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By B. Koraz. College of Saint Benedict.

Except one generic tenormin 100 mg on-line, others do not require notification to the health authorities a) Malaria b) Yellow fever c) Plague d) B and C e) Schistosomiasis 4 buy tenormin 50 mg overnight delivery. During sexual intercourse there is close body contact discount 50mg tenormin otc, which is an ideal situation for 127 Communicable Disease Control transmission buy cheap tenormin 100mg online. Therefore transmission of these agents from one person to another can only occur under very special circumstances, mostly during sexual intercourse. They may be professional prostitutes, barmaids, or persons who in other ways gain from casual sexual relationships. Marital status: unmarried people who often change their sexual partners are more frequently exposed. Occupation: soldiers, policemen, students, seasonal laborers, and other people who are temporarily away from home tend to expose themselves more easily. Residence: Due to industrialization and consequent urbanization there is usually a large group of single young men in towns. Women in towns may have more difficulty 128 Communicable Disease Control in earning their daily living than women in rural areas and may take up prostitution for money. Reservoir - Humans Mode of transmission:- by direct contact with lesion mainly during sexual intercourse. Period of communicability – variable and indefinite, during primary and secondary stages and also in mucocutaneous recurrences that may occur during the first 4 years of latency. Extent of communicability through sexual activity during this latent period is not established. Susceptibility and resistance – Susceptibility is universal, although only approximately 30% of exposures result in infection. Clinical Manifestation The clinical presentation is divided into three groups: a) Primary syphilis – consists of hard chancre, the primary lesion of syphilis, together with regional lymphadenitis. The hard chancre is a single, painless ulcer on the genitalia or elsewhere (lips, tongue, breasts) and heals spontaneously in a few weeks without treatment. These early skin lesions are highly infective and many spirochetes are demonstrated in them. Other disabling manifestations occur in the cardiovascular system (aortic incompetence, aneurysms) or central nervous system (dementia paralytica, tabes dorsalis). Diagnosis Serological test – will be positive 6 to 8 weeks after infection Dark field microscopy of smears from primary lesion (hard chancre) or from skin lesions in the early secondary stage will show the spirochaetes. Haemophilus ducreyi, the Ducrey bacillus Epidemiology Occurrence – endemic in many developing countries. Reservoir – Humans Mode of transmission – by direct sexual contact with discharges from open lesion and pus from buboes. Period of communicability – until healed and as long as the infectious agent persists in the original lesion or discharging 133 Communicable Disease Control regional lymph nodes, which lasts for several weeks or months without antibiotic treatment. Clinical manifestation Classic Chancroid ulcer begins as a tender papule that ulcerates within 24 hours. Diagnosis Clinical, but always rule out syphilis Gram stain of smear from ulcer shows typical rods in chain Culture. Do not incise lymph nodes even with fluctuation because they will completely heal with treatment. Thorough washing of genitalia with soap and water promptly after intercourse is very effective. Definition A venereal disease caused by chlamydia microorganisms, most commonly manifested by acute inguinal lymph adenitis. Infectious agent Chlamydia trachomatis (L Ll 2 and L3) Epidemiology Occurrence – Common in most parts of the world but very common in tropical and subtropical regions of Africa and Asia. Its incidence is more common in males than females, and is lower than Gonorrhea and Chancroid. Reservoir- Humans often asymptomatic (particularly in females) 135 Communicable Disease Control Mode of transmission- Direct contact with open lesions of infected people, usually during sexual intercourse. Period of communicability – variable, from weeks to years, during presence of active lesions. Clinical manifestation Lymph adenopathy with non-specific symptoms of fever, chills, head ache, malaise, anorexia and weight loss. Prevalence is greater (up to 60%) in 137 Communicable Disease Control lower socio-economic groups and persons with multiple sexual partners. Transmission to the neonate usually occurs via the infected birth canal, but less commonly occurs intrauterine or postpartum Incubation period – 2 – 12 Days Period of communicability – Patients with primary genital lesions are infective for about 7 –12 days, with recurrent disease for 4 days to a week. Clinical manifestation First – episode primary genital herpes is characterized by fever, head ache, malaise and myalgias Pain, itching, dysuria, vaginal and urethral discharge, and tender inguinal lymph adenopthy are the predominant local symptoms. Infectious agent Candida albicans (most common cause) Candida tropicalis (rare cause) 139 Communicable Disease Control Epidemiology Occurrence – Worldwide. Reservoirs – Humans Mode of transmission – contact with secretions or excretions of