food shortage or economic hardship which leads to food insecurity and result in inadequate intake of nutrients. Exposure to undernutrition in utero is associated with low birth weight and stunting in childhood, which are in turn associated with shorter adult height and reduced economic productivity [14,15]. Undernutrition in utero also has adverse effects on cognitive development and so is also associated with lower levels of educational attainment. Overnutrition occurs when the energy consumed outstrips energy expended and usually leads to overweight and obesity. For women during pregnancy, overnutrition leads to greater risk of gestational diabetes and hypertensive disorders of pregnancy. For the fetus, maternal gestational diabetes leads to an increased risk of macrosomia, high blood glucose and insulin and these are associated with neonatal hypoglycemia, congenital anomalies, preterm birth, stillbirth and neonatal death. There is also evidence that obese women accumulate more metabolites in their ovarian follicles and this has been associated with increased risk of cardiovascular disease and obesity in later life in their offspring . Deﬁciencies of speciﬁc vitamin and minerals can be caused by insufﬁcient intake due to poor or inadequate diet, or by an increased demand for nutrients, for example because of rapid growth or menstrual bleeding. Micronutrient deﬁciencies can occur even when there is overnutrition, and lifestyle factors such as alcohol intake and smoking can affect their absorption. Deﬁciencies of vitamins and minerals in mothers will affect their offspring as many micronutrients pass across the placenta from mother to fetus. Similar results have emerged from the Southampton Women’s Survey (at birth and six years) , with recent ﬁndings from the Australian Raine cohort demonstrating relationships persisting to 20 years old , around the age of peak bone mass . Many interventions to improve maternal nutrition begin only once a women knows she is pregnant and seeks ante-natal care, thus missing the majority of the ﬁrst trimester, when placentation and organogenesis occur. Studies in Southampton have shown that women of childbearing age, who are disadvantaged by having low levels of educational attainment, have diets of poor quality . Maternal diets of poor quality have been associated with less optimal patterns of skeletal development, adiposity and cognitive development in their children . Evidence shows that many women (especially young women) do not plan or prepare for pregnancy and unplanned pregnancies are still common . The health behaviors of women during pregnancy are strongly inﬂuenced by their social circumstances and studies have shown that only a small proportion of women planning a pregnancy follow the recommendations for a healthy pregnancy such as increased fruit and vegetable consumption, folic acid intake, smoking and alcohol cessation . Genetic polymorphisms could potentially explain both poor fetal development and later risk of disease. A study by the Wellcome Trust Care Control Consortium identiﬁed several new genetic loci and genes that inﬂuence an individual’s susceptibility to a range of conditions including coronary heart disease and type 1 and 2 diabetes . More importantly, Healthcare 2017, 5, 14 5 of 12 even combining the effects of known genetic loci associated with particular diseases does not account for a substantial levels of risk at the population level . Epigenetic Mechanisms The emergence of epigenetics is allowing exploration of the molecular mechanisms that link early exposures to later disease. Epigenetic mechanisms underlie the developmental plasticity, that is fundamental to the link between fetal development and risk of later disease . There is evidence that maternal factors can modulate gene expression in their offspring thus inﬂuencing [8,28]. For example maternal malnutrition had led to altered gene methylation and increased risk of offspring metabolic syndrome in adult life . In addition, recent studies have shown that prenatal exposure to gestational diabetes could lead to epigenetic alterations that increase the risk of type 2 diabetes later in life . Inﬂuences of early development on satiety and food preferences suggest that, once set points are established in early life, it may be difﬁcult or even impossible to reverse them. This might explain why lifestyle interventions in adult can have limited effects and are difﬁcult to sustain . Behavioural Mechanisms The health behaviors that people adopt will modify their risk of disease across the lifecourse. Childhood and adolescence are stages of the lifecourse when health behaviors become established [32,33]. These risk factors are responsible for considerable burden of disease on a global level . They can have direct effects on health or can act by inﬂuencing the development of high blood pressure and elevated blood glucose and cholesterol levels, which will then raise the risk of chronic diseases such as cardiovascular disease and diabetes. There is also evidence that infants who are breastfed have reduced risk of obesity and diabetes in adulthood. Poor diet is common during childhood including iron and vitamin deﬁciencies during infancy and consumption of inappropriate energy-dense foods that increase the risk of obesity during childhood [36,37]. The way in which parents feed their children and control what they eat has a strong inﬂuence on children’s early eating patterns and risk of childhood obesity, and physical activity and sedentary behaviors in parents are often mirrored in the behaviors of their children . Adolescence is a period of physical and psychological change and a phase when young people develop independence. New behaviors developed during adolescence can have positive or negative consequences for health . Behaviors like smoking and alcohol use developed during adolescence will track into adult life, highlighting the importance of intervening during this period to prevent later disease. Pregnancy during adolescence is an important issue in both developed country settings and in the developing world. Pregnancy at a young age, and early marriage, not only affect the health Healthcare 2017, 5, 14 6 of 12 and human rights of girls but also disrupts their education and development of skills and social networks, all of these undermining their future health and wellbeing, along with the health of their children . Adolescent pregnancy is associated with higher risk of adverse outcomes for both mother and child than pregnancies occurring when women are aged 20–30 years; stillbirths, neonatal deaths, preterm births, low birth weight and postnatal depression are all more common in adolescent pregnancies [40,41]. Pregnancies occurring at a younger age are often unplanned and so risk factors for adverse pregnancy outcome, such as low folic acid intake and alcohol use, are more likely. Interventions The observational and mechanistic evidence demonstrating the inﬂuence of maternal nutrition on the future health of their offspring, has led to a strong focus on the improvement of the health and nutrition of women of childbearing age.
