Amitriptyline

Liza J. Enriquez, MD

Departments of Anesthesiology
Montefiore Medical Center
Bronx, New York

Transvaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy Aided by Transcervical Instrumental Uterine Manipulation normal depression definition order 50 mg amitriptyline with mastercard. Transvaginal natural orifice transluminal endoscopic surgery: a new approach to ovarian cystectomy bipolar disorder generic 25mg amitriptyline with mastercard. Minimally invasive gynecologic surgery in the pregnant patient: considerations depression quiz free buy generic amitriptyline on-line, techniques mood disorder bipolar purchase amitriptyline toronto, and postoperative management per trimester anxiety shortness of breath amitriptyline 50 mg with mastercard. Obesity in total laparoscopic hysterectomy for early stage endometrial cancer: health gain and inpatient resource use. Infectious complications of laparoscopic and robotic hysterectomy: a systematic literature review and meta-analysis. The feasibility of laparoscopic surgery in gynecologic oncology for obese and morbidly obese patients. Laparoscopic versus robotic hysterectomy in obese and extremely obese patients with endometrial cancer: a multi-institutional analysis. Challenges of robotic gynecologic surgery in morbidly obese patients and how to optimize success. Laparoscopic and robotic hysterectomy in endometrial cancer patients with obesity: a systematic review and meta-analysis of conversions and complications. Impact of robotic platforms on surgical approach and costs in the management of morbidly obese patients with newly diagnosed uterine cancer. A comparison of operative outcomes between standard and robotic laparoscopic surgery for endometrial cancer: a systematic review and metaanalysis. Robotic-assisted vs traditional laparoscopic surgery for endometrial cancer: a randomized controlled trial. Influence of morbid obesity on surgical outcomes in robotic-assisted gynecologic surgery. Presurgical assessment of intraabdominal visceral fat in obese patients with early-stage endometrial cancer treated with laparoscopic approach: relationships with early laparotomic conversions. Impact of obesity on surgical treatment for endometrial cancer: a multicenter study comparing laparoscopy vs open surgery, with propensity-matched analysis. A randomized trial comparing vaginal and laparoscopic hysterectomy vs robot-assisted hysterectomy. Laparoscopic versus open obesity surgery: a meta-analysis of pulmonary complications. Influence of pneumoperitoneum pressure on surgical field during robotic and laparoscopic surgery: a comparative study. A systematic review about costing methodology in robotic surgery: evidence for low quality in most of the studies. Impact of body mass index and operative approach on surgical morbidity and costs in women with endometrial carcinoma and hyperplasia. Comparison of cost and operative outcomes of robotic hysterectomy compared to laparoscopic hysterectomy across different uterine weights. Review of strategies and factors to maximize cost-effectiveness of robotic hysterectomies and myomectomies in benign gynecological disease. An economic analysis of robotic versus laparoscopic surgery for endometrial cancer: costs, charges and reimbursements to hospitals and professionals. Incorporating roboticassisted surgery for endometrial cancer staging: analysis of morbidity and costs. Randomized controlled trial comparing operative times between standard and robot-assisted laparoscopic hysterectomy. Robot-assisted laparoscopy in benign gynecology: advantageous device or controversial gimmick The impact of obesity on surgeon ergonomics in robotic and straight stick laparoscopic surgery J Minim Invasive Gynecol 2019;18S1553-4650(19)30313-9. Laparoscopic hysterectomy is preferred over laparotomy in early endometrial cancer patients, however not cost effective in the very obese. The impact of obesity on surgical outcome in endometrial cancer patients: a systematic review. Robotics in urological surgery: evolution, current status and future perspectives. Robotic surgery in the obese patient: tips and tricks for the benign gynecologist. Comment on the paper by Mondzelewski and Colleagues: "Intraocular pressure during robotic-assisted laparoscopic procedures utilizing steep Trendelenburg positioning. Intraocular pressure during robotic-assisted laparoscopic procedures utilizing steep Trendelenburg positioning. Risks and benefits of prophylactic inferior vena cava filters in patients undergoing bariatric surgery. Concurrent prophylactic placement of inferior vena cava filter in gastric bypass and adjustable banding operations in the Bariatric Outcomes Longitudinal Database. Mechanical bowel preparation before laparoscopic hysterectomy: a randomized controlled trial. Consideration for safe and effective gynaecological laparoscopy in the obese patient. Patient safety incidents associated with obesity: a review of reports to the National Patient Safety Agency and recommendations for hospital practice. Umbilical stalk elevation technique for safer Veress needle insertion in obese patients: a case-control study. Guidelines for daycase surgery 2019: guidelines from the Association of Anaesthetists and the British Association of Day Surgery. Women face a greater risk of thrombosis throughout their reproductive years due to transient risk factors, such as hormonal therapy and pregnancy [9], and this risk is further increased by the presence of obesity [10]. Several mechanisms have been proposed to explain the increased risk of venous and arterial thromboembolism, including increased procoagulant activity, impaired fibrinolysis, increased inflammation, endothelial dysfunction, and altered lipid and glucose metabolism in metabolic syndrome [14]. Enlarged fat cells produce a higher amount of these substances that normal-sized fat cells [13]. A number of these substances are associated with procoagulant activity or inhibition of fibrinolysis [13], and a decrease in blood fibrinolytic activity has been reported in obese patients [5]. In addition, oxidative stress associated with adipose tissue leads to platelet activation, endothelial damage, and the shedding of thrombogenic endothelial cell-derived microparticles [16]. Lastly, obesity can be associated with venous stasis that promotes venous thrombosis [13]. Although poorly studied, larger sized deep veins with reduced flow velocities have been observed in obese subjects [17], and, hypothetically, there may be an additional effect from local compression on veins and valvular dysfunction [18]. However, there are obvious concerns regarding safety of their use when considering the thromboembolic and cardiovascular