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Management – If labour has not yet started and bleeding is light: bed rest and monitoring discount albuterol 100mcg. Uterine evacuation buy discount albuterol 100 mcg on line, using aspiration or misoprostol are usually recommended up to 12 weeks. Thus, these methods can be used up to an estimated gestational age of 12 to 14 weeks. Clinical features – Dark slight bleeding, sometimes absent, or shock not always consistent with the external blood loss as bleeding is internal. Uterine rupture Tear in the uterine wall, in most cases during labour, often related to inappropriate use of oxytocin. Clinical features – Impending rupture: prolonged labour, agitation, alteration of the general state, poor uterine relaxation, continuous abdominal pain, more severe than the contractions. Do not administer by sublingual route (risk of placental hypoperfusion, fœtal deatht), always by oral route. Continue for one hour after contractions have ceased, then reduce the rate by half every 6 hours. Monitor maternal pulse regularly, decrease the infusion rate in the event of maternal tachycardia (> 120/minute). Either tocolysis is effective and contractions cease or diminish: in both cases, do not prolong treatment over 48 hours. Or tocolysis is not effective, contractions persist and labour begins: take necessary steps for a premature birth. Post-partum haemorrhage Haemorrhage, exceeding the usual 500 ml of a normal placental delivery that occurs in the first 24 hours (usually immediately) following the delivery of the child. Post- partum haemorrhage is mainly due to placental retention and uterine atonia, but may also result from uterine rupture or cervical or vaginal lacerations. The procedure includes cleaning, disinfection and protection of the wound while respecting the rules of hygiene. Material – Sterile instruments • one Kocher or Pean forceps • one dissecting forceps • one pair of surgical scissors or one scalpel to excise necrotic tissue and to cut gauze or sutures Instruments for one dressing for one patient must be wrapped together in paper or fabric (or can be placed in a metallic box) and sterilised together to limit handling and breaks in asepsis. Use a clean, disinfected dressing trolley with: on the upper tray, sterile and/or clean material (dressing set, extra compresses, etc. Removal of an old dressing – Wash hands (ordinary soap) or disinfect them with an alcohol-based hand rub. If there is significant discharge, a greenish colour or a foul odour, a wound infection is likely. Observe the wound – In the case of an open wound, loss of cutaneous tissue or ulcer, the colour is an indicator of the stage in the healing process: • black area = necrosis, wet or dry infected eschar • yellow or greenish area = infected tissue and presence of pus • red area = granulation, usually a sign of healing (unless there is hypertrophy), however, red edges indicate inflammation or infection • pink area = process of epithelisation, the final stage of healing that begins at the edges of the wound – In the case of a sutured wound, the existence of local signs of suppuration and pain requires the removal of one or more sutures to avoid the infection spreading. Local signs include: • red, indurated and painful edges • drainage of pus between the sutures, either spontaneously or when pressure is applied on either side of the wound • lymphangitis • sub-cutaneous crepitations around the wound In any case, if local signs of infection are observed, look for general signs of infection (fever, chills, changes in the overall condition). Technique for cleaning and dressing of the wound – Wash hands again or disinfect them with an alcohol-based hand rub. Rinse thoroughly then dab dry with a sterile compress; or if not available, sterile 0. The principles remain the same if the dressing is done using instruments or sterile gloves. Subsequent dressings – Clean, sutured wound: remove the initial dressing after 5 days if the wound remains painless and odourless, and if the dressing remains clean. The decision to re-cover or to leave the wound uncovered (if it is dry) often depends on the context and local practices. Several basic rules apply: • rapidly treat wounds, while maintaining the rules of asepsis and the order of the initial procedures: cleaning-exploration-excision; • identify wounds that need to be sutured and those for which suturing would be harmful or dangerous; • immediately suture recent, clean, simple wounds (less than 6 hours old) and delay suturing contaminated wounds and/or those more than 6 hours old; • prevent local (abscess) or general (gas gangrene; tetanus) infections. Material Instruments (Figures 1a to 1d) – One dissecting forceps, one needle-holder, one pair of surgical scissors and one Pean or Kocher forceps are usually enough. Instruments to suture one wound for one patient must be packaged and sterilised together (suture box or set) to limit handling and breaks in asepsis. Renewable supplies – For local anaesthesia: sterile syringe and needle; 1% lidocaine (without epinephrine) – Sterile gloves, fenestrated sterile towel – Sterile absorbable and non-absorbable sutures – Antiseptic and supplies for dressings – For drainage: corrugated rubber drain or equivalent, nylon suture Technique – Settle the patient comfortably in an area with good lighting and ensure all the necessary material is prepared. Wound excision – The goal of the excision is to remove non-viable tissue, which favours the proliferation of bacteria and infection. Delayed suturing of a simple wound – Wounds that do not fill the above conditions should not be immediately sutured. Healing by second intention of infected wounds If the wound does not meet the conditions of cleanliness described above, the wound cannot be sutured. It will heal either spontaneously (healing by secondary intention), or will require a skin graft (once the wound is clean) if there is significant loss of tissue.