These diseases are often preventable order cytotec 100 mcg with visa, and of chronic disease through the increase in health costs as- frequently manageable through early detection cheap 100mcg cytotec with amex, improved sociated with greater demand for and use of diet buy 200 mcg cytotec with amex, exercise generic 200 mcg cytotec otc, and treatment therapy. This includes the “extra” cost t Chronic diseases are responsible for seven out of every of health insurance ($8 billion), sick leave ($2. The Global Burden of t Given current trends, one in three children born in 2000 15 Diabetic Foot Disease. Historical Overview of National Many chronic diseases could be prevented, delayed, or Health Expenditures. In some cases, inclusions are found exclusively in the central nervous system, whereas in others they may be diffusely disseminated in multiple tissues. This monoclonal antibody is going through rigorous validation testing and will provide more speciﬁcity and sensitivity than currently available routine histological diagnostics. Thus, there is conservation value in developing better diagnostic tools for screening snakes intended for release as part of reintroduction programs. It is not known what percentage of in- fected snakes will develop clinical signs of disease in Clinical Signs relation to those that will appear unaffected. It is possible that latent infections can persist for long From the late 1970s and extending into the mid- periods of time. Although several viruses, including ret- 4 early 1990s, more cases were diagnosed in boa con- roviruses, have been identiﬁed and isolated from strictors in relation to Burmese and other pythons. Although some snakes die within several mining the composition and factors affecting the weeks of ﬁrst manifesting illness, others may survive formation of this protein. Eventually the sequencing of lymphoproliferative disorders, and round cell tu- this protein will allow the creation of peptides that mors. Regurgitation was not a disease sign identiﬁed can be used in the development of better immuno- in Burmese pythons. Photomicrograph of amphophilic intracytoplasmic inclusions in neurons of the brain. If identiﬁed, encephalitis is generally more se- pared with those of chronically affected snakes. Photomicrograph of eosinophilic tonsil from a necropsied snake showing numerous eosinophilic intracytoplasmic inclusions (arrows) in neurons and glial cells in the intracytoplasmic inclusions (arrows) within submucosal lymphoid brain. Photomicrograph of the liver show- ing hepatocytes containing eosinophilic intracytoplasmic inclusions (arrows). Transmission electron photomicrograph derived clusters of small round subunits (Fig 8). During the initial stage of inclusion formation, protein deposited on the periphery of individual inclusions subunits from polyribosomes start accumulating in the adjacent cytoplasm. Deposited protein subunits have a showing acinar cells containing eosinophilic intracytoplasmic inclu- virus-like appearance. Esophageal tonsils (ar- rows) are raised ovoid structures with a central cleft and covered by a mucous epithelium. Blood smears from sus- ageal tonsils are easily biopsied, ﬁxed, and routinely pect cases can be examined for presence of inclu- processed for light microscopy. For a more rapid diagnosis, cytological also have inclusions in circulating white blood cells. Hematoxylin and eosin–staining recommendations for impression smears and blood ﬁlms 1. Peripheral blood ﬁlm with an erythrocyte (arrow) and lymphocyte (arrowhead) containing eosino- Figure 15. Based on size (80-110 nm) and morphology, the virus resem- Cause and Transmission bled C-type retroviruses. Using transmission electron microscopy, 4 observed in transmission electron microscopy of tis- viral morphogenesis in cell culture was described. Huder and coworkers isolated and sequenced endogenous retroviruses from Bur- Figure 16. Extracellular retroviral phocyte containing an eosinophilic-staining inclusion (arrow). Transmission studies have been performed in Burmese pythons and boa constrictors by inocu- lating young Burmese pythons with the supernatant of primary cultured kidney cells taken from an in- fected boa constrictor, resulting in the development of clinical signs and microscopic lesions associated Figure 17. A single egg can be seen within the were administered ﬁltered liver homogenate ob- mite. First and foremost, a solid preventative is impossible to implicate a retrovirus as the under- medicine program should be established. Although lying etiology of inclusion formation in the inocu- no such program is 100% effective, the main objec- lated snakes. The protein and the isolated important component to a preventative medicine viruses must be sequenced to gain a better under- program. Thus, preventing mites from entering a are sold over the internet and purchased at reptile collection and eliminating established infestations expositions, new snake “breeders” establish them- are essential components of a preventive medicine selves, seemingly, on a daily basis. It is also possible the causative agent is authors’ experience, the vast majority of snakes that passed through vertical transmission from mother to die in a collection never have a thorough necropsy young in both egg-laying and live-bearing snakes. Inclusion Body Disease 223 Quarantining new animals is essential for risk re- mining exposure to a speciﬁc pathogen. Second, there is the development of vaccines Ideally, quarantined animals should be housed in a that can protect animals from infection and disease. Vac- when all new animals enter the facility on the same cine research and development are extremely costly, day and leave on the same day, 90 days later. Biopsy sam- samples can be obtained from a snake’s tonsils, liver, ples and blood smears can be obtained from ex- and kidneys. If it is ﬁnan- practical in all situations, but antemortem diagnostic cially impossible to obtain samples from all animals testing improves the owner’s ability to identify an within a collection, then select a subset for evalua- infected animal. House- anorexia and weight loss should never be added to hold bleach is the best overall disinfectant and must an established collection. Although it with a good appetite and excellent body condition will not kill every pathogen known to snakes and should be added after the quarantine period is over. Once mites infest a large snake collection, they may A question that has been asked many times is be impossible to totally eliminate. We have very little information to determine whether ver- Managing a Collection tical transmission of this disease is possible. Typically, where there is one case not forwarded to the authors for substantiation. Snake owners in denial often decide that the agent can be transmitted to offspring; there- to conduct business as usual. What has made a difference in controlling and Present and Future Research Needs managing infectious disease outbreaks in domestic animals is 2-fold. Once the virus is puriﬁed and sequenced, speciﬁc primers against the viruses will be made and used in a polymerase chain reaction test. Western blot is another practical test that can be developed for making an antemortem diagnosis. Using Western blot technology, inclusion protein in small amounts obtained from biopsied tissue or isolated peripheral white blood cells from a blood sample can be tested. Studies to evaluate the sensitivity and speciﬁcity of the diagnostic testing methods described above are planned. J Zoo Wildl Med 25:511-524, 1994 pet trade, the need for such molecular-based tests is 3. Am J Vet Res 62:217-224, 2001 been inappropriate for the studies needed to have a 5. Vanncraeynest D, Pasmans F, Martel A, et al: Inclu- around the world is probably responsible for its sion body disease in snakes: a review and description spread. Jacobson E, Heard D, Isaza R: Future directions in reptile bling inclusion body disease of boid snakes. The aim of the leaflet is to provide you with detailed information about the condition. To view the online version of this leaflet, type the text below into your web browser: http://www. But most urologists suspect that it is under-reported, and may affect as many as 1 in 10 men (10%). This begins as a localised inflammation, which may then mature into a hardened scar. The scar is inelastic (stiff) and stops the penis stretching with erections, leading to the development of a curvature on erection.
