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Stuart D. Katz, MD

• Helen L. and Martin S. Kimmel Professor of Advanced
• Cardiac Therapeutics
• Chair Cardiovascular Medicine
• Director Heart Failure Program
• New York University Lagone Medical Center
• Leon H. Charney Division of Cardiology
• New York City, New York

The symptoms often are progressive and may severely limit a patients activities and reduce the patients functional status symptoms crohns disease avodart 0.5 mg with mastercard. An individual with proximal stenosis medicine effects buy 0.5mg avodart with amex, such as aortoiliac disease treatment 34690 diagnosis generic avodart 0.5 mg on line, may complain of exertional pain in the buttocks and thighs medicine cabinet buy online avodart. Severe occlusion may produce rest pain medications osteoarthritis pain purchase avodart uk, which often occurs at night and may be relieved by sitting up and dangling the legs treatment ingrown hair order cheap avodart on line, using gravity to assist blood flow to the feet. On physical examination, palpation of the peripheral pulses may be diminished or absent below the level of occlusion; bruits may indicate accelerated blood flow velocity and turbulence at the sites of stenosis. Bruits may be heard in the abdomen with aortoiliac stenosis and in the groin with femoral artery stenosis. Elevation of the feet above the level of the heart in the supine patient often induces pallor in the soles. If the legs are then placed in the dependent position, they frequently develop rubor as a result of reactive hyperemia. Chronic arterial insufficiency may cause hair loss on the legs and feet, thickened and brittle toenails, and shiny atrophic skin. Systolic blood pressures are measured by Doppler ultrasonography in each arm and in the dorsalis pedis and posterior tibial arteries in each ankle. In fact, blood pressures in the legs often are higher than in the arms because of an artifact of measurement, so the normal ratio of ankle to brachial pres sures is more than 1. Further evaluation with exercise treadmill testing can clarify the diagnosis when symptoms are equivocal, can allow for assessment of functional limitations (eg, maximal walking distance), and can evaluate for concomitant coronary artery disease. Management the goals of therapy include reductions in cardiovascular morbidity and mortality, improvement in quality of life by decreasing symptoms of claudication and eliminat ing rest pain, and preservation of limb viability. Smoking is, by far, the single most important risk factor impacting both claudication symp toms and overall cardiovascular mortality. Besides slowing the progression to critical leg ischemia, tobacco cessation reduces the risk of fatal or nonfatal myocardial infarction by as much as 50%, more than any other medical or surgical inter vention. In addition, treatment of hypercholesterolemia, control of hypertension and diabetes, and use of antiplatelet agents such as aspirin or clopidogrel all have been shown to improve cardiovascular health and may have an effect on peripheral arterial circulation. Carefully supervised exercise programs can improve muscle strength and prolong walking distance by promoting the development of collateral blood flow. Specific medications for improving claudication symptoms have been used, with some benefit. Pentoxifylline, a substituted xanthine derivative that increases erythrocyte elasticity, has been reported to decrease blood viscosity, thus allowing improved blood flow to the microcirculation; however, results from clinical trials are conflicting, and the benefit of pentoxifylline, if present, appears small. It has been shown in randomized controlled trials to improve maximal walking distance. This can be accomplished by percutaneous angio plasty, with or without placement of intraarterial stents, or surgical bypass grafting. Angiography (either conventional or magnetic resonance arteriography) should be performed to define the flow-limiting lesions prior to any vascular procedure. Ideal candidates for arterial revascularization are those with discrete stenosis of large ves sels; diffuse atherosclerotic and small-vessel disease respond poorly. Less common causes of chronic peripheral arterial insufficiency include throm boangiitis obliterans, or Buerger disease, which is an inflammatory condition of small and medium-size arteries that may affect the upper or lower extremities and is found almost exclusively in smokers, especially males younger than 40 years. Fibro muscular dysplasia is a hyperplastic disorder affecting medium and small arteries that usually occurs in women. Takayasu arteritis is an inflammatory condi tion, seen primarily in younger women, that usually affects branches of the aorta, most commonly the subclavian arteries, and causes arm claudication and Raynaud phenomenon, along with constitutional symptoms such as fever and weight loss. Patients with chronic peripheral arterial insufficiency who present with sud den unremitting pain may have an acute arterial occlusion, most commonly the result of embolism or in situ thrombosis. Artery-to-artery embolization of athero sclerotic debris from the aorta or large vessels may occur spontaneously or, more often, after an intravascular procedure, such as arterial catheterization. Emboli tend to lodge at the bifurcation of two vessels, most often in the femoral, iliac, popliteal, or tibioperoneal arteries. Arterial thrombosis may occur in atherosclerotic vessels at the site of stenosis or in an area of aneurysmal dilation, which may also complicate atherosclerotic disease. Patients with acute arterial occlusion may present with a number of signs, which can be remembered as six Ps: pain, pallor, pulselessness, paresthesias, poikilothermia (coolness), and paralysis. The first five signs occur fairly quickly with acute ischemia; paralysis will develop if the arterial occlusion is severe and persistent. Rapid restoration of arterial supply is mandatory in patients with an acute arterial occlusion that threatens limb viability. Initial management includes anti coagulation with heparin to prevent propagation of the thrombus. The affected limb should be placed below the horizontal plane without any pressure applied to it. Conventional arteriography usually is indicated to identify the location of the occlusion and to evaluate potential methods of revascularization. Alternatively, a catheter can be used to deliver intraarterial thrombolytic therapy directly into the thrombus. In comparison with systemic fibrinolytic therapy, local ized infusion is associated with fewer bleeding complications. Which of the following therapies might offer him the greatest benet in symptom reduction and in overall mortality Which of the following is the most liekly cause of arterial insufficiency in this patient Which of the following is the most likely cause of arterial insufficiency in this patient She is evaluated by the cardiovascular surgeon but not felt to be a surgical can didate. Cilostazol may help with claudication symptoms but will not affect cardiovascular mortality. Thromboangiitis obliterans, or Buerger disease, is a disease of young male smokers and may cause symptoms of chronic arterial insufficiency in either legs or arms. Takayasu aortitis is associated with symptoms of inammation such as fever, and most often affects the subclavian arteries, producing stenotic lesions that may cause unequal blood pressures, diminished pulses, and ischemic pain in the affected limbs. Embolism of cholesterol and other atherosclerotic debris from the aorta or other large vessels to small vessels of skin or digits may complicate any intraar terial procedure. Surgical therapy is reserved for severe symptoms after exercise and pharmacologic agents are used, and quality of life is impaired. Pain at rest, lack of symptoms for medical therapy, nonhealing ulcers, and gangrene are some of those indications. Duplex ultrasound can