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Dirty gray patches of an adherent membrane form in the back of the throat and in the windpipe itself best kamagra effervescent 100 mg. These patches resemble dead skin and when brushed purchase kamagra effervescent 100mg free shipping, come away with difficulty leaving tiny bleeding points in the uncovered mucous membrane cost of kamagra effervescent. The most serious complications include suffocation, due to the mechanical blocking of the windpipe by the diphtheritic membrane, and an overwhelming systemic poisoning due to the toxin. Because of special affinity for certain nerves, the toxin may produce paralysis of the throat, eyes, or extremities; or death from heart failure. Although antibiotics are considered to have little effect on the clinical course of diphtheria, treatment with penicillin or erythromycin can kill the diphtheria bacteria. If diphtheria is confirmed, the entire crew should report to health authorities at the next port. Diarrheal disease is usually caused by viral, bacterial, parasitic or other agents, though it can have non-infectious causes as well. When managing these patients, emphasis should be placed on fluid support and rehydration. Dehydration leading to coma or death may occur when extreme diarrhea is combined with vomiting or fever. In addition to the loss of water, the loss of various chemicals normally dissolved in body fluids may cause complications and death. Useful signs in determining the cause of intestinal illness and its severity include: Character of stools—Are they watery? Good hygiene aboard ship is necessary for the crew to meet its operations missions. In foreign ports, drink bottled or boiled water, and avoid uncooked foods or foods that may not have had adequate refrigeration. Choose restaurants that seem to care about sanitation – the cleanliness of a restaurant’s “head” can be a good indicator of the sanitation available to its food handlers. However, as a casual customer, it is often difficult to assess the cleanliness of a restaurant’s galley. A liquid or low- residue diet should be given that includes soft drinks and broths containing salts. Milk products should be avoided as the intestinal lining often is denuded and lacking the enzymes necessary to metabolize them. Specific causes of diarrhea and some special treatments are outlined below: Viruses - Many viruses present as intestinal illness. The onset of illness lasts several hours and is usually over within two or three days. The patient often feels reasonably well in between bouts of diarrhea and vomiting. Bacteria - Salmonella, shigella, campylobacter, yersinia, and cholera are some of the bacterial causes of dysentery. Clinically these infections can resemble viral gastrointestinal illness, although blood or mucus in the stool is more typical. Salmonella may be carried in undercooked poultry, powdered eggs, powdered milk, or other food, as well as by livestock and pets. Toxin induced food poisoning - Although staphylococcal organisms are bacteria, it is the toxin they produce that is responsible for the symptoms of food poisoning. Undercooked poultry and poorly refrigerated foods such as pastries, custards, and App. Symptoms usually begin rapidly and violently within one to six hours after eating contaminated food. Antibiotics destroy normal gut flora which allows this organism to take over and multiply, producing bloody or non-bloody diarrhea. History of antibiotic use, severity of symptoms, and prolonged illness can be clues to diagnosis. Stool cultures are required to detect the toxin, and medical advice and referral are necessary. Amebic dysentery - The only known human infectious cause of amebic dysentery is via the parasite Entamaeba histolytica. Amoebiasis tends to be a chronic diarrheal illness that may produce an acute colitis which is indistinguishable from bacterial dysentery. Abcesses may form in the liver or elsewhere, which may prove fatal in exceptional cases. Other - Chronic forms of diarrheal illness can be non-ifectious such as ulcerative colitis, regional enteritis, functional/spastic colon, and malabsorption syndromes. Basic medical advice should be sought by radio for any diarrheal illness that causes serious acute symptoms or persists for more than a week or two. Advice should also be sought if there is any question regarding hydration status, mentation, or lack of response to therapy. Agents that slow gut motility, such as over-the-counter or prescription anti-diarrheal medications, should be avoided unless advised medically otherwise. They cause the infectious agent to be retained in the gut and can lengthen the infection and increase its severity. Many agents cause hepatitis including viruses, drugs, alcohol, and other non-viral infectious diseases. It is important to exclude non-viral causes of hepatitis since their treatment differs. This discussion will focus on viral causes of hepatitis (hepatitis A, B, C, D, and E). These viral agents have similar clinical presentations and require specific diagnostic tests to distinguish the causative agent in an individual patient. Hepatitis A and E virus transmission mainly occurs by a fecal-oral route via person-to-person transmission and foodborne outbreaks. Hepatitis B, hepatitis C, and the hepatitis delta agents are transmitted by percutaneous and mucous membrane exposures to infectious blood and other body fluids. Acute hepatitis implies a condition lasting less than 6 months, with either complete resolution or rapid progression toward necrosis and death. The most frequent symptoms of acute viral hepatitis are fatigue, muscle pains, nausea, and absence of appetite, which typically develop 1 to 2 weeks before the onset of jaundice. H-20 may note yellowing of the skin or eyes, dark brown urine and/or clay-colored stools. Headaches, joint pains, vomiting, and right-upper-quadrant tenderness are also common. Lymph node enlargement is not a clinical feature and may be suggestive of other disease. Chronic hepatitis is defined as an inflammation of the liver lasting longer than 6 months. Hepatitis B plus or minus the hepatitis delta agent, and hepatitis C typically cause chronic hepatitis.