risks, and some additional concern remains as to whether there is reduced efficacy due to the altered pharmacokinetics associated with obesity [8]. E2 had low bioavailability, but this has been enhanced by micronization and esterification [25]. Focusing on nonoral hormonal contraception, a retrospective study of four national Danish registries, which included 1. Obesity and contraceptive efficacy There is ongoing concern that obese women may experience reduced efficacy and, therefore, contraceptive failure due to differences in pharmacokinetics. The limited available evidence suggests that progesterone-only methods are effective in obesity [19]. Contraception and the fear of weight gain Many women avoid using hormonal contraception due to a belief that contraceptive hormones promote weight gain [31] and perceived weight gain is one of the leading causes of discontinuation [19]. However, both adolescent and reproductive women tend to gain weight over time regardless of contraceptive use, which can make proving a causal association difficult unless accounted for in studies, and perceptions of weight gain while using contraception have been shown to be incongruent with actual weight [19]. The results of Cochrane reviews to evaluate the potential association between contraceptive use, and weight gain have examined combination contraceptive use and progesterone-only contraceptives. They concluded that most comparisons of different combination contraceptives showed no substantial difference in weight and that while available evidence was insufficient to determine the effect of combination contraceptives on weight, no large effect was evident [32]. It is important to note that obese women are underrepresented in the majority of studies researching the impact of contraception on weight [19]. As such, women should be advised that it is possible that medications that induce diarrhea and/or vomiting could reduce the effectiveness of oral contraceptives [19]. Advising on progestinonly contraceptives, the consensus highly recommends desogestrel 75 g as an important and safe option. Obese women now make up an increasing proportion of peri- and postmenopausal women cared for by gynecologists and general practitioners, and while obesity rates are increasing, it is also noteworthy that the natural process of menopause itself may be obesogenic [42]. Intraabdominal fat accumulation rapidly rises in the 2 years before menopause that alters the hormonal milieu and can accelerate the development of metabolic syndrome [42]. Furthermore, obese women may experience more menopausal symptoms when compared to their leaner counterparts. Pharmacological thromboprophylaxis in this context comprises low-molecular-weight heparin or fondaparinux, and the guidelines acknowledge that while higher doses are often used in obesity, there is continued uncertainty about the optimal dose in obese patients [55]. Conclusion the inexorable rise in obesity has significant and widereaching implications for all aspects of health care, and gynecology is no exception. There are limited data for women with obesity, particularly in morbid and supermorbid obesity, and while public health measures aim to tackle the obesity epidemic, the increasing number of these patients offers the chance for further studies. Combined hormonal contraception and the risk of venous thromboembolism: a guideline. Risk of venous thrombosis: obesity and its joint effect with oral contraceptive use and prothrombotic mutations. Visceral adiposity is an independent determinant of hypercoagulability as measured by thrombin generation in morbid obesity. Abdominal obesity and the risk of venous thromboembolism among women: a potential role of interleukin-6. A multicenter randomized clinical trial of etonogestrel and levonorgestrel contraceptive implants with nonrandomized copper intrauterine device controls: effect on weight variations up to 3 years after placement. Weight gain in obese and nonobese adolescent girls initiating depot medroxyprogesterone, oral contraceptive pills, or no hormonal contraceptive method. Obesity and risk of venous thromboembolism among postmenopausal women: differential impact of hormone therapy by route of oestrogen administration. Venous thromboembolism risk in relation to use of different types of postmenopausal hormone therapy in a large prospective study. The effect of estrone on thrombin generation may explain the different thrombotic risk between oral and transdermal hormone replacement therapy. Venous thromboembolism in relation to in vitro fertilization: an approach to determining the incidence and increase in successful cycles. Increased venous thrombosis incidence in pregnancies after in vitro fertilization. Maternal and pregnancy characteristics affect plasma fibrin monomer complexes and D-dimer reference ranges for venous thromboembolism in pregnancy. Body mass index, surgery, and risk of venous thromboembolism in middle-aged women: a cohort study. Venous thromboembolism in ovarian cancer: incidence, risk factors and impact on survival. Chapter 28 Obesity and cardiovascular disease in reproductive health Isioma Okolo1 and Tahir A. Obesity prepregnancy and antenatally is a recognized risk factor for the metabolic syndrome in later life-diabetes, hypertension, and ischemic heart disease. In the most recent 2019 report, one-third of mothers who died were classified as obese [7]. Around 29% of children in the United Kingdom are classified as overweight or obese. It is well recognized that the maternal in utero environment has an impact on fetal programing from neonatal health to long-term adult health [8]. The exact pathways that map this progression of maternal and fetal cardiovascular risk are still not well understood. It is not known to which extent these factors might act as independent contributors to increase morbidity. However, in obese individuals, these risk factors are often cumulative and may act as confounding factors. Lower adiponectin levels found in chronic smokers confirm that they are insulin resistant. Endothelial dysfunction, an early marker of atherosclerosis, is present in obese individuals as well as chronic cigarette smokers. The male-to-female ratio is 2:1 but the gap narrows as women reach postmenopausal age [12]. Being overweight or obese is linked with elevated oxidative stress and systemic inflammation. A decrease in oxidative stress after dietary restriction and weight loss has been reported in obese individuals [12]. Pathogenesis of visceral obesity Adipose tissue is now recognized as a key metabolically active endocrine organ. The amount and distribution of adipose tissue determines the level of metabolic risk.