mouth, skin, vagina and feces, from patients or carriers. Susceptibility and resistance – Susceptibility is very low except in low host defense. Oral contraceptive users, individuals with prolonged steroid therapy are susceptible. Clinical manifestation Severe vulvar pruritis (prominent feature) vaginal discharge (scanty, whitish, yellow, thick to form curds, non-offensive) sore vulva due to itching speculum examination – thick whitish plugs attached to vaginal wall 140 Communicable Disease Control vaginal epithlium bleeds when the plug is removed but the cervix is normal Diagnosis Based on clinical grounds Microscopic demonstration of pseudohyphae or yeast cells in infected tissue or body fluids (vaginal discharge) Culture (vaginal discharge) Treatment 1. Infectious agent Neisseria gonorrhea, the gonococcus 141 Communicable Disease Control Epidemiology Occurrence – worldwide, affecting both genders, especially sexually active adolescents and young adults. In most industrialized countries, the incidence has decreased during the past two decades. Reservoir - Strictly a human disease Mode of transmission - almost always as a result of sexual activity Incubation period - usually 2-7 days Period of communicability - may extend for months in untreated individuals. Clinical manifestations Males- Usually involves the urethra resulting in purulent discharge, dysurea and frequency. Most common site of infection is cervix, followed by urethra, anal canal and pharynx. Salpingitis as a complication 142 Communicable Disease Control occurs in 20% of women. Neonates borne to infected mothers develop a purulent discharge which exudes from between eyelids which are edematous and erythematous 2 -3 days postpartum. Diagnosis Gram stain of discharge (urethral, cervical, conjuctival discharge) Culture on selective media Treatment 1. Infectious agent Trichomonas vaginalis, a flagellate protozoan 143 Communicable Disease Control Epidemiology Occurrence - worldwide spread, a frequent disease of all continents and all races, primarily of adults, with the highest incidence among females 16 - 35 years. Overall, about 20% of females may become infected during their reproductive years. Mode of transmission- by contact with vaginal and urethral discharges of infected people during sexual intercourse. Period of communicability - the duration of the persistent infection, which may last for years. Susceptibility and resistance -Infection is general, but clinical disease is seen mainly in females. Clinical manifestation Most men remain asymptomatic although some develop arthritis, and a few have epididymitis or prostatitis.

The branches have irregular flat expansions that tend to be close to the internal surface of the villus epithelium tenormin 50 mg otc. Each villus afferent fiber typically innervates a cluster of two or more neighboring villi trusted 50mg tenormin. The crypt afferents form subepithelial rings of varicose processes below the 3 The Enteric Nervous System and Gastrointestinal Innervation: Integrated buy 100 mg tenormin overnight delivery. Assessment of single fibers filled by anterograde transport indicates that the villus and crypt afferents are independent endings of different vagal sensory neurons [13] cheap 50mg tenormin fast delivery. Vagal Efferent Pathways The vagal efferent pathways arise from the dorsal motor nucleus of the vagus and the nucleus ambiguus. Most of these neurons are pre-enteric, that is, they form synapses with neurons in enteric ganglia, but some run directly to the striated muscle cells of the esophagus. The major roles of the vagal innervation are to control esophageal propulsion, to relax the lower esophageal sphincter for swallowed food to pass, to increase gastric capacity, to facilitate antral contractions, to relax the pylorus, to increase gastric acid secretion, to contract the gallbladder and to promote pancreatic exocrine secretion (Fig. Intracellular micro- electrode recordings from individual gastric enteric neurons indicate that the majority, at least 2/3, of gastric myenteric neurons receive direct cholinergic excitatory synaptic inputs from pre-enteric vagal neurons [22]. These experiments were done by stimulating a vagal branch connected to an isolated region of gastric corpus. It is possible that not all inputs to each neuron were retained or effectively stimulated, so the data might underestimate the numbers of neurons receiving direct excitatory inputs from the vagus. Structural studies also indicate that the majority of gastric neurons receive vagal input, and even suggest that the vagal inputs out- number those that arise from intrinsic gastric neurons [23–26]. Surprisingly, only about 10 % of myenteric ganglia in the striated muscle part of the esophagus receive vagal efferent inputs [26]. Comparable analyses of projections of vagal pre-enteric neurons to the small intestine do not appear to have been made. However, tracing studies indicate that there is a sparse vagal innervation of myenteric and submucosal ganglia in the small intestine [25]. Consistent with a minor vagal influence, structural and functional investigations of nerve circuits in the small intestine indicate that there is a predominance of local connections made with enteric neurons [27]. In contrast, vagal pre-enteric neurons