help to discern whether the patient is a potential surgical candidate. Diffuse atherosclerotic disease is a contraindication for surgery since bypass would not help in the face of signicant and widespread disease. Other treatments include pent oxifylline or cilostazol, regular exercise, and cardiovascular risk factor modification. Revascularization by angioplasty or bypass grafting may be indicated for patients with debilitating claudication, ischemic rest pain, or tissue necrosis. Acute arterial occlusion that threatens limb viability is a medical emer gency and requires immediate anticoagulation and investigation with conventional arteriography. Acute severe ischemia of an extremity causes the six Ps: pain, pallor, pulselessness, paresthesias, poikilothermia, and paralysis. Chronic incom plete arterial occlusion may result only in exertional pain or fatigue, pallor on elevation of the extremity, and rubor on dependency. Seven years ago at a work-related health screening, he was diagnosed with hypertension and hyper cholesterolemia. At that time, he saw a physician who prescribed a diuretic and encouraged him to lose some weight and to diet and exercise. During the past 2 months, he has been experiencing occasional headaches, which he attributes to increased stress at work. He denies chest pain, shortness of breath, dyspnea on exertion, or paroxysmal nocturnal dyspnea. He smokes one pack of cigarettes per day and has done so since he was 15 years old. His blood pressure is 168/98 mm Hg in the right arm and 170/94 mm Hg in the left arm. Funduscopic examination reveals narrowing of the arteries, arteriovenous nicking, and flame-shaped hemorrhages with cotton wool exudates. Cardiac examination reveals that his point of maximal impulse is displaced 2 cm left of the midclavicu lar line. His point of maximal impulse is displaced laterally, suggesting cardiomegaly, and a fourth heart sound is consistent with a thickened, noncompliant ventricle. In addition, he has multiple cardiovascular risk factors, including his age, obesity, and smoking. Start the patient on a two-drug antihypertensive regimen that includes a thiazide diuretic. Be familiar with the most common antihypertensive medications, and indica tions and cautions regarding their usage. Be familiar with the various causes of secondary hypertension and when to pursue these diagnoses. Considerations this is a 56-year-old man with severe hypertension, who has evidence, on physical examination, of hypertensive end-organ damage, that is, hypertensive retinopathy and left ventricular hypertrophy as well as multiple risk factors for atherosclerotic disease. The most likely diagnosis is essential hypertension, but secondary causes still must be considered. It has no known cause, yet it comprises approximately 80% to 95% of all cases of hypertension. Alcohol consumption should be moderated, no more than two glasses of wine per day for men and one glass per day for women. The major risk factors of cardiovascular disease are age, cigarette smoking, dyslipidemia, diabetes mellitus, obesity, kidney disease, and a family history of pre mature cardiovascular disease. Target organ damage of hypertension includes car diomyopathy, nephropathy, retinopathy, and cerebrovascular disease. A complete history and physical examination, including funduscopic examination, ausculta tion of the major arteries for bruits, palpation of the abdomen for enlarged kid neys, masses, or an enlarged abdominal aorta, evaluation of the lower extremities for edema and perfusion, and a neurologic examination should be standard. Counseling patients on lifestyle changes is important at any blood pressure level and includes weight loss, limitation of alcohol intake, increased aerobic physical activity, reduced sodium intake, cessa tion of smoking, and reduced intake of dietary saturated fat and cholesterol. For those with prehypertension (blood pressure 120-139/80-89 mm Hg), lifestyle modifica tions are the only interventions indicated unless they have another comorbid condi tion, such as heart failure or diabetes, which necessitates use of an antihypertensive. The target blood pressure typi cally is 135/85 mm Hg, unless the patient has diabetes or renal disease, in which case the target would be lower than 130/80 mm Hg. Whatever drug class is used, a long-acting formulation that provides 24-hour efficacy is preferred over short-acting agents for better compliance and more con sistent blood pressure control. For some patients, there are specific compelling indications to use specific drug classes. Beta-blockers would be first-line agents in patients with hypertension and coronary artery disease. Alpha-blockers may be considered in men with hypertension and benign prostatic hypertrophy. It is critical to tailor the treat ment to the patients personal, financial, lifestyle, and medical factors, and to peri odically review compliance and adverse effects. Renal artery stenosis is caused by atherosclerotic disease with hemodynamically significant blockage of the renal artery in older patients or by fibromuscular dysplasia in younger adults. The clinician must have a high index of suspicion, and further testing may be indicated, for instance, in an individual with diffuse atherosclerotic disease. Potassium level may be low or borderline low in patients with renal artery stenosis caused by secondary hyperaldosteronism. A captopril-enhanced radionuclide renal scan often is helpful in establishing the diag nosis; other diagnostic tools include magnetic resonance angiography and spiral computed tomography. The clas sic clinical findings are positive family history of polycystic kidney disease, bilateral flank masses, flank pain, elevated blood pressure, and hematuria. Anabolic steroids, sympathomimetic drugs, tricyclic antidepressants, oral contraceptives, nonsteroidal anti-inflammatory agents, and illicit drugs, such as cocaine, as well as licit ones, such as caffeine and alcohol, are included in possible secondary causes of hypertension. The cause of obstructive sleep apnea is a critical narrowing of the upper airway that occurs when the resistance of the upper airway musculature fails against the negative pressure generated by inspiration. In most patients, this is a result of a reduced airway size that is congenital or perhaps complicated by obesity. These patients frequently become hypoxic and hypercarbic multiple times during sleep, which, among other things, eventually can lead to systemic vasoconstriction, systolic hypertension, and pulmonary hypertension. The patient will have a widened pulse pressure with increased systolic blood pressure and decreased diastolic blood pressure, as well as a hyperdynamic precordium. The patient may have warm skin, tremor, and thyroid gland enlargement or a palpable thyroid nodule. Glucocorticoid excess states, including Cushing syndrome, and iatrogenic (treatment with glucocorticoids) states usually present with thinning of the extrem ities with truncal obesity, round moon face, supraclavicular fat pad, purple striae, acne, and possible psychiatric symptoms. An excess of corticosteroids can cause secondary hypertension because many glucocorticoid hormones have mineralocor ticoid activity. Dexamethasone suppression testing of the serum cortisol level aids in the diagnosis of Cushing syndrome. Coarctation of the aorta is a congenital narrowing of the aortic lumen and usu ally is diagnosed in younger patients by finding hypertension along with discor dant upper and lower extremity blood pressures. Coarctation of the aorta can cause leg claudication, cold extremities, and diminished or absence of femoral pulses as a result of decreased blood pressure in the lower extremities. Carcinoid tumors arise from the enterochromaffin cells located in the gastrointestinal tract and in the lungs. Clinical manifestations include cutaneous flushing, headache, diarrhea, and bronchial constriction with wheezing, and often, hypertension.