Although the seizures appeared to stabilize at slightly more than half the 2005 involving the Dominican Republic in Europe were not level – 109 mt generic albuterol 100mcg with amex. Together with other indicators generic albuterol 100 mcg amex, this sug- large in comparison with other transit countries, some gests that the availability of cocaine in the United States large seizures were made in the Dominican Republic has stabilized at a reduced level. According to Costa Rican authorities,21 in National Drug Law Enforcement Agencies, Latin America and the Caribbean, Lima, Peru, 4-7 October 2010. This was largely Several countries in the Americas, notably in Central due to a decline in purity, which fell from an average of America and the Caribbean, as well as Brazil, the United 70% in the last quarter of 2006 to 45% in the last quar- States and the Bolivarian Republic of Venezuela, report ter of 2008 and 46% in the last quarter of 2009. They accounted for approximately amounted to 194 kg in Panama, 163 kg in the United one half of the total for the United States in 2009. In States and 80 kg in the Bolivarian Republic of Vene- terms of seizure cases, the majority continued to be zuela; in 2008, the largest quantity was seized in Brazil smaller domestic cases. The price at the Europe wholesale level is about one quarter of the price at the Europe is the world’s second largest consumer market retail level, while the price in producing countries only for cocaine and continues to account for the majority of amounts to 1% of the final (retail) price. Seizures At the global level, the total reported quantity of crack- peaked at 121 mt in 2006, then declined for three years cocaine seizures is negligible in comparison with seizures in a row, falling to less than half this level – 57 mt – in of cocaine base and cocaine salts. The decreasing trend was observed in the West to the fact that some countries do not report seizures of European countries that account for the biggest seizures crack-cocaine, but also because individual seizures of in Europe, though several other countries have regis- crack-cocaine, possibly made at street levels, tend to be tered increases. In Ireland, seizures peaked in 2007, and have also used is that corresponding to the year 2008, and is only included declined significantly since then. One pos- sible explanation could be that heightened law enforce- 25 ment efforts impacted on the availability of cocaine in the European cocaine market, and traffickers responded to this by selling the drug at reduced purities rather than 0 raising the bulk price. The purity-adjusted price – expressed in euros - declined between 2006 and Spain Portugal 2008, and appeared to stabilize in 2009. France United Kingdom** Italy Belgium When adjusted for inflation, the purity-adjusted retail Rest of Europe Netherlands* price in 2009, expressed in euros, was equal to (within 1%) that in 2005, prior to the increase in 2006. While The Iberian peninsula is an important point of entry for these data need to be interpreted with caution, it is plau- cocaine reaching continental Europe. Spain consistently sible that alternative cocaine trafficking methods and reports the highest cocaine seizures in Europe, though routes adopted by traffickers to counter more effective seizures fell from 50 mt in 2006 to 25 mt in 2009. In law enforcement efforts have corrected a short-term neighbouring Portugal, the decrease has been more pro- drop of cocaine availability in the European market. In relative terms, seizure trends across Europe in recent Africa years appear to fall broadly along a continuum ranging Cocaine seizures remained limited in Africa, amounting from strong declines close to the trafficking hubs that to less than 1 mt in 2009, down from 2. Although this quantity is very small Europe to strong increases in countries, notably further in comparison with the quantities likely to be trafficked east, that historically have not been associated with traf- in and via Africa, seizure data from other regions also ficking of cocaine in large amounts. When comparing point to a decreasing trend for Africa, notably West average seizures over 2005-2006 with 2008-2009, Africa, for cocaine trafficking from South America to marked declines (in both relative and absolute terms) Europe. Nevertheless, cocaine trafficking in West Africa were registered in Portugal, Spain, Belgium and the 26 persisted, and Africa, especially West Africa, remained Netherlands; more moderate declines were registered vulnerable to a resurgence. Benin, Burkina Faso, Ethio- in the United Kingdom and France, while seizures were pia, the Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, essentially stable in Italy and Germany. In 2009, China 300 reported seizures of 163 kg, including 112 kg in Hong 200 Kong, China. According to Chinese authorities, cocaine 100 was mainly smuggled from South America across the Pacific ocean to cities on China’s south-east coast. The increase was partly due to a large quantity of cocaine that was jettisoned in December The Asia-Pacific region continued to account for less 2009 close to the Eastern Samar province from a vessel than 1% of global cocaine seizures. Two other signs that cocaine trafficking might be making inroads significant cases resulted in the seizure of a total of 15. The size of the United of the decline may be explained by