innervate all intrinsic neurons in the bladder [28]. The exocrine pancreas has a strong reliance on vagal control [29], suggesting that here also there are pre-enteric inputs to a high proportion of pancreatic neurons. The greater splanchnic nerve that supplies the upper abdomen contains about 3,000–4,000 afferent fibers and the lumbar splanchnic nerves contain about 4,000–5,000 afferent 46 J. A high proportion of the afferent neuron endings is around arterioles in the gut wall [7]. The axons of spinal afferent neurons also provide a sparse network of varicose axons in the myenteric ganglia [30, 33]. Thoracolumbar afferent endings also branch within the lamina propria of the mucosa throughout the gastrointestinal tract, although their branching patterns have not been defined [7]. As they pass through sympathetic prevertebral ganglia, the axons of spinal afferent neurons provide collaterals that form synapses with cell bodies of postganglionic neurons [34]. In fact, it seems remarkably insensitive to stimuli, such as cutting, that would cause pain elsewhere. Gastrointestinal pain is associated with inflammation, and post- inflammatory disorders [35, 36]. Experimental studies indicate that inflammation causes long term changes in the properties of spinal afferents, that causes unresponsive neurons to become sensitive and responsive neurons to become hypersensitive [37, 38]. The sympathetic efferent pathways have four primary targets: myenteric ganglia, submucosal ganglia, blood vessels and sphincter muscle (Fig. The preganglionic sympathetic neurons have their cell bodies in the intermediolateral columns of the spinal cord. Postganglionic neurons of vasoconstrictor pathways are in sympathetic chain and prevertebral ganglia. Postganglionic (pre-enteric) neurons with cell bodies in prevertebral ganglia provide a dense innervation of myenteric and submucosal ganglia. In both cases these are inhibitory; the sympathetic inner- vation of myenteric ganglia inhibits excitatory effects of enteric neurons on the muscle of the stomach and intestine, thus slowing passage of the contents of the gastrointestinal tract [39]. The innervation of submucosal ganglia inhibits secretomotor neuron activity (see later section “Neural Control of Fluid Movement: Secretomotor and Vasomotor Reflexes”). Sympathetic post-ganglionic neurons contract the sphincters of the gastrointestinal tract, which, like the innervation of myenteric ganglia, inhibits transit of contents. Pelvic Innervation The distal colon and rectum are provided with afferent and efferent innervation via the pelvic nerves and sacral plexuses. The pelvic nerves are commonly regarded as providing an innervation to the distal gut similar to that provided by the vagus to the proximal gut. However, unlike the vagal afferent nerves, the pelvic afferents include pain fibers [40]. This diagram illustrates the inner- vation pathways for the non-sphincter regions of the stomach, small and large intestines. The densest innervation is of the myenteric ganglia throughout these regions, the submucosal ganglia of the small and large intestines, and intramural arteries. Few sympathetic fibers innervate the muscle of non-sphincter regions, whereas the sphincter muscle is densely innervated. The post- ganglionic neurons that innervate gut effectors have noradrenaline as their primary transmitter. The participation of the sympathetic innervation of the gastrointestinal tract in disease states. It is established that the pelvic nerves carry afferent information from low threshold mechanoreceptors. Mucosal mechanoreceptors in the large intestine are similar to those in the stomach and proximal small intestine, in that they respond to mild stroking of the mucosa, but not to distension or contraction of the colon [45]. The efferent pathways in pelvic nerves provide innervation to enteric ganglia of the distal colon and rectum [46]. Retrograde tracing indicates that nerve cells in the sacral spinal cord project directly to the colon, and that there are also nerve cells that project from the pelvic ganglia to the colon [47], suggesting that pre-enteric neurons are in both the spinal cord and in pelvic ganglia (Fig. For motility control, the innervation of enteric ganglia comes from the defecation centers that are in the lumbosacral spinal cord, between L5 and S3 (the levels being slightly different between species) [48]. In the rat the center is located primarily at L6-S1 [49–51] and in the guinea-pig at S1–S2 [47]. Reflexes through this center can be initiated by irritation or distension of the rectum; they persist after transection of the more rostral spinal cord, but are eliminated by section of the sacral outflows or the pelvic nerves [48, 52, 53]. In healthy individuals, the propulsive reflexes of the distal colon and rectum are kept in check to maintain fecal continence by central control centers that relay in the spinal defection center, and when defecation is appropriate it is triggered by central commands that impinge on the defecation center. Voluntary control of defecation (both inhibition and facilitation) is lost if cortico-spinal connections to the defecation centers are severed by spinal injury [55]. The pelvic pathways also carry pathways that cause vasodilation in the colorectum [57].

