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Regular and frequent review of the amount of progress being made towards the goal promotes effective leaning 3) Distribution of practice board: ­ Shorter practice period are more effective than longer periods this will reduces the mental fatigue 4) Whole versus part method: ­ Whole method should be adopted with easy unit and difficult material can be learned in small units 5) Logical learning: ­ Logical learning calls for an arrangement and also assimilation with ideas in minds order levitra professional 20 mg overnight delivery erectile dysfunction caused by performance anxiety. Students should try to grasp the meaning of text 6) Rest:­ Take rest in between studies prevents mental fatigue 7) Levels of anxiety: ­ Avoids undue worry discount 20 mg levitra professional visa erectile dysfunction after 80, anxiety & nervousness to promote better learning effective levitra professional 20 mg icd 9 code erectile dysfunction neurogenic. Otherwise it will have an inhibiting and interfering effect 8) Over learning/repetitions at regular intervals helps to retain the material over a longer period of time Theories of learning 1) Trail and error 2) Theory of conditioned reflexes A) Classical conditioning B) Operant conditioning 3) Cognitive learning A) Insight learning B) Sign learning Trial and error: ­ Edward Lee Thorndike American Psychologist considered as the father of educa­ tional, psychology conducted series of experiments on trial and error method of learning by animals and found out that all learning is trial & error and he has developed certain laws of learning. They are · Law of effect:­ The response followed by a reward will be strengthened · Law of Exercise:­ There is a direct relationship between repetition and the strength of the stimulus response. Any task that is repeated shows a tendency for the strengthening of the bond Eg: Reading, writing, typing, singing, dancing, drawing learned by constant practice · Law of readiness: Learning takes place best when a person is ready to learn Theory of conditioned reflexes Classical conditioning:­ Ivan Pavlov a Russian physiologist, a researcher experimented on a dog. Later Pavlov observed that the dog salivated at the mere sound of the bell without giving meat powder. Principles of classical conditioning used in the following areas for learning 75 1) Developing good habits 2) Breaking of bad habits and elimination of fear 3) Training of animals 4) Use in psychotherapy 5) Useful in developing favorable attitude Operant conditioning:­ Skinner experimented on a rat which was placed inside a glass box containing a lever and food tray. Pressing the lever was the response to be learned (the operant response) and the food was the stimulus consequences (reinforcement). Thus the rate of presses increased with rewarding of the rat with food Cognitive learning Learning by insight: ­Gestalt psychologist concluded that the individual learns by his ability known as insight & not by trial & error method. Mean while one end of one stick got incidentally fastened in to the ring fixed on the end of the other stick, with the result that both the sticks were joined together. It takes place by cognition which includes concepts like knowledge, thinking, planning, inference and purpose. Learning consists in the recognition of signs and their meanings in relation to goals in sign learning, a comparison was made between two group of hungry rats in a maze. In one group, each subject received food each time it ran the maze and steady improvement was noticed. In the other, each subject was given access to the maze without finding a food reward and little improvement occurred in time or error scores. However, when food was introduced at the tenth trial, performance soon approximated that of the group which had been rewarded continually. Such sudden improvement suggests that the animals had acquired information about the maze which they did not utilize until, after the tenth day it became advantageous for them to do so. The rats had developed a cognitive map of the maze 76 Bandura’s social cognitive theory: ­Just as Tolman believed that rats gather information and form cognitive maps about their environments through exploring, Bandura believes that humans gather infor­ mation about their environments and behavior of other through observations Social cognitive learning results from watching, imitating and modeling and does not require the observer to perform any observable behavior or receive any observable reward Bandura believes that four process – attention, memory, imitation and motivation – operate during social cognitive learning Theories of transfer of learning: As per Thorndike, the transfer of learning from one situation to another is possible because of identical common elements. For example, in learning cycling and driving a care, the transfer takes place because of the common elements like stearing movements, knowledge of the rules of the road and looking ahead. Ex · Attention to loud sounds · Bright lights · Strong penetrating odours Factors increasing attention by external factors: ­ 1) Nature of the stimulus: ­ More attractive stimulus catches maximum attention (Picture) 2) Locationof the stimulus: ­ Stimulus in front of the eye attracts our attraction 3) Intensity : ­ Loud sound, bright colors 4) Change in the intensity of the stimulus: ­ Ticking of a clock in our room may not attract our attention but when it stops our attention is attracted 5) Movement: ­ A fast moving electric sign attracts our attention 6) Size: ­ Bigger size attracts more attention 7) Contracts:­ A single man among the many woman, a spot on a clean white dress attracts our attention 8) Novelty:­ A new fashion dress attracts our attention 9) Repetition: ­ Repeated cry, repeated ringing of a call bell attracts our attention 77 Factors increasing attention by internal factors: ­ 1) Interest: ­ When we are motivated to a goal 2) Motives: ­ When a child is hungry he looks for a feeding bottle rather than a toy 3) Experience: ­ We attend to object with which we are familiar 4) Mental set: ­ While excepting a friend, we perceive any knocking sound as that of friend’s footstep 5) Emotional stage: ­ Under stressful conditions we fail to perceive our surroundings fully Voluntary or habitual: ­ There is no conscious effort