Syndromes

• Use moisturizer on the skin, particularly in the dry winter months. Dry skin is a common cause of itching.
• Excessive bleeding
• Abnormal amino acids in blood and urine
• Noisy breathing
• Diabetes
• Congenital cytomegalovirus (CMV)
• Bladder spasms

Haematinics Give iron supplements (ferrous sulphate: 200 mg tid) in the later postoperative period to help restore the haemoglobin level medicine hat lodge order generic avodart canada. C Circulation and control of haemorrhage 1 Control haemorrhage: s Control extensive bleeding by pressure on bleeding site 181 s Tourniquets are not recommended as they may increase tissue destruction s Leave penetrating objects in-situ until surgical exploration treatment definition math generic avodart 0.5mg free shipping. D Disorders of the central nervous system 1 Check conscious level: blood loss >30% reduces cerebral perfusion and unconsciousness results treatment 2 purchase avodart 0.5 mg overnight delivery. This is a useful guide 20 medications that cause memory loss generic avodart 0.5 mg fast delivery, but patients may not fit a precise class and variations will occur medicine 1975 generic avodart 0.5 mg amex. A patients response to hypovolaemia is influenced by: s Age s Medical disorders medications for osteoporosis cheap avodart 0.5 mg line. Catheterization of the internal jugular vein should only be performed by a trained person. Fluid resuscitation 1 Give intravenous fluids within minutes of admission to hospital to restore the circulating blood volume rapidly and maintain organ perfusion. Internal jugular vein External jugular vein Identify the point midway between a In the head-down position, the external line joining the mastoid and sternal jugular vein will fill and become visible. Sternal notch Subclavian vein Clavicle Internal jugular vein External jugular vein Mastoid 190 Reassessment Evaluate the response to resuscitation 1 Reassess the patients clinical condition. In trauma, a failure to respond may also be due to heart failure caused by myocardial contusion or cardiac tamponade. Detailed examination Perform a detailed examination as soon as the patient is stabilized. It may only be possible to conduct the secondary survey after surgical control of exsanguinating haemorrhage. The aim is to achieve this within one hour of presentation, using techniques to conserve and manage blood loss during surgery (see pp. Administering large volumes of blood and intravenous fluids may give rise to complications (see pp. Other causes of hypovolaemia Hypovolaemia due to medical and surgical causes other than haemorrhage should be initially managed in a very similar way, with specific treatment. The need for blood transfusion and surgical intervention will depend on the diagnosis. Other causes of hypovolaemia Medical Surgical s Cholera s Major trauma s Diabetic ketoacidosis s Severe burns s Septic shock s Peritonitis s Acute adrenal insufficiency s Crush injury Paediatric patients the principles of management and resuscitation are the same as for adults. Venous access 1 Venous access is difficult in children, especially if they are hypovolaemic. Intraosseous infusion 1 the intraosseous route can provide the quickest access to the circulation in a shocked child if venous cannulation is impossible. Transfusion 1 Children who have a transient response or no response to initial fluid challenge require further crystalloid fluids and blood transfusion. Hypothermia 1 Heat loss occurs rapidly in a child due to the high surface-to mass ratio. Gastric dilatation 1 Acute gastric dilatation is commonly seen in the seriously ill or injured child. Analgesia 1 Give analgesic after initial fluid resuscitation, except in the case of head injury. Using the correct amount of fluid in serious burns injuries is much more important than the type of fluid used. Special points 1 First aiders must first protect themselves from the source of danger: heat, smoke, chemical or electrical hazard. Features of an airway injury Definite features Suspicious features s Pharyngeal burns s History of confinement in burning area s Sooty sputum s Singed eyebrows and nasal hair s Stridor s Cough s Hoarseness s Wheeze s Airway obstruction s Respiratory crepitations s Raised carboxyhaemoglobin level 199 5 Cool the burned area with large amounts of cold water as soon as possible following the burn. Assessing the severity of the burn Morbidity and mortality rise with increasing burned surface area. They also rise with increasing age so that even small burns may be fatal in elderly people. Burns are considered serious if: s >15% in an adult s >10% in a child s the burned patient is very young or elderly. Estimating the burned surface area Adults the Rule of 9s is commonly used to estimate the burned surface area in adults. Children the Rule of 9s is too imprecise for estimating the burned surface area in children because the infant or young childs head and lower extremities represent different proportions of surface area than in an adult. It is common to find all three types within the same burn wound and the depth may change with time, especially if infection supervenes. Depth of burn Characteristics Cause First degree s Erythema s Sunburn (superficial) burn s Pain s Absence of blisters Second degree or s Red or mottled s Contact with hot liquids partial thickness s Swelling and blisters s Flash burns burn s Painful Third degree or full s Dark and leathery s Fire thickness burn s Dry s Prolonged exposure to s Sensation only at hot liquids/objects edges s Electricity or lightning Other factors in assessing the severity of the burn Location/site of burn Burns to the face, neck, hands, feet, perineum and circumferential burns (those encircling a limb, neck, etc. Other injuries Inhalation injury, trauma or significant pre-existing illness increase risk. Treatment must restore the circulating blood volume in order to maintain tissue perfusion and oxygenation. Calculating fluid requirements 1 Assess the severity of the burn s Ascertain the time of the burn injury s Estimate the weight of the patient s Estimate the % burned surface area. Children First 24 hours Fluid required due to burn (ml) = 3 x weight (kg) x % burned area plus Fluid required for maintenance (ml): First 10 kg = 100 x weight (kg) Second 10 kg = 75 x weight (kg) Subsequent kg = 50 x weight (kg) Give half this volume in the first 8 hours and the other half over the remaining 16 hours Note 1 the upper limit of burned surface area is sometimes set at 35% for children as a caution to avoid fluid overload. There is no clear evidence that they significantly improve outcomes or reduce oedema formation when used as alternatives to crystalloids. There is no justification for the use of blood in the early management of burns, unless other injuries warrant its use for red cell replacement. Monitoring 1 Formulae for calculating fluid requirements should be used only a guide. Monitoring burns patients s Blood pressure s Heart rate s Fluid input/output (hydration) s Temperature s Conscious level and anxiety state s Respiratory rate/depth Continuing care of burns patients 1 Give anti-tetanus toxoid: it is essential for burned patients. The procedure is painless and, if necessary, can be performed on the ward under sterile