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Other options- All are transmitted by carriers – Vibrio-Fecal carries are common – Staphylococcal carriers – skin and anterior nare – Hemophilus carrier- in nasopharynx 17 cheap 100mg kamagra polo with visa erectile dysfunction urology tests. About Other Options- – Both Diphtheria and Tetanus toxoid are aluminum phosphate Adsorbed toxoid increases immunogenicity – Both whole cell killed B generic kamagra polo 100 mg with mastercard erectile dysfunction treatment natural food. Ans (c) (10 yrs) Ref: Park 22/e p286 cheap 100 mg kamagra polo fast delivery ritalin causes erectile dysfunction, 21 e/p287 – Individuals sustaining tetanus-prone wounds should be immunized if their vaccination status is incomplete or unknown or if their last booster was given >10 years earlier – Two doses of immunization provides immunity for several years safe silvitra 120 mg. discount finasteride 1mg visa. Ans (a) (Full course of tetanus toxoid) Ref: Park 22/e p286 discount 120mg sildalis fast delivery,21 e/p287 – It’s a case of simple wound (clean and non penetrating) and category-D (unimmunized) – The recommendation for simple wound and category D is - Full dose of tetanus toxoid – 33. Past exposure in adult, indicates– 3 Marker of prevalence of tuberculosis – All tuberculin reactors in a community 1. Prevalence of infection, 3 Marker of incidence of tuberculosis- New converters to tuberculin test in a community 3. Sputum examination of symptomatic patients if sputum smear and microscopy is negative c. Exacerbation of lesions in patients of borderline leprosy is in indian classification? Interpretation of result of tuberculin test: • Adults: Positive test only confrms past infection but does not indicate presence of active stage of the disease. About Other Options Option b-“Tuberculin test sensitivity slowly wanes over time and repeat test may appear negative in non infected persons. Ananthanarayan 9th/p354-55,8/e p356 185 Review of Microbiology and Immunology Option c- Results are given in terms of positive (>10mm) and negative (<5mm) and doubtful/equivocal (6-9mm) Option d- Indurations given in terms of breadth only – “Horizontal transverse diameter of the induration in mm using a plastic ruler or caliper” Option e- Mantoux test is an Indicator of -Active infection in infants, past exposure in adult 35. These infections are typically accompanied by painful, erythematous, draining subcutaneous nodules, usually without associated fever or systemic symptoms. Kansasii) Ref: Ananthanarayan 9/e p354, 359, 8/e p357-361, Jawetz 25/e p290, 297 M tuberculosis complex – include species – M. Although men are frequently infected, overt disease is very uncommon except who are profoundly immunocompromised. It is commonly found in West African countries, causing up to a quarter of cases of tuberculosis in countries such as the Gambia. Escherichia, Klebsiella- Pink colony on MacConkey agar I • Non Lactose fermenter- E. Shigella, Salmonella, Proteus, Yesinia- Pale colony on Lactose fermenter: MacConkey agar E. Treatment: • Mild- no treatment required • Severe- Ampicillin, Cotrimoxazole, Norfoxacin. Typhi O, H, Vi Antigens H antigen→ Flagellar antigen • Heat labile, alcohol labile. Paratyphi A) O Ag→ Somatic polysaccharide • Heat stable • Formaldehyde labile • Less immunogenic, • O antibody appears early, goes early – indicates recent infection • Reacts to O Antibody- forms granular chalky clumps Vi Ag – Surface polysaccharide covering O Ag I • Heat labile, when present it renders the bacterium in agglutinable by O antiserum Persistance of Vi Ab in • Possessed by S Typhi and S. Typhi- by Vi specifc • Persistance of Vi Ab in convalescent stage – carrier state bacteriophage • Epidemiological typing of S.