of sensation. Ex: The attention that a teacher gives to her students Span of attention: ­ The maximum amount of material that can be attend to in one period of attention is called span of attention Distraction of attention: ­ Refers to shifting of attention from one stimulus to another. External distraction: Noise pollution Internal distraction: Pain headache Division of attention:­ Refers to the process of dividing our attention equally and simultaneously between two or more objects. Ex: While students reading a book may hear his favorite song Perception : Perception is the process by which we discriminate among stimuli and interpret their meanings and appreciate their significance. Ex When we hear a sound, we are able to identify it as being produced by an aero plane Perceptions are divided in to 1) Visual perception 2) Auditory perception Factors influencing perception: ­ · Functioning of the sense organs · Functioning of the brain · Previous experience · Frequency of exposure · Psychological state of the individual · Interest · Motivation · Behavior of the organism Theories of laws of perceptual organization: ­ 1) Figure – ground relationship: ­ The most fundamental process in form perception is the recognition of a figures standing out from a background. This is because the polar bear is white in color 78 In the above figure you see the light portion as a figure, you will see a water glass or candle holder, if you see the dark portion as a figure, you will see two faces. Either one is a figure against background Grouping of stimuli in perceptual organization: ­ Stimuli are grouped into the smallest possible pattern that has meaning. Important principles of grouping are proximity, similarity, symmetry, closure and continuation Proximity: ­ When objects are close to each other, the tendency is to perceive than together rather than separately. We see three sets of two lines each and not six separately lines Proximity Similarity: ­ Items that most closely resemble each other or perceived as units In above figure the circles and triangles are seen as two vertical rows of triangles and one row of circles and not three horizontal rows of triangles and circles Symmetry: ­ Items that form symmetrical units are grouped together We see three sets of brackets. We do not see six unconnected lines Closure: ­ Items are perceived as complete units even though they may be interrupted by gaps Continuation: ­Anything which extends itself into space in the same shape, size and color with­ out a break in perceived as a whole figure. We do not see a straight line with small semi­ circles above and below it Perceptual constancies: ­ Perceptual constancies refers to our tendency to perceive objects as relatively stable and unchanging despite changing information. Perceptual constancies 1) Space constancy 2) Sex constancy 3) Brightness and color constancy 4) Perception of space binocular depth cues 5) Visual monocular clues Types of perceptual constancies: ­ 1) Observer characteristics: ­ Depends greatly on past experience and learning 2) Depth perception: ­ Is the ability to perceive space and distance accurately 3) Binocular cues: ­ Helps in the perception of depth by integrating and synchronizing the images of both the eyes. According to psychologist Ward, “it is the complete psychosis involving cognition, pleasure – pain and conation”. The difference between motives and emotions are as follows: Emotions are usually aroused by external stimuli and that emotional expression is directed toward the stimuli in the environment that arouses it. Motives on the other hand, are more often aroused by internal stimuli and naturally directed towards certain objects in the environment. Most of the motivated behaviour has some affective or emotional accompaniment although we may be too pre occupied in our striving towards goal. The bodily effects of pain, hunger, fear and rage have all the emotions of characteristically, negative polarity. The sympathetic system is responsible for the following changes: 1) Blood pressure and heart rate increases. Nerve impulses with sympathetic system, which reach adrenal glands located on the top of the kidneys, trigger the secretion of hormones. Theories of emotion: James theory or emotion proposes the following sequences of events in emotional state. The major objection to James Lang theory came from Cannon who pointed out 1) That changes do not seem to differ very much from one emotional state to another. James Langes Theory Perception of Activation of Feed back to brain emotion Visceral and from bodily producing skeletal responses produce stimulus responses experience of emotion Canon theory Messages to cortex produce experience Perception of Stimulus processed by of emotion emotion Thalamus, which producing simultaneously send stimulus messages to the cortex and other parts of the body Messages from thalamus activates visceral and skeletal responses Emotion when sufficiently intense can seriously impair the process that control organized behavior. Motion pictures and recording of children’s cries indicate that the infants’ response to stimuli designated to arouse emotion are very diffuse and lacking in organization. Emotional shocks and hurts suffered by individuals at an early age can handicap them as long as they live. Children sooner or later acquire the capacity for experiencing negative emotions such as anger, fear, and also sorrow or grief to an intense degree. This capacity develops, before the child is mature enough to use language, to formulate his experience in words. These improvements in the young child’s ability to respond in specific ways to situations that arouse him, parallel the development of his mental and motor abilities. As the child’s intellectual and motor capacity matures, he acquires large variety of means and forms of expression such as overt and direct to more graded covert and indirect. If a person may mask intense feeling of anger tat occurs when someone hunts his pride very sharply and then still harboring his anger may explode on another occasions because of a very trivial affront. The most important factors in a child’s emotional development and the affection that he receives from his parents, peer group and society. The more genuine the parents love for the child, the, more the child tends to feel free to love other people.

