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By S. Kamak. Kansas City Art Institute. 2019.

Malignancy of nose: A malignant lesion in A variety of lesions may present as polypoidal the nose (carcinomatous order 160mg super p-force oral jelly free shipping erectile dysfunction rings for pump, sarcomatous or masses in the nose purchase super p-force oral jelly master card erectile dysfunction psychogenic causes. Ethmoidal and antro- melanotic) may present as a polypoidal choanal polyps have already been described 160 mg super p-force oral jelly erectile dysfunction medication does not work. Sometimes poly- turbinate may sometimes be mistaken for poidal changes are associated features of a polyp. Therefore, all polyps removed sensitive to touch as compared to an from the nose should be examined ethmoidal polyp and is firm to feel unlike histologically. Nasopharyngeal angiofibroma: Nasopharyn- cannot be passed around the turbinate as geal angiofibroma (Figs 36. Rhinosporiodiosis: This fungal infection of history of epistaxis in an adolescent male the nose produces a bleeding polypoidal with a lobulated mass in the nasopharynx mass in the nose usually arising from indicates a nasopharyngeal lesion rather the septum and is strawberry like in than antrochoanal polyp. It is common in people living prominent vessels are visible on the in coastal areas of India. A malformation consisting of a tumour-like careful examination reveals its site of growth of tissue. Transitional cell or squamous papilloma: according to size and location and but it Papilloma arising from the lateral wall in rarely becomes malignant. It is are isolated which include Pneumococcus, usually the maxillary sinus which gets Streptococcus, Staphylococcus, Haemophilus involved. The local symptoms depend upon the sinus The acute inflammation of the sinus mucosa involved, the most important feature being commonly follows an attack of acute rhinitis pain. In maxillary sinusitis the pain is felt in as in common cold or influenza when the the cheeks below the eyes, it may be referred bacteria invade as secondary organisms. Pain is aggravated on follow dental infections, particularly of the stooping or coughing. The sinus may get In ethmoiditis, the pain is localised over the infected after trauma or through a blood- nasal bridge, inner canthus and behind the borne infection. Other contributory factors which the forehead and the patient complains of play a role in the development of sinusitis headache. The pain is severe in the morning include a deflected nasal septum, nasal polypi and gradually subsides towards noon as the and other benign tumours of the nose. Patients infected material gets drained out from the of chronic suppurative lung disease constantly sinus. Inflamma- Sinusitis 209 tion of more than one sinus is marked by pain Tenderness on applying pressure over the over all the sinuses. Presence of mucopus Signs in the nose is suggestive of sinus infection and its position determines the sinus involved. Usually no external signs are present except Posterior rhinoscopy also reveals the in fulminating cases where, there may be presence of mucopus and congestion. The X-ray examination of paranasal sinuses, occipitomental view (Water’s view), is helpful in revealing the condition of the sinuses (Figs 37. Usually penicillin or broad-spectrum antibiotics like amoxycillin, cefuroximes and amoxycillin- clavulinic acid combinations are prescribed. However, if the symptoms do not subside, particularly in frontal sinusitis with increasing cellulitis, then drainage of the frontal sinus is done through the floor of frontal sinus above the inner canthus. Occasionally chronic sinusitis may be due to both aerobic and anaerobic organisms or may even be fungal in origin. The cilia get damaged by the infection with resultant inadequate drainage of the sinus cavity, particularly the maxillary sinus where the ostium is situated Fig. The retained secre- haziness of the left maxillary sinus (maxillary sinusitis) tions thereby lead to reinfection. Periphlebitis and perilymphangitis may occur, leading to oedema and polyp formation, the so-called hypertrophic or polypoidal sinusitis. Sometimes, there occurs metaplasia of the ciliated colum- nar epithelium to the stratified squamous type with intersperced papillary hyperplastic epithelial and inflammatory cells producing a picture of papillary hypertrophic sinusitis. Occasionally the chronic inflammatory process may induce atrophic changes in the sinus mucosa with increase in submucosal fibrous tissue (atrophic sinusitis). Chronic sinusitis is usually nose like a deviated septum, polyposis or the result of incompletely resolved acute hypertrophied turbinates, or because of sinusitis. It may follow insidiously