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Initial entry is probably through sewage disposal are fundamental to the prevention of uptake by M cells (the ‘antigenic samplers’ of the bowel) with 258 Gastrointestinal Tract Infections animal feed Salmonella enteriditis ingestion absorbed to epithelial cells in domestic human terminal portion of small intestine man ‘food’ animals food wild animals bacteria penetrate cells and migrate to lamina propria layer of ileocecal region effluent sewage man Fig kamagra effervescent 100mg without prescription. With the exception of multiply in lymphoid follicles Salmonella typhi order kamagra effervescent 100mg with amex, salmonellae are widely distributed in animals discount kamagra effervescent master card, causing reticuloendothelial providing a constant source of infection for man. Excretion of large hyperplasia and hypertrophy numbers of salmonellae from infected individuals and carriers allows the organisms to be ‘recycled’. A similar route of inva- sion occurs in Shigella, Yersinia and reovirus infections. The vast majority of salmonellae cause infection localized to with particular predispositions (e. Vomiting is rare and fever needed for salmonella diarrhea is usually a sign of invasive disease (Fig. Fluid and electrolyte replacement may be required, of approximately 150 cases, with about 70 deaths. Unless there is should be set in context against the approximately 30 000 evidence of invasion and septicemia, antibiotics should be reported cases of diarrhea. Salmonella diarrhea can be diagnosed by culture on selective media Salmonellae may be excreted in the feces for The methods for culturing fecal specimens on selective media several weeks after a salmonella infection are summarized in the Appendix. The large animal reservoir small numbers may require enrichment in selenite broth makes it impossible to eliminate the organisms and therefore before culture. Preliminary identification can be made preventive measures must be aimed at ‘breaking the chain’ rapidly, but the complete result, including serotype, takes at between animal and man, and person to person. It is difficult, if not impossible, to determine the likely cause of a diarrheal illness on the basis of clinical features alone, and laboratory investigations are essential to identify the pathogen. Person to person spread Following an episode of salmonella diarrhea, an individual by the fecal–oral route is rare, as is transmission from food can continue to carry and excrete organisms in the feces for handlers. Although in the absence of symptoms the organisms will not be dispersed so liberally into the environ- Campylobacter diarrhea is clinically ment, thorough handwashing before food handling is essen- indistinguishable from that of salmonella tial. People employed as food handlers are excluded from diarrhea work until three specimens of feces have failed to grow The pathogenesis of campylobacter diarrhea has not yet salmonella. The gross pathology and histologic appear- ances of ulceration and inflamed bleeding mucosal surfaces Campylobacter in the jejunum, ileum and colon (Fig. The delay in recog- nizing the importance of these organisms was due to their Fig. Several species of the genus Gram-negative, Campylobacter are associated with human disease, but S-shaped bacilli. As with salmonellae, there is a large animal reservoir of campylobacter in cattle, sheep, rodents, poultry and wild birds. Infections are acquired by consumption of contami- nated food, especially poultry, milk or water. Recent studies have shown an association between infection and consumption of milk from bottles with tops that have been 260 Gastrointestinal Tract Infections The clinical presentation is indistinguishable from diarrhea Cholera flourishes in communities with caused by salmonellae although the disease may have a longer inadequate clean drinking water and sewage incubation period and a longer duration. The 1990s have witnessed the seventh pandemic of cholera spreading into Latin America, and the disease remains Cultures for campylobacter should be set up endemic in South East Asia and parts of Africa and South routinely in every investigation of a diarrheal America. Asymptomatic human carriers are tant to note that the media and conditions for growth differ believed to be a major reservoir. Growth is often contaminated food; shellfish grown in fresh and estuarine somewhat slow compared with that of the Enterobacteria, waters have also been implicated. Direct person to person but a presumptive identification should be available within spread is thought to be uncommon. Cases still occur in developed countries, but high campylobacter diarrhea standards of hygiene mean that secondary spread should Erythromycin is the antibiotic of choice for cases of diarrheal not occur. Over the past 20 years there have been 66 cases disease that are severe enough to warrant treatment. Serotype O1 is the most important and is further divided into two biotypes: classical and El Tor (Fig. The El Cholera Tor biotype, named after the quarantine camp where it was Cholera is an acute infection of the gastrointestinal tract first isolated from pilgrims returning from Mecca, differs caused by the comma-shaped Gram-negative bacterium V. The disease has a long history charac- causes only a mild diarrhea and has a higher ratio of carriers terized by epidemics and pandemics. The El introduction of the bacterium by sailors arriving from Tor biotype, which was responsible for the