Some people may have some Keep in mind that forgetting some trouble with attention tenormin 100mg otc, thinking information sometimes is normal and memory purchase tenormin 100 mg on-line. Dementia refers to a much more serious failing of memory and thinking skills that affects day-to-day activities generic tenormin 100mg with mastercard. Changes in mental ability happen There are some very early studies as the disease starts to spread into (not yet proven in Parkinson’s) order tenormin 100mg with mastercard, the parts of your brain that control which suggest that the following may attention, thinking and memory. You will need to discuss strategies, supportive care and other resources to help you manage. If you are starting to have more serious memory problems, make sure that: • A trusted caregiver has power of attorney. In case you are no longer able, power of attorney will give this person the right to speak for you, arrange your fnances, pay your bills and more. You will not be able to change your will if you have severe attention, thinking or memory problems. Medications, such as rivastigmine (Exelon), galantamine (Reminyl) and donepezil (Aricept), can help. For this reason, always make sure your doctor knows about all the medications you are taking. Key points * Common changes include problems with memory, planning, attention, and slowing of thoughts. Some medications can sometimes cause attention, thinking and memory problems or make them worse. On its own, this does not mean you have dementia or any other thinking and attention problems. As these problems often blend together, they will be covered together in this section. If you are depressed, you may not Apathy is the feeling of no interest be able to experience joy. You might stop may feel tired all the time (although hobbies that you once enjoyed, or feeling tired can happen even with not want to carry out your day-to- normal mood). Apathy may be part of depression, but can also be a If you have anxiety, you may fnd separate problem. Often, family yourself worrying about everyday members can feel very frustrated by things, even things that you should this. Living with Parkinson’s disease can This is actually your body playing a certainly lead to stress and sadness. When your medications However, depression may also be wear off, the muscles in your chest caused by changes in areas of the wall can tighten. This feeling will pass when your Sometimes, you may feel that you medications kick in again. The support of your friends and family can make a big difference in preventing or curbing the effects of depression and anxiety. In some cases, you may fnd it helpful to speak with a psychologist or another mental health professional. Certain types of psychological therapy (the commonest being “cognitive behavioural therapy”) have been shown to help depression, although they have not yet been proven to help depression in Parkinson’s. Key points * Depression and anxiety can sometimes begin before you have any movement problems. Your doctor may suggest depression medications or adjust your dopamine medications. Hallucinations mean hearing or For example, you might notice a spot seeing things that are not really on the foor or the wall that moves or there. If hallucinations than feeling disoriented, having vivid continue to get worse, you may see dreams, or having false beliefs. In Parkinson’s, people are more At frst, you may be aware that these likely to have visual hallucinations, hallucinations are not real. They can be related to what you are seeing, and be a way that you ‘make sense’ of it. Examples of common delusions are: believing that other people are living in your house, that a spouse is cheating or that something has been stolen. This may also be caused by the disease moving into the areas of your brain that are involved in making sense of what you see. For some people who are only taking only low doses of medications, delusions and hallucinations usually happen when they are experiencing changes in their mental ability. That is, they may actually be having attention, thinking and/or memory problems (see page 98 to learn more about this). Either way, no matter how minor or serious these problems might be, it is important to discuss them with your health care team. If hallucinations are a problem, Another treatment option is to use your doctor may try lowering the the medications that boost your strength (dose) of some of your memory and cognition (see previous medications. Even if your cognition is movement problems worse or does only mildly decreased, they often not help, your doctor may prescribe help a lot. To keep this from happening, your doctor will ask you to take regular blood tests so that he or she can watch this closely. He or she may suggest lowering some of your medications, or starting new medications, (e. This problem affects 1 in 8 people who are taking certain Parkinson’s medications called dopamine agonists. These can include: • Excessive gambling • Hyper-sexuality – This refers to feeling preoccupied with sexual feelings and thoughts and/or having much more interest in sexual arousal. This can lead to sexual behavior that is ‘out of character’, or that might be harmful to yourself or others. Certain dopamine medications (Pramipexole (Mirapex), ropinirole (Requip) and rotigotine patch) are most likely to cause you to have trouble controlling your impulses. Since this is usually a medication side effect, your doctor will usually lower the strength (dose) or your medications. Sometimes, though, when medications are stopped or adjusted, your movement problems can become worse. This way, they can make sure that your health care team is aware and you can get the help you need. Almost all people with Parkinson’s will have changes in the ability to smell, and 1 out of 3 people will have no sense of smell at all. You may also notice changes in taste, as your sense of smell is directly linked to taste. People do not often notice these changes right away as they come on slowly over time.