Syndromes

  • Stage one can last from hours to a few days. Symptoms may resemble a cold or the flu, and can include fever, chills, sweating, fatigue, malaise, headache, cough, shortness of breath, and chest pain.
  • A vaccination to prevent a form of viral encephalitis that often affects people living in dorms or in the military
  • Abnormally dark or light skin
  • Cisplatin
  • What body parts swell? Your ankles, feet, legs? Above the knee or below?
  • Shoulders
  • Bloody stools
  • Retroperitoneal fibrosis

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A hard order kamagra polo on line amex chewing tobacco causes erectile dysfunction, ten- 1 hour or less from 3 cm cervical dilatation to delivery der uterus that does not relax characterises placental for primigravid women buy kamagra polo amex low testosterone erectile dysfunction treatment, and half an hour or less for abruption cheap kamagra polo erectile dysfunction exercise video. Several countries in the Middle East use three induction of labour in women of high parity; hours or less from the start of uterine contractions placental abruption; until delivery as their defnition sildenafil 50 mg line. In many defnitions some variants of Ehlers–Danlos syndrome; the inclusion of the third stage is not clearly stated discount viagra jelly 100mg with amex. The risk of death or neurosensory disability ofen need emotional support during and afer the increases with decreasing gestational age purchase cipro with a mastercard. Preterm event, as many women can fnd this type of labour birth can have huge psychosocial and emotional very distressing. Tere is an association with postpartum nant uterus quiescent until parturition at term. Removal of this inhibition plus an increase in proven beneft in using tocolytic agents to ‘normalise’ myometrial receptors for prostaglandins and oxy- the labour. Long-duration, low-frequency pected, then it should be assessed and managed in uterine contractions change to high-intensity and the usual way, including fetal blood sampling to aid more frequent contractions. The common pathway in labour, activated Further reading through the diferent causes of premature labour, Erkkola R, Nikkanen V. Eur Clinically, the importance of premature labour is J Obstet Gynaecol Reprod Biol 2004; 116: correct diagnosis so that the mother is in the optimal 43–47. Approximately one third are iatro- considered in preterm labour will remain undeliv- genic for causes such as pre-eclampsia, fetal growth ered 48 hours later, and one-third will continue the restriction, and abruption, while the remainder pregnancy to term. A preterm birth, defned as one The diagnosis is made by history, abdominal that occurs before 37+0 weeks of gestation, is the palpation, and by using a uterine tocograph, if single most important determinant of adverse one is available. The strength, frequency, and the infant outcome in terms of both survival and qual- patient’s response to the uterine contractions are ity of life. Using a cut-off measurement of 15 mm or Low body mass index (<18) less, 90–95 per cent will go into labour within 7 days. Previous premature labour social tocolysis Lower socioeconomic class Single parent Whilst the use of tocolytics reduces the proportion of births afer treatment starts, there is little availa- Lifestyle activities ble evidence about its efect on perinatal mortality or Smoking severe morbidity. High caffeine intake Recreational drugs (cannabis, cocaine, ecstasy) The main indications for tocolytic drugs in pre- mature labour in the short term are: to allow a course of maternal steroid injections for fetal lung maturation; to allow transfer of the mother to a maternity unit with Box 2 Clinical risk factors for appropriate neonatal intensive care unit facilities for that particular gestation. In addition, steroid treatment Fetoplacental unit reduces the cost and duration of neonatal intensive Multiple pregnancy care. Polyhydramnios Fetal growth restriction Further reading Placental abruption Green-top Guideline 7: Antenatal corticoste- Maternal trauma roids to reduce neonatal morbidity. Congenital Green-top Guideline 1B: Preterm labour, toco- Uterine and cervical anomalies lytic drugs. Deepa Janga and Nigel Bickerton The World Health Organisation defnes prolonged labour as a woman having experienced labour pains for 12 hours or more without delivery. This is a slow process for primigravid women is 10 hours, compared with until the cervix is 3–4 cm dilated. As a general rule, the cervix should dilate at the dilated (no cervix palpable around the fetal head).