improved upstream States’ market – the single largest cocaine market for interception efforts as a result of improved sharing of decades – has been shrinking in recent years, mainly due intelligence with counterparts in South America. Cocaine trafficking and use have started to limited (a few studies conducted in North America, affect countries in the Oceania region (already showing South America, Europe and Australia) and any calcu- high annual cocaine use prevalence rates by interna- lated results must be treated with caution (and results tional standards), countries in western and southern are subject to change, whenever more reliable informa- Africa affected by the transit flow, and in some parts of tion becomes available). The best reading of existing Asia (some countries in the Near and Middle East as data and estimates suggests that some 440 mt of pure well as some emerging pockets in a few countries in the cocaine were consumed in 2009. Cocaine use in East Europe, in con- Of the 440 mt available for consumption, around 63% trast, is still limited. The volume of cocaine consumed were consumed in the Americas, 29% in Europe, 5% in in Europe has doubled over the last decade, even though Africa, 3% in Asia and less than 1% in Oceania. The data for the last few years show signs of stabilization at largest subregional markets were found in North Amer- the higher levels. These three subregions account for increased their efforts, traffickers continue to innovate, 63% of global cocaine consumption. The single largest seeking novel ways of getting their product to the con- cocaine market – despite strong declines in recent years sumer. Around 2004, South American traffickers began - continues to be the United States of America, with an to experiment with some new trafficking routes via West estimated consumption of 157 mt of cocaine, equivalent Africa.

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ClO2 generates a residual which is used for the calculation of Ct as a measure of disinfection performance generic albuterol 100mcg line. Chapter 6 of this Manual details the use and efficacy of chlorine dioxide as either as an oxidant or a primary disinfectant which is often followed by chlorine as a residual generating secondary disinfection purchase albuterol 100 mcg amex. As a disinfectant, ClO2 can inactivate most waterborne microorganisms over a wide pH range between 5 and 10. The Ct values for the inactivation of protozoa are generally much higher than ozone. However due to the formation of chemically stable chlorate by-product in water dosed with ClO2, dose rates are limited by regulation internationally. Further information on chlorite and chlorate by-product formation and on the possibility of halogenated by-product formation consequent to downstream secondary chlorine disinfection are detailed in section 6. In the case of each possible cause, it sets out what the likely symptoms of malfunction and the remedial action to be taken together with possible preventative operational practices or maintenance to be taken Water Treatment Manual:Disinfection Malfunction: Possible Cause Fault Analysis Possible prevention Corrective action What is ClO2 residual? Regular maintenance and re- Increase the ClO2 dose manually Low ClO2 Dose controller not calibration of ClO2 sensor and dose or dose supply with chlorine residual operating properly or Check maintenance record for the most control calibration pending rectification. ClO2 sensor or controller as Is the water vapour content of air above appropriate. Monitoring of ClO2 residuals particularly following water quality Train staff in the correct method for Check preventative maintenance log variability dose calculations Check records of dose calculation – are Checking of dose calculation by Recalculate dose rates and alter frequent errors recorded? Obtain proof from suppliers that the Use alternative or larger ClO2 Low ClO2 Inadequate system as designed has been generator to increase the required residual equipment design Is the ClO2 system suitably sized to effective in operation in similar water design Ct maintain the required log inactivation of quality applications especially for targeted waterborne pathogens especially sources with high risk of protozoa and Cryptosporidium in Cryptosporidium. Can the required disinfection inactivation be achieved given the internationally recommended maximum dose rates? Can the generator deliver the maximum recommended dose rate at the highest ClO2 demand? Low level set point alarms on Dose supply with chlorine pending Low ClO2 No ClO2 from constituent generation chemicals rectification. A log of chemical deliveries and Install low set point alarms on expected replacement dates. Adequate spare chemical deliveries Water Treatment Manual:Disinfection Malfunction: Possible Cause Fault Analysis Possible prevention Corrective action Check deliver record for ClO2 generation Comprehensive commissioning tests Train staff in the correct chemical Low ClO2 ClO2 generation chemical concentrations i. Adhere to planned preventative maintenance and keep record Check ClO2 residual levels Adhere to planned preventative Increase the ClO2 generation Low ClO2 Insufficient ClO2 maintenance of pump and keep chemical feed rates or manually residual solution being dosed Is pump capacity sufficient to meet record dose water supply with chlorine maximum ClO2 