In certain cases order tenormin 100 mg otc, other individuals who have contributed meaningfully and meet journal eligibility for co-authorship may also be included discount 100mg tenormin with mastercard. Any Core Analytic Theam member who contributed intellectually to the development of new covariates that were used to generate the estimates of non-fatal health outcomes or causes of death purchase 50mg tenormin mastercard. In certain cases cheap tenormin 50mg with amex, other individuals who have contributed meaningfully and meet journal eligibility for co-authorship may also be included. Any Core Analytic Theam member who contributed intellectually to the development of new covariates that were used to generate the estimates of risk factors. In certain cases, other individuals who have contributed meaningfully and meet journal eligibility for co-authorship may also be included. Given the large authorship on the capstone papers the following authorship order is anticipated: • First author: the lead of the research presented in the capstone paper 37 • Additional lead authors, when appropriate: given the robust scope of these papers there may be additional research leads listed at the beginning of the manuscript • Co-authors: the bulk of the co-authors will be listed next in alphabetical order • Senior author(s): given the robust scope of these papers there may be more than one senior author listed last • Corresponding author: responsible for managing the publication submission process, responding to feedback to reviewers, and finalizing accepted papers with editors of the relevant journal. All eligible authors will need to submit an authorship form in accordance with the journal regulations in order to be included. All authors will have the opportunity to opt out of being included on the publication prior to the time the manuscript is accepted. Disease-specific, Risk Factor-Specific, Disability Weight, and General Methodology Papers We highly encourage the publication of a robust set of additional manuscripts. We envision that a large range of publications will be drafted that examine more closely: 1) the results and trends for specific diseases, injuries, or risk factors, 2) data sources, lay descriptions, or methodological enhancements for disability weights, and/or 3) innovations in methodology used. Eligibility for co-authorship will follow the principles as outlined in the requirements of the peer- reviewed journal to which a given publication in submitted. In certain cases, other individuals who have contributed meaningfully and meet journal eligibility for co-authorship may also be included. All eligible co-authors will have the opportunity to contribute to the draft manuscript and comment on the accepted manuscript. In some cases, a paper may require novel analyses to be conducted to produce the results that are desired. In such cases, the authoring Core Analytic Theam member(s) will be responsible for carrying out such analyses. Policy Reports and Briefs In addition to the more traditional, peer-reviewed academic publications, there are likely to be publications that are intended to reach non-academic audiences such as policymakers and donors. They may summarize results overall or for a specific region, disease, injury, or risk factor. During this period there will be no specific author attribution on these publications. Individuals who play a significant role in the content creation and assembly will be noted in the acknowledgements of the publication. In general, authorship on the abstract should follow the same principles as described above for the appropriate topic-specific subcategory of peer-reviewed publications. Presentations Individuals may also wish to give presentations about analyses or methods in different venues. In addition, the presentation must include the full study citation listed near the beginning of the “Publications and Presentations” section. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Common values in assessing health outcomes from disease and injury: disability weights measurement study for the Global Burden of Disease Study 2010. Healthy life expectancy for 187 countries, 1990–2010: a systematic analysis for the Global Burden Disease Study 2010. Age-specific and sex-specific mortality in 187 countries, 1970–2010: a systematic analysis for the Global Burden of Disease Study 2010. Contact us at: a non-proft, volunteer-driven organization dedicated to fnding the cures for Crohn’s disease and ulcerative 888. Today, we fund cutting-edge studies at major medical institutions, nurture investigators at the early stages of their careers, and fnance underdeveloped areas of research. The Crohn’s & Colitis Foundation of America provides information for educational purposes only. We encourage patients to review this educational material with their healthcare professional. The Foun- dation does not provide medical or other healthcare opinions or services. The inclusion of another organization’s resources or referral to another organization does not represent an endorsement of a particular individual, group, company, or product. Investi- gation of these genes will revolutionize our under- standing of Crohn’s disease and ulcerative colitis and form the basis for discovering new drugs and diagnostics. These chronic, life-long conditions be of use to patients and their families, as well as can be treated but not cured. It most commonly affects the 3 5 Small Intestine end of the small intestine (the ileum) where it joins the 4 beginning of the colon. In 5 7 8 Rectum Crohn’s disease, the infammation may extend through 6 the entire thickness of the bowel wall. It usually begins in the rectum and lower colon, but may also spread continuously to involve the entire colon. The immune system usually attacks and kills Reports of a disease with similar symptoms to ulcer- foreign invaders, such as bacteria, viruses, fungi, and ative colitis date back to before the Civil War and even other microorganisms. Crohn’s disease was frst described in 1932 by three This abnormal immune system reaction occurs in peo- doctors—Burrill Crohn, Leon Ginzberg, and Gordon ple who have inherited genes that make them suscep- D. Unidentifed environmental factors serve intestine was thought to be intestinal tuberculosis. They described a new disease entity, which was Immune Genetic frst called regional ileitis, and later, Crohn’s disease. Most people and ulcerative colitis are chronic illnesses, and changes with Crohn’s disease or ulcerative colitis experience an are likely to occur over time. Symptoms may recur at urgency to have a bowel movement and have crampy times and complications may develop. These can join Symptom Recurrence together and become large ulcers that bleed, result- ing in bloody stools. Seventy percent of patients who have active disease in a given year will have another episode of active disease in the following year. Only 30% of those in remission Symptoms related General symptoms in a given year will have active disease in the following to infammation of that may also be year. With medical and/or surgical treatment: • About 50% of patients will be in remission or have mild disease over the next fve years • 45% of those in remission will remain relapse-free over the next year • 35% will have one or two relapses • 11% will have chronically active disease For a Crohn’s disease patient in remission, relapse 7 rates at one, two, fve, and ten years are estimated at 20%, 40%, 67%, and 76%, respectively. Death due specifcally to Crohn’s disease or its compli- • Stricture—a narrowing of a section of intestine cations is uncommon. However, people with Crohn’s caused by scarring, which can lead to an intestinal disease have a slightly higher overall mortality rate blockage than the general healthy population.