after chronic turgescence of the nasal mucosa repeated attacks of common cold or tooth which results in a stuffy nose. The general symptoms of chronic sinusitis include a sense of tiredness, low grade fever and a feeling of being unwell. Chronic sinusitis may produce effects on other systems like gastrointestinal upsets and chronic bronchitis, etc. In maxillary sinusitis pus is seen in the middle meatus, particularly when the head is kept down with the infected sinus uppermost (Fig. If pus is seen trickling over the posterior end of the inferior which could be mucoid, mucopurulent or turbinate, it indicates that the anterior group purulent. Postnasal discharge is a common of sinuses is involved while pus above symptom which causes irritation and the middle turbinate indicates involvement of compels the patient to clear his throat fre- the posterior group of sinuses. Abnormalities of smell: The patient may Investigation complain of diminished acuity of smell (hyposmia). He may complain of unplea- Plain X-ray examination of the paranasal sant odour (cacosmia) or may have distor- sinuses, though not specific, may reveal the condition of the sinuses which appear hazy tion of smell perception (parosmia). Epistaxis: Inflammatory hyperaemia in the Besides, it can be cultured and its sensitivity nose may result in epistaxis but this is tests done. However, if the sinus mucosa is so damaged that recovery is not possible, then radical surgery is undertaken and the diseased mucosa removed. Recently evidence in favour of anaerobic infection of the sinuses has been noted and metronidazole has proved helpful, particularly in association with antibiotics. Surgical procedures like antrum washout for maxillary sinusitis are helpful and may be repeated frequently to clear the sinus cavity of the discharge. Antrum puncture Under local anaesthesia, the is closed by oedema, then a second cannula trocar and cannula are put under the inferior can be inserted through the inferior meatus. The trocar is directed towards discharge and can be sent for cytological or the outer canthus of eye of the same side. At the end of the firm and steady pressure, the nasoantral wall procedure, local medication may be instilled is pierced and antral cavity entered. The trocar into the sinus cavity, the cannula is withdrawn is withdrawn and cannula placed properly in and nose cleaned. Difficulties and Dangers of The sinus is irrigated with sterile normal Antral Lavage Procedure saline at body temperature and the patient is told to breath through the mouth with the 1. The discharge comes out through turbinate and cause laceration of the the natural ostium of the sinus.

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The major benefits will occur in individuals at high risk and in developing countries like India buy super p-force oral jelly master card impotence causes and cures. Financial assistance for drugs including erythropoietin has also been kept separately buy super p-force oral jelly online now erectile dysfunction pills herbal. Improving the standard of dialysis and auditing its delivery system to patients 10 buy generic super p-force oral jelly 160 mg online erectile dysfunction and pump. Training dialysis physician and dialysis technician through a structured programme. To undertake activities related to policy/programme correction as & when required. Develop a manpower training program for dialysis physician and dialysis technician 6. There are mainly two aspects (i) increasing the opportunities for training programs for different categories and (ii) training the existing personnel for skill in the area of dialysis. New Dialysis units established and older ones strengthened (At least some centers in each metro) th 4. While former will need lifestyle modification, behavioral changes, improved information campaign etc. Deceased Organ Retrieval as well as living donors’ promotion is going to be main area for improving supply. More transplant centre, dialysis centre, transplant surgeons and nurse will build up the capacity of improved services. Free or subsidized diagnostic services & immunosuppressive drug supply will ensure better outcome of transplant services. India is also taking steps towards managing its population burden of diseases contributing to end- stage organ failure. Despite limited budgetary support for public health, several comprehensive prevention initiatives have been implemented. Inter-sectoral health promotion efforts will also contribute to decreasing the burden of these diseases. Prototype of Dialysis (stand alone) centre Advisory group meetings were held to develop prototype for standalone dialysis centers. The aim is to provide long term high quality hemodialysis facility for general public (& Govt. In this