Chronic osteomyelitis is a persistent bone infection that can develop from acute osteomyelitis if the infection is not properly treated. It is characterized by the formation of dead bone (sequestra) surrounded by infected tissue. Treatment requires extensive surgical debridement to remove all infected and dead bone, followed by long-term antibiotics and procedures to fill dead space and promote healing. Complications can include continued infection, bone deformities, fractures and joint stiffness if not adequately addressed.
Open fractures are unique, complex, and emergently presenting injuries that expose sterile bone to the contaminated environment.
Because a fracture disrupts the intramedullary blood supply, the additionally stripped soft tissue envelope further devitalizes the bone.
The more severe the soft tissue injury or open wound, the more severe the osseous injury.
Historically, open fractures were associated with infection, delayed union, nonunion, amputation, or death.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
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2 Case Reports of Gastric Ultrasound
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
2. INTRODUCTION
• In pre antibiotic era mortality and morbidity
following osteomyelitis was very high.
• Antimicrobials drugs have changed the course
of osteomyelitis but in developing and under
developed countries , where health care
facilities are inadequate ,osteomyelitis
remains a problem.
3. Reason for such a situation(4 failures).
• Failure to suspect correct diagnosis within the
first 3 – 4 days of onset due to lack of a “high
index of suspicion”.
• Failure to perform the simple clinical
investigations which can confirm the suspicion.
• Failure to initiate properly planned therapeutic
program.
• Failure to continue treatment till the disease is
eliminated.
4. INTRODUCTION (Contd).
• Hematogenous osteomyelitis is the generic name
for a whole spectrum of clinical manifestations ,
the cause of which is infection of bone and
marrow from circulating organisms in the blood
from distant source.
• The infection can be acute , subacute and
chronic osteomyelitis depending on the nature ,
virulence and dose of the infecting organisms ,
the age , immune system and general condition
of host.
5. INTRODUCTION (Contd)
• ACUTE OSTEOMYELITIS – produces the signs
of systemic and local infection
• SUBACUTE OSTEOMYELITIS – does not show
signs of systemic involvement though local
signs are there
• CHRONIC OSTEOMYELITIS – presents with
discharging sinus and recurrent infections.
6. PATHOLOGY
• In any infection of bone , there is an attempt
at repair that ,if incomplete it results in
chronic persistence of infection.
• This repair is accomplised by hyperemia of the
surrounding tissue , which effects the
decalcification of the bone.
• Granulation tissue forms and carries in
osteoclasts n osteoblasts.
7. PATHOLOGY(contd).
• Necrotic cancellous bone is readily absorbed and
replaced by new bone.
• Dead cortex is gradually absorbed about its
surface and is detached from living bone to form
a sequestrum.(this requires several months)
• SEQUESTRUM – is a piece of dead bone ,
surrounded by infected granulation tissue trying
to “eat” the sequestrum away. It appears pale
having smooth inner surface and a rough outer.
8. Different types of SEQUESTRA
TYPE DISEASE
TUBULAR PYOGENIC
RING EXTERNAL FIXATORS
BLACK ACTINOMYCOSIS
CORALLIFORM PERTHE’S DISEASE
COKE TUBERCULOSIS
SANDY TUBERCULOSIS
FEATHERY SYPHILIS
9. PATHOLOGY (Contd)
• When SEQUESTRUM IS COMPLETE, it lies in the free
cavity and is LESS attacked by granulation tissue and is
absorbed more slowly.
• Meanwhile , the surrounding living bone attempts to
wall off the infection by forming a thick , dense wall , the
INVOLUCRUM.
• (INVOLUCRUM is the dense sclerotic bone overlying the
sequestrum).
• An involucrum usually has multiple openings , the
cloacae , through which exudate , bone debris , and
sequestra find exit and pass through sinus tracts to the
surface.
10. Pathology (contd).
• CONSTANT DESTRUCTION of neighboring soft
tissue leads to
THIN skin which is easily traumatised , skin
epithelium grows inwards to line the sinus tract.
• In chronic osteomyelitis of long standing ,
multiple cavities and sequestra exist throughout
the bone
• The shaft becomes thickened , irregular and
deformed.