conditions. Additive solution Proprietary formulas designed for reconstitution of red cells (red cell additive solution) after separation of the plasma to give optimal red cell storage conditions. Anti-D immunoglobulin Human immunoglobulin G preparation containing a high level of antibody to the RhD antigen. Balanced salt solution Usually a sodium chloride salt solution with an electrolyte composition that resembles that of extracellular fluid. Colloid solution A solution of large molecules which have a restricted passage through capillary membranes. Crystalloid solution Aqueous solution of small molecules which easily pass through capillary membranes. Decompensated anaemia Severe clinically significant anaemia: anaemia with a haemoglobin level so low that oxygen transport is inadequate, even with all the normal compensatory responses operating. Desferrioxamine An iron-chelating (binding) agent that increases excretion of iron. Dextran A macromolecule consisting of a glucose solution that is used in some synthetic colloid solutions. Fibrin degradation products Fragments of fibrin molecule formed by the action of fibrinolytic enzymes. Elevated levels in the blood are a feature of disseminated intravascular coagulation. Gelatin A polypeptide of bovine origin that is used in some synthetic colloid solutions. Haematocrit (Hct) An equivalent measure to packed cell volume, derived by automated haematology analyses from the red cell indices. Hypochromia Reduced iron content in red cells, indicated by reduced staining of the red cell. The main classes of immunoglobulin are IgG, IgM (mainly in plasma), IgA (protects mucosal surfaces) and IgE (causes allergic reactions). Kernicterus Damage to the basal ganglia of the brain, caused by fat soluble bilirubin. Kleihauer test Acid elution of blood film to allow counting of fetal red cells in maternal blood. A feature of the red cells in, for example, anaemia due to deficiency of folic acid, vitamin B12. Maintenance fluids Crystalloid solutions that are used to replace normal physiological losses through skin, lung, faeces and urine. Usually due to deficiency of vitamin B12 and/or folate and develop into macrocytic red cells (enlarged red cells). Packed cell volume Determined by centrifuging a small sample of blood in an anticoagulated capillary tube and measuring the volume of packed red cells as a percentage of the total volume. Plasma derivative Human plasma protein prepared under pharmaceutical manufacturing conditions. Replacement fluids Fluids used to replace abnormal losses of blood, plasma or other extracellular fluids by increasing the volume of the vascular compartment. See Bacterial contamination of blood Children products 52, 68 chronic anaemia 86 Balanced salt solutions 15 chronic blood loss 86 Bilirubin concentration in clinical assessment 89, 91, infants 151 125 Bleeding and clotting disorders. See Platelets assessing the severity of 200 prescribing decisions 82 burned surface area 200 risk of transfusion-transmissible continuing care 206 infection 4 depth of burn 202 whole blood 23 fluid requirements 203 Blood donation fluid resuscitation 203 preoperative 174 inhalation injury 199 Blood loss. See Disseminated intravascular vital signs, normal, by age 193 coagulation vitamin K deficiency 145 Disseminated intravascular Citrate toxicity 75 coagulation 115 Clotting. See Fluids children 144 RhD management 106 antigen 47 transfusion 106 incompatibility 132 Thrombin time 117 prevention of Rhesus Thrombocytopenia disease 133 children 145, 147, 155 screening of pregnant surgery 161 women 132 Transfusion-associated acute lung Ringers lactate: See balanced salt injury 70 solutions Tranexamic acid 113, 114, 164 Rule of 9s Transfusion adverse effects 60 anaemia in pregnancy 126 S anaemia, severe chronic 90 Salvage of blood. Requests for permission to change, adapt or translate any of the contents, with a statement of the purpose and extent, should be addressed to Blood Safety and Clinical Technology, World Health Organization, 20 Avenue Appia, 1211 Geneva 27. The Organization shall not be liable for any damages incurred as a result of use of the data or programs. Roos-Hesselink (The Netherlands), Maria Schaufelberger (Sweden), Ute Seeland (Germany), Lucia Torracca (Italy). Popescu (Romania), Zeljko Reiner (Croatia), Udo Sechtem (Germany), Per Anton Sirnes (Norway), Adam Torbicki (Poland), Alec Vahanian (France), Stephan Windecker (Switzerland). Working Groups: Thrombosis, Grown-up Congenital Heart Disease, Hypertension and the Heart, Pulmonary Circulation and Right Ventricular Function, Valvular Heart Disease, Cardiovascular Pharmacology and Drug Therapy, Acute Cardiac Care, Cardiovascular Surgery. Councils: Cardiology Practice, Cardiovascular Primary Care, Cardiovascular Imaging. Health professionals are encouraged to take them fully into account when exercising their clinical judgement. The level of evidence and the strength of recommendation of particular treatment options were weighed and graded according to pre-dened scales, as outlined in 1. Guidelines summarize and evaluate all available evidence, at the the experts of the writing and reviewing panels lled in declara time of the writing process, on a particular issue with the aim of tions of interest forms which might be perceived as real or poten assisting physicians in selecting the best management strategies tial sources of conicts of interest. Any changes in declarations of inter of particular diagnostic or therapeutic means. However, the nal decisions new Guidelines produced by Task Forces, expert groups, or con concerning an individual patient must be made by the responsible sensus panels. Because ate revisions it is approved by all the experts involved in the Task of the impact on clinical practice, quality criteria for the develop Force. Implementation Table 1 Classes of recommendation Classes of Denition Suggested wording to use recommendations Class I Evidence and/or general agreement Is recommended/is that a given treatment or procedure indicated is benecial, useful, effective. The Guidelines are based on a systematic search of the literature Consensus of opinion of the experts and/ Level of of the last 20 years in the National Institutes of Health database or small studies, retrospective studies, Evidence C (PubMed). Also the treatment of congenital heart patient, and, where appropriate and necessary, the patients guar disease has improved, resulting in an increased number of women with heart disease reaching childbearing age. It is also the health professionals responsibility to verify the rules and regulations applicable to drugs and devices at countries maternal heart disease is now the major cause of maternal death during pregnancy. Nevertheless, the number of such Cardiomyopathies are rare, but represent severe causes of car patients presenting to the individual physician is small. Such guidelines have to give special consideration to the fact that all measures metabolic alterations during pregnancy concern not only the mother, but the fetus as well. Therefore, Pregnancy induces changes in the cardiovascular system to meet the optimum treatment of both must be targeted. Systolic function increases rst but may Genetic testing may be useful: decrease in the last trimester.