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One group is located adjacent to the alveoli and is accessible from the pulmonary circulation and sometimes referred to as pulmonary C fibers purchase cheapest kamagra polo erectile dysfunction shake recipe. A second group cheap kamagra polo 100 mg on-line doctor yourself erectile dysfunction, bronchial C fibers discount kamagra polo 100mg overnight delivery impotence effect on relationship, is accessible from the bronchial circulation and purchase 130 mg malegra dxt amex, consequently cheap viagra soft 50mg overnight delivery, is located in airways cheap malegra fxt 140 mg amex. The pulmonary C fibers are stimulated by physical engorgement of the pulmonary capillaries, such as pulmonary edema, pulmonary emboli, or congestive heart failure. The bronchial C fibers are stimulated by hyperinflation of the lungs and to products of inflammation. Proprioceptors are located in tendons and skeletal muscle and can play a role in breathing, particularly when more than quiet breathing is called for or when breathing efforts are opposed by increased airway resistance or reduced lung compliance. One type of proprioceptors, muscle spindle receptors, provides information about changes in muscle length. A considerable number of muscle spindles are located in the intercostal muscles, but not in the diaphragm. Another type, Golgi tendon organ, is located in the tendons that attach muscle to bone and provide information muscle tension. When both types of proprioceptors are stimulated, they cause a reflex of increased ventilation. Central and peripheral chemoreceptors respond to changes in arterial blood gases and hydrogen ion concentration. Another set of receptors that profoundly affect breathing are the chemoreceptors (see Fig. These + receptors are stimulated by the hydrogen ion concentration [H ] and respiratory gas composition of the arterial blood. Responses to carbon dioxide and, to a lesser extent, blood pH depend on sensors in the brainstem, carotid arteries, and aorta. In contrast, responses to hypoxia are brought about only by the stimulation of arterial receptors. The source of this2 chemosensitivity has been localized to bilaterally paired groups of cells just below the surface of the ventrolateral medulla immediately caudal to the pontomedullary junction. Each side contains a rostral and a caudal chemosensitive zone, separated by an intermediate zone in which the activities of the caudal and rostral groups converge and are integrated together with other autonomic functions. Cerebrospinal fluid has a weak buffering system and is sensitive to changes in carbon dioxide partial pressure. This selective barrier is termed the blood– brain barrier and is illustrated in Figure 21. Brain interstitial fluid is also separated from blood by the blood–brain barrier (capillary endothelium), which has its own transport capability.

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Fibroids – submucous generic 100mg kamagra polo with mastercard effexor xr impotence, intramural Sporadic miscarriages occur in up to 25 per cent of Uterine synechiae pregnancies kamagra polo 100 mg low price erectile dysfunction treatment by food. A woman may have three sporadic mis- T-shaped uterus carriages during her reproductive career cheap kamagra polo online visa impotence definition, but these Cervical incompetence are usually interspersed with viable births and are not inherited thrombophilia classifed as recurrent miscarriages purchase online provera. The autosomal trisomies commonly commonest immunological cause of recurrent mis- encountered are those of chromosomes 3 discount 80 mg tadapox otc, 4 order 20mg prednisone with visa, 9, 13–16, carriage. Polycystic ovarian syndrome is one acquired anatomical defects, such as submucous or of the commonest endocrinal abnormalities afecting intramural fbroids, endometrial polyps, and Asherman’s female reproductive performance. Besides infertility, syndrome; it presents higher risks of frst- and second-trimester small tubular uterine cavity: this may be secondary to miscarriages. Women with poorly controlled type 1 (insulin- dependent) diabetes mellitus with glycosylated haemoglobin levels greater than eight standard devi- thrombophilias ations above the mean have a higher pregnancy loss 13–15 Tese are rare inherited disorders that predispose rate. Well-controlled diabetics have pregnancy 16 an individual to venous and arterial thrombosis. Premature ovarian failure remains an important The most common acquired thrombophilia is the factor responsible for recurrent miscarriage, owing to antiphospholipid antibody syndrome. Pregnancy in a rhesus-sensitised Anatomic abnormalities of the uterus and cervix are woman with a high titre of anti-D antibodies will also amenable to surgery. Bacterial infec- and treated through in-vitro fertilisation and tions such as Brucella abortus also cause recurrent pre-implantation genetic diagnosis. Genital infections Genitourinary tuberculosis is classically associated References with infertility but latent infection can also cause 1. The antiphospholipid syndrome: Obesity is associated with increased risk of mis- ten years on. A cytogenetic study of repeated diation and anaesthetic gases, pesticides, and other spontaneous abortions. Implantation abnormalities in spontaneous abortions: is a complex process that involves synchronisation frequency, pathology and genetic counsel- of endometrial maturity with fertilisation, expres- ling. Structural rearrangements leukaemia inhibitory factor in the endometrium is of chromosomes in men. New out mouse model, but its exact role in humans is yet York: Academic Press, 1977: 81–97. Glycemic control and spontaneous abor- Mike Papesch and Eva Papesch tions in insulin dependent diabetic women. Spontaneous abortions in patients with Epidemiology insulin dependent diabetes mellitus: the Nosebleeds are common in children, nearly always effect of preconceptional diabetic control. Pregnancy in patients with mild thyroid Tey occur in about 15 per cent of the population, abnormalities: maternal and neonatal reper- and peak in childhood and late adult life.