Side Subjects of 1st Year Mbbs Modular Exam

SIDE SUBJECTS OF 1ST YEAR
MBBS MODULAR EXAM

PATHOLOGY, PHARMACOLOGY, FORENSIC MEDICINE, COMMUNITY MEDICINE
AND PRIME
THIS BOOK PROVIDES A COMPREHENSIVE APPROCH TO SPECIFIC TOPICS OF ABOVE MENTIONED SUBJECTS
INCLUDED IN 1ST YEAR MBBS MODULAR EXAM OF KMU.
MAIN SOURCES: WIKIPEDIA, HEALTHLINE, MAYO CLINIC
1st Edition
Copyright @ 2019 Gomal Medical College
PLEASE SHARE THIS BOOK WITH YOUR MATES SO EVERYONE WOULD HAVE AN EASE ACCESS TO THESE
TOPICS. ANY REQUEST FOR EDITING WOULD BE HIGHLY APPECIATED
doctornisarahmad@yahoo.com
DEDICATED TO ALL GMCITES
NISAR AHMAD
1SY YEAR MBBS
GOMAL MEDICAL COLLEGE, DI KHAN
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PREPARED BY: DOCTOR NISAR AHMAD 1 YEA R MB BS (G MC) |1
Contents
PAPER-A PAGE 1-110
PAPER-B PAGE 111-125
PAPER-C PAGE 126-213
PAPER-A
1) PATHOLOGY
FOUNDATION MODULE
INTODUCTION TO PATHOLOGY AND ITS
IMPLICATION IN MEDICINE
Pathology is the study of the causes and effects of disease or injury. The word pathology also refers
to the study of disease in general, incorporating a wide range of bioscience research fields and
medical practices. However, when used in the context of modern medical treatment, the term is
often used in a more narrow fashion to refer to processes and tests which fall within the
contemporary medical field of "general pathology," an area which includes a number of distinct but
inter-related medical specialties that diagnose disease, mostly through analysis of tissue, cell,
and body fluid samples. Idiomatically, "a pathology" may also refer to the predicted or actual
progression of particular diseases (as in the statement "the many different forms of cancer have
diverse pathologies"), and the affix path is sometimes used to indicate a state of disease in cases of
both physical ailment (as in cardiomyopathy) and psychological conditions (such
as psychopathy).[1] A physician practicing pathology is called a pathologist.
As a field of general inquiry and research, pathology addresses four components of disease: cause,
mechanisms of development (pathogenesis), structural alterations of cells (morphologic changes),
and the consequences of changes (clinical manifestations). [2] In common medical practice, general
pathology is mostly concerned with analyzing known clinical abnormalities that are markers or
precursors for both infectious and non-infectious disease and is conducted by experts in one of two
major specialties, anatomical pathology and clinical pathology. Further divisions in specialty exist on
the basis of the involved sample types (comparing, for example, cytopathology, hematopathology,
and histopathology), organs (as in renal pathology), and physiological systems (oral pathology), as
well as on the basis of the focus of the examination (as with forensic pathology).
Pathology is a significant field in modern medical diagnosis and medical research.
CELL INJURY
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Cell damage
Cell damage (also known as cell injury) is a variety of changes of stress that a cell suffers due to
external as well internal environmental changes. Among other causes, this can be due to physical,
chemical, infectious, biological, nutritional or immunological factors. Cell damage can be reversible
or irreversible. Depending on the extent of injury, the cellular response may be adaptive and where
possible, homeostasis is restored.[1] Cell death occurs when the severity of the injury exceeds the
cell’s ability to repair itself.[2] Cell death is relative to both the length of exposure to a harmful stimulus
and the severity of the damage caused.[1] Cell death may occur by necrosis or apoptosis.
Causes
• Physical agents such as heat or radiation can damage a cell by literally cooking
or coagulating their contents.
• Impaired nutrient supply, such as lack of oxygen or glucose, or impaired production
of adenosine triphosphate (ATP) may deprive the cell of essential materials needed to survive.
Targets
The most notable components of the cell that are targets of cell damage are the DNA and the cell
membrane.
• DNA damage: In human cells, both normal metabolic activities and environmental factors such
as ultraviolet light and other radiations can cause DNA damage, resulting in as many as
one million individual molecular lesions per cell per day.
• Membrane damage: damage to the cell membrane disturbs the state of cell electrolytes,
e.g. calcium, which when constantly increased, induces apoptosis.
Types of damage
Some cell damage can be reversed once the stress is removed or if compensatory cellular changes
occur. Full function may return to cells but in some cases a degree of injury will remain.
Sub-lethal (reversible)
Cellular swelling
Cellular swelling (or cloudy swelling) may occur due to cellular hypoxia, which damages the sodium-
potassium membrane pump; it is reversible when the cause is eliminated. Cellular swelling is the first
manifestation of almost all forms of injury to cells. When it affects many cells in an organ, it causes
some pallor, increased turgor, and increase in weight of the organ. On microscopic examination,
small clear vacuoles may be seen within the cytoplasm; these represent distended and pinched-off
segments of the endoplasmic reticulum. This pattern of non-lethal injury is sometimes called
hydropic change or vacuolar degeneration. Hydropic degeneration is a severe form of cloudy
swelling. It occurs with hypokalemia due to vomiting or diarrhea.
The ultrastructural changes of reversible cell injury include:
• Blebbing
• Blunting
• distortion of microvilli
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• loosening of intercellular attachments

• mitochondrial changes
• dilation of the endoplasmic reticulum
Fatty change
The cell has been damaged and is unable to adequately metabolize fat. Small vacuoles of fat
accumulate and become dispersed within cytoplasm. Mild fatty change may have no effect on cell
function; however more severe fatty change can impair cellular function. In the liver, the enlargement
of hepatocytes due to fatty change may compress adjacent bile canaliculi, leading to cholestasis.
Depending on the cause and severity of the lipid accumulation, fatty change is generally reversible.
Fatty Change is also known as fatty degeneration, fatty metamorphosis, or fatty steatosis.
Lethal
Necrosis
Necrosis is characterised by cytoplasmic swelling, irreversible damage to the plasma membrane,
and organelle breakdown leading to cell death. The stages of cellular necrosis include pyknosis;
clumping of chromosomes and shrinking of the nucleus of the cell, karyorrhexis; fragmentation of the
nucleus and break up of the chromatin into unstructured granules, and karyolysis; dissolution of the
cell nucleus. Cytosolic components that leak through the damaged plasma membrane into the
extracellular space can incur an inflammatory response.
There are six types of necrosis:
• Coagulative necrosis
• Liquefactive necrosis
• Caseous necrosis
• Fat necrosis
• Fibroid necrosis
• Gangrenous necrosis
Apoptosis
Apoptosis is the programmed cell death of superfluous or potentially harmful cells in the body. It is
an energy dependent process mediated by proteolytic enzymes called caspases, which trigger cell
death through the cleaving of specific proteins in the cytoplasm and nucleus. The dying cells shrink
and condense into apoptotic bodies. The cell surface is altered so as to display properties which
lead to rapid phagocytosis by macrophages or neighbouring cells. Unlike necrotic cell death,
neighbouring cells are not damaged by apoptosis as cytosolic products are safely isolated by
membranes prior to undergoing phagocytosis. In the average adult between 50 and 70 billion cells
die each day due to apoptosis. Inhibition of apoptosis can result in a number of cancers,
autoimmune diseases, inflammatory diseases, and viral infections. Hyperactive apoptosis can lead
to neurodegenerative diseases, hematologic diseases, and tissue damage.
Repair
When a cell is damaged the body will try to repair or replace the cell to continue normal functions. If
a cell dies the body will remove it and replace it with another functioning cell, or fill the gap with
connective tissue to provide structural support for the remaining cells. The motto of the repair
process is to fill a gap caused by the damaged cells to regain structural continuity. Normal cells try to
regenerate the damaged cells but this cannot always happen. Asexual reproduction is what repairs
cells
Regeneration
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Regeneration of parenchyma cells, or the functional cells, of an organism. The body can make more
cells to replace the damaged cells keeping the organ or tissue intact and fully functional.
Replacement
When a cell cannot be regenerated the body will replace it with stromal connective tissue to maintain
tissue/organ function. Stromal cells are the cells that support the parenchymal cells in any organ.
Fibroblasts, immune cells, pericytes, and inflammatory cells are the most common types of stromal
cells.
Biochemical changes in cellular injury

ATP (adenosine triphosphate) depletion is a common biological alteration that occurs with cellular
injury. This change can happen despite the inciting agent of the cell damage. A reduction in
intracellular ATP can have a number of functional and morphologic consequences during cell injury.
These effects include:
• Failure of the ATP dependent pumps (Na+

/K+
pump and Ca2+
pump), resulting in a net influx of Na+
and Ca2+
ions and osmotic swelling.
• ATP-depleted cells begin to undertake anaerobic metabolism to derive energy from glycogen
which is known as 'glycogenolysis'.
• A consequent decrease in the intracellular pH of the cell arises, which mediates harmful
enzymatic processes.
• Early clumping of nuclear chromatin then occurs, known as 'pyknosis', and leads to eventual cell
death.
DNA damage and repair

DNA damage
DNA damage (or RNA damage in the case of some virus genomes) appears to be a fundamental
problem for life. As noted by Haynes. the subunits of DNA are not endowed with any peculiar kind of
quantum mechanical stability, and thus DNA is vulnerable to all the "chemical horrors" that might
befall any such molecule in a warm aqueous medium. These chemical horrors are DNA damages
that include various types of modification of the DNA bases, single- and double-strand breaks, and
inter-strand cross-links (see DNA damage (naturally occurring). DNA damages are distinct from
mutations although both are errors in the DNA. Whereas DNA damages are abnormal chemical and
structural alterations, mutations ordinarily involve the normal four bases in new arrangements.
Mutations can be replicated, and thus inherited when the DNA replicates. In contrast, DNA damages
are altered structures that cannot, themselves, be replicated.
Several different repair processes can remove DNA damages (see chart in DNA repair). However,
those DNA damages that remain un-repaired can have detrimental consequences. DNA damages
may block replication or gene transcription. These blockages can lead to cell death. In multicellular
organisms, cell death in response to DNA damage may occur by a programmed process,
apoptosis. Alternatively, when a DNA polymerase replicates a template strand containing a
damaged site, it may inaccurately bypass the damage and, as a consequence, introduce an
incorrect base leading to a mutation. Experimentally, mutation rates increase substantially in cells
defective in DNA mismatch repair or in Homologous recombinational repair (HRR).
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In both prokaryotes and eukaryotes, DNA genomes are vulnerable to attack by reactive chemicals
naturally produced in the intracellular environment and by agents from external sources. An
important internal source of DNA damage in both prokaryotes and eukaryotes is reactive oxygen
species (ROS) formed as byproducts of normal aerobic metabolism. For eukaryotes, oxidative
reactions are a major source of DNA damage (see DNA damage (naturally occurring) and
Sedelnikova et al. In humans, about 10,000 oxidative DNA damages occur per cell per day. In the
rat, which has a higher metabolic rate than humans, about 100,000 oxidative DNA damages occur
per cell per day. In aerobically growing bacteria, ROS appear to be a major source of DNA damage,
as indicated by the observation that 89% of spontaneously occurring base substitution mutations are
caused by introduction of ROS-induced single-strand damages followed by error-prone replication
past these damages. Oxidative DNA damages usually involve only one of the DNA strands at any
damaged site, but about 1–2% of damages involve both strands. The double-strand damages
include double-strand breaks (DSBs) and inter-strand crosslinks. For humans, the estimated
average number of endogenous DNA DSBs per cell occurring at each cell generation is about
50. This level of formation of DSBs likely reflects the natural level of damages caused, in large part,
by ROS produced by active metabolism.
Repair of DNA damages
Five major pathways are employed in repairing different types of DNA damages. These five
pathways are nucleotide excision repair, base excision repair, mismatch repair, non-homologous
end joining and homologous recombinational repair (HRR) (see chart in DNA repair) and
reference. Only HRR can accurately repair double strand damages, such as DSBs. The HRR
pathway requires that a second homologous chromosome be available to allow recovery of the
information lost by the first chromosome due to the double-strand damage.
DNA damage appears to play a key role in mammalian aging, and an adequate level of DNA repair
promotes longevity (see DNA damage theory of aging and reference.). In addition, an increased
incidence of DNA damage and/or reduced DNA repair cause an increased risk of cancer
(see Cancer, Carcinogenesis and Neoplasm) and reference). Furthermore, the ability of HRR to
accurately and efficiently repair double-strand DNA damages likely played a key role in the evolution
of sexual reproduction (see Evolution of sexual reproduction and reference. In extant eukaryotes,
HRR during meiosis provides the major benefit of maintaining fertility.
NECROSIS
Necrosis
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Structural changes of cells undergoing necrosis and apoptosis
Necrosis is a form of cell injury which results in the premature death of cells in
living tissue by autolysis.[1]
Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma which
result in the unregulated digestion of cell components.
In contrast, apoptosis is a naturally occurring programmed and targeted cause of cellular death.
While apoptosis often provides beneficial effects to the organism, necrosis is almost always
detrimental and can be fatal.[2]
Cellular death due to necrosis does not follow the apoptotic signal transduction pathway, but rather
various receptors are activated, and result in the loss of cell membrane integrity and an uncontrolled
release of products of cell death into the extracellular space.[1]
This initiates in the surrounding tissue an inflammatory response which attracts leukocytes and
nearby phagocytes which eliminate the dead cells by phagocytosis. However, microbial damaging
substances released by leukocytes would create collateral damage to surrounding tissues. [3] This
excess collateral damage inhibits the healing process. Thus, untreated necrosis results in a build-up
of decomposing dead tissue and cell debris at or near the site of the cell death. A classic example
is gangrene. For this reason, it is often necessary to remove necrotic tissue surgically,
a procedure known as debridement.
Classification
Structural signs that indicate irreversible cell injury and the progression of necrosis include dense
clumping and progressive disruption of genetic material, and disruption to membranes of cells
and organelles.[4]
Morphological patterns
There are six distinctive morphological patterns of necrosis: [5]
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1. Coagulative necrosis is characterized by the formation of a gelatinous (gel-like) substance in