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References to opium smoking are common in Oriental history depression of 1837 cheap amitriptyline online american express, and some people in Asian countries still smoke opium anxiety yoga amitriptyline 50mg on-line. Users in the Western coun tries depression prayer order amitriptyline 25 mg free shipping, including the United States depression heart disease buy cheap amitriptyline 25 mg line, prefer opium deriv atives such as morphine and heroin mood disorder drugs list purchase amitriptyline in india. Glimpse of the Future Nasal Spray for Overdoses study testing the effectiveness of a nasal spray treatment for victims of drug overdoses is being conducted in the United States. This drug is used at present time to treat overdoses, most commonly those caused by morphine, heroin, and oxycodone. The drug rapidly goes into the bloodstream and effects change within a few seconds to a couple minutes. The hope of the study is that a quicker response might save more lives and that friends and families will be more likely to call 911 and get help for overdose victims if they see the officers as being lifesavers. The results of the study, if positive, might influence other law enforcement departments to use this treatment for overdose victims, hopefully saving more lives. Heroin use usually gives a rush, or intense feeling of well-being, followed by a sleepy, drowsy state. Symptoms of withdrawal include sweating, shaking, diarrhea, vomiting, and sharp pain and cramps in the stomach and legs. Inhalant Abuse Inhalants are chemicals that produce a vapor that can be inhaled and that produce a mind-altering effect. Young people are more likely to abuse inhalants than adults and often treat the use of inhalants as a game or a way to get a cheap high. Inhalants include over 1,000 legal substances, including glue, spray paint, hair spray, nail polish, lighter fluid, and gasoline. These substances commonly contain harmful hydrocarbons and an oily base that, when inhaled, coats the inner lining of the lungs. Inhalant abuse refers to intentionally breathing the vapors of a substance to get high. Bagging is the most dangerous because it entails placing a plastic bag over the head to get a longer effect, thereby increasing the risk of accidental suffocation. Using inhalants over a period of time can result in permanent brain, heart, kidney, and liver damage. Some products, such as paint and gasoline, contain lead and can result in death from lead poisoning. Inhalant abuse is the third most common substance abused by individuals aged 12 to 14 years, surpassed only by alcohol and tobacco. Symptoms of inhalant abuse include spots or sores around the mouth, a glassyeyed look, fumes on the breath or clothing, anxiety, and loss of appetite. Anabolic Steroid Abuse Anabolic steroids are the synthetic derivatives of testos terone, the male sex hormone. They are widely abused by athletes and others trying to promote growth of skeletal muscle and increase lean body mass. From the fitness craze of the 1980s, the use of anabolic steroids has increased significantly in young males and even in females who want to develop athletic, lean bodies. They are up 78% over the last decade, which puts them ahead of car accidents on the accidental injury causes list. Some accidental overdoses and poisonings could certainly be avoided if individuals were more careful about reading labels on medications and not mixing them with alcohol or other prescription medications without consulting with their health care provider. Some of the overdoses are attributed to suicide, but far more are due strictly to misuse or overuse of prescription or over-the-counter medications. Many of these overdoses occur in those addicted to pain medications such as oxycodone. The overuse and abuse of prescription medications is rampant in the United States. Pain medications, such as the opiate drugs, are the most common ones that are abused. However, other over-the-counter drugs such as loperamide, decongestants, cough suppressants, and antihistamines are also abused. These drugs are generally considered to be safe, but should only be taken as prescribed by the health care provider and/or as noted on the label. The old adage "Read the Label," certainly applies when trying to prevent overdoses, but the individuals also need to "follow the instructions" after reading the label. Source: Associated Press (2016) and Davidson (2016) Copyright 2019 Cengage Learning. They do pro duce increases in muscle strength, lean body mass, and improved performance over periods of time, but the long-term effects are dangerous. The side effects include shrinking of the testes, reduced sperm count, infertility, and baldness in males; and growth of facial hair, changes in menstruation, enlargement of the cli toris, and a deepened voice in females. A spectrum of behaviors is exhibited by people on anabolic steroids: these behaviors range from being somewhat more assertive, to being frankly aggressive, to displaying what is described as "roid rage. Adolescents or preteen children can experience accelerated puberty changes and growth cessation from premature skeletal maturation. These disorders affect the cognitive abilities-the abilities to think, remember, and make judgments by the affected indi vidual. Dementia is common in the elderly; it was called senility in the past and thought to be caused by aging. Dementia is a progressive deterioration of mental abilities due to physical changes in the brain. We now know that dementia is not part of the normal aging process but, rather, is caused by a variety of medical conditions. Factors important in determining whether dementia will occur in an individual include nutritional status, family history, chronic diseases, and general state of health. An affected individual might lose items, get lost when driving even in familiar areas, get confused in conversations, and lose the ability to perform common tasks such as balancing a checkbook. Symptoms often develop gradually and show a progressive deterioration of cognitive or mental abilities, including severe memory loss, disorientation, impaired judgment, and the inability to learn new thorough medical, physical, and neurologic examination. The American Psychiatric Association has established two criteria to support the diagnosis of dementia. The second is the loss of one of the following functions: language, motor activity, recognition, and executive function (unable to plan, organize, or think abstractly). These include correcting drug doses, ensuring that prescribed medications are being taken correctly, withdrawing misused drugs, treating depression and other medical conditions, and ensuring proper nutrition and hydration. Prompt and effective treatment of the cause often reverses the symptoms of delirium. Activities such as reading, playing musical instruments, dancing, playing board games, and doing puzzles are beneficial. Delirium is not a disease but a clinical syndrome, or set of symptoms, that might result from a disease. Thorough assessment is necessary to distinguish it from other psychiatric disorders. Deliriums commonly affect 1 in 10 hospitalized patients and as many as 80% of those in intensive care units. Delirium is more common in the elderly and, although it is not a disease in and of itself, those who have it usually do not do as well as those with the same illness who do not have delirium. Delirium is an acute condition that can develop suddenly or over a period of days. There are a variety of causes of delirium, including medications, alcohol, fever, dehydration, or physical illness. The classic symptom of delirium is a fluctuating level of