Medical Instructor, University of Wisconsin School of Medicine and Public Health
A municipal water company heart attack or stroke discount cardizem online, for example arteria 3d buy cardizem 60mg fast delivery, cannot control upstream water pollution without the involvement of other agencies; nor can a ministry of health on its own define and control manufacturing standards of products such as handpumps blood pressure lowering herbs purchase discount cardizem online. Capacity building for water quality starts with the identification of institutional stakeholders arteria jugular order 120 mg cardizem visa, and an assessment of their current ability to meet roles and responsibilities. Inputs and support to institutions may involve training and professional development, but should focus on the development of sustainable systems within institutions and practical collaboration mechanisms between institutions. In some countries, for example, the bulk of water supply activities are carried out by the private sector but state water supply agencies have yet to make the transition from being service providers themselves to a role of monitoring and supervision. In other countries, decentralization of water supply activities is underway but central government agencies do not yet have the institutional structure to facilitate the trend. In such cases, directing capacity building efforts towards the strengthening of new institutional systems in support of sectoral reform will have a significant impact. Capacity building is an ongoing process and is sustainable only when national and local institutions are available for providing training and institutional development services for water agencies. Sectoral training programmes do not always include water quality, and even when they do it is often only a minor component. Training course subject areas include risk assessment and management, water quality guidelines and standards, health-based planning for water safety, sanitation and hygiene promotion, monitoring and surveillance, groundwater and surface water quality, research skills and techniques, water treatment (including appropriate low-cost remediation technologies), treatment of effluents and water policy development. Training resources for water quality are available from the academic community and through a variety of sectoral agencies and resources, including the United Nations (see box). People also have a right to know about what solutions are available to improve water quality. Safe water is a basic human right Two core human rights treaties have explicitly recognized the right to water: the Convention on the Rights of the Child and the Convention on the Elimination of All Forms of Discrimination Against Women. In both cases, the right to water was affirmed as a prerequisite for the realization of child and human rights to health and adequate living conditions. In 2002, the United Nations formally declared access to domestic water supply service a human right in and of itself, through the Committee on Economic, Social and Cultural Rights. Convention on the Elimination of All Forms of Discrimination Against Women, 1979, Article 14 states that women have the right to "adequate living conditions, particularly in relation to housing, sanitation, electricity and water supply, transport and communication. People should also be informed of the responsibilities of duty-bearers in governments, water service providers and the community to ensure domestic water safety. When families and communities are aware of the problem, the solution and the responsibilities they and others have to keep water safe, they can more effectively take action. Knowledgeable communities are also more likely to demand improved service from providers such as water companies or contractors and to challenge politicians and government officials when there are water quality problems in the community. This can sometimes lead to resistance to awareness-raising programmes of this nature. In developing countries the most serious water quality problem is faecal contamination, and the most effective way of protecting water sources and interrupting the faecal-oral cycle is through hygiene and sanitation. The challenge is not only to inform people about the links between sanitation and health, faecal contamination pathways and remedial measures, but to promote behavioural change and safe hygiene practices. In addition to hygiene and sanitation promotion, awareness-raising programmes are used as a starting point for community-based water quality surveillance programmes (see 3. They should be based on the best available Assessment information and new research on the Assessment Evaluation issue and on the target communities themselves. In the case of water quality, the assessment includes best available knowledge of the extent of the water quality problem and its effect on communities. The communication analysis is the basis for the design of the communication campaign itself: the development of messages and choices of media and methodologies. The campaign material is developed, field tested, modified as necessary and launched. In the case of emerging or poorly understood problems, technical advice from specialists and agreement among national stakeholders will be necessary before messages can be formulated. Communication programmes must ensure that methods, means and messages chosen in the campaign reach poor people.
Syndromes
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Other blood tests
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H -- hemolysis (the breakdown of red blood cells)
Kidney failure
Age and health of the person
Irritability
Symptoms: Slight displacement may be of no functional significance to the patient blood pressure medication headache 60mg cardizem amex. More pronounced displacement produces severe optical distortion with loss of visual acuity blood pressure wrist band purchase cardizem without prescription. Diagnostic considerations: Cardinal symptoms include tremulous motion of the iris and lens when the eye moves (iridodonesis and phacodonesis) hypertension yahoo 120 mg cardizem otc. Treatment: Optical considerations (see symptoms) and the risk of secondary angle closure glaucoma from protrusion of the iris and dislocation of the lens into the anterior chamber are indications for removal of the lens blood pressure 360 buy generic cardizem 120mg line. As the zonule fibers are intact, a certain measure of accommodation is still possible. The uveal tract consists of the following structures: O Iris, O Ciliary body, O Choroid. Neurovascular supply: Arterial supply to the uveal tract is provided by the ophthalmic artery. O the short posterior ciliary arteries enter the eyeball with the optic nerve and supply the choroid. O the long posterior ciliary arteries course along the interior surface of the sclera to the ciliary body and the iris. They form the major arterial circle at the root of the iris and the minor arterial circle in the collarette of the iris. The anterior ciliary arteries originate from the vessels of the rectus muscles and communicate with the posterior ciliary vessels. Venous blood drains through four to eight vorticose or vortex veins that penetrate the sclera posterior to the equator and join the superior and inferior ophthalmic veins. The posterior layer is opaque and protects the eye against excessive incident light. The anterior surface of the lens and the pigmented layer are so close together near the pupil that they can easily form adhesions in inflammation. Minor arterial circle of the iris (collarette of the iris) Major arterial circle of the iris Anterior ciliary artery Long posterior ciliary artery Vorticose vein Short posterior ciliary artery. The collarette of the iris covering the minor arterial circle of the iris divides the stroma into pupillary and ciliary portions. The pupillary portion contains the sphincter muscle, which is supplied by parasympathetic nerve fibers, and the dilator pupillae muscle, supplied by sympathetic nerve fibers. These muscles regulate the contraction and dilation of the pupil so that the iris may be regarded as the aperture of the optical system of the eye. Pupil dilation is sometimes sluggish in preterm infants and the newborn because the dilator pupillae muscle develops relatively late. Surface: the normal iris has a richly textured surface structure with crypts (tissue gaps) and interlinked trabeculae. Eyes with a high melanin content are dark brown, whereas eyes with less melanin are grayish-blue. Caucasians at birth always have a grayish-blue iris as the pigmented layer only develops gradually during the first year of life. Even in albinos (see impaired melanin synthesis), the eyes have a grayishblue iris because of the melanin deficiency. The suspensory ligament, the zonule, extends from the pars plana and the intervals between the ciliary processes to the lens capsule. The doublelayered epithelium covering the ciliary body produces the aqueous humor. The choroid is highly vascularized, containing a vessel layer with large blood vessels and a capillary layer. Function: the choroid regulates temperature and supplies nourishment to the outer layers of the retina. Iris vessels are only visible in atrophy of the iris, inflammation, or as neovascularization in rubeosis iridis. Where vessels are present, they can be visualized by iris angiography after intravenous injection of fluorescein sodium dye.