dead tissues in which the architecture of the tissue is maintained, [5] and can be observed by
light microscopy. Coagulation occurs as a result of protein denaturation, causing albumin to
transform into a firm and opaque state. [4] This pattern of necrosis is typically seen
in hypoxic (low-oxygen) environments, such as infarction. Coagulative necrosis occurs
primarily in tissues such as the kidney, heart and adrenal glands. [4] Severe ischemia most
commonly causes necrosis of this form.[6]
2. Liquefactive necrosis (or colliquative necrosis), in contrast to coagulative necrosis, is
characterized by the digestion of dead cells to form a viscous liquid mass. [5] This is typical of
bacterial, or sometimes fungal, infections because of their ability to stimulate an
inflammatory response. The necrotic liquid mass is frequently creamy yellow due to the
presence of dead leukocytes and is commonly known as pus.[5] Hypoxic infarcts in the brain
presents as this type of necrosis, because the brain contains little connective tissue but high
amounts of digestive enzymes and lipids, and cells therefore can be readily digested by their
own enzymes.[4]
3. Gangrenous necrosis can be considered a type of coagulative necrosis that resembles
mummified tissue. It is characteristic of ischemia of lower limb and the gastrointestinal tracts.
If superimposed infection of dead tissues occurs, then liquefactive necrosis ensues (wet
gangrene)[7]
4. Caseous necrosis can be considered a combination of coagulative and liquefactive
necrosis,[4] typically caused by mycobacteria (e.g. tuberculosis), fungi and some foreign
substances. The necrotic tissue appears as white and friable, like clumped cheese. Dead
cells disintegrate but are not completely digested, leaving granular particles. [4] Microscopic
examination shows amorphous granular debris enclosed within a distinctive inflammatory
border.[5] Granuloma has this characteristic.[8]
5. Fat necrosis is specialized necrosis of fat tissue,[8] resulting from the action of
activated lipases on fatty tissues such as the pancreas. In the pancreas it leads to
acute pancreatitis, a condition where the pancreatic enzymes leak out into
the peritoneal cavity, and liquefy the membrane by splitting the triglyceride esters into fatty
acids through fat saponification.[5] Calcium, magnesium or sodium may bind to these lesions
to produce a chalky-white substance.[4] The calcium deposits are microscopically distinctive
and may be large enough to be visible on radiographic examinations. [6] To the naked eye,
calcium deposits appear as gritty white flecks.[6]
6. Fibrinoid necrosis is a special form of necrosis usually caused by immune-mediated vascular
damage. It is marked by complexes of antigen and antibodies, sometimes referred to as
"immune complexes" deposited within arterial walls[5] together with fibrin.[5]
Other clinical classifications of necrosis
1. There are also very specific forms of necrosis such as gangrene (term used in clinical
practices for limbs which have suffered severe hypoxia), gummatous necrosis (due
to spirochaetal infections) and hemorrhagic necrosis (due to the blockage of venous
drainage of an organ or tissue).
2. Some spider bites may lead to necrosis. In the United States, only spider bites from
the brown recluse spider (genus Loxosceles) reliably progress to necrosis. In other
countries, spiders of the same genus, such as the Chilean recluse in South America, are
also known to cause necrosis. Claims that yellow sac spiders and hobo spiders possess
necrotic venom have not been substantiated.
3. In blind mole rats (genus Spalax), the process of necrosis replaces the role of the
systematic apoptosis normally used in many organisms. Low oxygen conditions, such as
those common in blind mole rats' burrows, usually cause cells to undergo apoptosis. In
adaptation to higher tendency of cell death, blind mole rats evolved a mutation in the tumor
suppressor protein p53 (which is also used in humans) to prevent cells from undergoing
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apoptosis. Human cancer patients have similar mutations, and blind mole rats were thought
to be more susceptible to cancer because their cells cannot undergo apoptosis. However,
after a specific amount of time (within 3 days according to a study conducted at the
University of Rochester), the cells in blind mole rats release interferon-beta (which the
immune system normally uses to counter viruses) in response to over-proliferation of cells
caused by the suppression of apoptosis. In this case, the interferon-beta triggers cells to
undergo necrosis, and this mechanism also kills cancer cells in blind mole rats. Because of
tumor suppression mechanisms such as this, blind mole rats and other spalacids are
resistant to cancer.[9][10]
Causes
Necrotic leg wound caused by a brown recluse spider bite
Necrosis may occur due to external or internal factors.

External factors
External factors may involve mechanical trauma (physical damage to the body which causes cellular
breakdown), damage to blood vessels (which may disrupt blood supply to associated tissue),
and ischemia.[11] Thermal effects (extremely high or low temperature) can result in necrosis due to
the disruption of cells.
In frostbite, crystals form, increasing the pressure of remaining tissue and fluid causing the cells to
burst.[11] Under extreme conditions tissues and cells die through an unregulated process of
destruction of membranes and cytosol. [12]
Internal factors
Internal factors causing necrosis include: trophoneurotic disorders; injury and paralysis of nerve
cells. Pancreatic enzymes (lipases) are the major cause of fat necrosis. [11]
Necrosis can be activated by components of the immune system, such as the complement
system; bacterial toxins; activated natural killer cells; and peritonealmacrophages.[1] Pathogen-
induced necrosis programs in cells with immunological barriers (intestinal mucosa) may alleviate
invasion of pathogens through surfaces affected by inflammation.[1] Toxins and pathogens may
cause necrosis; toxins such as snake venoms may inhibit enzymes and cause cell death.[11] Necrotic
wounds have also resulted from the stings of Vespa mandarinia.[13]
Pathological conditions are characterized by inadequate secretion of cytokines. Nitric oxide (NO)
and reactive oxygen species (ROS) are also accompanied by intense necrotic death of cells. [11] A
classic example of a necrotic condition is ischemia which leads to a drastic depletion
of oxygen, glucose, and other trophic factors and induces massive necrotic death of endothelial cells
and non-proliferating cells of surrounding tissues (neurons, cardiomyocytes, renal cells,
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etc.).[1] Recent cytological data indicates that necrotic death occurs not only during pathological
events but it is also a component of some physiological process.[11]
Activation-induced death of primary T-lymphocytes and other important constituents of the immune
response are caspase-independent and necrotic by morphology; hence, current researchers have
demonstrated that the occurrence of necrotic cell death can not only occur during pathological
processe, but also during normal processes such as tissue renewal, embryogenesis, and immune
response.[11]
Pathogenesis
Pathways
Until recently, necrosis was thought to be an unregulated process. [14] However, there are two broad
pathways in which necrosis may occur in an organism.[14]
The first of these two pathways initially involves oncosis, where swelling of the cells
occurs.[14] Affected cells then proceed to blebbing, and this is followed by pyknosis, in which nuclear
shrinkage transpires.[14]In the final step of this pathway cell nuclei are dissolved into the cytoplasm,
which is referred to as karyolysis.[14]
The second pathway is a secondary form of necrosis that is shown to occur after apoptosis and
budding.[14] In these cellular changes of necrosis, the nucleus breaks into fragments (known
as karyorrhexis).[14]
Cellular changes
The nucleus changes in necrosis and characteristics of this change are determined by manner in
which its DNA breaks down:
• Karyolysis: the chromatin of the nucleus fades due to the loss of the DNA by degradation. [5]
• Karyorrhexis: the shrunken nucleus fragments to complete dispersal.[5]
• Pyknosis: the nucleus shrinks, and the chromatin condenses.[5]
Plasma alterations
Plasma alterations are also seen in necrosis. Plasma membranes appear discontinuous when
viewed with an electron microscope. This discontinuous membrane is caused by cell blebbing and
the loss of microvilli.[5]
Treatment
There are many causes of necrosis, and as such treatment is based upon how the necrosis came
about. Treatment of necrosis typically involves two distinct processes: Usually, the underlying cause
of the necrosis must be treated before the dead tissue itself can be dealt with.
• Debridement, referring to the removal of dead tissue by surgical or non-surgical means, is the
standard therapy for necrosis. Depending on the severity of the necrosis, this may range from
removal of small patches of skin to complete amputation of affected limbs or organs. Chemical
removal of necrotic tissue is another option in which enzymatic debriding agents, categorised
as proteolytic, fibrinolytic or collagenases, are used to target the various components of dead
tissue.[15] In select cases, special maggot therapy using Lucilia sericata larvae has been
employed to remove necrotic tissue and infection. [16]
• In the case of ischemia, which includes myocardial infarction, the restriction of blood supply to
tissues causes hypoxia and the creation of reactive oxygen species (ROS) that react with, and
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PREPARED BY: DOCTOR NISAR AHMAD 1 Y E A R M B B S ( G M C ) | 10
damage proteins and membranes. Antioxidant treatments can be applied to scavenge the
ROS.[17]
• Wounds caused by physical agents, including physical trauma and chemical burns, can be
treated with antibiotics and anti-inflammatory drugs to prevent bacterial infection and
inflammation. Keeping the wound clean from infection also prevents necrosis.
• Chemical and toxic agents (e.g. pharmaceutical drugs, acids, bases) react with the skin leading
to skin loss and eventually necrosis. Treatment involves identification and discontinuation of the
harmful agent, followed by treatment of the wound, including prevention of infection and possibly
the use of immunosuppressive therapies such as anti-inflammatory drugs or
immunosuppressants.[18] In the example of a snake bite, the use of anti-venom halts the spread
of toxins whilst receiving antibiotics to impede infection.[19]
Even after the initial cause of the necrosis has been halted, the necrotic tissue will remain in the
body. The body's immune response to apoptosis, which involves the automatic breaking down and
recycling of cellular material, is not triggered by necrotic cell death due to the apoptotic pathway
being disabled.[20]
BLOOD MODULE
ANEMIA’S OF DIMINISHED
ERYTHROPOIESIS
Anemia (a decrease in the number of RBCs, hemoglobin (Hb) content, or hematocrit (Hct) can
result from decreased RBC production(erythropoiesis), increased RBC destruction, blood loss, or a
combination of these factors. (See also Approach to the Patient with Anemia.)
Anemias due to decreased erythropoiesis (termed hypoproliferative anemias) are recognized by
reticulocytopenia, which is usually evident on the peripheral smear.
The RBC indices, mainly the mean corpuscular volume (MCV), can narrow the differential diagnosis
of deficient erythropoiesis and help determine what further testing is necessary.
Microcytic anemias result from deficient or defective heme or globin synthesis. Microcytic
anemias include iron deficiency anemias, iron-transport deficiency anemias, iron-utilization
anemias (including some sideroblastic anemias and lead poisoning), and thalassemias (which also
cause hemolysis). Patients with microcytic anemias typically require testing of iron stores.
Normocytic anemias are characterized by a normal RBC distribution width (RDW) and
normochromic indices. The two most common causes are hypoproliferation due to a deficiency of
or inadequate response to erythropoietin (EPO) and anemia of chronic disease. Acquired primary
bone marrow disorders such as aplastic anemia, pure red cell aplasia, and myelodysplastic
syndrome(MDS) can also present with a normocytic anemia.
Macrocytic anemias can be caused by impaired DNA synthesis leading to megaloblastosis, as
occurs with deficiencies of vitamin B12 or folate (see Megaloblastic Macrocytic Anemias). Other
causes include chronic alcohol intake (independent of vitamin deficiency), liver disease,
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myelodysplastic syndrome (MDS), and hemolysis. Some patients with hypothyroidism have
macrocytic RBC indices, including some without anemia.
Many anemias have variable findings on the peripheral smear. Anemia of chronic disease may be
microcytic or normocytic. Anemias due to myelodysplastic syndromes may be normocytic or
macrocytic. Anemias due to endocrine disorders (such as hypothyroidism) or elemental
deficiencies (such as copper or zinc) can have variable manifestations, including a normocytic or
macrocytic anemia.
Treatment of deficient RBC production depends on the cause.
HEMOLYTIC ANEMIA
Hemolytic anemia
Hemolytic anemia is a form of anemia due to hemolysis, the abnormal breakdown of red blood
cells (RBCs), either in the blood vessels (intravascular hemolysis) or elsewhere in the human body
(extravascular, but usually in the spleen). It has numerous possible consequences, ranging from
relatively harmless to life-threatening. The general classification of hemolytic anemia is
either inherited or acquired. Treatment depends on the cause and nature of the breakdown.
Symptoms of hemolytic anemia are similar to other forms of anemia (fatigue and shortness of
breath), but in addition, the breakdown of red cells leads to jaundiceand increases the risk of
particular long-term complications, such as gallstones[1] and pulmonary hypertension.[2]
Signs and symptoms