Three passes at grade 6 at Standard level cheap 100mcg cytotec with amex, including Mathematcs purchase cytotec 200mcg mastercard, Biology or English if not ofered at Higher level order cytotec 200 mcg amex. Not scored but health-related work experience required for applicant to be Personal statement considered for interview order cytotec 200 mcg overnight delivery. Applicants should have gained work or shadowing experience in a caring or health environment. Widening partcipaton applicants who have engaged with outreach projects at St Andrews, will be considered for interview if academic requirements are met. In additon, similar widening partcipaton Widening partcipaton candidates who do not meet the academic requirements may be considered for the Pre Med programme. Higher level: Combined score of 18, with at least two subjects at grade 6 or Internatonal Baccalaureate above including Biology and/or Chemistry. Any experience of providing care or help for other people which leads to an understanding of the realites of working in a caring profession. Candidates should be able to refect on how their work experience helped them to develop some of the attudes and Work experience behaviours essental to being a doctor. The medical schools is interested in what the applicant has learned about him/herself, other people and how care is delivered and received. Candidates are asked to provide further details of their work experience and/or confrmaton leters or references for verifcaton. Applicants are eligible for the Adjusted Criteria Scheme if applying from a school or college ranked in the botom 20% natonally in relaton to the average point score per full tme equivalent A Level student. In additon, the medical school runs a full of range of actvites including taster days, summer schools and work experience scheme for those from widening partcipaton backgrounds. Three Higher level subjects to add up to 19 points, including Internatonal Baccalaureate Biology and Chemistry with one at grade 7 and the other at grade 6. The Personal statement criteria assessed are: work experience, motvaton, teamwork, leadership etc. Any experience that involves working with other people, building relevant skills or gaining Work experience insight into healthcare professions. A sample of students are asked to provide further details of their work experience (approximately one third of candidates) and/or confrmaton leters or references for verifcaton. Widening partcipaton criteria are identfed and considered during assessment of the applicaton and selecton for interview. Many universites accept a degree in any subject, but some require the previous degree to be science- or health-related. It is a four- year accelerated degree in most cases, but in some universites it is a fve-year course. There is a preference for Work experience voluntary placements involving contact with patents. Those who do not hold these grades should be aware that their applicaton will be in direct competton with those who do. Academically compettve applicants will generally have at least 36 points with 6,6,6 at Higher level including Chemistry. Those who do not hold these grades should be aware that their applicaton will be in direct competton Internatonal Baccalaureate with those who do. A minimum of Chemistry must be taken at Higher level at 6, plus either two of the following at Higher or Standard level: Physics, Biology, Mathematcs. Personal statement Personal statement is reviewed prior to interview but not scored. Degree qualifcatons Applicants must have studied in one of the four listed insttutons and achieved at least a 2. Non-academic criteria assessed: medical motvaton and awareness of the career; sense of responsibility; evidence of a balanced approach to Personal statement life; evidence of self-directed learning and extracurricular actvites; caring ethos and a sense of social awareness; referee’s report. The university recognises that opportunites for work experience will vary according to individual circumstances. Applicants are to showcase Work experience an appreciaton of the length of the training programme and the career structure. The Feeder Stream accelerated entry programmes have been developed as part of Cardif University’s commitment to widening access to medicine, enabling a small number of selected students within specifc programmes to join the feeder stream, taking on additonal modules and graduatng from these programmes with a frst or 2:1 honours degree, to enter the Widening partcipaton second year of the fve-year A100 medical programme. Applicants applying from these routes will need to have fulflled all the minimum requirements as outlined for graduate entry. Evidence of motvaton to study medicine, understanding of medicine as a Personal statement career, community actvites, leadership qualites, ability to work in a team, general interests. Widening partcipaton candidates are fagged at applicaton stage and this may be a factor at the short-listng stage. All candidates (not just widening Widening partcipaton partcipaton) can check eligibility by the relevant admissions email address which is published on the website. This rule is also applied to all similar allied health-related topics (nutriton, physiotherapy, occupatonal health, dietetcs, speech and language therapy). Applicants will also have to take Chemistry to A level if they cannot demonstrate that 50% of their course was chemistry-based. Currently scored against non-academic criteria of healthcare awareness Personal statement and insight, caring contributon to the local community and writen communicaton skills. No specifc work experience is required though what each applicant has done in order to address non-academic criteria is taken into consideraton. Work experience Applicants who are invited to interview are asked to complete a questonnaire where they give details of those whom they claim to have worked with. Widening partcipaton can be taken into account at any stage of the process but most usually at the frst and second stage. There is no formal Widening partcipaton process and usually graduates with widening partcipaton backgrounds are relied on for making use of