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The arrangement in the liver of a set of sinusoids between veins is called the hepatic portal system blood pressure 5080 purchase 60mg cardizem with amex. The liver also has an arterial supply from the hepatic artery pulse pressure normal rate purchase cardizem 180mg overnight delivery, and both the venous (portal) and arterial (hepatic) bloods percolate through the liver sinusoids and exit by way of the hepatic vein blood pressure chart and pulse rate generic cardizem 180 mg with amex. The liver acinus is defined as the hepatic tissue supplied by a terminal branch of the hepatic artery and portal vein and drained by a terminal branch of the bile duct heart attack labs generic 60 mg cardizem free shipping. It is represented by a diamond-shaped area with central veins at two of the opposite comers. Branches of the blood vessels and a branch of the bile duct lie between the two portions of adjacent hepatic lobules that they supply. It consists of the hepatic tissue that is drained by the bile duct of the portal area. A portal lobule is triangular in shape and contains parts of three adjacent hepatic lobules. The bile produced by hepatocytes flows in a direction opposite that of blood toward the periphery of the classic hepatic lobule. The sinusoidal lining consists of a simple layer of squamous epithelium supported by very little connective tissue. Three types of cells are associated with the sinusoidal lining: endothelial cells, stellate cells (Kupffer cells or hepatic macrophages), and fat-storing cells (lipocytes). Endothelial cells constitute the major cellular element of the sinusoidal lining and form a discontinuous endothelium. The sinusoidal lining is separated from the liver cells by a narrow perisinusoidal space (of Disse). A single layer of small, dark hepatocytes limits the liver parenchyma beneath the capsule and is called the subcapsular limiting plate. A similar wall of hepatic cells surrounds the portal areas and forms the periportal limiting plate, which is pierced by tributaries of the hepatic artery, portal vein, lymphatic vessels, and bile ductules. The limiting plates of hepatocytes prevent blood from escaping the classic hepatic lobules. Blood plasma flows freely through the endothelium and into the space, but the sinusoidal lining does hold back erythrocytes. Although occasional bundles of reticular fibers and fine collagenous fibers are present in the perisinusoidal space, there is no ground substance, and the flow of blood plasma is unhindered. Because the plasma has direct access to the perisinusoidal space, the liver cells are constantly bathed on one surface by fluid that is rich in the nutrients absorbed by the intestinal tract. The plasmalemma of the hepatocytes that face the perisinusoidal space bear numerous well-developed microvilli that project into the space and greatly increase the surface area and facilitate absorption. Not all the formed tissue fluid is absorbed by the hepatocytes or passes back into the sinusoidal lumen and as a result a considerable amount of lymph is produced by the liver. Like bile flow, lymph flows within the perisinusoidal space from the center of the hepatic lobule toward the periphery. Lymphatic vessels within the portal areas course parallel to the branches of the portal vein and ultimately empty into the thoracic duct. Also present in the sinusoidal lining are actively phagocytic cells, variously called hepatic macrophages or Kupffer cells. These form part of the sinusoidal lining and are irregularly shaped cells that expose the greater part of their cytoplasm to the blood in the sinusoid and extend processes between the endothelial cells. Unlike the neighboring endothelial cells, the cytoplasm of the hepatic phagocytes contains vacuoles, lysosomes, Golgi bodies, and short profiles of granular endoplasmic reticulum. These cells are part of the mononuclear system of macrophages and arise from monocytes of the bone marrow. The third type of cell is located on the side of the sinusoidal lining that faces the perisinusoidal space. This cell accumulates lipid and is most numerous in the peripheral and intermediate zones of the hepatic lobule. They have been called lipocytes, fat-storing, stellate, or interstitial cells, and function to store vitamin A. The nuclei of hepatocytes are large and round and usually occupy the center of the cell. A single nucleus usually is present, but as many as 25% of hepatocytes are binucleate. There also is considerable variation in the size of nuclei from cell to cell, reflecting the polyploid nature of hepatocytes.