seventh pandemic, Europe, and in 1849 Snow published his historic essay On has now spread throughout the world and has largely dis- the Mode of Communication of Cholera. The originated from the El Tor O1 biotype when the latter methods are given in the Appendix. This provided the recipient strain with a selective advantage in a region where a large part of the population is immune to O1 strains. The symptoms of cholera are caused by an enterotoxin sensitive to stomach acid large dose needed to cause The symptoms of cholera are entirely due to the produc- disease unless patient tion of an enterotoxin in the gastrointestinal tract (see achlorhydric or taking antacids Chapter 12). However, the organism requires additional virulence factors to enable it to survive the host defenses and adhere to the intestinal mucosa. The severe watery non-bloody diarrhea is known as production of mucinase rice water stool because of its appearance (Fig. It is this specific receptors fluid loss and the consequent electrolyte imbalance that results in marked dehydration, metabolic acidosis (loss of massive loss of fluid bicarbonate), hypokalemia (potassium loss) and hypovolemic and electrolytes (no damage to toxin production shock resulting in cardiac failure. Untreated, the mortality enterocytes; no blood or from cholera is 40–60%; rapidly instituted fluid and elec- white blood cells in stool) trolyte replacement reduces the mortality to less than 1%. When associated with severe malnutrition it may precipitate complications such as the protein deficiency syndrome ‘kwashiorkor’. Shigellae appear to be able to initiate infection from a small infective dose (10–100 organisms) and there- fore spread is easy in situations where sanitation or personal Fig. Shigella diarrhea is usually watery at first, but later contains mucus and blood Prompt rehydration with fluids and Shigellae attach to, and invade, the mucosal epithelium of electrolytes is central to the treatment of the distal ileum and colon, causing inflammation and ulcera- cholera tion (Fig. However, they rarely invade through the Oral or intravenous rehydration may be used. Enterotoxin is produced, but not necessary, but tetracycline may be given as some evidence its role in pathogenesis is uncertain since toxin-negative indicates that this reduces the time of excretion of V. There have, how- The main features of shigella infection are summarized in ever, been reports of tetracycline-resistant V. Lower abdominal cramps can be As with other diarrheal disease, a clean drinking water severe. The disease is usually self-limiting, but dehydration supply and adequate sewage disposal are fundamental to the can occur, especially in the young and elderly. As there is no animal reservoir, it can be associated with malnutrition (see above). However, carriage in humans, albeit for only a few weeks, Antibiotics should only be given for severe occurs in 1–20% of previously infected patients making erad- shigella diarrhea ication difficult to achieve.

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Clause 9 provides for meetings buy 100mg kamagra effervescent otc, its Chairperson buy kamagra effervescent 100 mg with mastercard, quorum and other ancillary matters connected to meetings order discount kamagra effervescent online. Clause 10 provides for powers and functions of the Commission including:— (a) formulation of policies and framing of guidelines for ensuring high quality and standards in medical education and research; (b) Coordination of functioning of the Commission, Autonomous Boards and State Medical Councils; (c) formulation of policy for regulation of medical profession; (d) power to delegate and form sub-committees. It shall consist of one nominee from every State who shall be the Vice-Chancellor of State Health University or the University with maximum medical colleges under it. Ministry of Home Affairs shall nominate one Member to represent each Union territory. Every Member of National Medical Commission shall be ex officio Members of the Advisory Council. Chairman, University Grants Commission, Director, National Assessment and Accreditation Council, and four Members from among Directors of Indian Institutes of Thechnology, Indian Institutes of Management and the Indian Institute of Science shall also be its Members. Clause 12 provides for functions of Medical Advisory Council to advise the Commission on minimum standards in medical education, training and research. Clause 15 provides that National Licentiate Examination for students graduating from the medical institutions for granting licence to medical practice, enrolment and admission to postgraduate medical courses. Clause 16 provides for constitution of four Autonomous Boards under the overall supervision of the Commission. The four Autonomous Boards are Under-Graduate Medical Education Board, Post-Graduate Medical Education Board, Medical Assessment and Rating Board and Ethics and Medical Registration Board. Clause 17 provides for composition of Autonomous Boards consisting of the President and two Members. The second Member of Medical Assessment and Rating Board and Ethics and Medical Registration Board shall be from non-medical background. Clause 18 provides for Search Committee for appointment of the President and Members of the Autonomous Boards. Clause 19 provides for duration of office, salary and allowances and other terms and conditions of service of the President and Members of the Autonomous Boards. Clause 20 provides for Advisory Committees