States should establish procedures until the trainee attains the necessary skills treatment quad strain purchase discount avodart on-line. Consistency in to ensure compliance of the training requirement by agency interpretation of licensing rules is essential for effective and personnel medications related to the lymphatic system generic 0.5 mg avodart mastercard. Achieving consistency across inspectors throughout the state is diffcult to achieve and maintain symptoms quit smoking buy 0.5 mg avodart amex. Every state should have tection of children medications via g-tube buy avodart 0.5 mg low price, licensing inspectors should undergo individual standards that are applied to the following types periodic retraining and reevaluation to assess their ability to of facilities: recognize sound and unsound practices symptoms uterine cancer 0.5 mg avodart sale. In addition symptoms 7dp3dt buy avodart 0.5mg low price, all staff a) Family child care home: A facility providing care involved in licensing such as agency directors, attorneys, and education of children, including the caregiver/ policy staff, managers, clerical/support personnel, and infor teachers own children in the home of the caregiver/ mation system staff need periodic training updates. States are beginning to put c) Drop-in facility: A child care program where children interpretive guidelines on their Websites for ready use by are cared for over short periods of time on a one providers. Licensing staff must be trained on the interpretive time, intermittent, unscheduled and/or occasional guidelines and treat it as a living document which is fre basis. Drop-in care is often operated in connection quently reviewed and revised as interpretation is refned. Procedure manu activities to school-age children before and after als, consisting of well developed and currendly used proce school, during vacations, and non-school days set dures to be used in the enforcement of licensing rules and aside for such activities as caregivers/teachers in regulatinos are also effective in achieving consistency when service programs; there is frequent training and revision as needed. Docu e) Facility for children who are mildly ill: A facility ments used by the agency for achieving consistency should providing care of one or more children who are mildly be conveniently accessible to caregivers/teachers (1). Achieving the vision: A workbook for human f) Integrated or small group care for children who are care regulatory agencies. For example, child care for should be at least as well informed about child abuse issues seven to twelve children in the residence of the caregiver/ teacher may be referred to as family day care, a group day 407 Chapter 10: Licensing/Community Caring for Our Children: National Health and Safety Performance Standards care home, or a mini-center in different states. While it is not all persons over ten years of age who live in a small or large essential that each state use the same terms and some vari family child care home where child care is provided. An past fve years, the other state(s) where the individual epidemiologic profle of children with special health care needs. It is important to recognize and cannot be used for the purposes of background the relevance of health and safety in the quality criteria (1,2). Department of Health and Human Services, Administration for Children and Families, National Child Care Information and Compliance Technical Assistance Center. Stair steps to quality: A guide for states and ment is being met by equivalent means and does not com communities developing quality rating systems for early care and promise the health, safety or protection of children (1). Flexibility in applying licensing regulations should be permitted to the Before granting a license to a facility, the licensing agency extent that childrens need for protection is met. Suffcient numbers both an announced and unannounced basis with meaning of licensing inspectors should be hired to provide adequate ful sanctions for noncompliance (1). When unannounced time visiting and inspecting facilities to insure compliance inspections are used, they should be conducted at any hour with regulations the facility is in operation, i. Unannounced Complaints should be investigated promptly, based on inspections have been shown to be especially effective severity of the complaint. States are encouraged to post the when targeted to providers with a history of low compliance (1). Licensing and public regulation of early childhood programs: A position statement. Guides for day care facilities to achieve and maintain full compliance with licens licensing. Technical assistance and consultation provided the licensing agency should adopt monitoring strategies by licensing inspectors on an on-going basis are essential that ensure compliance with licensing requirements. These to help programs achieve compliance with the rules and strategies should include the provision of technical as go beyond the basic level of quality. These positive strate sistance, advice and guidance to help providers achieve gies are most effective when they are coupled with the and maintain compliance with licensing requirements and non-regulatory methods used by other parts of the early consultation, advice and guidance to encourage upgrad care and education community to promote quality (such as ing the quality of care to exceed licensing requirements (1). All of these methods are most effective when they lected policies and performance indicators and/or conduct a work together within a coordinated early care and educa random sampling of licensing requirements at least annually. Research has demonstrated that posting of the licensing agency should have procedures and staffng in licensing information on the Internet has a positive effect on place to increase the level of compliance monitoring for any compliance with licensing rules (3). Technical assistance bulletin #99 assisting programs and providers to achieve and maintain 01. The team should Each licensing agency should have a procedure for receiv eliminate duplication of inspections to create more effcient ing complaints regarding violation of the regulations. Examples of activities to be coordinated complaints should be recorded, investigated, and appropri include: ate action, if indicated, should be taken. At a minimum, the licensing agency has responsibil e) Reporting child abuse; ity for consumer protection. Complaints serve as an early f) Training and technical consultation; warning before more serious adverse events occur. In most cases complaint inves health workers, licensors, and employers about their roles in tigation should include an unannounced inspection. To State law should ensure that caregivers/teachers and child use limited resources, agencies must avoid contradictions care staff who report violation of licensing requirements in in regulatory codes, simplify inspection procedures, and the settings where they work are immune from discharge, reduce bureaucratic disincentives to the provision of safe retaliation, or other disciplinary action for that reason alone, and healthy care for children. Each member of the team gains that they feel safe about reporting these defciencies, they opportunities to learn about the responsibilities of other must be assured immunity from retaliation by the child care team members so that close working relationships can be facility unless the report is malicious. This immunity is best established, conficts can be resolved, and decisions can be provided when a state statute mandates it. In small states, a state level task force may be suf report problems in their own workplace may be known as fcient. Department of Labor, Northern Hudson Valley Job Services personnel, including school nurses, and local government to Employer Committee. This data should be shared infected children; with appropriate agencies and the child care health consul 4) Arranging a source and method for the tant for analysis. When outbreaks or emergencies specify where diseases are to be reported and occur, quick identifcation of, and appropriate response to , what information is to be provided by the child an unusual circumstance is critical. Conducting daily health care provider to the health department and to checks and keeping symptom records is a good way to parents/guardians; identify the potential for an infectious disease emergency 6) Requiring that all facilities, regardless of licensure or outbreak. When children in a group seem to have similar status, and all health care providers report certain symptoms that suggest a contagious disease is spreading, infectious diseases to the responsible local the program should consult with its child care health con or state public health authority. Licensing agencies can make licensing authority should require such reporting appropriate and preventive changes to licensing regulations under its regulatory jurisdiction and should and program monitoring if they have accurate data on which collaborate fully with the health department when to base those changes (2). Fatalities and the organization of child strategy that is based on sound public health and care in the United States. This role includes the following activities to be con annual training programs for caregivers/teachers. Specialized training for staff maintenance of a system of child care health who care for children who are ill should focus on the consultation; recognition and management of childhood illnesses, b) Monitoring the occurrence of serious injury events as well as the care of children with infectious and outbreaks involving children or providers; diseases; c) Alerting the responsible