11.
12.
13. BACTERIOLOGY
• STAPHLOCOCCUS AUREUS ,is the most common infecting
organism.
• Other organisms are – group A streptococci , pseudomonas
aeruginosa , proteus , E.coli , staphylococcus epidermidis .
• Hemophilus influenzae – culprit in childrens below 2 years
of age.
• Bacteroids.
• Salmonella in patients suffering from sickle cell anaemia.
14.
15.
16. CLINICAL PICTURE
• During the period of inactivity no symptoms
are present.
• The bone is misshapen and the shin is dusky
,thin , scarred and poorly nourished.
• A break in the skin causes an ulceration that is
slow to heal.
• Muscles are scarred and cause contractures of
the adjacent joints.
17. CLINICAL PICTURE(contd)
• Pain is aching type and usually worsens in the
night.
• The overlying soft tissues become swollen ,
edematous , warm , reddened and tender.
• As the infection progresses a sinus is formed n
is drained indefinitely.
• Spontaneous closure of the sinus and
subsidence of infection often occur following
explusion of large fragment.
18. CLINICAL PICTURE(contd)
• Recurrent flare ups occurs indefinitely over a
period of months and years . A sinus may
drain continously.
• Recurrent toxemia over a long period will
causes amyloidosis.
19. DIAGNOSIS
• The diagnosis is based on
Clinical ,
Laboratory and
Imaging studies.
• The “GOLD STANDARD” is to obtain a biopsy
specimen for histological and microbiological
evaluation of the infected bone.
20. CLINICAL
• Physical examination should be focused on
integrity of skin and soft tissue .
• Determination of area of tenderness.
• Assessing bone stability.
• And evaluation of neuro vascular status of the
limb
21. LABORATORY
• Lab studies generally are
nonspecific and give no
indication for severity of the
infection.
• ESR and C- Reactive protein are
elevated in most patients.
• But WBC’S elevated in only 35%.
22. Multiple imaging technique are available to evaluate chronic
osteomyelitis ,however no technique can absolutely confirm
or exclude presence of osteomyelitis.
• Imaging should be done to
confirm the diagnosis and
prepare for surgery.
• Initial plain radiographs to
be performed it yields
valuable info .
• Signs of cortical destruction
and periosteal reaction
strongly suggest the
diagnosis of osteomyelitis.
23. • Sinography can be preformed if a sinus track is present and
can be valuable adjunct to surgical planning.
• Isotopic bone scanning is more useful in acute osteomyelitis
than chronic osteomyelitis.
• CT provides excellent definition of cortical bone and a fair
evaluation of the surrounding soft tissues and is especially
useful in identifying sequestra.
• MRI provides a fairly accurate measure of pathological
insult to bone and soft tissue , so it is superior to CT in soft
tissue evaluation.
• MRI may reveal a well defined rim of high signal intensity
surrounding the focus of active disease (RIM SIGN).
24. TREATMENT
• Requires a multi faceted approach.
• In addition to antibiotic and surgical debridement
n reconstruction.
• 1st objective is removal of dead
bones(sequestrum).
• 2nd objective is to find a method of obliterating
any dead space left after debridement.
• 3rd objective is to obtain soft tissue coverage of
exposed bone which is a part of the objective of
the obliterating dead space.
25. TREATMENT(contd).
• In spite of somewhat clear objectives, the
actual decision making process is not always
easy or clear cut.
• The real test of a surgeon’s judgement lies not
only in deciding when to operate , but also
how to avoid meddlesome surgery.
• Total eradication of all areas of potentially
infected bone is hardly possible.
26. TREATMENT(contd).
• Surgery for osteomyelitis consists of sequestrectomy and
resection of scarred and infected bone and soft tissue.
• Ring External fixators are generally used for soft tissue and
dead space management after radical debridement.
• The GOAL of surgery is to eradicate infection by achieving a
viable and vascular environment.
• Extensive debridement creates a large dead space – this is
treated with ANTIBIOTIC POLYMETHYL METH ACRYLATE
(PMMA) beads that fills the dead space and prevents
recurrences.
27. TREATMENT(contd).
• The duration of post operative antibiotics is
controversial .