consciousness with periods of calmness and extreme anxiety. The affected individual is often frightened and disoriented in place and time and has illusions, hallucinations, and incoherent speech. Individuals with delirium expend great amounts of energy, continually wandering and performing aimless activities. Diagnosis is made after a thorough medi- theories include an inherited chromosomal defect, viral infection, a deficiency in neurochemicals in the brain, and an immunologic defect. Interestingly, postmortem studies have revealed a high level of aluminum in the brain and a higher incidence of a serious head injury. In the final stage, the affected individual is often depressed and paranoid and might have hallucinations. Death usually occurs in 10 to 15 years from onset and is usually due to complications of immobility. Research currently compares these biomarkers to postmortem autopsy findings to determine if these match up. If there is a correlation, use of these biomarkers in the future may greatly aid in the diagnosis of the disease. A thorough medical history involving cal history and physical and mental status examinations. A calm, quiet atmosphere along with simple, clear communication, especially from family Treatment. Treatment is aimed at relieving symptoms and managing behavior problems (see Chapter 15, "Nervous System Diseases and Disorders," for more information). Wearing helmets and seatbelts and preventing falls to protect the brain from jarring or injury. Studies indicate, however, that an integrated approach, using a variety of therapies, prevents relapses better than routine care (medication, monitoring, and access to rehabilitation programs). Activities that reduce or prevent relapses include recognizing the first signs of relapse so early intervention is possible, reducing stress, avoiding alcohol and illegal drugs, and taking medications as prescribed. These men tal disturbances might or might not be due to a physical or structural change in the brain. Various theories exist as to the cause of ized by a firm belief in a delusion in an otherwise normally adjusted and balanced personality. The delusions often center on feelings of persecution and grandiosity and often involve romance, religion, and politics. These delusions often develop slowly and involve a false interpretation of an actual occurrence. Delusional individuals become firmly convinced that something is true no matter how convincing evidence is to the contrary. Types of delusional disorders affecting the thinking of affected individuals include the following: Grandiose-an inflated sense of self-worth, power, and knowledge. Persecutory-seeing suspicious actions and having feelings that people are spying on them with harmful intentions. It is generally agreed that schizophrenics have a genetic vulnerability because an individual with a schizophrenic parent, sibling, or other close relative has an increased possibility of becoming schizophrenic. Another theory suggests that schizophrenic individuals were deprived of meaningful relationships with family members during childhood years. This theory is supported by the fact that most schizophrenics felt that as children, they were unloved, unwanted, and unimportant. This disorder often appears in individu- als aged 16 to 25 and is more common in females than in males. Specific symptoms include delusions, hallucinations, flat tone of voice, incoherent speech, bizarrely disorganized behavior such as lack of speech, unresponsiveness, and muscular rigidity. If one or more of the symptoms persist for six or more months, the diagnosis may be confirmed. People with delusional disorder can often continue to socialize and function normally apart from their delusion. Other symptoms include an irritable, angry, or low mood and hallucinations of sight, hearing, or things that are not really there. After a thorough medical and physical examination, if there is no physical reason for the condition, referral to a psychiatrist or psychologist is needed. A diagnosis is made if the individual has nonbizarre delusions for at least one month. The most common medications used to treat delusional disorders are antipsychotics. These disorders are usually chronic, but if properly treated, many get relief from symptoms. Unfortunately, many will not seek help because they do not recognize that they are ill. Mood ranges on a spec trum with extreme depression at one end and extreme elation or happiness at the other. When these emotions are not appropriate to the events of life, last for an inappro priate length of time, or are extreme in nature, mood disorders might be suspected. Some individuals with mood disorders can have extreme depression, whereas others will exhibit both extreme depression and extreme elation at alternating times (bipolar disorder). A study found that individuals who believe they are always treated unfairly are 55% more likely to have a heart attack. It is different from grief, which is a realistic sadness related to a personal loss. Prolonged grief might become depression because depression is often associated with loss of a loved one, possessions, selfesteem, and youth. Depression involves the entire body, thoughts, and mood, and it affects sleep patterns, outlook on life, and self-esteem. Women are often affected, with approximately 12 mi llion women experiencing depression each year. The causes of depression are many and may include genetic, biological, and environmental factors. In some cases, the cause can be singular, whereas in others, it might be multifactorial. For some, the cause appears to be due to a decrease in chemicals in the brain known as neurotransmitters.

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Recent remarkable advances in forecasting weather-related disasters (hurricanes and floods) have to be matched with adequate disaster preparedness in those communities at high risk if they are to be translated into effective warnings depression expressed as anger order amitriptyline master card, especially in low-income countries depression symptoms relapse buy 25 mg amitriptyline visa. Earthquakes remain notoriously unpredictable and have the greatest mortality toll of all natural disasters depression no friends amitriptyline 25mg without prescription. Rising sea levels will increase the severity and the frequency of coastal floods everywhere anxiety in dogs symptoms purchase amitriptyline 50 mg amex. On the positive side definition depression im kindesalter cheap amitriptyline online, climate change fears have been an important catalyst in making some countries pay more attention to addressing the mitigation of their present weather-related disasters. The scale of some recent catastrophes events has added a further sense of urgency. The three mega-disasters (so- called because mortality exceeded 100 000 people in each) -the Southeast Asian tsunami (2004), Hurricane Nargis, Burma (2008), and the Haiti earthquake (2010) -were followed by the Tohoku earthquake (2011), Japan, in which tsunami waves caused over 18 000 deaths and severely damaged the supposedly earthquake-resistant Fukushima nuclear plant that had been built along the same coast with tsunami protection that proved to be inadequate. Very high mortality is not necessary in this definition, which is not specifically health based. The occurrence rates of geophysical hazards like earthquakes and volcanic eruptions have not varied much since the time of Neanderthals over 40 000 years ago, but there is evidence in recent years for a rise in the number of weather-related disasters, such as severe floods and windstorms. Furthermore, the potential for increasing losses of life and property as populations expand in