A good monitoring system makes it possible to Individual health facilities are the end users of medi- estimate realistic delivery times and to decide whether any cal supplies cheap tenormin 100mg visa. Maintaining information from health facili- supplementary or emergency orders are needed purchase tenormin 100 mg on-line, well before ties is essential in order to monitor consumption generic tenormin 100 mg overnight delivery, forecast a stockout occurs discount 50mg tenormin with visa. Many medical stores information systems milestones during the lead-time period to facilitate com- also keep general information on facility location, facility munication with suppliers and to prompt corrective action status, population served, method of distribution, delivery if required. Important milestones of the procurement lead schedule, value of issues, and extent of current budget uti- time are— lization. Stock records are a vital source of information on how efectively the dis- An efective supplier information system should include tribution system is being managed; therefore, maintain- general information on suppliers and products, lead times, ing these records accurately and keeping them up-to-date merit ratings, value of purchases, product quality, payment is vital. They provide detailed evidence of how prod- methods, and prequalifcation based on good manufac- ucts fow through the system and can be used to identify turing practices. Information about supplier performance where problems are occurring so that corrective action should be compiled throughout the procurement cycle to can be taken. Chapter 21 discusses at two critical levels: from the supplier to the store, or the features of a procurement information system in more “upstream,” and from the store to clients, or “downstream. Upstream information includes lead-time from supplier to the store, number of medicines procured, and monthly Stock records stock status reports. At the downstream level, the store should collect routine lead-time information; distribution Stock records contain information about suppliers, custom- information by facility, district, and product; client sat- ers, prices, stock receipts, stock issues, stock losses, and stock isfaction and consumption data; and order-fll rate. The medical stores A stock record (manual or computerized) must be main- should prepare regular reports on stock and order status, tained for each item in the inventory. The stock record docu- such as those described in Chapter 23, and send them ments all transactions relating to an item. It may contain to relevant parties such as the ministry of health, pub- information about reorder level, reorder interval, reorder lic health programs, donors, lower-level warehouses, and quantity, lead time, stock on order, and estimated consump- health facilities. Many stores also maintain bin cards for each prod- uct in each storage area to record information on issues, Communications receipts, and stock balances. In some stores, this bin card is the most current and accurate record of inventory move- The medical stores must maintain efective communica- ment. Periodic the design, selection, and use of diferent types of inventory meetings with the staf members of client facilities can help control systems, see Chapter 23; examples of a stock record ensure good communications and a more efective supply card and a bin card are provided in Annexes 44-1 and 44-2. Order assembly: Individual orders are assembled and Examples of monitoring and evaluation checked in the packing area. Dispatch and delivery: The packed goods are held • Number of sites to which medicines are in designated secure areas pending shipment, then distributed loaded onto the transport and dispatched, accom- • Quarterly report delivered on time panied by the necessary documentation, including a • Payment voucher processing time packing list recording all items and quantities. Ideally, • Number of patients receiving treatment an invoice showing unit costs of medicines and total • Percentage of medicines that are wasted (as value should accompany the shipment. Signed delivery a result of breakages, expiries, pilferage) as a notes are checked when the vehicle returns. If errors proportion of overall stocks or damage have been reported, appropriate action is • Time elapsed from order receipt by store until taken. Port • Percentage of cost savings as a result of price clearing may, however, be contracted to a clearing agent or negotiations made the responsibility of the supplier. With the exception of locally purchased items, multiple Stock, and the information that accompanies it, should fow