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Priapism Defnition: Is a persistent erection for greater than 4 hours unrelated to sexual stimulation levitra professional 20mg on-line impotence new relationship. Causes/risk factors - Most priapiasms are idiopathic - Sickle cell disease - Medication (e purchase 20mg levitra professional otc erectile dysfunction 60 year old man. Paraphymosis Defnition: Is the retraction of foreskin behind the corona of the glans penis reducing a tonic efect proven 20 mg levitra professional erectile dysfunction age 25. Causes - Trauma - Latrogenic Signs and symptoms - Oedema of the fore skin and glans penis - Pain - Fore skin ulceration Management - Reduction under anesthesia - Operation (circumcision) 7. Phymosis Defnition: Is tightness of the fore skin of such a degree as to prevent retraction. Causes - Congenital - Secondary to infection Signs and symptoms - Ballooning of the fore skin micturation - Failure of retraction - Small contracted orifce Management - Circumcision Surgery Clinical Treatment Guidelines 177 Chapiter 7: Genito-Urinary Disorders 7. Hypospadias Defnition: A condition where the urethral orifce opens in abnormal position on the ventral surface of the penis or scrotum. Causes /risk factors - Use of maternal estrogen or progesterone during pregnancy - Hereditary Signs and symptoms - Difculty directing the urinary stream and stream spraying - Chordee - Males with this condition ofen have a downward curve (ventral curvature or chordee) of the penis during an erection - Abnormal spraying of urine - Having to sit down to urinate - Malformed foreskin that makes the penis look “hooded” Investigations - A physical examination can diagnose this condition - A buccal smear and karyotyping - Urethroscopy - cystoscopy - Excretory urography Complications - Difculty with toilet training - Problems with sexual intercourse in adulthood - Urethral strictures and fstulas may form throughout the boy’s life Management - Infants with hypospadias should not be circumcised - For a Minor degree of hypospadias (e. Te repair may require multiple surgeries 178 Surgery Clinical Treatment Guidelines Chapiter 7: Genito-Urinary Disorders 7 • Relief of the chordee • Urethral reconstruction • In some cases, more surgery is needed to correct fstulas or a return of the abnormal penis curve Recommendations - Surgery is usually done before the child starts school - Surgery can be done as young as 4 months old, better before the child is 18 months old 7. Carcinoma of the Penis Te majority of penis malignancies are squamous cell carcinomas. Impotence Defnition: Persistent inability to obtain and sustain an erection sufcient for sexual intercourse. Causes - Psychological - Neurological causes (spinal cord lesions, myelodisplasia, multiple sclerosis, tabes dorsalis,peripheral neuropathies) - Diabetes mellitus - Endocrine (hypogonadotrophic hypogonadism Klinefelter’s Syndrome or surgical orchidectomy) - Low testosterone levels (prolactin producing tumors) - Vascular (atherosclerosis) - Trauma (perineal, posterior urethra, pelvic fracture leading to arterial injury, uraemicchronic dialysis - Iatrogenic (radical prostatectomy, cystoprostatectomy, neurological surgical procedures,transurethral endoscopic procedures, pelvic irradiation procedures) - Medication (centrally acting agents, anticholinergic agents (antidepressant), anti-androgenic agents (digoxin), hyperprolactinemic agent (cimetidine), sympatholitic agent (methyl dopa) Diagnosis - Detailed history - Physical examination - Length, plaques and deformity of the corporal bodies of penis - Presence or absence of testis - Size and consistency of the penis 180 Surgery Clinical Treatment Guidelines Chapiter 7: Genito-Urinary Disorders 7 - Gynecomastia (endrogene defciency) - Neurological assessment - Sensory function of the penis and perineal skin - Bulbo cavernosus refexe to evaluate the sacral refexes Investigations - Nocturnal penile turnescence (change in penis size during sleep) - Dynamic infusion cavernosometry and cavernosonography (to assess venous/corporal leak) Management Psychological • Treated by trained psychotherapist or sex therapist Medical therapy • Sildenafl(viagra), tadalafl (cialis) • Apomorphine (uprima) • Intracorporal administration of vasoactive substances (papaverine hydrochloride alone or associated with vasodilator like phentolamine, or prostaglandin E1) • Androgen replacement therapy with testosterone • Vacuum suction devices Surgical therapy • Penile prostheses • Vascular surgical techniques like micro surgical anastomosis of inferior epigastric artery to the dorsal penile artery Surgery Clinical Treatment Guidelines 181 Chapiter 7: Genito-Urinary Disorders 7. Urethra Meatal Stenosis Defnition: Is a narrowing of the opening of the urethra, the tube through which urine leaves the body. Causes - Not known - Predisposing factors are age, normally functioning testes, race, geographical location, sexual behavior, diet, alcohol, tobacco (no evidence that they play a part). Bladder Calculi/stones Defnition: Bladder calculi/stones