In general, signs of anemia (pallor, fatigue, shortness of breath, and potential for heart failure) are
present. In small children, failure to thrive may occur in any form of anemia.[3][4] Certain aspects of the
medical history can suggest a cause for hemolysis, such as drugs, consumption of fava beans due
to Favism, the presence of prosthetic heart valve, or other medical illness.
Chronic hemolysis leads to an increased excretion of bilirubin into the biliary tract, which in turn may
lead to gallstones.[1] The continuous release of free hemoglobin has been linked with the
development of pulmonary hypertension (increased pressure over the pulmonary artery);[2] this, in
turn, leads to episodes of syncope (fainting), chest pain, and progressive breathlessness. Pulmonary
hypertension eventually causes right ventricular heart failure, the symptoms of which are peripheral
edema (fluid accumulation in the skin of the legs) and ascites (fluid accumulation in the abdominal
cavity).
Causes
They may be classified according to the means of hemolysis, being either intrinsic in cases where
the cause is related to the red blood cell (RBC) itself, or extrinsic in cases where factors external to
the RBC dominate.[5] Intrinsic effects may include problems with RBC proteins or oxidative stress
handling, whereas external factors include immune attack and microvascular angiopathies (RBCs
are mechanically damaged in circulation).
Intrinsic causes
Hereditary (inherited) hemolytic anemia can be due to :
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• Defects of red blood cell membrane production (as in hereditary spherocytosis and hereditary
elliptocytosis)
• Defects in hemoglobin production (as in thalassemia, sickle-cell disease and congenital
dyserythropoietic anemia)
• Defective red cell metabolism (as in glucose-6-phosphate dehydrogenase
deficiency and pyruvate kinase deficiency)
• Paroxysmal nocturnal hemoglobinuria (PNH), sometimes referred to as Marchiafava-Micheli
syndrome, is a rare, acquired, potentially life-threatening disease of the blood characterized by
complement-induced intravascular hemolytic anemia.
Extrinsic causes
Acquired hemolytic anemia may be caused by immune-mediated causes, drugs and other
miscellaneous causes.
• Immune-mediated causes could include transient factors as in Mycoplasma

pneumoniae infection (cold agglutinin disease) or permanent factors as in autoimmune
diseases like autoimmune hemolytic anemia (itself more common in diseases such as systemic
lupus erythematosus, rheumatoid arthritis, Hodgkin's lymphoma, and chronic lymphocytic
leukemia).
• Spur cell hemolytic anemia
• Any of the causes of hypersplenism (increased activity of the spleen), such as portal
hypertension.
• Acquired hemolytic anemia is also encountered in burns and as a result of certain infections
(e.g. malaria).
• Lead poisoning resulting from the environment causes non-immune hemolytic anemia.
• Similarly, poisoning by arsine or stibine also causes hemolytic anemia.
• Runners can suffer hemolytic anemia due to "footstrike hemolysis", owing to the destruction of
red blood cells in feet at foot impact.[6][7]
• Low-grade hemolytic anemia occurs in 70% of prosthetic heart valve recipients, and severe
hemolytic anemia occurs in 3%.[8]
Mechanism
Hemolytic anemia involves the following:
1. Abnormal and accelerated destruction of red cells and, in some anemias, their precursors
2. Increased breakdown of hemoglobin, which may result in:
1. increased bilirubin level (mainly indirect-reacting) with jaundice
2. increased fecal and urinary urobilinogen
3. Hemoglobinemia, methemalbuminemia, hemoglobinuria and hemosiderinuria (where
there is significant intravascular hemolysis).
3. Bone marrow compensatory reaction:
1. Erythroid hyperplasia with accelerated production of red cells, reflected
by reticulocytosis, and slight macrocytosis in peripheral blood
2. Expansion of bone marrow in infants and children with severe chronic hemolysis –
changes in bone configuration visible on X-ray
4. The balance between red cell destruction and marrow compensation determines the severity
of anemias.
In a healthy person, a red blood cell survives 90 to 120 days in the circulation, so about 1% of
human red blood cells break down each day[citation needed]. The spleen (part of the reticulo-endothelial
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system) is the main organ that removes old and damaged RBCs from the circulation. In healthy
individuals, the breakdown and removal of RBCs from the circulation is matched by the production of
new RBCs in the bone marrow.
In conditions where the rate of RBC breakdown is increased, the body initially compensates by
producing more RBCs; however, breakdown of RBCs can exceed the rate that the body can make
RBCs, and so anemia can develop. Bilirubin, a breakdown product of hemoglobin, can accumulate
in the blood, causing jaundice.
In general, hemolytic anemia occurs as a modification of the RBC life cycle. That is, instead of being
collected at the end of its useful life and disposed of normally, the RBC disintegrates in a manner
allowing free iron-containing molecules to reach the blood. With their complete lack of mitochondria,
RBCs rely on glycolysis for the materials needed to reduce oxidative damage. Any limitations of
glycolysis can result in more susceptibility to oxidative damage and a short or abnormal lifecycle. If
the cell is unable to signal to the reticuloendothelial phagocytes by externalizing phosphatidylserine,
it is likely to lyse through uncontrolled means.[9][10][11]
The distinguishing feature of intravascular hemolysis is the release of RBC contents into the blood
stream. The metabolism and elimination of these products, largely iron-containing compounds
capable of doing damage through Fenton reactions, is an important part of the condition. Several
reference texts exist on the elimination pathways, for example. [12][13][14] Free hemoglobin can bind
to haptoglobin, and the complex is cleared from the circulation; thus, a decrease in haptoglobin can
support a diagnosis of hemolytic anemia. Alternatively, hemoglobin may oxidize and release the
heme group that is able to bind to either albumin or hemopexin. The heme is ultimately converted to
bilirubin and removed in stool and urine.[12] Hemoglobin may be cleared directly by the kidneys
resulting in fast clearance of free hemoglobin but causing the continued loss of hemosiderin loaded
renal tubular cells for many days.
Additional effects of free hemoglobin seem to be due to specific reactions with NO. [15]
Diagnosis
The diagnosis of hemolytic anemia can be suspected on the basis of a constellation of symptoms
and is largely based on the presence of anemia, an increased proportion of immature red cells
(reticulocytes) and a decrease in the level of haptoglobin, a protein that binds free hemoglobin.
Examination of a peripheral blood smear and some other laboratory studies can contribute to the
diagnosis. Symptoms of hemolytic anemia include those that can occur in all anemias as well as the
specific consequences of hemolysis. All anemias can cause fatigue, shortness of breath, decreased
ability to exercise when severe. Symptoms specifically related to hemolysis include jaundice and
dark colored urine due to the presence of hemoglobin (hemoglobinuria). When restricted to the
morning hemoglobinuria may suggest paroxysmal nocturnal haemoglobinuria. Direct examination of
blood under a microscope in a peripheral blood smear may demonstrate red blood cell fragments
called schistocytes, red blood cells that look like spheres (spherocytes), and/or red blood cells
missing small pieces (bite cells). An increased number of newly made red blood cells (reticulocytes)
may also be a sign of bone marrow compensation for anemia. Laboratory studies commonly used to
investigate hemolytic anemia include blood tests for breakdown products of red blood
cells, bilirubin and lactate dehydrogenase, a test for the free hemoglobin binding protein haptoglobin,
and the direct Coombs test to evaluate antibody binding to red blood cells suggesting autoimmune
hemolytic anemia.
Treatment
Definitive therapy depends on the cause:
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• Symptomatic treatment can be given by blood transfusion, if there is marked anemia. A positive
Coombs test is a relative contraindication to transfuse the patient. In cold hemolytic anemia
there is advantage in transfusing warmed blood.
• In severe immune-related hemolytic anemia, steroid therapy is sometimes necessary.
• In steroid resistant cases, consideration can be given to rituximab or addition of an
immunosuppressant (azathioprine, cyclophosphamide).
• Association of methylprednisolone and intravenous immunoglobulin can control hemolysis in
acute severe cases.
• Sometimes splenectomy can be helpful where extravascular hemolysis, or hereditary
spherocytosis, is predominant (i.e., most of the red blood cells are being removed by the
spleen).[16]
2) PHARMACOLOGY
FOUNDATION MODULE
INTRODUCTION TO PHARMACOLOGY AND
ITS ROLE IN MODERN MEDICINE
Pharmacology is the branch of biology concerned with the study
of drug or medication action,[1] where a drug can be broadly defined as any man-made, natural, or
endogenous (from within the body) molecule which exerts a biochemical or physiological effect on
the cell, tissue, organ, or organism (sometimes the word pharmacon is used as a term to encompass
these endogenous and exogenous bioactive species). More specifically, it is the study of the
interactions that occur between a living organism and chemicals that affect normal or abnormal
biochemical function. If substances have medicinal properties, they are considered pharmaceuticals.
The field encompasses drug composition and properties, synthesis and drug design, molecular and
cellular mechanisms, organ/systems mechanisms, signal transduction/cellular communication,
molecular diagnostics, interactions, chemical biology, therapy, and medical applications and
antipathogenic capabilities. The two main areas of pharmacology
are pharmacodynamics and pharmacokinetics. Pharmacodynamics studies the effects of a drug on
biological systems, and pharmacokinetics studies the effects of biological systems on a drug. In
broad terms, pharmacodynamics discusses the chemicals with biological receptors, and
pharmacokinetics discusses the absorption, distribution, metabolism, and excretion (ADME) of
chemicals from the biological systems. Pharmacology is not synonymous with pharmacy and the two
terms are frequently confused. Pharmacology, a biomedical science, deals with the research,
discovery, and characterization of chemicals which show biological effects and the elucidation of
cellular and organismal function in relation to these chemicals. In contrast, pharmacy, a health
services profession, is concerned with application of the principles learned from pharmacology in its
clinical settings; whether it be in a dispensing or clinical care role. In either field, the primary contrast
between the two are their distinctions between direct-patient care, for pharmacy practice, and the
science-oriented research field, driven by pharmacology.
A route of administration in pharmacology and toxicology is the path by which a drug, fluid, poison,
or other substance is taken into the body.[1] Routes of administration are generally classified by the
location at which the substance is applied. Common examples
include oral and intravenous administration. Routes can also be classified based on where the target
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of action is. Action may be topical (local), enteral(system-wide effect, but delivered through the
gastrointestinal tract), or parenteral (systemic action, but delivered by routes other than the GI tract).
Route of administration and dosage form are aspects of drug delivery.
ROUTES OF DRUG ADMINISTRATION