demand pending rectification Is malfunction due to scaling in dosing lines Replace pump if deficient or injectors? If scaling of dosing lines or injectors is a problem consider softening of sodium chlorite make- up water Is ClO2 residual in disinfected water only A properly designed and optimised Turn up ClO2 dose manually Low ClO2 High ClO2 demand low during periods of poor water quality? Process redesign to assess the demand of variability in water most cost effective way to reduce If very high - is the ClO2 generator able to quality Dose control strategy with feedback ClO2 demand e. Lower ClO dose pending pump residual malfunction due to delivery curve and checking of pump 2 incorrect calibration Incomplete pump maintenance record? Has chlorite or chlorate been detected in controller A high set-point alarm on ClO2 water supply? How high is ClO residual in disinfected Scheduled sampling and testing for Change dose controller settings 2 High ClO2 Calculated ClO2 ClO2 on surface water affected water– is it in excess of 0. Recalculate dosage rate and check residual dose incorrect sources of variable quality for adequate Ct. Supervisor review of dose calculation Implement feedback control of flow following changes of water quality proportional dosing using residual Is dose controller operating properly? How high is ClO residual in disinfected Verify measured solution strength Lower the ClO2 dose pending a 2 High ClO2 % ClO2 solution investigation of solution strength water– is it in excess of 0. ClO2 solution testing Water Treatment Manual:Disinfection Malfunction: Possible Cause Fault Analysis Possible prevention Corrective action How high ClO2 is residual in disinfected Comprehensive commissioning tests Change chemical generation High level of By-products water– is it in excess of 0. This validation should be based on biodosimetry testing for the particular reactor from an independent third party testing facility undertaken in accordance with international standards and their validation protocols. In the case of each possible cause, it sets out what the likely symptoms of malfunction and the remedial action to be taken together with possible preventative operational practices or maintenance to be taken. Introduction Regulation 13 of the Drinking Water Regulations sets out the obligations of Water Service Authorities and regulated Private Water Suppliers with respect to the monitoring and verification of disinfection systems. Verification of primary disinfection systems involving approved chemical disinfectants requires that data is monitored and collated to demonstrate that that the necessary Ct value has been consistently maintained during drinking water disinfection. Operators will be required to collate records of the following data to establish the consistent efficacy of chlorination as a primary disinfectant the establishment of t (effective chlorine contact time) in minutes between the point of application of the chlorine dose and the chlorine residual monitor closest to the first consumer following chlorination, based on day to day flow records, This calculation of effective t should take account of Section 4. The form can be adapted to mirror site specific requirements of each particular disinfection station and can be built up over a period of time. Water Treatment Manual: Disinfection Revision of Water Treatment Manual on Disinfection Water Treatment Manual: Disinfection Revision of Water Treatment Manual on Disinfection Water Treatment Manual: Disinfection Revision of Water Treatment Manual on Disinfection Environmental Protection Agency Water Treatment Manual: Disinfection Appendix 2. Introduction Practical guidance relating to the delivery and storage of chemicals for disinfection at treatment plants, secondary disinfection points and re-chlorination stations are typically confined to those used chemicals for chlorination purposes.

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Note:  The key to making the diagnosis of any headache is the history given by the patient  If the health care practitioner finds an abnormality buy cheap albuterol 100 mcg on-line, then the diagnosis of tension headache would not be considered until the potential for other types of headaches have been investigated buy cheap albuterol 100 mcg on line. Treatment Tension headaches are painful, and patients may be upset that the diagnosis is "only" a tension headache. Even though it is not life-threatening, a tension headache can affect the activities of daily life. Thus, the headache becomes a symptom of the withdrawal of medication (rebound headache). Cluster headaches Cluster headaches are headaches that come in groups (clusters) lasting weeks or months, separated by pain-free periods of months or years. Some evidence shows that brain scans performed on patients who are in the midst of a cluster headache, shows abnormal activity in the hypothalamus. Cluster headaches:  May tend to run in families and this suggests that there may be a genetic role  May be triggered by changes in sleep patterns  May be triggered by medications (for example, nitroglycerin) 5 | P a g e If an individual is in a susceptible period for cluster headache, cigarette smoking, alcohol, and some foods (for example, chocolate) also can be potential causes for headache. Diagnosis  Pain typically occurs once or twice daily and last for 30 to 90 minutes  Attacks