the school’s criteria for those ofering non- traditonal qualifcatons. Emphasis on applicants being able to show a commitment to caring, which can be accomplished in a number of ways other than in a hospital or Work experience general practce setng, e. May be voluntary, employed, part- Work experience tme or full-tme, involving people who are ill, disabled or disadvantaged. Re-applicaton is considered, subject to conditon applicant has not been interviewed twice previously. Previous study of medicine applicants also Widening partcipaton considered, but required to demonstrate how the factors responsible for earlier failure have been addressed and remedied. Internatonal Baccalaureate At least two sciences at Higher level including Chemistry. No specifc requirement, although some work experience (whether paid or Work experience voluntary) in the health or related sectors is valuable. Experience encouraged in health- or care-related Work experience environments and volunteering. Informaton to be updated, please visit medical school website for up to Internatonal Baccalaureate date informaton. Personal statement is considered only if the applicant is invited to atend a Personal statement selecton day. Selectors will look at the personal statement for evidence of non-academic criteria. However, applicants are expected to demonstrate what they have learned Work experience from their experiences of interactng with people in health or social care setngs. Applicants will not be considered if their frst degree does not meet this requirement, even if they subsequently gain further degrees (bachelor’s, master’s or PhD). Applicants who are on, or have been on, a medical degree course will not be considered, including any intercalatng degree. Informaton to be updated, please visit medical school website for up to Internatonal Baccalaureate date informaton. Personal statement is considered only if the applicant is invited to atend a Personal statement selecton day. Selectors will look at the personal statement for evidence of non-academic criteria. Applicants should have had work experience in a health situaton: with people who may be ill, disabled, elderly or by shadowing a doctor at work. The volume of work experience is not credited and applicants are discouraged from seeking to acquire experience in excess of two weeks. Work experience Work experience in resource-poor setngs, where candidates may be exposed to risk or take up scarce staf tme, is not encouraged Medically related work experience is not ‘scored’ but instead forms part of the discussions at interview.
The American leishmaniases: some observations on their ecology and epidemi- ology order 200mcg cytotec with visa. Las leishmanias y la leishmaniasis del Nuevo Mundo trusted cytotec 100mcg, con particular referencia al Brasil cheap cytotec 100 mcg visa. Cutaneous leishmani- asis: Review of 59 cases seen at the National Institutes of Health discount cytotec 200mcg without prescription. Molecular evidence for the importa- tion of Old World Leishmania into the Americas. Leishmaniose tegumentar americana na região nordeste do estado de São Paulo-Brasil. Epidemiological survey on canine population with the use of immunoleish skin test in endemic areas of human American cutaneous leishmaniasis in the state of Rio de Janeiro, Brazil. Cutaneous leishmaniasis in primary school children in the south-eastern Iranian city of Bam, 1994–95. Modificação na epidemiologia da leishmaniose tegumentar no Vale do Ribeira, Estado de São Paulo, Brasil. Confirmation of clinical differentiation of three Leishmania strains by computerized image analyser system. The earliest reports of the disease—from Peru in 1986—referred to cyanobacteria-like bodies found in human feces. Apparently, similar organisms had been observed in New Guinea in 1977 and had been confused with Isospora (Sterling and Ortega, 1999). It is not known whether these forms must leave the host cell and invade new cells to begin the next phase of sexual mul- tiplication, which concludes with the formation of oocysts. The oocysts, which must sporulate in the external environment to become infective, are passed from the body in feces. The mature oocyst contains two sporocysts, each of which contains two sporozoites (Ortega et al. Occurrence in Man: The distribution of Cyclospora is similar to that of Cryptosporidium, although it is only a third to a half as prevalent (various surveys have found prevalence rates of 1% to 20%). It infects mainly children between 2 and 4 years of age, and the prevalence diminishes rapidly with age. Although the infection does affect travelers and immunocompromised patients, it does not appear to be predominantly associated with these groups. Occurrence in Animals: Animals do not appear to be susceptible to cyclosporia- sis. The Disease in Man: The disease in humans is characterized by watery diarrhea, which begins abruptly after an incubation period of 12 hours to 11 days. In immuno- competent individuals, it lasts from six to eight weeks, while in immunodeficient patients it may persist for up to three months (Looney, 1998). In a study in Egypt, the diarrhea lasted 28±8 days in children and 37±12 days in adults, with more than 5 evacuations per day (Nassef et al. Of 63 infected individuals in Peru, 68% were asymptomatic and the highest prevalence occurred among children aged 2 to 4 years. Examinations have shown malabsorption, atrophy of villi, and crypt hyperplasia (Connor, 1997). In Haiti, 15%–20% of the population examined were found to be carriers of Cyclospora oocysts, but few had diarrhea (Eberhard et al. The Disease in Animals: Cyclospora does not appear to infect animals (see Occurrence in Animals). Source of Infection and Mode of Transmission: Cyclosporiasis is acquired through ingestion of raw fruits and vegetables and contaminated water. A later study, in which 5,552 stool samples were collected from workers on raspberry farms in Guatemala, found infection rates of between 2. A study of the water in domestic containers in Egypt showed that 56% was contaminated with Giardia, 50% with Cryptosporidium, 12% with Blastocystis,9% with Cyclospora, and 3% with microsporidia (Khalifa et al. Using microscopy and molecular biology tech- niques, Sturbaum (1998) identified Cyclospora oocysts in wastewater. Diagnosis: Cyclospora infection is suggested by the patient’s symptoms and by epidemiological circumstances, especially in travelers who have visited endemic areas. The diagnosis is confirmed by detection of the double-walled oocysts meas- uring 8–10 microns in diameter in stool samples. The oocysts are concentrated by formol-ether sedimentation and flotation in Sheather’s sucrose solution. They can be detected by staining, autofluorescence under ultraviolet light, phase contrast microscopy, or polymerase chain reaction (Ortega et al. The stains used most frequently (to make it easier to visualize the organisms and to differentiate them from yeasts) are trichrome stains, Ziehl-Neelsen, Giemsa, safranin with methylene blue, calcofluor white, and auramine phenol. Safranin has been found to be the most effective and appropriate stain for use in diagnostic laboratories (Negm, 1998). Control: Cyclosporiasis can be prevented by applying the classic