are hard buildups of minerals that form in the urinary bladder. Causes - Calculi from the kidney - Bladder outfow obstruction - Presence of foreign bodies ( e. Bladder Cancer Defnition: Bladder cancer is a cancer that starts in the bladder; 90% is transitional cell carcinoma, 5-7% is squamous cell carcinoma, and 1-2% is adenocarcinoma/urachal carcinoma. Staging helps guide future treatment and follow-up and gives idea on patient prognosis. Cystocele Defnition: Is a medical condition that occurs when the tough fbrous wall between a woman’s bladder and her vagina is torn by childbirth, allowing the bladder to herniate into the vagina. Urinary Incontinence Defnition: Is the involuntary loss of urine Classifcation Classifcation of incontinence according to anatomical abnormality Class Sub- class Causes/risk factors Signs and symptoms Urethral Urethral Involuntary abnormalities incompetence urine loss Incontinence less common in men Urethral afer prostatectomy incontinence or pelvic fracture Bladder Inhibited detrusor Frequency and abnormality contractions by: urgency (urge Neuropathic incontinence) (detrusor hyperrefexia) non neuropathic (detrusor instability Non urinary impaired mobility abnormalities(in Impaired mental elderly patients) function Non urethral Fistula incontinence Ureteral ectopia Classifcation of incontinence according to clinical presentation Stress Ref. Vesico-Ureteric Refux Defnition: A congenital condition from the ureteral bud coming of too close to the urogenital sinus on the mesonephric duct which result in short intravesical length (intramural) of ureter. Urine travels retrograde from the bladder into the ureter and ofen into the kidney. Calculus Calcium stones (Ca oxalate, Ca phosphate) are the most common types in 70% of the cases. Management Palliation • Renal artery embolisation (may stop hematuria) • Chemotherapy (10% response rate) • Hormonal therapy (5% response rate) • Immunotherapy (under review) Surgery • Partial nephrectomy, if small peripheral lesions • Radical nephrectomy (Gerota’s fascia and regional lymphnodes) • Isolated lung metastases should also be removed surgically 7. Pelvi-Ureteric Junctions Defnition: Blockage of the ureter where it meets the renal pelvis. Cause - Congenital from either abnormalities of the muscles itself or crossing vessels. Signs and symptoms - Abdominal mass in the new born - Flank pain and infection in later life Surgery Clinical Treatment Guidelines 195 Chapiter 7: Genito-Urinary Disorders Investigations - Ultrasound - Diuretic renal scan Management - Pyeloplasty (Anderson- Hayne) 7. Tey account for approximately 10% of all renal tumours and approximately 5% of all urotherial tumours. A urethral catheter should be lef in situ for at least 10 days - High fstula (supratrigonal): Suprapubic approach 7. Posterior Urethral Valves Defnition: Obstructive urethral lesions usually diagnosed in male newborns and infants. Cause and Risk factors - Congenital Signs and symptoms - Assymptomatic till adolescence or childhood in incomplete valves - Urinary retention - Weak stream - Dysuria (infection) - Able to pass catheter without difculty Investigations - Urinalysis - Ultrasound scan - Voiding cyctogram (dilatation of the urethra above the valves) Management - Detect and treat early to avoid renal failure - Suprapubic catheter - Transurethral resection Surgery Clinical Treatment Guidelines 199 Chapiter 7: Genito-Urinary Disorders 7. Urethral Stricture Defnition: Congenital narrowing of the urethra Cause - Duplication of the urethra. Causes - Idiopathic - Predisposing factors: age, normally functioning testes, sexual behavior, diet, alcohol, tobacco (no evidence that they play a part) 200 Surgery Clinical Treatment Guidelines Chapiter 7: Genito-Urinary Disorders 7 Signs and symptoms - Nocturia - Urinary urgency and frequency - Acute urinary retention - Urinary tract infections - Renal failure - Urinary stones - Haematuria Management Conservative management Medical therapy • Alpha Blockers: e. Adenocarcinoma Defnition: Adenocarcinoma is a cancer originating in glandular epithelial tissue. Epithelial tissue includes, but is not limited to, skin, glands and a variety of other tissue that lines the cavities and organs of the body. It is of two forms, transitional cell carcinoma (> 90%) and squamous cell carcinoma (5-7%). Causes/Risk factors - Cigarette smoking - Chemical exposure at work (carcinogens - dye workers, rubber workers, aluminum workers, leather workers, truck drivers, and pesticide applicators) - Chemotherapy (e. Renal Cell Carcinoma Defnition: Renal cell carcinoma is a type of kidney cancer that starts in the lining of the kidney tubules. Burns Defnition: Burns are skin and tissue damage caused by exposure to or contact with temperature extremes, electrical current, a chemical agent or radiation. Electrical Burns Defnition: Electrical burns are body injuries caused by electrical current itself. Te current generates intense heat along its path through the body, which can lead to severe muscle, nerve and blood vessel damage. Animal Bites