copies of the supplier’s shipping documents and supplier’s through the warehouse in an orderly manner. This information is recorded on a man- ual or computerized form to track each purchase order. Receiving: Goods that arrive in the receiving room are addition, the import unit should record the arrival informa- quarantined, inspected, and if found to be acceptable, tion. This advisory is clipped to the purchase order in the entered into the stock-recording system. Storage: Accepted goods are moved to their allocated the necessary customs forms are completed. Records for stocks on hand and on Containers are inspected against the supplier’s shipping order are adjusted. Any apparent damage and missing shipping determines whether to allocate the complete quantities cases are noted and reported to the port authorities, insur- requested when a requisition is received. Workers use this list to identify and col- predefned criteria is essential to quality assurance and as a 44. The annotated invoice is signed and dated by a senior staf In addition, managing these “strategic” stocks can be chal- member. Observations are summarized on the second part lenging; for example, in the case of what to do with “dead” of the receiving report. Stores, therefore, need to work One copy of the receiving report is fled according to the carefully with their clients to communicate about scale-up purchase order number to which it corresponds. The other of initiatives such as antiretroviral therapy and distribu- copy and the annotated supplier’s invoice are passed to the tion of bed nets to prevent malaria that will afect space and stock control section. In some warehouses, a separate copy distribution planning and to develop policies on managing goes to the accounting department. The new stock on hand and on order Stock storage totals are calculated, as well as the average cost per unit for each item. If a computerized system is used, receipts are Afer incoming stock has been checked and approved, it is entered into the system as prescribed in the sofware manual. New stock Planning for space requirements may be stored on foor pallets, pallet racks, or shelves. If a bin funding for pharmaceuticals from global health initiatives card system is in use, receipts should be entered on the bin such as the Global Fund and the U. Table 44-1 Inspection checklist for medicine receipts Product Notes Checklist all shipments compare the goods with the supplier’s invoice ❏ number of containers delivered is correct and original purchase order or contract. Stock must be stored so that earliest- is also assigned the responsibility of managing these prod- expiring or frst-delivered batches can be picked and issued ucts. When small quantities are involved, this goal can be picking list for a given customer into several smaller pick- achieved by placing the newly received stock at the back of ing lists, according to the number of separate storerooms or the shelf behind the existing stock. A similar approach would be needed when gen- are involved—for example, several pallet loads—the newly erating goods received notes and transferring fresh supplies received items can be placed on the upper levels of the pallet to individual storage areas. They remain there until the older stock has been If bin cards are used, the stock issued should be recorded issued. The picking stock is kept in an accessible position, on the bin card as it is pulled from the storage area. In warehouses where whole pallet loads are Order assembly picked for distribution to lower-level stores, accessibility is less of a concern because mechanical transporters are used. At a secured shipping location, the supplies are arranged Newly arrived stock sometimes has an earlier expiry date in the order in which they appear on the picking list or than a previously received batch of the same item. The order is double checked by the system is used, this stock should be “promoted” so that it is storekeeper or shipping clerk before the items are packed, issued before later-expiring stock. Some items, such as vac- is particularly important with products that have short shelf cines and controlled substances, require special packing and lives, such as vaccines. Note that the system for stock rotation may be determined by the scheme for price increases, if medicines are sold to Order dispatch and delivery clients. In some instances, a collection system may be Order allocation used, whereby representatives from health facilities col- lect supplies from the store. The shipping clerk completes a Under a pull distribution system, lower-level stores and delivery voucher (Annex 44-5).