Routes of administration are usually classified by application location (or exposition).
The route or course the active substance takes from application location to the location where it has
its target effect is usually rather a matter of pharmacokinetics (concerning the processes of uptake,
distribution, and elimination of drugs). Exceptions include the transdermal or transmucosal routes,
which are still commonly referred to as routes of administration.
The location of the target effect of active substances are usually rather a matter
of pharmacodynamics (concerning e.g. the physiological effects of drugs [2]). An exception is topical
administration, which generally means that both the application location and the effect thereof is
local.[3]
Topical administration is sometimes defined as both a local application location and
local pharmacodynamic effect,[3] and sometimes merely as a local application location regardless of
location of the effects.[4][5]
By application location[edit]
Enteral/gastrointestinal[edit]
Oral administration of a liquid
Administration through the gastrointestinal tract is sometimes termed enteral or enteric

administration (literally meaning 'through the intestines'). Enteral/enteric administration usually
includes oral[6] (through the mouth) and rectal (into the rectum)[6] administration, in the sense that
these are taken up by the intestines. However, uptake of drugs administered orally may also occur
already in the stomach, and as such gastrointestinal (along the gastrointestinal tract) may be a more
fitting term for this route of administration. Furthermore, some application locations often classified
as enteral, such as sublingual[6] (under the tongue) and sublabial or buccal(between the cheek and
gums/gingiva), are taken up in the proximal part of the gastrointestinal tract without reaching the
intestines. Strictly enteral administration(directly into the intestines) can be used for systemic
administration, as well as local (sometimes termed topical), such as in a contrast enema, whereby
contrast media is infused into the intestines for imaging. However, for the purposes of classification
based on location of effects, the term enteral is reserved for substances with systemic effects.
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A medical professional injects medication into a gastric tube.
Many drugs as tablets, capsules, or drops are taken orally. Administration methods directly into the
stomach include those by gastric feeding tube or gastrostomy. Substances may also be placed into
the small intestines, as with a duodenal feeding tube and enteral nutrition. Enteric coated tablets are
designed to dissolve in the intestine, not the stomach, because the drug present in the tablet causes
irritation in the stomach.
Administering medication rectally
The rectal route is an effective route of administration for many medications, especially those used
at the end of life.[7][8][9][10][11][12][13] The walls of the rectum absorb many medications quickly and
effectively.[14] Medications delivered to the distal one-third of the rectum at least partially avoid the
"first pass effect" through the liver, which allows for greater bio-availability of many medications than
that of the oral route. Rectal mucosa is highly vascularized tissue that allows for rapid and effective
absorption of medications.[15] A suppository is a solid dosage form that fits for rectal administration.
In hospice care, a specialized rectal catheter, designed to provide comfortable and discreet
administration of ongoing medications provides a practical way to deliver and retain liquid
formulations in the distal rectum, giving health practitioners a way to leverage the established
benefits of rectal administration.
Parenteral[edit]
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Needle insertion angles for 4 types of parenteral administration of medication: intramuscular, subcutaneous,
intravenous, and intradermal injection.
The parenteral route is any route that is not enteral (par- + enteral).
Parenteral administration can be performed by injection, that is, using a needle (usually
a hypodermic needle) and a syringe,[16] or by the insertion of an indwelling catheter.
Locations of application of parenteral administration include:
• central nervous system
• epidural (synonym: peridural) (injection or infusion into the epidural space), e.g. epidural
anesthesia
• intracerebral (into the cerebrum) administration by direct injection into the brain. Used in
experimental research of chemicals[17] and as a treatment for malignancies of the
brain.[18] The intracerebral route can also interrupt the blood brain barrier from holding up
against subsequent routes. [19]
• intracerebroventricular (into the cerebral ventricles) administration into the ventricular
system of the brain. One use is as a last line of opioid treatment for terminal cancer
patients with intractable cancer pain.[20]
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A transdermal patch which delivers medication is applied to the skin. The patch is labelled with the
time and date of administration as well as the administrator's initials.
A medical professional applies nose drops.
Administering medication vaginally
• epicutaneous (application onto the skin). It can be used both for local effect as in allergy
testing and typical local anesthesia, as well as systemic effects when the active substance
diffuses through skin in a transdermal route.
• sublingual and buccal medication administration is a way of giving someone medicine orally
(by mouth). Sublingual administration is when medication is placed under the tongue to be
absorbed by the body. The word "sublingual" means "under the tongue." Buccal
administration involves placement of the drug between the gums and the cheek. These
medications can come in the form of tablets, films, or sprays. Many drugs are designed for
sublingual administration, including cardiovascular drugs, steroids, barbiturates, opioid
analgesics with poor gastrointestinal bioavailability, enzymes and, increasingly, vitamins and
minerals.
• extra-amniotic administration, between the endometrium and fetal membranes
• nasal administration (through the nose) can be used for topically acting substances, as well
as for insufflation of e.g. decongestant nasal sprays to be taken up along the respiratory
tract. Such substances are also called inhalational, e.g. inhalational anesthetics.
• intra-arterial (into an artery), e.g. vasodilator drugs in the treatment
of vasospasm and thrombolytic drugs for treatment of embolism
• intra-articular, into a joint space. It is generally performed by joint injection. It is mainly used
for symptomatic relief in osteoarthritis.
• intracardiac (into the heart), e.g. adrenaline during cardiopulmonary resuscitation (no longer
commonly performed)
• intracavernous injection, an injection into the base of the penis
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• intradermal, (into the skin itself) is used for skin testing some allergens, and also for mantoux
test for tuberculosis
• intralesional (into a skin lesion), is used for local skin lesions, e.g. acne medication
• intramuscular (into a muscle), e.g. many vaccines, antibiotics, and long-term psychoactive
agents. Recreationally the colloquial term 'muscling' is used. [21]
Intraocular administration
• intraocular, into the eye, e.g., some medications for glaucoma or eye neoplasms
• intraosseous infusion (into the bone marrow) is, in effect, an indirect intravenous access
because the bone marrow drains directly into the venous system. This route is occasionally
used for drugs and fluids in emergency medicine and pediatrics when intravenous access is
difficult. Recreationally the colloquial term 'boning' is used. [21]
• intraperitoneal, (infusion or injection into the peritoneum) e.g. peritoneal dialysis
• intrathecal (into the spinal canal) is most commonly used for
spinal anesthesia and chemotherapy
• Intrauterine
• intravaginal administration, in the vagina
• intravenous (into a vein), e.g. many drugs, total parenteral nutrition
• Intravesical infusion is into the urinary bladder.
• intravitreal, through the eye
• Subcutaneous (under the skin).[22] This generally takes the form of subcutaneous injection,
e.g. with insulin. Skin popping is a slang term that includes subcutaneous injection, and is
usually used in association with recreational drugs. In addition to injection, it is also possible
to slowly infuse fluids subcutaneously in the form of hypodermoclysis.
• transdermal (diffusion through the intact skin for systemic rather than topical distribution),
e.g. transdermal patches such as fentanyl in pain therapy, nicotine patches for treatment
of addiction and nitroglycerine for treatment of angina pectoris.
• perivascular administration (perivascular medical devices and perivascular drug delivery
systems are conceived for local application around a blood vessel during open vascular
surgery).[23]
• transmucosal (diffusion through a mucous membrane), e.g. insufflation (snorting)
of cocaine, sublingual, i.e. under the tongue, sublabial, i.e. between the lips
and gingiva, nitroglycerine, vaginal suppositories.
Topical[edit]
Main article: Topical medication
The definition of the topical route of administration sometimes states that both the application
location and the pharmacodynamic effect thereof is local.[3]
In other cases, topical is defined as applied to a localized area of the body or to the surface of a
body part regardless of the location of the effect.[4][5] By this definition, topical administration also
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includes transdermal application, where the substance is administered onto the skin but
is absorbed into the body to attain systemicdistribution.
If defined strictly as having local effect, the topical route of administration can also
include enteral administration of medications that are poorly absorbable by the gastrointestinal
tract. One poorly absorbable antibiotic is vancomycin, which is recommended by mouth as a
treatment for severe Clostridium difficile colitis.[24]
Choice of routes[edit]
The reason for choice of routes of drug administration are governing by various factors:
• Physical and chemical properties of the drug. The physical properties are solid, liquid and
gas. The chemical properties are solubility, stability, pH, irritancy etc.
• Site of desired action: the action may be localised and approachable or generalised and not
approachable.
• Rate of extent of absorption of the drug from different routes.
• Effect of digestive juices and the first pass metabolism of drugs.
• Condition of the patient.
In acute situations, in emergency medicine and intensive care medicine, drugs are most often
given intravenously. This is the most reliable route, as in acutely ill patients the absorption of
substances from the tissues and from the digestive tract can often be unpredictable due to
altered blood flow or bowel motility.
Convenience[edit]
Enteral routes are generally the most convenient for the patient, as no punctures
or sterile procedures are necessary. Enteral medications are therefore often preferred in the
treatment of chronic disease. However, some drugs can not be used enterally because their
absorption in the digestive tract is low or unpredictable. Transdermal administration is a
comfortable alternative; there are, however, only a few drug preparations that are suitable for
transdermal administration.
Desired target effect[edit]

Identical drugs can produce different results depending on the route of administration. For
example, some drugs are not significantly absorbed into the bloodstream from the
gastrointestinal tract and their action after enteral administration is therefore different from that
after parenteral administration. This can be illustrated by the action of naloxone (Narcan), an
antagonist of opiates such as morphine. Naloxone counteracts opiate action in the central
nervous system when given intravenously and is therefore used in the treatment of opiate
overdose. The same drug, when swallowed, acts exclusively on the bowels; it is here used to
treat constipation under opiate pain therapy and does not affect the pain-reducing effect of the
opiate.
Oral[edit]
Main article: Oral administration
The oral route is generally the most convenient and costs the least. [25] However, some drugs can
cause gastrointestinal tract irritation.[26] For drugs that come in delayed release or time-
release formulations, breaking the tablets or capsules can lead to more rapid delivery of the drug
than intended.[25] The oral route is limited to formulations containing small molecules only while
biopharmaceuticals (usually proteins) would be digested in the stomach and thereby become
ineffective. Biopharmaceuticals have to be given by injection or infusion. However, recent
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research (2018) found an organic ionic liquid suitable for oral insulin delivery (a
biopharmaceutical) into the blood stream.[27]
Oral administration is often denoted "PO" from "per os", the Latin for "by mouth".
Local[edit]
By delivering drugs almost directly to the site of action, the risk of systemic side effects is
reduced.[25] However, skin irritation may result, and for some forms such as creams or lotions,
the dosage is difficult to control.[26]
Inhalation
A dummy wears a nebulizer mask, used to administer inhaled medications.
Inhaled medications can be absorbed quickly and act both locally and systemically. [26] Proper
technique with inhaler devices is necessary to achieve the correct dose. Some medications can
have an unpleasant taste or irritate the mouth.[26]
Inhalation by smoking a substance is likely the most rapid way to deliver drugs to the brain, as
the substance travels directly to the brain without being diluted in the systemic circulation. [28] The
severity of dependence on psychoactive drugs tends to increase with more rapid drug delivery.[28]
Parenteral
A peripheral IV placed on the hand.