Defnition: Animal bites are wounds inficted on the body due to animals sinking teeth into one’s body. Animal bites and scratches, even when they are minor can become infected and spread bacteria to other parts of the body. Whether the bite is from a family pet or an animal in the wild, scratches and bites can carry disease. Animal Type Evaluation and Post-exposure 9 Disposition of Prophylaxis Animal Recommendations Dogs and cats Healthy and available Should not begin prophylaxis, 10 days observation, unless animal develops symptoms of rabies Rabid or suspected Immediate rabid vaccination (consider also tetanus toxoids) Unknown (escaped) Consult public health ofcials Skunks, Regarded as rabid Immediate raccoons, bats, unless geographic area vaccination foxes, and is known to be free of most other rabies or until animal carnivores; proven negative by woodchucks laboratory tests Livestock, Consider individually Consult public health rodents, and ofcials; bites of lagomorphs squirrels, hamsters, (rabbits and guinea pigs, gerbils, hares) chipmunks, rats, mice, other rodents, rabbits, and hares almost never require anti-rabies treatment Surgery Clinical Treatment Guidelines 213 Chapiter 9: Bites and Stings of Animals and Insects 9. Rabies Defnition: Rabies is a deadly viral infection that is mainly spread by infected animals. Snakebites and Venom Defnition: Poisonous snakes inject venom using modifed salivary glands The venom apparatus Venomous snakes of medical importance have a pair of enlarged teeth, the fangs, at the front of their upper jaw. Tese fangs contain a venom channel (like a hypodermic needle) or groove along which venom can be introduced deep intp the tissue of their natural prey. If a human is bitten, venom is usually injected subcutaneously or intramuscularly.

Complementary analysis of the Mycobacterium tuberculosis proteome by two-dimensional electrophoresis and isotope-coded affinity tag technology buy 20mg levitra professional fast delivery erectile dysfunction in the young. The cold-shock stress response in Mycobacterium smegmatis in- duces the expression of a histone-like protein buy 20 mg levitra professional with mastercard impotence emedicine. The largest open reading frame (pks12) in the Mycobacterium tuberculosis genome is involved in patho- genesis and dimycocerosyl phthiocerol synthesis buy discount levitra professional 20 mg erectile dysfunction doctor cape town. Multiple paralogous genes related to the Streptomyces coelicolor developmental regulatory gene whiB are present in Streptomy- ces and other actinomyetes. Gap, a mycobacterial specific integral membrane protein, is requiered for glycolipid transport to the cell surface. Rsh, an anti-sigma factor that regulates the activity of the mycobacterial stress response sigma factor SigH. Definition of Mycobacterium tuberculosis culture filtrate proteins by two-dimensional polyacrylamide gel electrophoresis, N-terminal amino acid sequencing, and electrospray mass spectrometry. Restricted structural gene polymorphism in the Mycobacterium tuberculosis complex indicates evolutionarily recent global dissemi- nation. Acute infection and macrophage sub- version by Mycobacterium tuberculosis require a specialized secretion system. Comparative proteome analysis of Mycobacterium tuberculosis grown under aerobic and anaerobic conditions. Myco- bacterium tuberculosis WhiB3 interacts with ProV to affect host survival but is dispensa- ble for in vivo growth. Lipoproteins of Mycobacterium tuberculosis: an abundant and functionally diverse class of cell envelope components. A new approach for the analysis of bacterial microarray-based Comparative Genomic Hybridization: insights from an empirical study. Differential expression of iron-, carbon-, and oxy- gen-responsive mycobacterial genes in the lungs of chronically infected mice and tuber- culosis patients. Functional and evolutionary genomics of Mycobacterium tuberculosis: insights from genomic deletions in 100 strains. Genomic deletions classify the Beijing/W strains as a distinct genetic lineage of Mycobacterium tuberculosis. Effect of slow growth on metabolism of Escherichia coli, as revealed by global metabolite pool ("metabolome") analysis. Comparison of predicted and observed properties of proteins encoded in the genome of Mycobacterium tuberculosis H37Rv. Gene expression profiling of human macrophages at late time of infection with Mycobacterium tuberculosis. Integrating metabolomics into a systems biology framework to exploit metabolic complexity: strategies and applications in micro- organisms. An in vitro model for sequential study of shiftdown of Mycobacte- rium tuberculosis through two stages of nonreplicating persistence. Recently, it has become clear that, in order to develop a more efficient vaccine, a better understanding of the relation between the immune re- sponse of the host and the tubercle bacillus is needed. In view of this, the present chapter provides an updated overview of the cellular and molecular immune mechanisms involved in the development of the disease. Neutrophil leukocytes