regions of high natural risk was exemplified by the Southeast Asian tsunami that devastated the Indian Ocean region on 26th of December 2004 leaving more than 250 000 people dead and at least 1. By 2030, the Framework calls for substantial global reductions in the following areas: mortality, the number of people affected, direct economic losses, and damage to critical infrastructure. Countries will have to make their own plans to support the implementation of the Framework, with greater international cooperation to support developing countries. Natural disasters are by definition chaotic, but communities in disaster-prone countries can plan and prepare against them. Scientists are working on improving forecasting and on the modelling of their impacts. Most deaths in sudden-onset disasters happen before outside aid arrives, hence strengthening local response capacity in the first hours is crucial. However, international disaster relief can be rapidly and effectively dispatched to needy countries that are politically willing to accept it: although medical relief teams might arrive too late to treat most of the critically injured, teams with engineering and disaster relief skills will have an important role in restoring roads and bridges, bringing in potable water, ensuring solid waste management, food protection, vector control, and sanitation. Even in disasters that have major human impacts, attendances at medical facilities can return to normal levels even within a few days of the acute phase, once the injured have been cared for, when the priority becomes the restoration of primary healthcare and the needs of survivors. Rehabilitation in the post-disaster phase should be an essential consideration in the emergency response phase, and ultimately directed towards measures for reducing the pre-disaster vulnerability. Yet many financial donors view disasters as mere temporary interruptions in development. In April and May 2015 two earthquakes in Nepal killed some 8000 people and reduced 300 000 houses to rubble. For a poor country it will take many years to recover-blowing away the myth that life gets back to normal in a few weeks after a disaster. History should not have to repeat itself-with the limited progress in the past over strengthening building codes, reinforcing old buildings, protecting health facilities, and educating the population about risks in a country where seismologists had warned for years about the severe earthquake risk. Pre-disaster measures Accurately forecasting the timing and size of these sudden-onset natural disasters is rarely possible. This fact constrains efforts to prevent loss of life by timely evacuation of people from the areas at risk before disaster strikes. Disasters leave a trail of devastation and are quite different from the major incidents hospitals usually plan for, in that normal lifelines and infrastructure break down in the devastation. Thus, essentials such as transport, communications, and power will be the first to fail or will be severely curtailed, thereby crippling the immediate emergency response. In the worst examples hospitals can be severely damaged and the staff being among the victims. But despite their chaotic aspects, disasters are amenable to scientific study and a growing body of physical scientists in various fields are directing their energies towards disaster mitigation, particularly in devising hazard warning systems, engineering solutions, and disaster risk information and assessment. There is a growing need for social scientist involvement in implementing risk reduction interventions and developing community resilience in disaster-prone areas. As well as implementing forecasts and warnings, the traditional approach to disaster risk reduction, depending upon the hazard, relies on a platform of engineering measures such as constructing river and coastal flood defences, ensuring regulations are followed to build seismic resistant buildings in earthquake zones, cyclone shelters, and land-use planning to minimize the occupation of risky zones-the commonest example being floodplains. Community preparedness and emergency planning should include the full involvement of the health sector. We should add to this traditional list improving resilience and communicating risk, as well as effectively translating into practice the findings of the latest scientific research. Poverty and social marginalization in mid- to low-income countries, especially, remain potent sources of global vulnerability to natural disasters. Less well-publicized are disasters occurring in regions of conflict and humanitarian crisis, or complex emergencies, for example, in the Democratic Republic of Congo, Darfur (Sudan), and Eritrea (Ethiopia). International relief organizations might not be able to safely or freely move in their response. Hence, in the Southeast Asian tsunami, access to some regions of Indonesia and Thailand was prevented by security issues. In 2008, Burmese people living in the Irrawaddy Delta had no warning from the government of the approach of Cyclone Nargis and hurricane preparedness measures were nonexistent. Over 138 000 people died, most from drowning, but the crisis was made worse when, in the immediate aftermath, 1. International disaster relief is nowadays capable of being rapidly dispatched to needy countries and is on such a global scale that epidemics and 10. Earthquakes Over time more deaths are caused by earthquakes than by any of the other causes of natural disaster. Many parts of the world lie along fault lines and are known to be vulnerable to devastating earthquakes, but it remains impossible to predict precisely where and when a quake will strike. Most deaths and injuries are caused by collapsing buildings, but secondary causes such as fires can take their toll. When timber, masonry, reinforced concrete, and other types of buildings collapse, they inflict injuries to occupants in different ways and with different degrees of severity. In the collapse of masonry buildings, an important cause of death is often suffocation from the weight and dust shaken from the wall or roof material which may also bury the victims. Falling masonry causes crush injuries to the head and chest, external or internal haemorrhage, and chest compression (traumatic asphyxia). Little is known about the survival times of people when they get trapped in collapsed buildings, but most victims will die immediately or within 24 hours from their injuries if they are not rescued, depending upon such factors as the severity of after-shocks, fire outbreaks, cold, and rain. Greatest demand for emergency medical care is within the first 24 hours and the need for emergency treatment quickly fades, though search and rescue teams might continue trying to find survivors for three to five days. Multiple trauma is the main feature, with the risk of doctors missing internal injuries in the stress of the emergency. Causes of delayed death include dehydration, hypothermia, crush syndrome, and postoperative sepsis. Most of those requiring medical assistance suffer minor injuries such as lacerations and contusions. In the Southeast Asian tsunami, an earthquake of magnitude 9 on the Richter scale off the coast of the island of Sumatra on 26 December 2004 suddenly forced the seafloor upwards by some 10 m, creating a wave that surged through the Indian Ocean. The surface perturbation was initially small, but when the water grew shallow, near the coast, the tsunami waves formed. Without warning, the waves hit Indonesia and Thailand within an hour, and then Sri Lanka and India, ultimately reaching as far as East Africa. The province at the north-western end of Sumatra, Aceh, suffered overwhelming devastation. More