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A medical professional performs an intradermal (ID) injection.
The term injection encompasses intravenous (IV), intramuscular (IM), subcutaneous (SC)
and intradermal (ID) administration.[29]
Parenteral administration generally acts more rapidly than topical or enteral administration, with
onset of action often occurring in 15–30 seconds for IV, 10–20 minutes for IM and 15–30
minutes for SC.[30] They also have essentially 100% bioavailability and can be used for drugs that
are poorly absorbed or ineffective when they are given orally. [25] Some medications, such as
certain antipsychotics, can be administered as long-acting intramuscular
injections.[31] Ongoing IV infusions can be used to deliver continuous medication or fluids.[32]
Disadvantages of injections include potential pain or discomfort for the patient and the
requirement of trained staff using aseptic techniques for administration.[25]However, in some
cases, patients are taught to self-inject, such as SC injection of insulin in patients with insulin-
dependent diabetes mellitus. As the drug is delivered to the site of action extremely rapidly with
IV injection, there is a risk of overdose if the dose has been calculated incorrectly, and there is
an increased risk of side effects if the drug is administered too rapidly.[25]
Research
Neural drug delivery is the next step beyond the basic addition of growth factors to nerve
guidance conduits. Drug delivery systems allow the rate of growth factor release to be regulated
over time, which is critical for creating an environment more closely representative of in vivo
development environments.[33]
TRANSMEMBRANE DRUG TRANSPORT

Many drugs need to pass through one or more cell membranes to reach their site of action. A
common feature of all cell membranes is a phospholipid bilayer, about 10 nm thick. Spanning this
bilayer or attached to the outer or inner leaﬂets are glycoproteins, which may act as ion channels,
receptors, intermediate messengers (G-proteins) or enzymes. Cells obtain molecules and ions from
the extracellular fluid, creating a constant in and out flow. The interesting thing about cell
membranes is that relative concentrations and phospholipid bilayers prevent essential ions from
entering the cell. Therefore in order for drugs to move across the membrane these problems must
be addressed. In general, this is completed by facilitated diffusion or active transport. In facilitated
diffusion, relative concentrations are used to transport in and out. Active transports uses energy
(ATP) to transfer molecules and ions in and out of the cell.[1]
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Concept of drug cross the cell membrane[edit]

Cellular signals cross the membrane through a process called signal transduction. This three-step
process proceeds when a specific message encounters the outside surface of the cell and makes
direct contact with a receptor. A receptor is a specialized molecule that takes information from the
environment and passes it throughout various parts of the cell. Next, a connecting switch molecule,
transducer, passes the message inward, closer to the cell. Finally, the signal gets amplified,
therefore causing the cell to perform a specific function. These functions can include moving,
producing more proteins, or even sending out more signals. [2]
Methods of Drug cross the cell membrane[edit]
Passive Transport[edit]
The most common method for drugs to cross the cell membrane is by Passive Diffusion. Drug
molecules will diffuse down its concentration gradient without expenditure of energy by the cell.
However, the membranes are selectively permeable, so it has different effects on the rate of
diffusion on different drug molecules. The rate of diffusion also can be enhancing by transport
proteins in the membrane by Facilitated Diffusion. There are two types of transport proteins that
carry out the facilitated diffusion, Channel protein and Carrier Protein. [3]
Active transport[edit]
Active transport is an energy-requiring process. The drug molecule, transport against the a
concentration gradient, and most of the protein used are carrier proteins, rather than channel
proteins. There are also two type of active transport
Primary active transport which directly uses energy to transport molecules across a
membrane.Sometime the carrier protein can be an electrogenic pump. [4]
In secondary active transport or Co-transport also uses energy to transport molecules across a
membrane. However, It differs from primary transport is that there is no direct coupling of Adenosine
triphosphate|ATP; instead, the electrochemical potential|electrochemical potential difference created
by pumping ions out of the cell is used. [5]
RECEPTOR AND CELLULAR BASIS

Cell surface receptors (membrane receptors, transmembrane receptors) are receptors that are
embedded in the plasma membrane of cells. They act in cell signaling by receiving (binding
to) extracellular molecules. They are specialized integral membrane proteins that allow
communication between the cell and the extracellular space. The extracellular molecules may
be hormones, neurotransmitters, cytokines, growth factors, cell adhesion molecules, or nutrients;
they react with the receptor to induce changes in the metabolism and activity of a cell. In the process
of signal transduction, ligand binding affects a cascading chemical change through the cell
membrane.
Structure and mechanism[edit]

Many membrane receptors are transmembrane proteins. There are various kinds,
including glycoproteins and lipoproteins.[1] Hundreds of different receptors are known and many more
have yet to be studied. [2][3] Transmembrane receptors are typically classified based on
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their tertiary (three-dimensional) structure. If the three-dimensional structure is unknown, they can be
classified based on membrane topology. In the simplest receptors, polypeptide chains cross the lipid
bilayer once, while others, such as the G-protein coupled receptors, cross as many as seven times.
Each cell membranecan have several kinds of membrane receptors, with varying surface
distributions. A single receptor may also be differently distributed at different membrane positions,
depending on the sort of membrane and cellular function. Receptors are often clustered on the
membrane surface, rather than evenly distributed.[4][5]
Mechanism[edit]
Two models have been proposed to explain transmembrane receptors' mechanism of action.
• Dimerization: The dimerization model suggests that prior to ligand binding, receptors exist in
a monomeric form. When agonist binding occurs, the monomers combine to form an
active dimer.
• Rotation: Ligand binding to the extracellular part of the receptor induces a rotation
(conformational change) of part of the receptor's transmembrane helices. The rotation alters
which parts of the receptor are exposed on the intracellular side of the membrane, altering how
the receptor can interact with other proteins within the cell.[6]
Domains[edit]
E = extracellular space
P = plasma membrane
I = intracellular space
Transmembrane receptors in plasma membrane can usually be divided into three parts.
Extracellular domains[edit]
The extracellular domain just externally from the cell or organelle. If the polypeptide chain crosses
the bilayer several times, the external domain comprises loops entwined through the membrane. By
definition, a receptor's main function is to recognize and respond to a type of ligand. For example,
a neurotransmitter, hormone, or atomic ions may each bind to the extracellular domain as a ligand
coupled to receptor. Klotho is an enzyme which effects a receptor to recognize the ligand (FGF23).
Transmembrane domains[edit]
Two most abundant classes of transmembrane receptors are GPCR and single-pass
transmembrane proteins.[7][8] In some receptors, such as the nicotinic acetylcholine receptor, the
transmembrane domain forms a protein pore through the membrane, or around the ion channel.
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Upon activation of an extracellular domain by binding of the appropriate ligand, the pore becomes
accessible to ions, which then diffuse. In other receptors, the transmembrane domains undergo a
conformational change upon binding, which effects intracellular conditions. In some receptors, such
as members of the 7TM superfamily, the transmembrane domain includes a ligand binding pocket.
Intracellular domains[edit]
The intracellular (or cytoplasmic) domain of the receptor interacts with the interior of the cell or
organelle, relaying the signal. There are two fundamental paths for this interaction:
• The intracellular domain communicates via protein-protein interactions against effector proteins,
which in turn pass a signal to the destination.
• With enzyme-linked receptors, the intracellular domain has enzymatic activity. Often, this
is tyrosine kinase activity. The enzymatic activity can also be due to an enzyme associated with
the intracellular domain.
Signal transduction[edit]
External reactions and internal reactions for signal transduction (click to enlarge)
Signal transduction processes through membrane receptors involve the external reactions, in which
the ligand binds to a membrane receptor, and the internal reactions, in which intracellular response
is triggered.[9][10]
Signal transduction through membrane receptors requires four parts:
• Extracellular signaling molecule: an extracellular signaling molecule is produced by one cell and
is at least capable of traveling to neighboring cells.
• Receptor protein: cells must have cell surface receptor proteins which bind to the signaling
molecule and communicate inward into the cell.
• Intracellular signaling proteins: these pass the signal to the organelles of the cell. Binding of the
signal molecule to the receptor protein will activate intracellular signaling proteins that initiate a
signaling cascade.
• Target proteins: the conformations or other properties of the target proteins are altered when a
signaling pathway is active and changes the behavior of the cell. [10]
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Three conformation states of acetylcholine receptor (click to enlarge)
Membrane receptors are mainly divided by structure and function into 3 classes: The ion channel
linked receptor; The enzyme-linked receptor; and The G protein-coupled receptor.
• Ion channel linked receptors have ion channels for anions and cations, and constitute a large
family of multipass transmembrane proteins. They participate in rapid signaling events usually
found in electrically active cells such as neurons. They are also called ligand-gated ion
channels. Opening and closing of ion channels is controlled by neurotransmitters.
• Enzyme-linked receptors are either enzymes themselves, or directly activate associated
enzymes. These are typically single-pass transmembrane receptors, with the enzymatic
component of the receptor kept intracellular. The majority of enzyme-linked receptors are, or
associate with, protein kinases.
• G protein-coupled receptors are integral membrane proteins that possess seven
transmembrane helices. These receptors activate a G protein upon agonist binding, and the G-
protein mediates receptor effects on intracellular signaling pathways.
Ion channel-linked receptor[edit]
Main article: Ligand-gated ion channel
During the signal transduction event in a neuron, the neurotransmitter binds to the receptor and
alters the conformation of the protein. This opens the ion channel, allowing extracellular ions into the
cell. Ion permeability of the plasma membrane is altered, and this transforms the extracellular
chemical signal into an intracellular electric signal which alters the cell excitability. [11]
Acetylcholine receptor is a receptor linked to a cation channel. The protein consists of 4 subunits: α,
β, γ, and δ subunits. There are two α subunits, with one acetylcholine binding site each. This
receptor can exist in three conformations. The closed and unoccupied state is the native protein
conformation. As two molecules of acetylcholine both bind to the binding sites on α subunits, the
conformation of the receptor is altered and the gate is opened, allowing for the entry of many ions
and small molecules. However, this open and occupied state only lasts for a minor duration and then
the gate is closed, becoming the closed and occupied state. The two molecules of acetylcholine will
soon dissociate from the receptor, returning it to the native closed and unoccupied state. [12][13]
Enzyme-linked receptors[edit]
Main article: Enzyme-linked receptor
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Sketch of an enzyme-linked receptor structure (structure of IGF-1R) (click to enlarge)
As of 2009, there are 6 known types of enzyme-linked receptors: Receptor tyrosine kinases;
Tyrosine kinase associated receptors; Receptor-like tyrosine phosphatases;
Receptor serine/threonine kinases; Receptor guanylyl cyclases and histidine kinase associated
receptors. Receptor tyrosine kinases have the largest population and widest application. The
majority of these molecules are receptors for growth factors such as epidermal growth
factor (EGF), platelet-derived growth factor (PDGF), fibroblast growth factor (FGF), hepatocyte
growth factor (HGF), nerve growth factor (NGF) and hormones such as insulin. Most of these
receptors will dimerize after binding with their ligands, in order to activate further signal
transductions. For example, after the epidermal growth factor (EGF) receptor binds with its ligand
EGF, the two receptors dimerize and then undergo phosphorylation of the tyrosine residues in the
enzyme portion of each receptor molecule. This will activate the tyrosine kinase and catalyze further
intracellular reactions.
G protein-coupled receptors[edit]
Main article: G protein-coupled receptor
G protein-coupled receptors comprise a large protein family of transmembrane receptors. They are
found only in eukaryotes.[14] The ligands which bind and activate these receptors include:
photosensitive compounds, odors, pheromones, hormones, and neurotransmitters. These vary in
size from small molecules to peptides and large proteins. G protein-coupled receptors are involved
in many diseases, and thus are the targets of many modern medicinal drugs. [15]
There are two principal signal transduction pathways involving the G-protein coupled receptors:
the cAMP signaling pathway and the phosphatidylinositol signaling pathway.[16] Both are mediated
via G proteinactivation. The G-protein is a trimeric protein, with three subunits designated as α, β,
and γ. In response to receptor activation, the α subunit releases bound guanosine
diphosphate (GDP), which is displaced by guanosine triphosphate (GTP), thus activating the α
subunit, which then dissociates from the β and γ subunits. The activated α subunit can further affect
intracellular signaling proteins or target functional proteins directly.
Membrane receptor-related disease[edit]