tend to occur at about the same time every day  The pain typically is excruciating and located around or behind one eye. The affected eye may become red, inflamed, and watery Note: Cluster headaches are much more common in men than women. Stopping smoking and minimizing alcohol may prevent future episodes of cluster headache. Early diagnosis and treatment is essential if damage is to be limited Examples of Secondary headache:  Head and neck trauma  Blood vessel problems in the head and neck 1. Temporal arteritis (inflammation of the temporal artery)  Non-blood vessel problems of the brain 6 | P a g e 1. Idiopathic intracranial hypertension, once named pseudo tumor cerebri,  Medications and drugs (including withdrawal from those drugs) Infection 1. Systemic infections Diagnosis  If there is time, the diagnosis of secondary headache begins with a complete patient history followed by a physical examination and laboratory and radiology tests as appropriate  However, some patients present in crisis with a decreased level of consciousness or unstable vital signs. In these situations, the health care practitioner may decide to treat a specific cause without waiting for tests to confirm the diagnosis 3. Infections are the most common cause of fevers, however as the temperature rises other causes become more general. Note: Hyperpyrexia is considered a medical emergency as it may indicate a serious underlying conditions. Where causative/precipitating factors cannot be detected, the following treatments may be offered: For Non-productive irritating cough A: Cough syrup/Linctus (O) 5-10 ml every 6 hours Expectorants may be used to liquefy viscid secretions. A: Cough expectorants (O) 5-10 ml every 6 hours Note: Antibiotics should never be used routinely in the treatment of cough 5. Some investigations must be ordered:  Serum glucose level  Serum electrolyte  Pregnancy test for women of child bearing age. Therefore, the following are primarily assessed in children:  Prolonged capillary filling (more than 3 seconds)  Decreased pulse volume (weak thread pulse)  Increased heart rate (>160/minute in infants, > 120 in children)  Decreased level of consciousness (poor eye contact)  Rapid breathing  Decreased blood pressure and decreased urine output are late signs and while they can be monitored the above signs are more sensitive in detecting shock before irreversible. Table 2: Types of Shock Type of Shock Explanation Additional symptoms Hypovolemic Most common type of shock Weak thread pulse, cold Primary cause is loss of fluid from circulation due and clammy skin. Cardiogenic Caused by the failure of heart to pump Distended neck veins, shock effectively e. Septic shock Caused by an overwhelming infection, leading to Elevated body vasodilatation. Anaphylactic Caused by severe allergic reaction to an allergen, Bronchospasm, shock or drug. Intravenous fluid therapy is important in the treatment of all types of shock except for cardiogenic shock. Ringer-lactate, within 48 hours of administering ceftriaxone  Contra-indicated in neonatal jaundice  Annotate dose and route of administration on referral letter. There are three types of dehydration: hypotonic or hyponatremic (primarily a loss of electrolytes, sodium in particular), hypertonic or hypernatremic (primarily a loss of water), and isotonic or isonatremic (equal loss of water and electrolytes). In humans, the most commonly seen type of dehydration by far is isotonic (isonatraemic) dehydration which effectively equates with Hypovolemic, but the distinction of isotonic from hypotonic or hypertonic dehydration may be important when treating people who become dehydrated. Physiologically, dehydration, despite the name, does not simply mean loss of water, as water and solutes (mainly sodium) are usually lost in roughly equal quantities to how they exist in blood plasma. In hypotonic dehydration, intravascular water shifts to the extra vascular space, exaggerating intravascular volume depletion for a given amount of total body water loss. The former can lead to seizures, while the latter can lead to osmotic cerebral edema upon rapid rehydration. It defines water deficiency only in terms of volume rather than specifically water. Signs and symptoms Symptoms may include headaches similar to what is experienced during a hangover, a sudden episode of visual snow, and dizziness or fainting when standing up due to orthostatic hypotension. Untreated dehydration generally results in delirium, unconsciousness, swelling of the tongue and, in extreme cases, death. In the presence of normal renal function dehydration is associated usually with a urine output of less than 0. Differential diagnosis 12 | P a g e In humans, dehydration can be caused by a wide range of diseases and states that impair water homeostasis in the body.

Early in 2008, Sue Clark brought a handful of epigenetics researchers from Australia together to form the Australian Epigenetics Alliance. The AEpiA has now grown to a membership of nearly 300, with members spanning not only Australasia, but the globe. Last year we hosted our seventh flagship conference, Epigenetics 2017 in Brisbane, QLD, and the WA team are already busy preparing for Epigenetics 2019 – watch this space!

Past Epigenetics meetings:

2005 – Canberra, ACT
2007 – Perth, WA
2009 – Melbourne, VIC
2012 – Adelaide, SA
2013 – Shaol Bay, NSW
2015 – Hobart, TAS
2017 – Brisbane, QLD