Even though macrophages are considered the main targets for infection by Myco- bacterium tuberculosis, it has been recently proposed that other cell populations can also be infected by mycobacteria and therefore may be important in the devel- opment of the disease. Characteristically, they are among the earliest cells recruited into sites where any noxious agent enters into the body and/or inflammatory signals are triggered. They also have well-characterized microbicidal mechanisms such as those depend- ent on oxygen and the formation of neutrophil extracellular traps (Urban 2006). These cells have been detected at the beginning of infection as well as several days after infection (Pedrosa 2000, Fulton 2002) and were thought to have 158 Immunology, Pathogenesis, Virulence an important role in the control of mycobacterial growth. Indeed, if neutrophils are eliminated before infection, mycobacterial growth increases in the lungs of experi- mentally infected animals; and conversely, if mice are treated with an agent that increases neutrophils, the bacillary growth rate decreases (Appelberg 1995, Fulton 2002). However, when the microbicidal ability of neutrophils against mycobacteria was analyzed, controversial results were obtained. There are reports of neutrophils being able to kill mycobacteria (Jones 1990) and other reports where this phe- nomenon was not observed (Denis 1991). Nevertheless, it is believed that the func- tion of neutrophils goes beyond their microbicidal ability. Therefore, these cells are thought to contribute to the control of infection through the production of chemoki- nes (Riedel 1997), the induction of granuloma formation (Ehlers 2003) and the transference of their own microbicidal molecules to infected macrophages (Tan 2006). On the other hand, neutrophils have recently been ascribed a role in the develop- ment of the pathology, rather than the protection of the host. This event seems to be influenced by the differential expression of molecules which are chemoattractant to 5. Evidently, a more precise definition of the role played by neutrophils during infection will depend on an evaluation of the kinetics and magnitude of the response that these cells have in the early stages of the dis- ease. Mast cells Mast cells are effector cells with a relevant role in allergic reactions (Woodbury 1984, Miller 1996, Galli 1999, Williams 2000); and are also critical for the devel- opment of a T helper 2 (Th2) response (Galli 1999, Metcalfe 1997). They are found in the mucosa of the respiratory, gastrointestinal, and urinary tracts and can also be observed in the vicinity of blood and lymph vessels. Besides this interaction between IgE and the antigen, other agents are able to in- duce the activation of mast cells and the liberation of cytokines and other media- tors. The locations where mast cells are usually found are common gateways for infec- tious agents and there is evidence of these cells being excellent mediators of the inflammatory response (Williams 2000, Metcalfe 1997). At least in bacterial infec- tions by Klebsiella pneumoniae and Escherichia coli, mast cells are required for the triggering of innate immunity (Malaviya 1996, Malaviya 2001). In addition, due to their strategic distribution within the lung, mast cells have a fundamental role in the 160 Immunology, Pathogenesis, Virulence defense of the host against mycobacteria. An early study showed an increased number of mast cells and their degranulation in the lungs of animals experimentally infected with M. The presence of mast cells has also been described in the duodenum and the ileum of cows infected with Mycobacte- rium paratuberculosis, a microorganism that causes granulomatous enteropathic lesions (Lepper 1988). Indeed, alveolar macrophages have been shown to play an essential role in the elimination of particles that enter the organism through the airways; and have long been considered the first cell population to interact with the tubercle bacillus. More macrophages are recruited afterwards from the bloodstream, and are in charge of maintaining the infection in the host (Dannenberg 1991, Dannenberg 1994). Though it is unknown if the bacteria interact with one or more of these receptors during in vivo infection, the results of in vitro experiments suggest that the macrophage response depends on the type of receptor with which the bacteria interact. Their interaction with Fc receptors increases the production of reactive oxygen intermediates and allows the fusion of the bacteria-containing phagosomes with lysosomes (Armstrong 1975). The interactions of mycobacteria with members of the Toll-like receptor family have been studied for some years. Regardless of the receptor with which the bacteria interact, it has been observed that the cellular cholesterol present in the macrophage cell membrane is an essen- tial molecule for the internalization of the bacteria (Gatfield 2000). It is believed that cellular cholesterol works as a direct anchorage point for the bacterium and stabilizes its interaction with the macrophage membrane.