If the membrane receptors are denatured or deficient, the signal transduction can be hindered and
cause diseases. Some diseases are caused by disorders of membrane receptor function. This is due
to deficiency or degradation of the receptor via changes in the genes that encode and regulate the
receptor protein. The membrane receptor TM4SF5 influences the migration of hepatic cells
and hepatoma.[17]Also, the cortical NMDA receptor influences membrane fluidity, and is altered in
Alzheimer's disease.[18] When the cell is infected by a non-enveloped virus, the virus first binds to
specific membrane receptors and then passes itself or a subviral component to the cytoplasmic side
of the cellular membrane. In the case of poliovirus, it is known in vitro that interactions with receptors
cause conformational rearrangements which release a virion protein called VP4.The N terminus of
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VP4 is myristylated and thus hydrophobic【myristic acid=CH3(CH2)12COOH】. It is proposed that the

conformational changes induced by receptor binding result in the attachment of myristic acid on VP4
and the formation of a channel for RNA.
Structure-based drug design[edit]
Flow charts of two strategies of structure-based drug design
Main article: Drug design

Through methods such as X-ray crystallography and NMR spectroscopy, the information about 3D
structures of target molecules has increased dramatically, and so has structural information about
the ligands. This drives rapid development of structure-based drug design. Some of these new drugs
target membrane receptors. Current approaches to structure-based drug design can be divided into
two categories. The first category is about determining ligands for a given receptor. This is usually
accomplished through database queries, biophysical simulations, and the construction of chemical
libraries. In each case, a large number of potential ligand molecules are screened to find those fitting
the binding pocket of the receptor. This approach is usually referred to as ligand-based drug design.
The key advantage of searching a database is that it saves time and power to obtain new effective
compounds. Another approach of structure-based drug design is about combinatorially mapping
ligands, which is referred to as receptor-based drug design. In this case, ligand molecules are
engineered within the constraints of a binding pocket by assembling small pieces in a stepwise
manner. These pieces can be either atoms or molecules. The key advantage of such a method is
that novel structures can be discovered.[19][20][21]
Other examples[edit]
• Adrenergic receptor,
• Olfactory receptors,
• Receptor tyrosine kinases
• Epidermal growth factor receptor
• Insulin Receptor
• Fibroblast growth factor receptors,
• High affinity neurotrophin receptors
• Ephrin receptors
• Integrins
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• Low Affinity Nerve Growth Factor Receptor

• NMDA receptor
• Several Immune receptors
o Toll-like receptor
o T cell receptor
o CD28
o SCIMP protein
BLOOD MODULE
DRUG TREATMENT OF ANEMIA
Antianemia Drugs
Erythropoietin (Epoetin alpha)
▪ Trade Names: erythropoietin, Epo, Epogen, Procrit ®

▪ Drug Class: Drug Used in Anemia (normocytic)
▪ Mechanism of Action:
▪ a glycoprotein that stimulates red blood cell production. Epoetin alfa is a 165
amino acid glycoprotein manufactured by recombinant DNA technology, and has
the same biological effects as endogenous erythropoietin
▪ Hypoxia is the primary physiological stimulus for erythropoietin production in the
body
▪ Indications:
▪ treatment of anemia in:
1. chronic renal failure patients
2. zidovudine-treated HIV-infected patients
3. cancer patients on chemotherapy
4. reduction of allogeneic blood transfusion in surgery patients.
Erythropoietin deficiency can result from compromised renal function
(it's primary site of production). Erythropoietin deficiency results in
a normocytic anemia.
▪ Contraindications:
▪ Uncontrolled hypertension or known hypersensitivity to either mammalian cell-
derived products or to human albumin.
▪ Pharmacokinetics:
▪ given i.v. or s.c. Half life of 4-13 hrs in patients with chronic renal failure. It is
measured in international units (IU).
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▪ Side Effects:
▪ a rapid increase in hematocrit & hemoglobin may cause hypertension & thrombotic
complications. These can be minimized by raising the hematocrit slowly and
treating the hypertension.
Black Box Warnings:
▪ INCREASED DEATH, SERIOUS CARDIOVASCULAR and THROMBOEMBOLIC

EVENTS, and INCREASED RISK OF TUMOR PROGRESSION OR RECURRENCE.
Renal Failure Patients
▪ Patients experienced greater risks for death and serious cardiovascular events when
administered erythropoiesis-stimulating agents (ESAs) to target higher versus lower
hemoglobin levels (13.5 vs. 11.3 g/dL; 14 vs. 10 g/dL) in two clinical studies. Physicians
should individualize dosing to maintain hemoglobin levels within the range of 10 to 12
g/dL.
Cancer Patients
▪ Erythropoiesis-stimulating agents shortened overall survival and/or increased the risk of
tumor progression in some clinical studies in patients with breast, head and neck,
lymphoid, non-small cell lung, and cervical cancers. Use the lowest dose needed to avoid
RBC transfusions.
▪ Use only for treatment of anemia due to cocomitant myelosuppressive chemotherapy.
▪ Erythropoietin is not indicated for patients receiving myelosuppressive therapy when the
anticipated outcome is cure.
Perisurgery
▪ Erythropoietin increased the risk of deep vein thrombosis in patients not receiving
prophylactic anticoagulation.
▪ Notes:
▪ Epo is one of the drugs banned by the International Olympic Committee
▪ Darbopoetin alpha (Aranesp ®) is a glycosylated form of erythropoietin that differs
only in having a 2-3 fold longer half-life.
▪ Pronunciation:
e rith ro POE e tin
▪ References:
▪ Masters SB (2012): Agents Used in Anemias; Hematopoietic Growth Factors
(Chapter 33). In: Basic & Clinical Pharmacology. 12e. Katzung BG, Masters SB,
Trevor AJ (Editors). McGraw-Hill / Lange. (Access-Medicine)
▪ rxlist.com (Procrit ®)
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Keywords
Ferrous Sulfate
▪ Trade Name: generic

▪ Drug Class: Drug Used in Anemia (microcytic)
▪ Iron combines with porphyrin and globin chains to form hemoglobin, which is critical
for oxygen delivery from the lungs to other tissues.
▪ Iron deficiency causes a microcytic anemia due to the formation of small
erythrocytes with insufficient hemoglobin.
▪ Indications:
▪ Iron deficiency anemia, blood loss related to pregnancy or GI bleeding (NSAIDs),
hookworm infestation, or excess coffee
▪ Patients with hemochromatosis, hemosiderosis or hemolytic anemia
▪ An oral (absorbable) iron formulation.
▪ Side Effects:
▪ Therapeutic doses - nausea, upper abdominal pain, constipation or diarrhea
▪ Iron overdose (1-2 g) can lead to circulatory collapse and death. Non-
intentional iron overdose has been a leading cause of fatal poisoning in
children <6 years old. Keep out of reach of children.
▪ Iron overdose can be treated by gastric lavage with a phosphate solution
and deferoxamine (iron chelator).
▪ Drug interactions:
▪ it may decrease the absorption of other medications
▪ Notes:
▪ Primary hemochromatosis is a hereditary disease in which there is increased
accumulation of iron
▪ Pronunciation:
Fair us SUL fate
▪ Reference:
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Keywords
Iron Dextran
▪ Trade Name: INFeD ®

▪ Drug Class: Parental Iron Preparation
▪ Same as ferrous sulfate (but has a different route of administration)
▪ Indications:
▪ Patients with documented iron deficiency in whom oral administration is
unsatisfactory or impossible (e.g. malabsorption syndrome, prolonged
salicylate therapy, dialysis patients).
▪ Seldom used now (newer orally effective agents including iron sucrose & ferric
gluconate complex are most commonly used).
▪ Ferric gluconate & iron sucrose are two alternative parenteral forms of iron that
can be given i.v., but should NOT be given intramuscularly.
▪ Given by deep i.m. injection or i.v.
▪ Most adults with iron deficiency require 1-2 g of replacement iron, or 20-40 ml.
▪ The favored route of administration is i.v. infusion in several hundred mls of normal
saline over 1-2 hrs.
▪ Side Effects:
▪ More side effects compared to administering oral iron supplements
▪ Local pain & tissue staining (brown discoloration), headache, light-headedness,
fever, nausea, flushing, urticaria, bronchospasm, and rarely anaphylaxis &
death.
▪ Notes:
▪ A small test dose should be given before the full dose, to test for the risk of
hypersensitivity. Patients with a strong history of allergy or who have previously
received parenteral iron are more likely to have hypersensitivity reactions.
▪ Pronunciation:
EYE urn DEX tran
▪ References:
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▪ rxlist.com Infed (Iron Dextran)

Keywords
Deferoxamine
▪ Trade Name: Desferal ®

▪ Drug Class: Iron Chelator
▪ Binds iron avidly, but poorly binds other essential trace metals
▪ It competes in binding loosely bound iron, but fails to bind iron that is biologically
chelated, such as in microsomal and mitrochondrial cytochromes and
hemoproteins
▪ Indications:
▪ Iron poisoning. Used for treating both acute iron intoxication and in patients with
secondary iron overload from multiple transfusions.
▪ Deferoxamine plus hemodialysis may also be useful in treatment of aluminum
toxicity in renal failure. (It is not indicated for the treatment of primary
hemochromatosis, since phlebotomy is the method of choice for removing excess
iron in this disorder.)
▪ Patients with severe renal disease or anuria, since the drug and the iron chelate are
excreted primarily by the kidney
▪ Given parentally (i.m., s.c. or i.v.)
▪ It is poorly absorbed if taken orally, and may actually increase iron absorption if
given orally
▪ Iron-chelator complexes are excreted in the urine, often turning the urine an
orange-red color
▪ Side Effects:
▪ Rapid i.v. administration may cause hypotension
▪ Idiosyncratic responses such as flushing, rash, abdominal discomfort may occur
▪ Pronunciation:
de fer OX a meen
▪ References:
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▪ Olson KR (2007): Poisoning & Drug Overdose. 5th Edition. McGraw-Hill (Lange).
(ISBN: 978-0-07-144333-3).
▪ rxlist.com (Desferal ®)
Keywords
Folic acid
▪ Trade Name: Folvite ®