than 20 000 homes were destroyed, over a 100 000 people were killed, and some 700 000 people were displaced. In all countries affected by the tsunami the main public health infrastructure remained intact as the devastation was limited to coastlines, so the feared epidemics of vector-borne diseases, such as malaria and dengue, as well as cholera and dysentery, were able to be prevented. Large numbers of dead and small numbers of major injuries in survivors in comparison are typical of flood disasters in general, as the severely injured quickly succumb in the water; the injured survivors were mainly treated by local health teams. Many of the patients requiring surgery had infected wounds following contamination by sand and mud. Respiratory tract infections and pneumonia were common among patients who had come close to drowning. Psychosocial needs were identified on a massive scale, but the appropriateness and effectiveness of specific interventions in such disasters to prevent post-traumatic stress disorder remains a controversial issue. The power of tsunamis was demonstrated again in the Tohuko earthquake in 2011, which had its epicentre off the south-east coast of Japan and triggered a tsunami that swept the Japanese coastline leaving total devastation and 15 891 dead with 2579 missing. Many more people would have died but for the tsunami warnings that are routinely practised in the shoreline towns. But the tsunami waves also overcame the engineering defences of the Fukushima nuclear power plant, which in retrospect had not been built to withstand tsunami of this size. The evacuation of 170 000 residents within a radius of 30 km of the power plant was urgently undertaken, but concern grew that the possible spread of contamination in the atmosphere could have gone as far afield as Tokyo and beyond. These fears were later shown to be groundless, but they raised anxiety in Japan and neighbouring countries. One immediate economic casualty was the fishing industry along the coast due to market fears over radioactive contamination of the sea. The evacuation itself was not without risk, however, with 50 deaths attributed in hospital patients; in the first three months of the evacuation mortality rates in older people needing nursing or hospital care rose significantly. A rare example of the importance of disaster preparedness was the earthquake in Bam, Iran, on 26 December 2003, which resulted in 26 271 deaths and the nearly complete destruction of the city of 80 000 inhabitants. The loss of about one-third of the inhabitants, including 200 out of 500 doctors, was attributed to the weak, mud brick construction. The health infrastructure was destroyed, but within 48 hours some 11 972 of the 15 000 injured survivors had been air evacuated by the military to hospitals in the rest of the country, and others were transported to treatment facilities by relatives. By the time foreign medical teams arrived, their main task was to provide routine healthcare to the residual population living in shelters. By contrast, the Pakistan earthquake on 8 October 2005 hit the impoverished mountainous north of the country where access to hundreds of remote villages was hindered by damaged and blocked roads. Over 73 000 people died and 69400 people had serious injuries; over 3 million people were left homeless. As houses were mostly constructed of weak, rubble masonry walls supporting concrete slabs for roofs, the violent shaking easily razed buildings to the ground or triggered landslides. Significant numbers of amputations were performed, and post-disaster reconstructive plastic surgery was frequently needed to treat the often severe and localized soft tissue damage caused by entrapment. In 2008, the recent rapid economic development and accompanying building boom in China lay behind the destruction caused by the largest earthquake to strike the country in recent times (7. The earthquake ranked as the deadliest to have occurred in western hemisphere history. Casualties with multiple trauma were so numerous that they were sent for treatment to hospitals all over the Caribbean region. Collapsed concrete roof slab, typical example of vulnerable building construction in the impacted area (see text). Volcanoes About 500 to 600 volcanoes around the world are known to be capable of eruptive activity and several major eruptions occur every year. The vast majority of dangerous volcanoes are explosive and unpredictable in their behaviour, whereas the less common lava flow eruptions normally allow people to escape from their path. Survivors are uncommon, but will have severe, extensive skin burns and inhalation thermal injuries. The scope of the destruction was shown in the worst volcanic disaster in the 20th century at St Pierre, Martinique, in 1902, when 28 000 people were killed in a laterally directed pyroclastic surge, leaving only two survivors in the totally devastated city. Another major cause of death is the lahar (wet, debris flows) formed by newly erupted ash mixed with heavy rain or unstable masses that are mobilized by meltwater from glaciers or by crater lakes. The eruption of the Nevado del Ruiz volcano, Colombia, in 1984 triggered a huge lahar through the rapid melting of ice in the summit glacier: no warning was received in the towns below where some 24 000 people were buried by mud. By contrast, in one of the largest eruptions of the 20th century, at Mount Pinatubo in the Philippines in 1991, 50 000 people were successfully evacuated from the threat of pyroclastic flows, but over 300 died from the collapsing of roofs burdened with accumulated rain and ash, while sheltering inside their homes. After a slow start it gradually escalated, forcing the evacuation of thousands of people from their homes because of the threat of pyroclastic flows and surges. By 1997, these currents had devastated the southern part of the island, evicting three-quarters of the total island population of 12 000 people. Air pollution from volcanic gases and ash emissions was a major consideration because of the close proximity of the population to the volcano and the frequent eruption of fine, respirable-sized ash Sichuan province, leaving 80 000 people dead and at least 5 million homeless. Poor building quality has been blamed for the catastrophic failure of homes and schools, the latter being a major psychological issue for parents with one child families. Treating severe soft tissue crush injuries in a patient rescued from a collapsed building. Once overland they soon run out of energy and rapidly abate, but can still cause severe flooding from heavy rain. Very high wind speeds, up to 250 km/h, are restricted to a relatively narrow track, usually no more than 150 km wide, within which localized gusts may even achieve tornadoes speeds and be extremely destructive. Most deaths and injuries, however, are not from the effects of wind on people (who normally shelter indoors for protection) or from building damage (building collapse or being struck by flying debris). Instead, deaths and injuries are commonly the result of flooding by the sea surge as the hurricane strikes land, or concurrent heavy rainfall (typically up to 60 cm over a larger area and extending further inland than high winds) triggering landslides. Some storm surges can hit coasts well ahead of the landfall of the actual storm and can travel with nearly the same rapidity, and destructiveness, as tsunami waves. Over 90% of fatalities in hurricanes are drownings associated with storm surges or floods. Other causes of death include burial beneath houses collapsed by wind, penetrating trauma from broken glass or wood, blunt trauma from floating objects or debris, or entrapment in mudslides.