measures for control of parasitoses transmitted via the fecal-oral route: washing foods that are eaten raw, boiling suspicious water, and washing hands before eating. Treatment of water contaminated with Giardia, Cryptosporidium, Blastocystis, Cyclospora,or microsporidia with chlorine at 4 or 8 parts per million (ppm) or with ozone at 1 ppm showed that ozone was more effective in destroying the parasites, but that it did not totally inactivate Cyclospora or Blastocystis (Khalifa et al. Cyclospora cayetanensis infections in Haiti: A common occurrence in the absence of watery diarrhea. Attempts to establish experimental Cyclospora cayetanensis infection in laboratory animals. Ciclosporiasis: estudio clinicoepidemiológico en viajeros con Cyclospora cayetanensis importada. Epidemiology and treatment of Cyclospora cayetanensis infection in Peruvian children. Isolation of Cryptosporidium parvum and Cyclospora cayetanensis from vegetables collected in markets of an endemic region in Peru. Etiology: The taxonomy of the species of the genus Giardia is still controversial. Although in the past many species were described and named according to the host in which they were found—for example, G. Although Lamblia was the original name given to the genus by Lambl when he first described it in 1859, Stiles changed it to Giardia in 1915. The trophozoites are pyri- form and measure 10 µm to 19 µm long, 5 µm to 12 µm wide, and 2 µm to 4 µm thick. Those forms live in the anterior portion of the host’s small intestine, particularly in the duodenum, where they multiply by binary fission. Many of the trophozoites are carried to the ileum, where they secrete a resistant wall and become ovoid cysts measuring 7 µm to 10 µm by 8 µm to 13 µm. They can survive for more than two months in water at 8°C and around one month at 21°C; however, they are sensitive to desiccation, freezing, and sunlight. Solutions of quaternary ammonium recommended for disinfecting the environment will kill them in one minute at 20°C, but normal concentrations of chlorine in drinking water do not affect them. Once ingested, the parasite excysts in the duodenum, divides, and begins to multiply normally. Its prevalence generally ranges from 2% to 4% in industrialized countries, but it may be over 15% among children in developing countries. In the first epidemic, together with Cryptosporidium, it caused 40% of the cases, while in the second epidemic, together with Shigella sonnei, it was responsible for 9% of the cases (Kramer et al. In previously uninfected populations, morbidity rates may be as high as 20% or more of the total population (Knight, 1980). Outbreaks are relatively common in institutions for children, such as orphan- ages and daycare centers. Occurrence in Animals: The infection has been confirmed in a wide variety of domestic and wild mammal species. Surveys from all over the world have found prevalences of 20% to 35% in young dogs; 10% to 15% in young cats; 5% to 90% in calves; 6% to 80% in lambs; 17% to 32% in foals; and 7% to 44% in young pigs (Xiao, 1994). In a study in which feces of 494 dogs were examined for parasites, the infection was detected in 3. High rates of infec- tion have also been found in rats and other rodents, both synanthropic and wild, but whether the agent was G. The Disease in Man: The majority of infections are subclinical (Flanagan, 1992; Farthing, 1996). In symptomatic individuals, the incubation period is generally 3–25 days (Benenson, 1997).
In such a case purchase cytotec 100mcg mastercard, the interpreter simply has to make the conversion from one linguistic system into the other; the layers of meaning will automatically be understood generic cytotec 200mcg on line. As the dissimilarities between providers’ and patients’ assumptions increase generic cytotec 100 mcg with visa, however order 200 mcg cytotec mastercard, literal interpretations become inadequate, even dangerous. In such cases, to convey the intent of the message accurately and completely, the interpreter may have to articulate the hidden assumptions or unstated propositions contained within the discourse. Here the role of the interpreter is to assist in uncovering these hidden assumptions and, in doing so, to empower both patient and provider with a broader understanding of each other’s culture. Another major cultural linguistic problem occurs when a speaker uses ‘untranslatable’ words. For example, the concept of bacteria, a living physical organism that is not visible to the naked eye, is a concept that has no equivalent in many rural, non-literate societies. To get the concept across, the interpreter may have to work with the provider to find ways to transmit the essential information underlying this concept. Interpreters, therefore, have the task of identifying those occasions when unshared cultural assumptions create barriers to understanding or message equivalence. Their role in such situations is not to ‘give the answer’ but rather to help both provider and patient to investigate the intercultural interface that may be creating the communication problem. Cultural patterns, after all, are generalized abstractions that do not define the individual nor predict what an individual believes or does. They are simply hypotheses that may be more likely to occur in a member of that culture than in someone who is not a member (Avery, 1992). Ethical Behavior The role of interpreter, on the surface, appears to be straightforward and uncomplicated. The interpreter is present to convert a message uttered in one language into another. Professional interpreters, however, understand the profound complexities of what appears to be a simple task. In fact, even in the simplest of encounters, the interpreter may need to recognize and address a series of dilemmas. In face-to-face, interpreter-assisted, medical encounters, the very presence of the interpreter changes the power dynamic of the original dyadic relationship between patient and provider. In a very significant way, the interpreter holds tremendous power, often being the only one present in the encounter who understands both languages involved. In addition, the interpreter enters the interaction as an independent entity with individual beliefs and feelings. Both the patient and the provider have to be able to trust that the interpreter will not abuse this power. They need to trust that the interpreter will transmit faithfully what it is they have to convey to each other and not the interpreter’s own thoughts. They also need to trust that the interpreter will uphold the private and confidential nature of the clinician-patient relationship. A code of ethics provides guidelines and standards to follow, creating consistency and lessening arbitrariness in the choices interpreters make in solving the dilemmas they face (Gonzalez et. Too often educational and training programs are developed without clearly articulated connections to performance expectations in the field. These standards of practice were developed by practitioners with years of experience in the field who are also responsible for on-the-job training and supervision. As such, they reflect a comprehensive view of the basic skills and knowledge required on the job. Used as guideposts, these standards can serve as