▪ Drug Class: Drug used in anemia (megaloblastic)
▪ Essential cofactor for synthesis of amino acids, purines and DNA
▪ Indications:
▪ Treatment of megaloblastic anemias due to a deficiency of folic acid as may be
seen in tropical or non-tropical sprue, in anemias of nutritional origin, pregnancy,
infancy, or childhood
▪ A reduced form of folic acid known as citrovorum factor (or leucovorin) is given
to replenish endogenous folic acid in patients on methotrexate (which inhibits
dihydrofolate reductase). Citrovorin (leucovorin) is better absorbed compared to
folic acid.
▪ Folic acid should not be given alone in patients with pernicioius anemia
without knowing whether they also have a Vit B12 deficiency. The danger
is that folic acid supplements can mask the signs of Vit B 12 deficiency, yet not
prevent the development of irreversible neurological disease due to Vit B12
deficiency.
▪ The Shilling test can be used to test for abnormalities in Vit B12 absorption.
▪ 1 mg of folic acid orally daily is typically sufficient to reverse megaloblastic anemia
& restore normal folate levels.
▪ Side Effects:
▪ Allergic sensitization
▪ Notes:
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▪ Folate deficiency (in pregnant women) is implicated as a cause of congenital

malformations in newborns
▪ Folate may also play a beneficial role in preventing the development vascular
disease such as ischemic heart disease & stroke.
▪ Folic acid supplements may mask the signs of Vit B 12 deficiency, which can produce
neurological disease if undetected
▪ Folic acid deficiency is also known as Will's disease.
▪ Pronunciation:
FOE lik As id
▪ References:
▪ www.rxlist.com (Folvite ®)
Keywords
Vitamin B12
▪ Generic Names: generic, cyanocobalamin, hydroxocobalamin

▪ Drug Class: Vitamin
▪ A cofactor for several essential biochemical reactions.
▪ Indications:
▪ Used to treat or prevent deficiency of Vit B12.
▪ The most common causes of Vit B12 deficiency are:
▪ Pernicious anemia (results from defective secretion of intrinsic factor
by the gastric mucosal cells)
▪ Fish tapeworm infection
▪ Partial or total gastrectomy
▪ Various intestinal disorders that impair absorption of Vit B12.
▪ Different formulations can be administered orally, or by parenteral injection.
▪ Notes:
▪ Vit B12 deficiency leads to megaloblastic anemia, GI symptoms & neurological
abnormalities including degeneration of myelin sheaths in axons of the spinal
cord & peripheral nerves.
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▪ Vit B12 deficiency symptoms: paresthesias & weakness in peripheral nerves,

progressing to spasticity, ataxia & other CNS dysfunctions.
▪ Vit B12 deficiency in elderly patients due to abnormal absorption of dietary Vit B12
is relatively common and easily treated.
COAGULATION MODIFYING DRUG

The vascular system delivers oxygen and nutrients to all body cells and removes waste
products from tissues. This closed system functions as a pressure system, with blood
flowing continuously from high-pressure to low-pressure areas. Injury of a blood vessel
compromises the closed system, causing blood to flow out of the injured vessel (now a
low-pressure area). With severe injury to a vessel, the entire circulatory system may be
compromised and the patient could die.
Blood vessel injuries are common, occurring, for instance, when someone hits the edge
of a table, coughs too hard, or falls down. They initiate a series of normal reactions that
stops blood flow and maintains balance within the system. The reactions include:
• reflex vasoconstriction
• platelet aggregation
• blood coagulation (clot formation), which causes blood to solidify
• clot resolution, which returns blood to the fluid state.
In many clinical situations, drugs are used to slow or stop this process, with the goal of
preventing tissue damage from the decreased blood flow that occurs when the clotting
process cuts off blood supply to an area. This article reviews the processes the body
uses to maintain the cardiovascular system and discusses the mechanisms of action,
benefits, and risks of drugs used to alter coagulation. (See Inside the coagulation
process by clicking the PDF icon above.)
Indications for drugs that alter coagulation

In certain clinical situations—for instance, coronary artery disease, immobility, atrial
fibrillation, and joint replacement—interfering with coagulation helps prevent clots that
could impede blood flow and cause tissue damage or death. Patients with coronary
artery disease, for example, have narrowed vessels. An immobile patient loses the
protective massaging of veins caused by muscle fiber contractions; also, blood pools
and doesn’t return to the heart efficiently. With atrial fibrillation, blood pools in the
heart’s auricles and may clot. The artificial parts of a hip or knee replacement initially
may damage a blood vessel, leading to clotting.
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All drugs that alter coagulation interfere with the normal protective reflexes. As a nurse,
you need to be aware of the dangers of eliminating these reflexes, which could include
serious or even fatal bleeding episodes. Drugs that alter coagulation include platelet
inhibitors and anticoagulants. (See Classifying drugs that alter coagulation by clicking the
PDF icon above.)
Platelet inhibitors
Platelet inhibitors are often the first line of defense in preventing vascular clots; they
don’t affect clots that already have formed. These drugs block platelets’ ability to adhere
and aggregate to form the platelet plug—the first step in sealing the vascular system
and preventing blood loss into body tissues.
Current platelet inhibitors include abciximab (ReoPro), anagrelide (Agrylin), aspirin,
cilostazol (Pletal), clopidogrel (Plavix), dipyridamole (Persantine), eptifibatide (Integrilin),
ticlopidine (Ticlid), ticagrelor (Brilinta), and tirofiban (Aggrastat). These drugs are used to
treat cardiovascular diseases in which vessels become occluded, as well as to maintain
venous and arterial grafts and prevent cerebrovascular occlusion. They’re also given as
adjuncts to thrombolytic therapy in treating myocardial infarction (MI) and preventing
post-MI reinfarction. Ticagrelor, released in 2011, is indicated only to prevent
thromboembolic events in acute coronary syndrome. Its black-box warning cites the risk
of excessive bleeding and dangers of sudden withdrawal, which can trigger an acute
cardiovascular event.
Most platelet inhibitors block receptors on platelets to prevent adhesion; anagrelide
prevents platelet formation in the bone marrow. Bleeding (including bleeding caused by
toothbrushing and excessive bleeding after injury) is the most common adverse effect.
Easy bruising also may occur.
Nursing considerations
When caring for patients receiving platelet inhibitors, minimize invasive procedures and
take other steps to guard against blood loss. Be sure to teach about self-care. Advise
them to avoid injury, use a soft-bristled toothbrush, shave with an electric razor, and
avoid contact sports. Encourage them to carry or wear Medic-Alert jewelry that alerts
healthcare providers to platelet inhibitor use. Stress the importance of telling all
healthcare providers they’re taking a platelet inhibitor—especially dentists, surgeons,
and others planning an invasive procedure. Caution patients to check with a physician
before taking other agents that alter coagulation, including aspirin, nonsteroidal
inflammatory drugs, and certain herbs. Emphasize the need to avoid excessive dosages,
because no rapid antidote exists for excessive bleeding caused by drug overdose or
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overreaction. Teach patients about warning signs of excessive blood loss, and advise
them to report these immediately.
Anticoagulants
Although commonly called blood thinners, anticoagulants don’t actually thin the blood.
Like platelet inhibitors, they don’t dissolve clots that have already formed but they can
prevent formation of new clots. In patients with clots, deep vein thrombosis, or occluded
vessels that have caused an MI or a stroke, clot prevention is crucial, because new clot
formation may compound the patient’s problem. Anticoagulants fall into two
categories—injectable and oral.
Injectable anticoagulants
These agents act rapidly to directly block formation of thrombin from prothombin.
Clotting changes occur rapidly after injection. Injectable anticoagulants in current use
include antithrombin III (Thrombate III), argatroban (Acova), bivalirudin (Angiomax),
desirudin (Iprivask), fondaparinux (Arixtra), heparin (generic), and the low-molecular-
weight heparins dalteparin (Fragmin) and enoxaparin (Lovenox).
Indications for injectable anticoagulants include acute treatment and prevention of
venous thrombosis and pulmonary embolism, treatment of atrial fibrillation with
embolization, prevention of clotting in blood samples and in dialysis and venous tubing,
and diagnosis and treatment of disseminated intravascular coagulation.
Nursing considerations. Be aware that in patients with excessive bleeding caused by
anticoagulants, protamine sulfate can be injected as a rapid antidote to restore clotting
activity. This drug directly reacts with thrombin, freeing it up to allow clots to form.
Also, know that several serious to fatal medication errors have occurred when patients
have inadvertently received two anticoagulants at the same time. Such errors are
possible when, for instance, a hospital patient is put on a protocol that uses an
anticoagulant and then is transferred to another unit, where she receives an
anticoagulant from a different protocol. Warnings, labels, and effective communication
among nurses at transfer points can help prevent this problem.
The major drawback of injectable anticoagulants is that they must be injected. Some
patients may be discharged on low-molecular-weight heparin to inject themselves; be
sure to teach them proper injection technique and proper disposal of needles and
syringes. Advise patients that they must have their blood tested frequently to check
crucial coagulation indices. Whole blood clotting time must be maintained at 2.5 to 3
times the control value, or activated partial thromboplastin time (APTT) must be
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maintained at 1.5 to 3 times the control value. Be sure to provide other protective
measures and cover the same teaching topics as for patients receiving platelet
inhibitors.
Oral anticoagulants
Previously, warfarin (Coumadin) was the only oral anticoagulant available. In recent
years, two new oral anticoagulants have been approved by the Food and Drug
Administration. Dabigatran (Pradaxa) is a direct thrombin inhibitor; rivaroxaban (Xarelto)
inhibits activated thrombin. Both stop the coagulation process.
Warfarin Warfarin blocks the liver’s use of vitamin K to produce clotting factors. It’s
commonly prescribed for chronic conditions that might involve problems with clot
formation, such as coronary artery disease, atrial fibrillation, knee or hip replacement,
and immobility.
However, warfarin has several disadvantages. For one, it takes time to deplete already-
formed clotting factors; clot formation may not decrease until 48 to 72 hours after
warfarin therapy begins. Also, if the patient receives too much warfarin and is bleeding,
no precise antidote exists. Although vitamin K can be injected to trigger the liver to
resume making clotting factors, clotting activity may not return for 48 to 72 hours. In
severe overdose and bleeding, blood products containing clotting factors may be given
to stop the bleeding; however, the liver still needs time to restore a normal level of
clotting factors.
Traditionally, warfarin was the only oral anticoagulant patients could take at home. In
light of its slowness in halting clot formation, warfarin therapy usually is started while
the patient is still receiving an injectable anticoagulant; the latter drug is withdrawn
when warfarin kicks in. Also, warfarin may interact with many other drugs and certain
herbal supplements. What’s more, its effects may be altered by changes in the liver or in
vitamin K production by the normal intestinal flora. (See Herbs and other supplements
that increase bleeding risk by clicking the PDF icon above.)
Patients on warfarin need to have frequent blood tests to evaluate its effectiveness and
allow dosage adjustment, if needed. The desired prothrombin time (PT) is 1.5 to 2.5
times the control value; the desired International Normalized Ratio (INR) is 2 to 3. If a
drug is added to or removed from the patient’s regimen, warfarin dosage may need to
be adjusted. As with any drug used to alter coagulation, be sure to provide education
and support.
Dabigatran. This drug was approved in 2010 for prevention of stroke and blood clots in
patients with nonvalvular atrial fibrillation. Rather than affecting clotting-factor
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formation, it inhibits activation of a clotting factor, which stops the clotting cascade.
Dabigatran has become the drug of choice for preventing clots in patients with chronic
nonvalvular atrial fibrillation. It interacts with few drugs and its effects aren’t altered
directly by liver function changes, so patients don’t need frequent blood testing to
guide dosages. Because its half-life is 12 to 17 hours, the drug’s effects linger after the
patient stops taking it.
Teach patients to use all tablets within 60 days of opening the bottle. Instruct them to
swallow tablets whole without cutting, crushing, or chewing. Advise them to protect the
drug from humidity and light exposure. Because no antidote exists, caution patients to
stay alert for signs and symptoms of excessive bleeding, such as excessive bruising, easy
bleeding from minor injuries, and bleeding from toothbrushing. Stress that they
shouldn’t stop taking the drug suddenly, because cardiovascular problems could result.
Rivaroxaban. This drug was approved in 2011 to prevent deep vein thrombosis after
knee or hip replacement surgery and to reduce stroke risk in patients with nonvalvular
atrial fibrillation. It affects clot formation by inhibiting activated clotting factor. It has a
shorter half-life than dabigatran (5 to 9 hours), so it clears from the body faster and its
effects don’t last as long. No specific antidote exists.
Caution patients not to stop taking rivaroxaban suddenly because this may cause
sudden reversal of effects, triggering a stroke. Inform them that combining rivaroxaban
with other drugs or herbs that affect coagulation could lead to excessive bleeding.
Ensuring patient safety