child care administrators g) Assisting the licensing authority in the periodic review about identifed or potential injury hazards and of facility performance related to caring for children infectious disease risks in the child care setting; who are ill by: d) Controlling outbreaks, identifying and reporting 1) Reviewing written policies developed by facilities infectious diseases in child care settings including: regarding inclusion, exclusion, dismissal criteria 411 Chapter 10: Licensing/Community Caring for Our Children: National Health and Safety Performance Standards and plans for health care, urgent and emergency State and local health departments are legally required to care, and reporting and managing children with control certain infectious diseases within their jurisdictions infectious disease; (20). All states have laws that grant extraordinary powers 2) Assisting with periodic compliance reviews to public health departments during outbreaks of infec for those rules relating to inclusion, exclusion, tious diseases (1,11,12). Since infectious disease is likely dismissal, daily health care, urgent and emergency to occur in child care settings, a plan for the control of care, and reporting and management of children infectious diseases in these settings is essential and often with infectious disease; legally required. Early recognition and prompt intervention h) Collaborating in the planning and implementation will reduce the spread of infection. Outbreaks of infectious of appropriate training and educational programs disease in child care settings can have great implications for related to health and safety in child care facilities. Programs administered by local Such training should include education of parents/ health departments have been more successful in control guardians, primary care providers, public health and ling outbreaks of hepatitis A than those that rely primarily safety workers, licensing inspectors, and employers on private physicians. Programs coordinated by the local about how to prevent injury and disease as well health department also provide reassurance to caregivers/ as promote health and safety of children and their teachers, staff, and parents/guardians, and thereby promote caregivers/teachers; cooperation with other disease control policies (3). Infec i) Promoting that health care personnel, such as tious diseases in child care settings pose new epidemiologi qualifed public health nurses, pediatric and family cal considerations. Only in recent decades has it been so nurse practitioners, and pediatricians serve as child common for very young children to spend most of their days care health consultants; together in groups. Public health authorities should expand j) Ensuring child care programs are included and their role in studying this situation and designing new pre represented in local and state disaster preparedness ventive health measures (4,5). In small states, a state level task force that incidence of injuries in the child care setting (7-10). In the injuries described have not been serious, these occur larger or more populous states, local task forces in addi frequently, and may require medical or emergency attention. The Child care programs need the assistance of local and state collaboration should focus on establishing the role of each health agencies in planning of the safety program that will agency in ensuring that necessary services and systems minimize the risk for serious injury (11). This would include exist to prevent and control injuries and infectious diseases planning for such signifcant emergencies as fre, food, in facilities (6,19). A community health agency Health departments generally have or should develop the can collect information that can promptly identify an injury expertise to provide leadership and technical assistance to risk or hazard and provide an early notice about the risk or licensing authorities, caregivers/teachers, parents/guard hazard (14). An example is the recent identifcation of un ians, and primary care providers in the development of powered scooters as a signifcant injury risk for preschool licensing requirements and guidelines for the management children (15). The heavy reliance on the expertise of channels of communication are required to alert the child local and state health departments in the establishment of care administrators and to provide training and educational facilities to care for children who are ill has fostered a part activities. Infectious disease in pediatric out-of-home fective in improving the health and safety of children in child child care. Chapter 10: Licensing/Community 412 Caring for Our Children: National Health and Safety Performance Standards 4. Creating a regional ration with the licensing agency (if other than the health pediatric medical disaster preparedness network: Imperative and department), health care providers, caregivers/teachers, issues. Caring for children of caretakers during a community resources for successful implementation. The lack of disaster preparedness by the licensing agency (if other than the health department) for the public and its affect on communities. Internet J Rescue Disaster the promulgation and enforcement of child care facility stan Med 7 (2): 1. Disaster care: Public health emergencies and agencys assigned responsibilities for enforcement of the children. The effects development of the health department plan: of maternal employment on child injuries and infectious disease. Why Managing Infectious Diseases in Child Care and does Sweden have the lowest childhood mortality in the world The Schools, Managing Chronic Health Needs in Child role of architecture and public pre-school services. Policy Communicable Diseases Manual; statement: the pediatrician and disaster preparedness. National Association of Child Care Resource and Referral d) Guidelines from the U. Helping families and children cope with trauma in the Advisory Committee on Immunization Practices, aftermath of disaster. Impact of training on Infants, Children, and Adolescents; child care health consultant knowledge and practice. Outcomes of child care health consultation services for h) Current early childhood physical activity resources, child care providers in New Jersey: A pilot study. Pediatric Nursing such as Active Start: A Statement of Physical Activity 32:530-37. Edition; Moving with a Purpose: Developing Programs Child care health consultation improves health and safety policies and practices. National Child Care Information and Technical Assistance to institutionalize performance. The plan should identify child care health department and comply with state and local rules related risks and diseases as well as provide guidance for and regulations intended to prevent infectious disease that risk reduction, disease prevention and control. All states have laws that grant extraordinary ians about the incidence of infectious diseases in child care powers to public health departments during outbreaks or settings (1). Education of child care staff and parents/guard epidemics of infectious disease or bioterrorism attacks. Training should be recognition and prompt intervention will reduce the spread available to all parties involved, including caregivers/teach of infection. Good quality training, with imagina Outbreaks of infectious disease in child care settings can tive and accessible methods of presentation supported by have great implications for the general community (1,4). The number grams administered by local health departments have been of studies evaluating the importance of education of child more successful in controlling outbreaks of hepatitis A than care staff in the prevention of disease is limited. Programs data from numerous studies in hospitals illustrate the impor coordinated by the local health department also provide re tant role of continuing education in preventing and minimiz assurance to caregivers/teachers, staff, and parents/guard ing the transmission of infectious disease (1). The provision ians, and thereby promote cooperation with other disease of fact sheets on infectious childhood diseases at the time and safety control policies (2). Infectious diseases in child their child is admitted to a facility helps educate parents/ care settings pose epidemiological considerations. Public guardians as to the early signs and symptoms of these ill health authorities should expand their role in studying this nesses and the need to inform caregivers/teachers of their situation and designing new preventive health and safety existence. Infection control challenges mon illnesses available from such agencies as the American in child-care centers. Red book: 2009 report of the Committee on Infectious Common Illnesses Associated with Child Care Diseases. Health departments should help child care providers use prepared prototype parent and staff fact sheets on com mon illnesses associated with child care. Such e) Mode of transmission of the disease; training should emphasize the importance of conducting f) Period of communicability; regular safety checks and providing direct supervision of g) Disease prevention measures recommended by the children at all times. Training plans should include mecha public health department (if appropriate); nisms for training of prospective child care staff prior to h) Emphasize modes of transmission of respiratory their assuming responsibility for the care of children and for disease and infections of the intestines (often with ongoing/continuing education. The higher education institu diarrhea) and liver, common methods of infection tions providing early education degree programs should be control (such as hand hygiene).