Strategies for the prevention and treatment of dentofacial joint injury anomalies and malocclusion Medical interventions Non-medical interventions Distant causes 26 discount levitra professional 20mg visa enlarged prostate erectile dysfunction treatment,27 • Habit-breaking appliances • Control harmful oral habits • Endocrine im balance: H ypothroidism is related to an • Serial extractions • Prenatal and perinatal care abnorm al resorption pattern cheap levitra professional 20mg on line new erectile dysfunction drugs 2011, delayed eruption and • Space-maintainers and -regainers • Genetic counselling • Functional appliances in developing gingival disturbances discount 20 mg levitra professional with amex top erectile dysfunction pills. Etiological and predisposing factors Secondary prevention related to traum atic injuries to perm anent teeth. The N orthcroft tions, space maintainers/regainers, and functional appliances lecture, 1985 presented to the British Society for the Study of to correct jaw relations are other m odalities. Genetic and epigenetic regulation of craniofacial craniofacial growth patterns in patients with orofacial clefts: developm ent. Gingival and inadequate plaque rem oval, can also cause gingival periodontal diseases affect 90% of the population. Distant causes19–25 Aetiology 11111–66666 These include low socioeconomic and literacy level, difficult Direct causes access to an oral health care facility, poor oral health These include poor oral hygiene leading to accum ulation awareness, and lack of oral health insurance. O ral health such as puberty, pregnancy, menopause, and pathological education is required for the m aintenance of oral hygiene causes such as hyperthyroidism , hyperparathyroidism (brushing, flossing, rinsing, etc. Interventions for the prevention and • Blood disorders such as acute m onocytic leukaem ia and treatm ent of periodontal diseases are given in Table 6. Prevention and treatment of periodontal diseases Medical interventions Non-medical interventions Other interventions • Scaling and polishing of teeth • Oral health education • Make oral health care more accessible • Oral and systemic antibiotics • Nutrition and diet and affordable • Use of mouth washes • Proper methods of oral hygiene maintenance • Improve the socioeconomic and literacy • Gingival and periodontal surgery ·use of toothpaste and tooth brush level of the population ·gingivoplasty, gingivectomy, flap surgery, ·use of inter-proximal cleaning devices such as • Include oral health care in general health mucogingival surgeries, guided tissue interdental brushes, dental floss and water pik, etc. Periodontal m anifestations of system ic in com m unity settings for people with special needs: Preface. It is the m ost com m on cancer in cancers are diagnosed at a very late stage, when treatm ent m en and the fourth m ost com m on cancer in wom en, and not only becom es m ore expensive, but the m orbidity and constitutes 13% –16% of all cancers. The 5- Aetiology year survival rate is 75% for local lesions but only 17% for Direct causes those with distant m etastasis. Since the oral cavity is easily • Tobacco— M any form s of tobacco are used in India— accessible for examination and the cancer is always preceded sm oking (78% ); chewing of betel quid, paan m asala, by som e pre-cancerous lesion or condition such as a white gutka, etc. Increased incidence of • Bacterial infections such as syphilis, and fungal (candi- 8–10 m outh cavity, pharyngeal and laryngeal carcinom as. Dental factors in the genesis Table 7 lists the direct, indirect and distant causes of of squam ous cell carcinom a of the oral cavity. Prevalence of oral subm ucous fibrosis am ong the cashew workers of Kerala, Strategies for prevention and treatm ent of oral cancer are South India. Solar radiation, lip protection, and lip cancer risk in Los Angeles County wom en (California, United 1. The concentration of fluoride in drinking water to teeth, som etim es with structural defects in the enam el such give the point of m inim um caries with m axim um safety. Fluoride water, food and drugs with a high fluoride content, (ii) varnishes— a review of their clinical use, cariostatic m echanism , efficacy and safety. Causes of dental fluorosis Direct Indirect Distant • Exposure to high levels of fluorides: >1 ppm of • Tropical climate·excess ingestion of water • Poor nutritional status·deficiency of fluoride in drinking water and beverages with a high fluoride content vitamin D, calcium and phosphates • Airborne fluoride from industrial pollution (aluminium • Presence of kidney diseases affecting the • Decreased bone phosphatase activity is factories, phosphate fertilizers, glass-manufacturing excretion of fluoride linked to fluoride toxicity industries, ceramic and brick products) • Thyroid and thyrotrophic hormones have a • Fluoride-rich dietary intake·sea food, poultry, grain synergistic effect on fluoridetoxicity and cereal products (especially sorghum), tea, rock salt, green leafy vegetables, etc. Strategies for the prevention of dental fluorosis Primary prevention Secondary prevention Tertiary prevention • Specific guidelines on the use and • Improve the nutritional status, especially of Treat the discoloured/disfigured dentition by appropriate dose levels of fluoride expecting mothers, newborns and children up appropriate aesthetic treatment such as bleaching, supplements, and