of experts constituted by the Commission to render assistance to all Autonomous Boards for discharging of functions assigned under the Act. Clause 24 provides for powers and functions of Under-Graduate Medical Education Board including determination of standards of medical education at undergraduate level, framing of guidelines for establishment of medical institutions for imparting undergraduate medical courses, granting of recognition to medical institutions at undergraduate level. Clause 25 provides for powers and functions of Post-Graduate Medical Education Board including determination of standards of medical education at postgraduate and super-specialty level, framing of guidelines for establishment of medical institutions for imparting postgraduate and super-specialty medical courses, granting of recognition to medical institutions at postgraduate and super-specialty level. Clause 26 provides for powers and functions of Medical Assessment and Rating Board including determine the procedure for assessing and rating of medical institutions for compliance with prescribed standards, granting of permission for establishment of new medical institutions and carrying out of inspection for this purpose, imposing of monetary penalty on medical institution for failure to maintain minimum essential standards prescribed. Clause 27 provides for powers and functions of Ethics and Medical Registration Board including maintain a National Register for all licensed medical practitioners and regulate professional conduct, to develop mechanism for continuous interaction with State Medical Councils. Clause 29 provides for criteria for approval or disapproval of the scheme for establishment of new medical college. Clause 30 provides for State Medical Council and other provisions relating thereto. Clause 31 provides for the maintenance of a National Register by Ethics and Medical Registration Board which shall contain the name, address and all recognised qualifications possessed by licensed medical practitioner. The registers will be maintained in such forms including electronic form as may be specified. Clause 32 provides for rights of persons to have licence to practice and to be enrolled in National Register or State Register. A person who qualifies National Licentiate Examination shall be enrolled in the National Register or State Register. A person who is not enrolled in the State or National Register shall not be allowed to practice medicine or perform any of the function enrolled upon a qualifies medical practitioner such as holding an office of physician or surgeon, signing a medical certificate or giving evidence in matters related to medicine. The Commission may permit exceptions from qualifying National Licentiate Examination in certain cases. Foreign medical practitioners shall be permitted temporary registration in India in such manner as may be prescribed. Clause 34 provides for recognition of medical qualifications granted by Universities or medical institutions in India. The institutions shall apply Under-Graduate Medical Education Board or Post-Graduate Medical Education Board which shall examine the application and decide on grant of recognition. First appeal shall lie to the Commission and second appeal to the Central Government. Clause 35 provides for recognition of medical qualifications granted by medical institutions outside India. Clause 36 provides for recognition of medical qualifications granted by statutory or other bodies in India which are covered by the categories listed in the Schedule. Clause 37 provides for withdrawal of recognition granted to medical qualification granted by medical institutions in India. The Medical Assessment and Rating Board shall make a report to the Commission which shall decide the matter. Clause 38 provides for de-recognition of medical qualifications granted by medical institutions outside India. Clause 39 provides for special provisions in certain cases for recognition of medical qualifications. Clause 41 provides for National Medical Commission Fund which shall form part of the public account of India. All Government grants, fee, penalties and all sums received by the Commission shall form part of it. The fund shall be applied for making payments towards all expenses in the discharge of the functions of the Commission. The accounts of the Commission shall be audited by the Comptroller and Auditor-General of India. Clause 43 provides for furnishing of returns and reports to the Central Government. Clause 44 provides for power of the Central Government to give directions to Commission and Autonomous Boards on questions of policy. Clause 45 provides for power of the Central Government to give directions to State Governments. Clause 46 provides for information to be furnished by the Commissioner and publication thereof. They shall maintain a website at all times and display all such information as may be required by the Commission. Students who were studying in any medical institution before the commencement of this Act shall continue to study and complete in accordance with syllabus and studies as existed before such commencement. Clause 49 provides for joint sittings of the Commission, Central Councils of Homoeopathy and Indian Medicine to enhance interface between their respective systems of medicine. The joint sitting may reside on approving educational modules to develop bridges across the various systems of medicine and promote medical pluralism.

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