Surgery: When drugs fail to control seizures and the cause of seizures is an electrical focus which may be localized to a structure medicine checker generic avodart 0.5 mg without a prescription, then seizures can be controlled after appropriate surgery medicine 3605 v buy avodart pills in toronto. Hence medications ranitidine purchase avodart 0.5 mg visa, in refractory cases where a focus can be defined as a cause of epilepsy medicine keeper buy discount avodart 0.5mg, surgery can fully control seizures in 30 to 35 % patients medications vertigo buy avodart online from canada. The facilities for these surgeries are available in our Country and they do not carry much risk medicine 0636 purchase avodart on line amex. A team of experienced Neurosurgeon Neurophysician can decide as to which of the following surgeries would be beneficial to the patient. The parameters can be changed: For those patients who are not appropriate candidates for surgery, in whom a focus is not dependable or those who are awaiting surgery this method is beneficial, specially when anti-epileptic drugs have not worked. This form of treatment may sound difficult for children initially but slowly they adapt to this diet. Targeted drug delivery), newer surgical techniques will ensure brighter future for epileptic patients. However in view of the ever changing concepts and advances in the field of medicine, this discussion should be adequate; if not complete. Misconceptions: Unfortunately a lot of misconceptions are still prevailing about Epilepsy; therefore it has been observed that the patients do not get the correct treatment. Even after recovering from epilepsy it is advisable to stay away from fire and not drive or swim for some years. Epileptic patients should be considered as normal; one should not have a biased attitude towards them. Julius Cesar, Napoleon, Alfred Nobel, Vincent Van Gaugh, Jhonty Rhodes, and many other great personalities suffered from epilepsy, but still managed to excel in their respective professions. Thus, epilepsy is not a barrier to excellence in social life or business activities. To help the epileptic patients The Indian Epilepsy Association and Society have been very active in several cities. They provide detailed information on epilepsy and also arrange various group programmes. Various activities are carried out to provide moral support to the patient and family members, and to help patients gain acceptance in the society. It is really sad and surprising that there is very little awareness among the general public regarding this disease. Like heart attack, knowledge of the risk factors can prevent the occurrence of the disease in majority of cases. If the warning signs are identified in time, immediate safety measures can be taken easily, so that in future any major stroke can be averted. After a stroke it is essential that immediate diagnosis and correct treatment be given to prevent permanent disabilities. This will be beneficial socially, personally, financially, family wise and nationally. This is the main aim behind providing detailed information of paralysis (brain stroke) in this chapter. Paralysis can occur due to obstruction in the blood circulation in the main arteries supplying blood to the brain. During stroke, sometimes the ability of speech, comprehension and/or sight can also get affected. Due to the obstruction of some of the arteries of the brain, the blood circulation is affected leading to reduced nutrition and oxygen to brain cells, which hampers the normal working of these brain cells leading to a stroke. Some fortunate people get a transient paralytic attack, which is completely cured within 24 hours. In 30% of these kind of patients there is a possibility of getting a bigger stroke attack in next five years. Thus, this serves as a warning for such patients to take good care of themselves in order to avoid future strokes. The doctors evaluate the extent, type and location of the damage to the brain on the basis of the signs and the severity of the paralytic attack. If the left side of the brain is affected then the right side of the body is paralyzed, and usually speech is also affected. Similarly, if the right side of the brain is affected, the left Main 4 Arteries Supplying Blood to the Brain side of the body gets paralyzed. The two arteries in the anterior portion of the neck are called the Carotid arteries and the arteries in the posterior part of the neck are called the vertebral arteries, which provide uninterrupted blood supply to the brain. The posterior arteries then merge to form the Basilar artery, which is one of the most important arteries of our body. If there is a constriction or obstruction in the main artery supplying blood to the brain due to a clot, the circulation of blood in the brain is hampered. With advancing age the inner lining of the damaged arteries thickens causing an obstruction or reduction in the blood flow. Increase of lipids in the blood can cause thickening of blood and a local clot formed resulting in Thrombosis, or a clot from the heart or any other part of the body may travel to the arteries of the brain, obstructing blood supply to the brain. In 20% of the cases rupture of a blood vessel due to high blood pressure or any other reason, causes paralysis. Symptoms similar to stroke can also occur in other diseases like infections of brain, brain tumor, lymphomas, multiple sclerosis, hysteria, head injuries etc. This paralysis is different from stroke and other associated symptoms can usually help in differential diagnosis. Diseases of the blood that result in clotting or increased viscosity of the blood 12. These factors can be effectively controlled by regular treatment and preventive measures. People beyond the age of 40, need regular medical examinations If any of the family member has suffered from a heart disease or a stroke, it is necessary for the other members to take extra precautions. It should also be noted that 40% of the patients of stroke have no apparent and visible risk factors worth accounting for the stroke. Feeling of weakness in one side of the body; the limbs of the affected side may stop working or become numb. Vertigo, blurring of vision, diplopia, sudden headaches, nausea or vomiting, weakness in both the legs, stumbling, sudden momentary unconsciousness or falling down. These symptoms prevail for certain period of time and if the symptoms are ignored and if no treatment is commenced, paralysis of a whole side ensues, with loss of speech and the patient may be unconscious. In order to avoid this, obesity should be prevented by taking a proper nutritious diet. Blood Pressure: Blood pressure should be regularly checked and if it is high, proper medication should be taken to keep it under control. Even if a patient has come for any other disease or ailment, according to a notification of the National Stroke Association, it is the duty of the doctor to check the patients blood pressure. Regular check-up of blood pressure will prevent heart disease, paralysis and kidney diseases. Ideally, systolic blood pressure should be around 130 to 140 while the diastolic blood pressure should be maintained at 80 to 90. Time and again it has been proved that by merely controlling blood pressure alone, 40 to 50% cases of paralysis and heart diseases can be prevented. There are many people who are not ready to accept that they are suffering from high blood pressure because they do not get any symptoms like headache or dizziness. But