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Ionizing radiation has sufficient energy to break chemical bonds and produce charged ions in living tissue depression quiz buzzfeed generic 25 mg amitriptyline amex. Most of these changes are inconsequential tropical depression definition wikipedia order genuine amitriptyline on line, others can be repaired depression test phq 9 buy amitriptyline now, but there is a finite probability that damage might cause cell death depression definition dsm discount amitriptyline 50 mg fast delivery. Measuring radiation risk Acute cell damage depends on the energy imparted by the radiation mood disorder program buy cheap amitriptyline line. The mean energy absorbed per unit mass of tissue (absorbed dose) is measured in gray (Gy). Radiation and tissue-weighting factors are used to convert the absorbed dose in Gy to an effective dose in sieverts (Sv). This allows external and internal exposures from all types of ionizing radiation to be integrated into one dose, on the basis of equality of stochastic risk. The United Kingdom average annual individual natural background radiation dose is 2. Reproduced with permission from the Radiological Accident in Lilo, International Atomic Energy Agency, Vienna (2000). Health effects of exposure to ionizing radiation There are three types of health effects associated with exposure to ionizing radiation: stochastic effects, psychological effects, and tissue reactions. Radiation-induced cancer is clinically and pathologically indistinguishable from idiopathic cases. Risks at low-radiation doses are extrapolated from animal, experimental, and epidemiological studies at higher doses assuming a linear no-threshold model. The absolute cancer risk per unit of radiation dose (risk coefficient) is estimated to be 5. Recent data suggest that cardiovascular system damage might also be a stochastic effect of radiation, with a similar risk coefficient as for cancer induction. These include the acute radiation syndrome (radiation sickness) and radiation burns. Radiation accidents are rare and the initial symptoms of radiation sickness are nonspecific, resembling influenza or food poisoning, so physicians might be involved in diagnosis and treatment before the true cause is appreciated. Many people and large areas of land and property were contaminated before the true cause of the incident was appreciated. Clinical features of radiation-induced tissue reactions External exposures, either whole body or partial, do not render patients radioactive and thus pose no radiation risk to medical attendants. If the patient has ingested or inhaled radioactive materials, or has wounds containing them (internal exposure), they and their waste products can pose a persisting radiation or contamination hazard to other people. Decontamination of radioactive material on skin or clothing is often straightforward, but should not take precedence over life-saving procedures. If contamination is suspected, contact a radiation-protection expert for monitoring and avoid spread of material. Chelating agents, such as ethylenediamine tetraacetic acid, and ion-exchange resins, such as Prussian blue, can be used to enhance excretion of certain internal radionuclides, such as 137Cs and actinides. Partial-body exposures, especially of the extremities, might not be accompanied by systemic disease if the equivalent wholebody dose does not reach the symptom threshold. Radiation burns can extend deep into the soft tissue, increasing fluid loss and risk of infection. Skin injuries evolve slowly, usually over weeks to months, can become very painful, and are resistant to treatment. Acute radiation syndrome the acute radiation syndrome is a rare (handfuls of cases per year worldwide), multiphasic illness. The timing of onset, severity, and duration of prodromal symptoms depend on the radiation dose. After a latent period of apparent recovery, effects of the killing of cells-especially stem cells-appear. Several triage categories have been published, relating the severity and time-course of symptoms and signs to prognosis. Although the threshold radiation dose for symptoms is approximately 1 Gy, lymphocyte dosimetry can detect acute doses down to about 100 mGy. Without medical treatment, an acute dose of approximately 4 Gy is likely to be fatal within 60 days in 50% of those exposed. Similar doses over longer periods (days, weeks, and so on) might cause less severe symptoms as the body has time to repair the damage and the main concern in such patients may be the stochastic risks. Chromosome aberration assays, mainly dicentrics (chromosomes with two centromeres) in lymphocytes or other chromosomal abnormalities detected by fluorescence in situ hybridization, can be used to give a more precise estimate of whole-body dose. Treatment of acute radiation syndrome Good clinical care ensures the best chance of recovery, provided that some stem cells have survived the radiation exposure. Routine monitoring should include daily full blood counts, and blood cultures and other infection screens, especially in febrile patients. As a rule of thumb, patients with an estimated dose of 2 Gy or more should be observed in hospital and monitored for onset of acute radiation syndrome, but not all will require intensive treatment. Patients with doses of more than 4 Gy should be presumed to be developing acute radiation syndrome. Avoid antacids, proton pump inhibitors, and H2 blockers to maintain gastric acidity; use sucralfate to avoid stress ulcers Bone marrow transplants have not been proven to be beneficial. There is weak evidence for erythropoiesis stimulating agents and haematopoietic stem cells having benefit. Haematopoietic syndrome Reverse barrier nursing and topical treatments to decrease bacterial/ fungal colonization should be used. Intravenous lines should be kept to a minimum and sited to decrease infection risk. Established infections should be treated as for other patients with neutropenic sepsis. Early use of antifungal agents or antiviral drugs might be required to prevent late mortality. Clinical investigation this includes full history, examination, cytogenetic and regular blood tests. The estimated radiation dose is needed to predict the clinical course of the patient and plan treatment. This dose should be revised as treatment progresses because the heterogeneous nature of accidental exposures makes the scale of radiation damage difficult to estimate. However, there is considerable individual variation and vomiting is not invariable, even at high doses. The pattern of fall in blood levels of lymphocytes, granulocytes, platelets, and red cells depends on radiation dose. For pure -field exposures, the Gastrointestinal syndrome Use supportive therapy to prevent infection and dehydration. Care should be taken not to break intact skin and introduce internal contamination. Radiation burn treatments include: topical steroids, hyperbaric oxygen, pentoxifylline with oral vitamin E, wet dressings, alginates, hydrocolloids, and anti-inflammatory agents. Wide excision, surgical repair, and skin grafting might be necessary by surgeons experienced in the management of chronic vascular injury. Cumulative exposure to ultraviolet radiation is a major cause of cortical cataracts, but its importance in the general population remains uncertain. Immune responses Exposure to ultraviolet radiation can suppress immune responses by complex mechanisms, but the significance for human health and response to vaccinations is uncertain. Radiofrequency