the foundation of course and/or training objectives. Standards of practice can serve as pre-selected criteria against which the performance of students, trainees, or practitioners in the field can be evaluated. Both students and instructors can use the indicators as a formative evaluation tool in the academic or training setting to provide ongoing feedback on the skills students need to work on, the areas in which they have achieved mastery, and the tasks they still need to learn or improve. As an outcome measure, these standards can be used to determine whether or not a student has achieved mastery of the required skills. At the workplace, they can be used both to assess the level of competency at the point of entry and as a supervisory tool to provide ongoing feedback. Interpreters can also use these standards to continue to monitor and assess their own performance individually. These standards offer health care providers with a comprehensive overview of what to expect from interpreters. Since these standards represent a comprehensive articulation of the basic skills and knowledge a competent interpreter must master, they can also be used as a basis for a performance-based portion of a certification examination. For example, the certification candidate could be placed in a role play designed to include both a routine interpreting interaction and an unanticipated problem. The role play would require the interpreter to demonstrate in an integrated way the application of various skills to address the situation in an appropriate, professional manner. The members of the Subcommittee on Standards of Practice recognize that this document represents a first step in what needs to be an ongoing, developmental process. It is expected that by simultaneously setting clear, high standards of performance and creating rigorous training and academic programs, a marked increase in the quality of interpreting in the health care arena will follow. This increase in quality will in turn lead to a full recognition of competent, professional interpreters, who will be accorded the status and compensation commensurate with the critical nature of their work; and it will also create the demand for higher-level training and academic programs. Does not attempt to hold a to find out the provider’s goals for the pre-conference, even when encounter and other relevant possible background information B. Gives introduction missing and succinctly to provider and patient one or more components as follows: Gives name Indicates language of interpretation Checks on whether either provider or patient has worked with interpreter before Explains role, emphasizing: Goal of ensuring effective provider- patient communication Confidentiality Accuracy and completeness (i. Does not fulfill this minimum cannot be held and/or a full requirement introduction made, at a minimum asks provider to state briefly the goal of the encounter and informs patient and provider that the interpreter is obliged to transmit everything that is said in the encounter to the other party and, therefore, that if either party wishes something to be kept in confidence from the other, it should not be said in the presence of the interpreter D. Shows uneasiness in role from the beginning establishing and asserting the interpreter’s role E. Arranges spatial configuration to support direct communication place the interpreter at the center between provider and patient of communication or otherwise disrupt direct communication D. Chooses a physical location that privacy of the patient when makes the patient uncomfortable in necessary (e. Does not assess the patient’s prior to the triadic encounter to linguistic register or style assess the patient’s linguistic register and style (e. Does not assess potential areas of potential areas of discomfort for the discomfort patient (e. Fails to observe signs of discomfort and/or specific verbalization suggesting discomfort and: Checks to identify the source of distress Reassures the patient by providing information about credentials, professionalism, and the ethics of confidentiality Explains the reality of the situation (e. Does not use the mode that best comprehension and least interrupts enhances comprehension and least the speaker’s train of thought, given interrupts the speaker’s train of the demands of the situation thought, given the demands of the situation B. Does not demonstrate use of simultaneous mode, uses it when it alternative strategies to provide is important that the speaker not be accurate and complete interrupted (e. Cannot explain the switch briefly switch, briefly and unobtrusively, if and unobtrusively. Transmits message inaccurately so expressing the information that: 1) the transmitted message is conveyed in one language into its not equivalent to but different from equivalent in the other language, so the original; 2) the elicited response that the interpreted message has the does not answer the intended potential for eliciting the same message response as the original B. Transmits message incompletely includes denotative, connotative, and with improper paraphrasing and metanotative meaning, taking so that: 1) propositions are missing; into account the context, content, 2) function and affect are not function, affect, and register of the conveyed original message C. Omits, makes up, or inaccurately information and/or concepts she or interprets information and/or he did not understand or did not concepts she or he did not completely hear understand or completely hear D. Does not suggest or explain that provider address each other directly provider and patient should address each other directly B. Does not use the first-person form the standard, but can switch to the as the standard third person, when the first-person form or direct speech causes confusion or is culturally inappropriate C. Fails to stop provider and/or provider address each other directly patient from directing their communication to the interpreter D. Does not pay attention to verbal cues that may indicate the listener is and nonverbal cues indicating confused or does not understand possible confusion or lack of understanding B. Ignores and omits messages she or understood or not heard, clarifying he did not understand or hear that it is due to the interpreter’s completely need B. Guesses at what the speaker said speaker to say the same thing using or meant and transmits this other terminology C.