The agent that causes malaria (a parasite that must live in two different hosts--mosquitoes and man- -at different periods of its life cycle) is an example of such an organism purchase 50mg tenormin fast delivery. For some infectious agents cheap tenormin 50 mg fast delivery, either man or another animal can serve as reservoirs of infection buy tenormin 100 mg cheap. Fungi (such as those causing coccidioidomycosis discount tenormin 50mg on-line, histoplasmosis, and blastomycosis) and molds are found in soil and dust or on vegetation grown in endemic areas (places where the diseases are common). Certain species of bacteria that form spores also are found in the soil, but only if the soil has been 2-4 contaminated previously with the spores. Thetanus (lockjaw) and anthrax are examples of diseases that may be acquired through exposure to the environment. Portals of Entry and Exit Portals of entry and exit are the routes through which the infectious agent enters and exits the body of the host. Portals of entry and exit in the human body include the respiratory, digestive, and urinary systems, as well as the skin (including mucous surfaces such as the eye), wounds, and blood. Often the causative organism enters and exits the body through the part of the body primarily involved in the disease process. This is true, for example, for illnesses such as the common cold as well as other respiratory and digestive system diseases. Conversely, the portal of entry may have no relation to the organ system involved in the disease. For example, the infectious agents for malaria and yellow fever, transmitted by mosquitoes, enter and leave the host through the skin, but involve other areas of the body (such as the liver and brain) in the disease process. Modes Of Transmission The main modes of transmission of communicable diseases are person-to-person, common vehicle, airborne, vector-borne, sexual contact, and blood-borne spread. The chain of transmission of an illness can be broken by interrupting the route of transmission. Person-to-person spread occurs when the source and the host come in direct physical contact. This includes fecal-oral spread, in which fecal material from an infected person is transferred to the mouth of an uninfected person, usually by unwashed hands. The hands are often contaminated by touching an item, such as soiled clothing, and then touching the hands to the mouth. Examples of diseases spread from person-to-person include giardiasis, hepatitis A, rotavirus, and shigellosis. Common vehicle spread results when a single inanimate vehicle serves as the source of transmission of the infectious agent to multiple persons. Diseases transmitted through contaminated food and water include botulism, salmonellosis, campylobacteriosis, cholera, and Escherichia coli O157:H7. Airborne spread of disease consists of transmission of the infectious agent by droplets or dust. Droplets are produced whenever someone breathes out; these may be projected greater distances by a cough or a sneeze. Once the moisture in the droplets evaporates, bacteria and viruses form droplet nuclei (tiny particles that can float in the air) that may subsequently be inhaled by susceptible hosts. Diseases spread by the airborne route include tuberculosis, legionellosis, pertussis, measles, rubella, and chickenpox. Mechanical transmission occurs when the contaminated mouth or feet of an insect vector physically transfers the infectious organism to the host or to food. For example, houseflies can carry diarrhea-causing bacteria from human waste to human food. With biologic transmission, the vector (for example, the mosquito) carries the infectious agent within its body, and the agent passes through the skin via an insect bite. Examples of vector-borne diseases include Lyme disease, plague, and Rocky Mountain spotted fever. Sexually transmitted diseases are spread through sexual contact, either heterosexual or homosexual. Blood-borne diseases are transmitted by contact with blood from an infected patient. This mode of transmission usually occurs in the health-care setting, with infusion of contaminated blood products or by skin puncture with a contaminated syringe. Sharing of needles among injecting drug users also transmits blood-borne diseases. Even when the source of an outbreak is unknown, understanding and interrupting the most likely route of transmission can prevent further disease. Host Immunity and Resistance The host is the person or organism susceptible to the effect of the infectious agent. The general health status of the host, his/her genetic makeup, as well as other factors determine susceptibility to disease. Host defenses that contribute to resistance to infection include: Mechanical barriers (i. Thears, urine, digestive juices, perspiration, and respiratory mucus contain enzymes, acid, and nonspecific antibodies (a type of protein produced by the immune system) that combat infection. Certain cells of the immune system, found throughout the body, that remove infecting organisms from the body by engulfing and destroying them, in a process known as phagocytosis. Competition between normal, non-disease-causing (commensal) microorganisms normally found in the gut or on the skin and pathogenic (disease-causing) organisms to which the host is exposed. These defenses may be overcome by exposure to a large number of organisms or repeated exposure over an extended period of time. Defense mechanisms may 2-6 diminish when another disease-causing infection is occurring at the same time, following previous treatment with antibiotics (which wipes out commensal organisms), or when a breakdown in a barrier exists (such as a skin wound). This type of immunity usually lasts the longest period of time, often for the life of the host. Vaccination with weakened or killed infectious agents leads to active, induced immunity. Injection of antibodies or antitoxin leads to a passive, temporary immunity to an agent. Use of gamma globulin to protect against chicken pox is an example of passive immunity. To find ways to break the chain of disease transmission communicable diseases are prevented by increasing host resistance (through vaccinations); modifying the environment (to eliminate reservoirs or to interrupt transmission); inactivating the infectious agent. Vaccination Seagoing persons should be appropriately vaccinated against all diseases traditionally occurring during childhood (diphtheria, tetanus, poliomyelitis, measles, mumps, rubella, and chicken pox) and should consider vaccination to prevent hepatitis A and B. Though vaccines have reduced the occurrence of many of these diseases worldwide, susceptible travelers may still acquire these diseases. Vaccination against chicken pox is only necessary if there is no history of childhood infection.