use of fluoride to the age of 12 years. Equipment, minimum manpower required and approximate cost for medical interventions for oral and dental diseases Medical Equipment/instruments In dental In private clinics* interventions required Time required Personnel Set-up schools (in Rs) (in Rs) Dental check-up Gloves, face mask, 5 minutes Dental surgeon At all levels Nil 100–300 head light, mouth mirror, explorer, tweezers, cotton/ gauze, etc. Dental caries Though not life-threatening, these diseases are often very painful, expensive to treat and cause loss of several m an- Dental caries is a universal disease affecting all geographic days. It has now been recognized that oral and prevalence of dental caries is generally estim ated at the general health are closely interlinked. Periodontal (gum ) ages of 5, 12, 15, 35–44 and 65–74 years for global diseases are found to be closely associated with several m onitoring of trends and international com parisons. The serious system ic illnesses such as cardiovascular and prevalence is expressed in term s of point prevalence pulm onary diseases, stroke, low birth-weight babies and (percentage of population affected at any given point in preterm labour. In India, different caries, (ii) periodontal diseases, (iii) dentofacial anom alies investigators have studied various age groups, which can and m alocclusion, (iv) edentulousness (tooth loss), (v) oral be broadly classified as below 12 years, above 12 years, cancer, (vi) m axillofacial and dental injuries, and (vii) above 30 years and above 60 years (Tables 12–15). Periodontal diseases affect the supporting structures of Therefore, there is no uniform ity in data on the prevalence teeth, i. M ore advanced periodontal disease with pocket Table 17 docum ents only som e studies, and highlights form ation and bone loss, which could ultim ately lead to totally incoherent data. M oreover, m ost of the studies have tooth loss if not treated properly, m ay affect 40% –45% of been conducted on the child population, in whom periodontal the population. The major vary from m ild to severe, causing aesthetic and functional dentofacial deform ity is cleft lip and palate, which is seen problem s, and m ay also predispose to dental caries, in 1. Prevalence of dentofacial anomalies and malocclusion Author and year State Place Age group (years) Prevalence (%) Shourie 1952 Punjab Punjab 13–16 50 Guaba et al. Tooth loss (edentulousness) studies) Age group (years) Number of missing teeth Edentulousness (%) Incidence (%) 60–64 8. Tooth loss increases with advancing age (Table Data available from a field survey in Gujarat, H aryana 20). Loss of the teeth results in decreased m asticatory and Delhi are presented in Tables 22, 23 and 24, respectively. Distribution of fluoride analysis of ground water samples from different States of India Number of Fluoride Fluoride Fluoride Maximum fluoride States water samples <1. Distribution of fluoride analysis of ground water samples from different States of India Number of Fluoride Fluoride Fluoride Maximum fluoride States water samples <1. Incidence of dental fluorosis in two villages in Haryana Drinking water fluoride Incidence of dental Village level (mg/L) fluorosis (%) Sotai 1. Sponsored by the Task Force on Safe Drinking Water, Government of India, 2003) Oral cancer N ational Cancer Registries in M um bai and Chennai for the period 1988–92 is shown in Tables 28 and 29, In India, the incidence of oral cancer is the highest in the respectively. O verall, the incidence per 100,000 m ost im portant of all prem alignant lesions is oral population is 29 for males and 14. Given the large population of India, the paan m asala and gutka by persons of all age groups, actual num ber of cases of oral cancer is gigantic. The prevalence of oral cancer reported by Population- 1994 5961 Bihar, Gujarat, Himachal Pradesh and Maharashtra 1995 6794 Bihar, Gujarat and West Bengal based Cancer Registries is given in Table 27. A sum m ary 1996 9444 Bihar, Gujarat, Tripura and West Bengal of annual incidence of oral cancer of different sites from 1997 9165 Andhra Pradesh, Bihar, Gujarat and West Bengal Table 25. Oral cancer in Chennai (1988–1992) Age group Site of cancer Age group Site of cancer (years) Sex Lip Tongue Salivary gland Mouth (years) Sex Lip Tongue Salivary gland Mouth 0–4 M · · 0. N ational Cancer Registry Program m e, Indian Council of M edical tongue, oral cavity, pharynx (including oropharynx and Research. Number and relative proportion (%) of specific sites of cancer related to the use of tobacco relative to all sites of cancer Bangalore Barshi Bhopal Chennai Delhi Mumbai Site of cancer No. Prevalence Age group Prevalence (in lakh) Categories (%) (years) 2000 2005 2010 2015 Dental caries 50. If minor periodontal diseases are included, the proportion of population above the age of 15 years with this disease could be 80%–90%. The projections may best be viewed as upper bound except for severe periodontal diseases and oral cancers, which are lower bound. Abstract Background: Trauma in general is a major cause of morbidity and mortality worldwide, and causes more loss of productive years than ischemic heart disease and malignancy together. Cardiothoracic trauma occurs in 60% of multitrauma patients and is 2-3 times more common than intra-abdominal visceral injuries.

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