• Traditionally , a 6 week course of intravenous
antibiotics is prescribed after surgical
debridement.
28. TREATMENT(contd).
• The methods to eliminate the dead space are –
1. Bone grafting with primary and secondary closure.
2. Use of PMMA as a temporary filler of dead space.
3. Local muscle flaps and skin grafting with or
without bone grafting.
4. Microvascular transfer of muscle , osseous flaps.
5. The use of bone transport (ILIZAROV TECHNIQUE).
29. TREATMENT(contd).
• SEQUESTRECTOMY AND CURETTAGE FOR
CHRONIC OSTEOMYELITIS
SEQUESTRECTOMY means removal of the
sequestrum .if it lies within the medullary
cavity , a window is made in the overlying
involucrum and the sequestrum removed .
One must wait for adequate involucrum
formation before performing sequestrectomy.
30. SEQUESTRECTOMY AND CURETTAGE
FOR CHRONIC OSTEOMYELITIS.
• Sequestrectomy and curettage require more
time to perform and result in considerably
more blood loss than an inexperienced
surgeon would anticipate.
• Sinus tracks can be injected with methylene
blue 24 hours before surgery to make them
easier to locate and excise.
31. OPEN BONE GRAFTING
• Papineau et al described an open bone grafting
technique for the treatment of chronic
osteomyelitis .
• This procedure relies on the formation of healthy
granulation tissue in a bed of bone graft that will
become rapidly vascularised.
• The granulation tissue resists infection and is
allowed to adequately drained.
• This technique is used when free flaps or soft
tissue transfer options are limited because of
anatomic location .
32. OPEN BONE GRAFTING (contd)
• Archdeacon and messerschmitt described a
modification of the papineau technique using
a vaccum assisted closure (VAC).
• VAC helps in decreasing the edema and for
the closure of soft tissue dead space.
• It also promotes the formation of granulation
tissue.
33. POLYMETHYLMETHACRYLATE
ANTIBIOTIC BEAD CHAINS
• IT IS COMMONLY USED.
• Studies have shown that the
local concentrations achieved
are 200 times more than
intravenous.
• High concentration can be
achieved by primary closure of
the wound.
• Short term (10 days), long
term(80days) , permanent
implantation of PMMA beads
is possible.
34. BIODEGRADABLE ANTIBIOTIC
DELIVERY SYSTEM
• It offers a significant advantage over PMMA in
that a second procedure is not required to
remove the implant.
• It is useful when bone stability is not an issue and
soft tissue coverage is adequate.
• Many manufacturers produce a variety of
bioabsorbable substrates(calcium sulfate or
calcium phosphate)that can be mixed with
antibiotics like vancomycin and tobramycin).
• Its still under study.
35.
36. SOFT TISSUE TRANSFER
• It is mainly done to fill dead space which is left
behind after extensive debridement.
• Success rate reported in the literature ranges
from 66% to 100%.
• For eg chronic osteomyelitis of tibia a local
muscle graft from gastrocnemius or soleus is
used for transfer.
37. ILIZAROV TECHNIQUE
• This technique allows radical resection of the
infected bone
• A corticotomy is performed through the
normal bone proximal and distal to the area of
the disease.
• Disadvantage is – long time to achieve solid
unioun and high chances of infections.
• The treatment of segmental defects of upto
13cms can be achieved.
38. ADJUNCTIVE THERAPIES
• Hyperbaric Oxygen is not reliably effective but
is used as more traditional methods of
treatment.
• Bone morphogenic proteins (BMPs) and even
Platelet Rich Plasmas (PRPs) have been
advocated as it has the ability to acccelerate
or enchance osteogenesis.
39. COMPLICATIONS
• An acute exacerbation of the infections occurs commonly.
• Growth Abnormalities :
shortening –if growth plate is damaged.
Lengthening – coz of increased vasularity of the growth
plate due to near by osteomyelitis.
• Pathologic fracture .
• Joint stiffness – may occur because of scarring of soft tissues around the
joint.
• Sinus tract malignancy – rare complication (squamous cell carcinoma)
• Muscle contracture.
• Epithelioma.
• Amyloidosis.