Scalpel Handles Orth-07-000 149 Dermatomes Orth-07-001 149 Bandage and Cloth Scissors Orth-07-002 149 Thendon Forceps Orth-07-003 149 Piffard Dermal Curette Orth-07-004 150 Keyes Dermal Punch Orth-07-005 150 Finger Ring Cutter Orth-07-006 150 Nail Clipper Orth-07-007 150 Towel Clamps and safety pins Orth-07-008 151 Towel clamps Orth-07-009 151 Tubing Clamps Orth-07-010 151 Approximators Orth-07-011 151 Bulldog clamps Orth-07-012 152 Needle holders Orth-07-013 152 Suture instruments Orth-07-014 152 Guiding Probes Orth-07-015 152 Sondalar Probes Orth-07-016 152 Suction Tubes Orth-07-017 153 Nerve generic 100 mcg cytotec amex, Dura and Skin Hooks Orth-07-018 153 Retractor Orth-07-019 153 Nerve and nerve root retractor Orth-07-020 153 Bone Retractors Orth-07-021 154 Self-retaining retractors Orth-07-022 154 Hand and finger retractors Orth-07-023 154 Retractors for Cervical Spine Orth-07-024 154 Lamina Spreaders Orth-07-025 155 Raspatories Orth-07-026 155 Bone Levers Orth-07-027 155 Special Bone Levers Orth-07-028 156 Osteotomes buy cheap cytotec 100 mcg on line, chisels and Orth-07-029 156 Gouges Osteotomes Gouges Orth-07-030 156 Gouges Orth-07-031 156 Thempers Orth-07-032 157 Mallets Orth-07-033 157 Bone curettes Orth-07-034 157 Bone files and Rasps Orth-07-035 157 Reposition forceps and Orth-07-036 158 distractor Bone holding forceps Orth-07-037 158 Bone clamps Orth-07-038 158 Bone cutting forceps Orth-07-039 158 227 Orthopedic Instruments Instrument Name Reference No cheap cytotec 100mcg online. Synovectomy and Bone Orth-07-040 159 Rongeurs Bone Rongeurs Orth-07-041 159 Punches Orth-07-042 159 Rongeurs Orth-07-043 159 Skull Traction instruments Orth-07-044 160 Skull traction wrench Orth-07-045 160 Traction instruments Orth-07-046 160 Large size traction hook Orth-07-047 160 Cerclage Orth-07-048 161 Wire holding forceps Orth-07-049 161 Wire cutting forceps and scissors Orth-07-050 161 Wire cutting forceps hard metal Orth-07-051 161 Wire and screw cutting pliers Orth-07-052 162 Plaster spreaders Orth-07-053 162 Reamers and awls Orth-07-054 162 Amputation knives Orth-07-055 162 Amputation saws Orth-07-056 163 Hand drills Orth-07-057 163 Screw drivers Orth-07-058 163 Screw and plate instruments Orth-07-059 163 Ruskin-liston bone cutting forcep Orth-07-060 164 Double action rongeur Orth-07-061 164 Stille-luer rongeur Orth-07-062 164 Ruskin rongeur Orth-07-063 164 Dean bone rongeur Orth-07-064 165 Adson rongeur Orth-07-065 165 Cervical laminetomy rongeur Orth-07-066 165 Interverterbral disk rongeur Orth-07-067 165 Zielke intervertebral rongeur Orth-07-068 165 Bechman-adson retractor Orth-07-069 166 Neuro- retractor Orth-07-070 166 Still type osteotome Orth-07-071 166 Silver osteotome Orth-07-072 167 Harms impactor Orth-07-073 167 Bone tamper Orth-07-074 167 Bone packer dissector Orth-07-075 167 Lewis rasp Orth-07-076 168 Bone file Orth-07-077 168 Cone ring curette Orth-07-078 168 Lowman clamp Orth-07-079 168 228 Orthopedic Instruments Instrument Name Reference No generic cytotec 200mcg with mastercard. Lambotte bone holding forceps Orth-07-080 169 Lane bone holding forceps Orth-07-081 169 Plate and bone holding forceps Orth-07-082 169 Bone compression forceps Orth-07-083 169 Bone and cartilage clamp Orth-07-084 170 Tucker hallux forceps Orth-07-085 170 Bone hook Orth-07-086 170 Blount knee retractor Orth-07-087 170 Tibia retractor Orth-07-088 171 Spinal retractor Orth-07-089 171 Adson elevator Orth-07-090 171 Thendon strippers Orth-07-091 171 Thendon Transplantaion forceps Orth-07-092 172 Meniscus clamp Orth-07-093 172 Thendon forceps Orth-07-094 172 Thendon retriever Orth-07-095 172 Thendon passer with olive Orth-07-096 173 Metacarpal saw Orth-07-097 173 T-C wire puller Orth-07-098 173 Bone drill-offset handle Orth-07-099 173 Pediatric cast breaker Orth-07-100 174 Heavy duty cast spreader Orth-07-101 174 Multi-cut utility scissors Orth-07-102 174 Plaster spreader Orth-07-103 174 229 Rectal Instruments Instrument Name Reference No. Pratt rectal speculum Rec-09-000 176 Sims rectal speculum Rec-09-001 176 Bodenhammer rectal Rec-09-002 176 speculum Barr anal retractor Rec-09-003 176 Cook rectal retractor Rec-09-004 177 Pennington rectal speculum Rec-09-005 177 Hirschman anoscope Rec-09-006 177 Hirschman anoscope (large) Rec-09-007 177 Kelly sphincteroscope Rec-09-008 178 Biopsy forceps Rec-09-009 178 Rectal cottone carrier Rec-09-010 178 Rectal biopsy forceps with Rec-09-011 178 piston grip 230 Gynecology Instruments Instrument Name Reference No. Page No Dressing drum(drum Hos-13-000 204 sterilizer) Bowls- lotion and iodine Hos-13-001 204 Kidney dishes Hos-13-002 204 Instrument trays Hos-13-003 204 Infant incubators Hos-13-004 205 Armrest horse Hos-13-005 205 Armrest orthopedic horse Hos-13-006 205 Wheel chair Hos-13-007 205 Walker and sticks Hos-13-008 206 Oxygen inhalator Hos-13-009 206 Baby scale Hos-13-010 206 Body weight scale Hos-13-011 206 Flat bed Hos-13-012 207 Waggling hospital bed Hos-13-013 207 Hand folding bed Hos-13-014 207 Hospital child bed Hos-13-015 207 Infant bed Hos-13-016 208 Folding stretcher Hos-13-017 208 Stretcher for ambulance car Hos-13-018 208 Emergency bed Hos-13-019 208 buckets Hos-13-020 209 Catheter tray Hos-13-021 209 Steam sterilizer Hos-13-022 209 Jugs and Jars Hos-13-023 209 234 . Health services need to make informed choices about what to buy in order to meet priority health needs and avoid wasting limited resources. Many organisations have produced useful information about essential drugs, but less information is available about essential medical supplies and equipment. Despite the fact that there is a much wider range of different brands and items to choose from, selecting supplies and equipment is often given little attention. This often results in procurement of items that are inappropriate because they are technically unsuitable, incompatible with existing equipment, spare parts and consumables are not available, or because staff have not been trained to use them. Procurement is only one part of managing medical supplies and equipment, and effective storage, stock control, care and maintenance are also critical if health services are to get the most out of what they buy. However, there is also limited information available about these aspects of management of medical supplies and equipment. The manual is intended to be a practical resource for those responsible for procurement and management of medical supplies and equipment at primary health care level. It includes guiding principles for selecting supplies and equipment, provides guidelines for procurement, storage and stock control, care and maintenance, and considers safe disposal of medical waste. The manual also discusses the use of standard lists as a tool for encouraging good procurement practice and includes model lists of medical supplies and equipment required for primary health care activities in health facilities and in the community, and for basic laboratory facilities. Although Medical supplies and equipment for primary health care is mainly intended for primary health care level, it will also be a useful resource for those at national and district levels responsible for health planning and management, training, and managing medical stores. The content and information contained in this publication are intended as guidelines only. As such it plays an important role in ensuring that the right health sector goods (equipment, drugs, supplies etc. Good procurement practices do not only lead to savings in acquisition costs, they also facilitate downstream activities during the utilization phase, especially maintenance in the case of equipment. This book is a welcome document in this vein, as it provides a comprehensive resource for acquisition of health sector supplies and equipment, covering the needs of facilities at the primary health care level. If properly used, it should help ameliorate the situation in developing counties, where procurement of goods (and services) is often fraught with ineffectiveness and inefficiency. The book is fairly exhaustive in the range of products it covers - from cotton swabs to syringes, and from microscopes to waste disposal systems. The identification of equipment and supplies with the procedures they support, reasserts the need for acquisitions to be driven by health care goals, not procurement objectives. The practical tips and suggestions on routine inspection and preventive maintenance can extend the useful life of the items procured, especially in the developing world, where sometimes more than fifty per-cent of all health care equipment is unusable, for reasons ranging from operator misuse to lack of spare parts. The discussion on management again underscores the need for a holistic view of procurement as an activity in a broader context, whose object goes beyond simply procuring health sector goods, to improving health services. We trust that the book will get the readership it richly deserves, and most important, that its use will contribute positively to improving the health of the people and communities envisaged. Yunkap Kwankam, Scientist & Andrei Issakov, Coordinator, Service Outcome Department of Health Service Provision, World Health Organization, Geneva Medical supplies and equipment for primary health care i Preface Drugs, medical supplies and equipment account for a high proportion of health care costs. Health services in developing countries need to choose appropriate supplies, equipment and drugs, in order to meet priority health needs and to avoid wasting limited resources. Making sure that health facilities have adequate supplies, equipment and drugs is also essential if people are to have confidence in health services and health workers. Model lists of basic low-cost products can help people responsible for procurement to make cost-effective decisions. A lot of useful information is available about essential drugs, and the World Health Organisation and other organisations have produced model lists of essential drugs. Until recently, less information was available about medical supplies and equipment, despite the fact that there is a much wider range of different brands and items to choose from and the specifications for supplies and equipment are much less standardised than for essential drugs. This revised edition, Medical supplies and equipment for primary health care, covers effective procurement, management and maintenance of basic supplies and equipment. The model list of essential supplies and equipment has been updated to reflect changes and developments since 1995 and expanded to include laboratory supplies, supplies and equipment for community care, and essential drugs. The presentation of the list has been reorganised to show what supplies and equipment are required for different primary health care activities. New information has been included about selection, ordering, storage, care and maintenance of medical supplies and equipment, and about waste disposal. We hope that the revised edition will help readers to think about what supplies and equipment are needed and why, to decide how to obtain supplies and equipment, and to understand the basic principles of management and maintenance. Please use the feedback form at the end of the book to send your comments and suggestions, which will help us to improve future editions. It includes information from the first edition written by Ray Skinner, John Townsend and Victoria Wells and new material compiled and written by Manjit Kaur and Sarah Hall. Special thanks are due to Charles Olupet (Mbale Clinical Officer Training School) for his invaluable support during field testing of the manual in Uganda. Medical supplies and equipment for primary health care iii Glossary, acronyms, abbreviations and symbols Glossary disposable syringes and needles; expendables (sometimes also called consumables), items that are Accessories – are complementary and add to the used within a short time, e. User Maintenance – is day-to-day routine care and Cleaning – is the process of removing visible material, maintenance by users, including cleaning, inspection such as dirt, grease, blood and body fluids and for damage and reporting any defects, which is reducing the number of infectious micro-organisms essential to keep instruments and equipment in good (bacteria, viruses, fungi, and spores). Reusables should only be used after proper cleaning and sterilisation and/or disinfection. It is intended for health workers who are responsible for selecting and managing medical supplies and equipment for primary health care services provided by government facilities and by non-government organisations, including non-profit agencies and private companies such as mines and plantations. The way that primary health care is organised varies from country to country and the services provided depend on the type of facility and staff, and on the resources available. Primary care facilities include health posts, dispensaries, clinics and health centres. Some facilities may have only one health worker, others may have a number of staff. Primary care staff include medical assistants, clinical officers, nurses, midwives, community-based workers or other professional and non-professional health workers. In this book we have assumed that primary health care facilities offer the following services: • Diagnosis and treatment of common diseases and conditions – including malaria, skin diseases, respiratory infections, anaemia and malnutrition. Primary health care facilities usually provide community care, supporting and supervising community-based health workers (community health workers, traditional birth attendants and traditional healers), and home-care programmes for people with chronic or terminal illness and disabled people. Some primary health care services may also have a small delivery room for births and a few short stay beds for very sick patients, and basic laboratory facilities for conducting simple diagnostic tests. The information in this book will also be relevant for secondary level facilities, usually district hospitals, which deal with more complex cases and take referrals from primary level facilities. The more sophisticated needs of tertiary level facilities, which provide specialist services, are not discussed in this book. However, we hope that it will be useful to health planners, managers and trainers at national and district level in Ministries of Health, Finance and Planning, and to personnel responsible for purchase and supply and for managing medical stores. Medical supplies and equipment The term medical supplies means different things to different people, and the distinction between supplies and equipment is not always clear. In this book, we have defined medical supplies and equipment as follows: Supplies – items that need to be replaced on a routine basis, including: disposables, single use items, e. This can result in procurement (the process of obtaining items through purchase and donation) of inappropriate supplies and equipment. Items can be inappropriate because they are technically unsuitable or incompatible with existing equipment, because accessories or spare parts are not available, or because staff have not been trained to use them. Too often, supplies and equipment are not effective or efficient because they are poorly managed and maintained.