they dont understand that all patients of high blood pressure do not have these symptoms. Some patients take medications for some time and feel that their blood pressure is cured. Whenever the blood pressure is measured while taking the medication, it is bound to be normal and therefore the patient may discontinue the medication due to a false sense of security. On discontinuing the drugs, blood pressure starts increasing again, eventually resulting in paralysis or heart attack. Along with the right treatment, the patient should be careful about his lifestyle as well as eating habits. Diet: To prevent a stroke, the fat content in the diet should be reduced to bare minimum. Instead, salads, fresh fruits and vegetables should be consumed in larger quantity. Tensions and stress should be reduced and one should learn to relax and enjoy life. Jealousy, anger, negative thinking should be avoided and everyone should live in harmony, which will always be beneficial. Use of contraceptive pills should be reduced to bare minimum and other forms of contraception should be followed. The patients who have previously suffered a stroke or a heart attack should take drugs like Aspirin, Dipyridamol, Ticlopidine, Clopidogrel, etc; to keep the blood thin, as per prescription from the doctor. With the help of these drugs the chances of a heart attack or paralysis can be reduced by about 13% to 45%. This recent scientific invention has revolutionized the concept of treatment of heart attacks and paralysis and has averted several angioplasties, coronary bypass surgeries and perhaps carotid surgeries. Diagnosis: Paralysis is a disease of the brain and therefore it is necessary to get proper and timely treatment from an experienced Physician or a Neurophysician. Sometimes there can be another disease with similar symptoms and a scan will diagnose the same, preventing a fatal mistake. In addition to this, hematological tests, biochemistry (sugar, tests related to kidney etc. As observed earlier the risk factors of stroke as well as heart diseases are the same and heart disease is comparatively more prevalent than stroke. Therefore, investigations relating to heart disease are essential in patients of paralysis to prevent heart disease. According to a scientific research, number of paralytic patients dying due to heart disease is far more than the deaths caused by stroke. For young patients of paralysis, who do not have blood pressure or diabetes, special investigations like anticardiolipin test, homocysteine tests etc. The decision of the investigations required for the patient, is better left to the doctor. Details of the treatment of stroke: As soon as the symptoms of stroke or paralysis are seen, immediate treatment should be started in a hospital by an expert physician or a neurologist. If the patient gets a convulsion, it should be immediately brought under control and if he is suffering from blood pressure, diabetes etc then they should also be controlled immediately. Thrombolytic therapy: It is an undisputed fact that in case of thromboembolism, if immediate treatment is given with latest special techniques, in the first 3 to 6 hours of paralysis, then in many cases a) entire blocked artery opens up; b) the clot in the artery (thrombus) melts; c) the damage to the brain cells can be prevented or reduced. In addition, 4 to 7 % of the patients suffer from brain hemorrhage as a side effect. In foreign countries public awareness about stroke is very high and hence the person suffering from one is immediately taken to a hospital within 1 to 2 hours. We hope that the same happens in India too and the attitude of the people towards insurance changes for the better. Though our doctors are well aware of this therapy, there are many practical problems in our country. The other therapies available till now cannot cure paralysis beyond six hours after the stroke, as they can not rejuvenate the brain cells, which have died due to lack of blood and oxygen. Antithrombotic therapy: this therapy is easily available in our country and it aims to stop the clot formation in the blood vessels. It includes anticoagulant drugs like, heparin, low molecular heparin, drugs of antiplatelet group, like aspirin, dipyridamol, abciximab and drugs of fibrinolytic group, like ancrod. However, they can lead to side effects like hemorrhage and therefore they need to be administered in the right dose with proper investigations. About 10% to 15% of patients suffer from a strange situation called stroke-in-evolution. It is called strange because even after taking the necessary medications after the initial symptoms of stroke, the paralysis keeps on advancing for 2 to 4 days and eventually the entire side is completely paralyzed. This situation arises when the clot is obstructing the blood vessel gradually and the antithrombotic or antiplatelet drugs are not sufficient enough to offer complete protection against the disease. So patients should be informed about this possibility from the beginning of treatment. In the case of thrombosis, during the initial days the blood pressure should not be brought down rapidly, because this causes a decrease in the blood supply of the brain increasing paralysis further. The neurologists usually do not give any drug to reduce blood pressure (In the first 7 days of a paralysis related to thrombosis) if the systolic B. Neuroprotective Drugs: In cases of stroke, theoretically during the first 6 to 24 hours, chemicals should be given which provide nutrition and oxygen to the cells for a longer period, remove metabolic disturbances, protect the cell walls, and prevent the cells from breaking and dying (due to lack of blood and oxygen). But for reasons unknown, it has been seen that when they are administered to the patients, they do not give the expected results. There are some scientific reasons also for this failure and so better drugs are being developed which can prevent cell damage and keep the cells intact and alive for a longer period even if there is a deficiency of blood and oxygen. Treatment of Complications: During paralysis there can be various complications which increase the severity of the disease like swelling in the brain, unconsciousness, seizures, fever, pneumonia, increase or decrease of the water proportion in the body, bloating of the stomach, retention of urine and fluctuations in the levels of sodium or potassium. The doctor should constantly monitor the condition of the patient minutely so that the patient gets well soon. If a patient gets respiratory distress or goes into a coma due to excessive edema of brain, the patient should be kept on a ventilator and his/her life can be saved. Neurosurgery: In certain cases (2 to 5%) of paralysis, one may require the help of a neurosurgeon who may be able to save the life of a patient and reduce the damage of the brain cells by emergency operations like craniotomy-duraplasty, emergency carotid bypass and embolectomy etc. In a stroke due to hemorrhage, sometimes the skull is opened and the clots are removed (if the drugs are unable to improve the patients condition and if it is possible to remove the clot). Supportive Therapy: Along with the treatment, it is essential that the patient gets proper nutrition and fluids along with vitamin supplements. Within 1 to 2 days of a stroke the doctor usually consults a physiotherapist, who makes the patient undergo limb and chest (respiration) exercises.

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