business model, Government does not make an outright purchase of capital equipment for a dialysis clinic and instead, Government enters into a contractual agreement to lease its capital equipment requirements to private hemodialysis provider company or patient brings his own dialysis disposables. During the contractual period, Government purchases its dialysis consumable requirements exclusively from private partner. There has to be a fixed term of payment to private partner, say every month or say 30 day. The concept is to set up a chain of dialysis centers that would have a non nephrologist dialysis trained physician present at the centre round the clock. A tie up could be made with identified agency for provision of services including equipments, manpower and consumables etc. There would be one standalone dialysis centre operationalised in 100 districts with private public partnership. States would be encouraged to have dialysis facilities through decentralized National Rural Health Mission planning. The average cost of dialysis in Delhi is as follows: Item Cost Average cost of Dialysis  1000 Per dialysis cost for Haemo dialyser ( 600 for 4 time use)  150 Haemodialysis fluid used in each dialysis  200 Saline drip used in each dialysis  100 Inj. Heparin in each dialysis  50 Total cost of Each dialysis  1500 Cost of investigations and medicines  600 Total cost per dialysis including investigations & medicines  2100 121 Till the time dialysis facilities are developed, chronic kidney patients who are below poverty line would be paid for dialysis on per case basis. Reputed large Hospital in the region would be taken on retainership basis and paid per case basis. For this purpose if 1000 dialysis per month are to be supported the expenses would be about Rs. This model would be shifted to private public partnership wherein 1000 dialysis per month per centre would be assured. While former will need lifestyle modification, behavioral changes, improved information campaign and pharmacological interventions etc. Deceased Organ Retrieval is going to be main area for improving supply, although living organ transplant particularly for kidney and to some extent for liver needs to be continued. More dialysis centres and its staff, transplant centre with transplant surgeons and nurses will build up the capacity of improved services. Free or subsidized diagnostic services & immuno-suppressive drug supply for the poor and needy will ensure better compliance and outcome of transplant services. Post-transplant services to transplant recipients and living donors Strategies: • Enhancing the facilities for organ transplantation throughout India • Establishing network for equitable distribution of retrieved deceased organs. Objectives: • To organize a system of organ procurement & distribution for deserving cases for transplantation. Each zonal unit would look after few hospitals in their respective jurisdiction for organ retrieval/transplantation. One new transplant centre would be established and one would be strengthened in Govt. A co-ordination committee could be formed to look into the actions and co-operation required from various ministries and departments. National and regional workshops on issue of organ transplantation would be carried out with purpose of advocacy at all levels for various stakeholders. Certificate of recognition to the donors will be given by the transplant centre on behalf of the appropriate authority. Steps would be taken to make provision for diagnostic tests at affordable and subsidized cost to the transplant recipients and donors patients in the public sector health care delivery system. Free annual health check to living donor & free treatment of all donor related complications would be promoted. Financial assistance for immunosuppressant drugs has also been kept separately which would benefit about 5000 patients every year @ Rs. Establishing 10new facilities for Kidney & 2 new for liver Transplantation in Govt. Strengthening of 10 existing kidney & 2 existing liver transplantation facilities in Govt. Training retrieval team members, transplant surgeon, dialysis physician, nurse, grief counselor, coordinator and dialysis technician through a structured programme. To undertake activities related to policy/programme correction as & when required. To start scheme for promoting/facilitating deceased donation & protecting donors/transplant surgeons. Financial assistance to patients for maintenance therapy of immunosuppressive drugs. Scheme for promotion of organ donation/ protecting donor’s health/ protecting transplant surgeon/protecting vulnerable poor. It would have cell for kidney, liver & heart organs, dealing with policies, quality control etc.

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