electromagnetic waves the widespread adoption of radiofrequency microwaves in wireless technology, including mobile phones and wi-fi, has led to concerns about adverse health effects. There is no evidence that there is significant risk to the general public from exposure to radiofrequency radiation or from use of micro/radiowave appliances. However, these are new technologies and a cautious approach is appropriate because of the lack of scientific evidence. Surgical wounds and traumatic lacerations tend to heal more slowly in irradiated tissues. Power-frequency electric and magnetic fields There are concerns that power-frequency electric and magnetic fields might have adverse effects on health even at levels below those required to interfere with nerves through induced fields and currents. Health effects of exposures to nonionizing radiation Ultraviolet radiation Ultraviolet radiation primarily affects the skin and the eye. In some people, sunburn is followed by increased production of melanin (suntan) but this offers only minimal protection against further exposure. Acute ocular exposure to ultraviolet radiation can lead to photokeratitis and photoconjunctivitis (arc eye, snow blindness, and so on). The most serious long-term effect of ultraviolet radiation is induction of skin cancer. Nonmelanoma skin cancers, mainly basal cell carcinomas and squamous cell carcinomas, are common in white populations but are rarely fatal. The overall incidence is difficult to assess because of underreporting, but is likely to exceed 100 000 cases per year in the United Kingdom. The incidence of malignant melanoma, which is much more likely to be fatal, has increased substantially in white populations for several decades causing about 2150 deaths/year in the United Kingdom. Chronic exposure to solar radiation causes photo-ageing of the skin, characterized by a leathery, wrinkled appearance and loss of elasticity. Suberythemal quantities of ultraviolet radiation are beneficial in stimulating vitamin D synthesis in the skin. Vitamin D has been associated with several musculoskeletal and nonmusculoskeletal health outcomes, including hypotheses about protection from cancer. Repeated ocular exposure is a major factor in corneal and conjunctival diseases, such as climatic droplet keratopathy, pterygium, Static magnetic fields Head movements in static magnetic fields stronger than 2 T can cause symptoms such as vertigo, nausea, a metallic taste, and phosphenes (seeing light without light entering the eye). There are insufficient data to indicate long-term health effects of exposures to static electric and magnetic fields. Stronger fields should be used with care in controlled or experimental situations with more rigorous patient monitoring. First global consensus for evidence-based management of the hematopoetic syndrome resulting from exposure to ionising radiation. Literature review and global consensus on management of acute radiation syndrome affecting non-hematopoetic organ systems. European consensus on the medical management of acute radiation syndrome and analysis of the radiation accidents in Belgium and Senegal. The trend is for the impacts to increase alongside the continuing expansion of human populations into regions at risk and with environmental degradation making human settlements more vulnerable, especially in heavily urbanized areas and megacities. This reckless development is going on in most countries of the world, even in places prone to natural disasters. The greatest need in the post-impact phase is the provision of adequate shelter, water, food, and clothing, and sanitation. Most victims suffer from lacerations caused by flying glass or other debris, or minor trauma such as closed fractures and puncture wounds. Katrina was the third most powerful storm ever to make landfall in the United States of America, attaining hurricane category five status before it struck the Louisiana coast on the morning of 29 August 2005. One crowded public hospital left cut off for five days without electrical power, clean water, and medical supplies was rendered helpless by the engulfing floodwater. In the aftermath, nearby states were able to absorb several hundred thousand evacuees from the city in a few days. Despite forebodings, epidemics of diarrhoeal diseases, respiratory tract infections, and mosquito-borne disease, in particular West Nile virus, did not occur. Increases in suicide and psychiatric morbidity were found in follow-up studies of evacuees, and although psychological distress was common, it resolved in most of the people over time. Recent advances in meteorology on tracking the paths of hurricanes in time and space are now making inroads into reducing loss of life by forecasting their landfall far enough ahead for thousands of people to be directed to safety, provided the warnings are effectively communicated by government officials. In 1999 one of the largest cyclones to strike the coast left 10 000 dead in its wake: although it was forecast, no warnings were disseminated, and no preparedness to move the population to safety was in place. In October 2013 an almost identical cyclone hit the same coast, but with the loss of only 17 people-the difference was that the warning was followed by 1 million people being temporarily evacuated from the coastal area by the Indian army. Floods In addition to the major losses of life that can be caused by hurricanes and their associated sea surges, floods mostly result from moderate to large events (heavy rainfall, snowmelt, high tides) occurring within the expected range of streamflow or tidal conditions. In the United Kingdom, as in many countries with low-lying coastal land, the hazards of coastal flooding from sea surges and high tides dominates over river flooding, although the latter is becoming more frequent, particularly in the last few years when there has been a trend of abnormally wet winter months and localized repeated flooding, though it is not yet possible to attribute this to climate change. Flood warning and forecasting, combined with effective land management, community preparedness, and evacuation planning, are as essential as engineered river and coastal defences. The primary cause of death from floods is drowning, but trauma from impact with floating debris and by hypothermia due to cold exposure are also important. The proportion of survivors requiring emergency medical care is small as most injuries are minor, such as lacerations. This absence of survivors with severe or multiple trauma is likely to reflect the delay in search and rescue through the flood waters, and victims drown or die from their injuries and the effects of exposure before help arrives. An increase in suicides and mental health problems arose after the severe flooding caused by heavy rains in central Europe in July 1997.

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References

Dayan GH, Rubin S: Mumps outbreaks in vaccinated populations: are available mumps vaccines effective enough to prevent outbreaks?, Clin Infect Dis 47:1458n1467, 2008.
Alberts DS, Dorr RT, Einspahr JG, et al. Chemoprevention of human actinic keratoses by topical 2- (difluoromethyl)-dl-ornithine. Cancer Epidemiol Biomarkers Prev 2000;9(12):1281-1286.
Wagenvoort CA, Wagenvoort N. The pathology of pulmonary veno-occlusive disease. Virchows Arch A Pathol Anat Histol 1974;364(1):69-79.
Mitchell CR, Boorjian SA, Umbreit EC, et al: 20-year survival after radical prostatectomy as initial treatment for cT3 prostate cancer, BJU Int 110(11):1709n1713, 2012.