Patient safety is a major concern for patients receiving drugs that affect coagulation
because they’re at risk for excessive bleeding. Take the following measures to protect
patients from injury and minimize invasive procedures:
• Help consolidate required blood withdrawals so the patient has fewer chances to
bleed.
• Clearly document in the chart that the patient is on this drug, to alert other
caregivers that invasive procedures could lead to blood loss.
• Use compression dressings over areas that could bleed.
• Check all drugs and supplements the patient is taking for their potential to alter
coagulation, which could lead to more bleeding
• At least once during each shift, assess patients carefully for signs and symptoms
of bleeding.
• Evaluate clotting-test results to help determine the drug’s therapeutic dosage, if
appropriate.
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• To help prevent or check for possible interactions, ask patients about all drugs,
herbs, and other supplements they’re taking.
3) COMMUNITY MEDICINE
Community health
From Wikipedia, the free encyclopedia
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Community health is a major field of study within the medical and clinical sciences which focuses
on the maintenance, protection, and improvement of the health status of population groups and
communities. It is a distinct field of study that may be taught within a separate school of public
health or environmental health. The WHO defines community health as:
environmental, social, and economic resources to sustain emotional and physical well being among
people in ways that advance their aspirations and satisfy their needs in their unique environment. [1]
Community health tends to focus on a defined geographical community. The health characteristics of
a community are often examined using geographic information system (GIS) software and public
healthdatasets. Some projects, such as InfoShare or GEOPROJ combine GIS with existing datasets,
allowing the general public to examine the characteristics of any given community in participating
countries.
Medical interventions that occur in communities can be classified as three categories: primary
healthcare, secondary healthcare, and tertiary healthcare. Each category focuses on a different level
and approach towards the community or population group. In the United States, community health is
rooted within primary healthcare achievements.[2] Primary healthcare programs aim to reduce risk
factors and increase health promotion and prevention. Secondary healthcare is related to "hospital
care" where acute care is administered in a hospital department setting. Tertiary healthcare refers to
highly specialized care usually involving disease or disability management.
The success of community health programmes relies upon the transfer of information from health
professionals to the general public using one-to-one or one to many communication (mass
communication). The latest shift is towards health marketing.
Contents
Measuring community health[edit]

Community health is generally measured by geographical information systems and demographic
data. Geographic information systems can be used to define sub-communities when neighborhood
location data is not enough.[3] Traditionally community health has been measured using sampling
data which was then compared to well-known data sets, like the National Health Interview
Survey or National Health and Nutrition Examination Survey.[4] With technological
development, information systems could store more data for small scale communities, cities, and
towns; as opposed to census data that only generalizes information about small populations based
on the overall population. Geographical information systems (GIS) can give more precise information
of community resources, even at neighborhood levels.[5] The ease of use of geographic information
systems (GIS), advances in multilevel statistics, and spatial analysis methods makes it easier for
researchers to procure and generate data related to the built environment.[6]
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Social media can also play a big role in health information analytics. [7] Studies have found social
media being capable of influencing people to change their unhealthy behaviors and encourage
interventions capable of improving health status. [7] Social media statistics combined with
geographical information systems (GIS) may provide researchers with a more complete image of
community standards for health and well being.[8][9]
Categories of community health[edit]

Primary healthcare and primary prevention[edit]
Community based health promotion emphasizes primary prevention and population based
perspective(traditional prevention).[10] It is the goal of community health to have individuals in a
certain community improve their lifestyle or seek medical attention. Primary healthcare is provided
by health professionals, specifically the ones a patient sees first that may refer them to secondary or
tertiary care.
Primary prevention refers to the early avoidance and identification of risk factors that may lead to
certain diseases and disabilities. Community focused efforts including immunizations, classroom
teaching, and awareness campaigns are all good examples of how primary prevention techniques
are utilized by communities to change certain health behaviors. Prevention programs, if carefully
designed and drafted, can effectively prevent problems that children and adolescents face as they
grow up.[11] This finding also applies to all groups and classes of people. Prevention programs are
one of the most effective tools health professionals can use to greatly impact individual, population,
and community health.[11]
Secondary healthcare and secondary prevention[edit]
Community health can also be improved with improvements in individuals' environments. Community
health status is determined by the environmental characteristics, behavioral characteristics, social
cohesionin the environment of that community.[12] Appropriate modifications in the environment can
help to prevent unhealthy behaviors and negative health outcomes.
Secondary prevention refers to improvements made in a patient's lifestyle or environment after the
onset of disease or disability. This sort of prevention works to make life easier for the patient, since
it's too late to prevent them from their current disease or disability. An example of secondary
prevention is when those with occupational low back pain are provided with strategies to stop their
health status from worsening; the prospects of secondary prevention may even hold more promise
than primary prevention in this case.[13]
Chronic disease self management programs[edit]
Chronic diseases has been a growing phenomena within recent decades, affecting nearly 50% of
adults within the US in 2012. [14] Such diseases include asthma, arthritis, diabetes, and hypertension.
While they are not directly life-threatening, they place a significant burden on daily lives, affecting
quality of life for the individual, their families, and the communities they live in, both socially and
financially. Chronic diseases are responsible for an estimated 70% of healthcare expenditures within
the US, spending nearly $650 billion per year.
With steadily growing numbers, many community healthcare providers have developed self-
management programs to assist patients in properly managing their own behavior as well as making
adequate decisions about their lifestyle.[15] Separate from clinical patient care, these programs are
facilitated to further educate patients about their health conditions as a means to adopt health-
promoting behaviors into their own lifestyle.[16] Characteristics of these programs include:
• grouping patients with similar chronic diseases to discuss disease-related tasks and behaviors
to improve overall health
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• improving patient responsibility through daily disease-monitoring

• inexpensive and widely-known
Chronic Disease self-management programs are structured to help improve overall patient health
and quality of life as well as utilize less healthcare resources, such as physician visits and
emergency care.[17]Furthermore, better self-monitoring skills can help patients effectively and
efficiently make better use of healthcare professionals' time, which can result in better care. [18] Many
self-management programs either are conducted through a health professional or a peer diagnosed
with a certain chronic disease trained by health professionals to conduct the program. No significant
differences have been reported comparing the effectiveness of both peer-led versus professional led
self-management programs.[17]
The distribution of rural CDSME program participantsvaried across the US. Analysis across rurality indicated
that approximately 22.1% (using county-level rurality) to24.4% (using ZCTA/ZIP Code-level rurality) of CDSME
programparticipants resided in rural areas.
There has been a lot of debate regarding the effectiveness of these programs and how well they
influence patient behavior and understanding their own health conditions. Some studies argue that
self-management programs are effective in improving patient quality of life and decreasing
healthcare expenditures and hospital visits. A 2001 study assessed health statuses through
healthcare resource utilizations and self-management outcomes after 1 and 2 years to determine the
effectiveness of chronic disease self-management programs. After analyzing 800 patients diagnosed
with various types of chronic conditions, including heart disease, stroke, and arthritis, the study
found that after the 2 years, there was a significant improvement in health status and
fewer emergency department and physician visits (also significant after 1 year). They concluded that
these low-cost self-management programs allowed for less healthcare utilization as well as an
improvement in overall patient health.[19] Another study in 2003 by the National Institute for Health
Research analyzed a 7-week chronic disease self-management program in its cost-effectiveness
and health efficacy within a population over 18 years of age experiencing one or more chronic
diseases. They observed similar patterns, such as an improvement in health status, reduced number
of visits to the emergency department and to physicians, shorter hospital visits. They also noticed
that after measuring unit costs for both hospital stays ($1000) and emergency department visits
($100), the study found the overall savings after the self-management program resulted in nearly
$489 per person.[20] Lastly, a meta-analysis study in 2005 analyzed multiple chronic disease self-
management programs focusing specifically on hypertension, osteoarthritis, and diabetes mellitus,
comparing and contrasting different intervention groups. They concluded that self-management
programs for both diabetes and hypertension produced clinically significant benefits to overall
health.[15]
On the other hand, there are a few studies measuring little significance of the effectiveness of
chronic disease self-management programs. In the previous 2005 study in Australia, there was no
clinical significance in the health benefits of osteoarthritis self-management programs and cost-
effectiveness of all of these programs.[15] Furthermore, in a 2004 literature review analyzing the
variability of chronic disease self-management education programs by disease and their overlapping
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similarities, researchers found "small to moderate effects for selected chronic diseases,"
recommending further research being conducted.[16]
Some programs are looking to integrate self-management programs into the traditional healthcare
system, specifically primary care, as a way to incorporate behavioral improvements and decrease
the increased patient visits with chronic diseases.[21] However, they have argued that severe
limitations hinder these programs from acting its full potential. Possible limitations of chronic disease
self-management education programs include the following: [18]
• underrepresentation of minority cultures within programs

• lack of medical/health professional (particularly primary care) involvement in self-management
programs
• low profile of programs within community
• lack of adequate funding from federal/state government
• low participation of patients with chronic diseases in program
• uncertainty of effectiveness/reliability of programs
Tertiary healthcare[edit]
In tertiary healthcare, community health can only be affected with professional medical care
involving the entire population. Patients need to be referred to specialists and undergo advanced
medical treatment. In some countries, there are more sub-specialties of medical professions than
there are primary care specialists.[12] Health inequalities are directly related to social advantage and
social resources.[12]
Aspects of care that distinguish conventional health care from people-centred primary care[22]
Conventional ambulatory
Disease control
medical care in clinics or People-centred primary care
programmes
outpatient departments
Focus on illness and cure Focus on priority diseases Focus on health needs
Relationship limited to the Relationship limited to

Enduring personal relationship
moment of consultation programme implementation
Programme-defined disease Comprehensive, continuous and

Episodic curative care
control interventions personcentred care
Responsibility limited to Responsibility for the health of all in the

Responsibility for disease-
effective and safe advice to the community along the life cycle;
control targets among the
patient at the moment of responsibility for tackling determinants of
target population
consultation ill-health
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Population groups are

Users are consumers of the care People are partners in managing their own
targets of disease-control
they purchase health and that of their community
interventions
Challenges and difficulties with community health[edit]
Summary of Governance Issues, Strategies, and New/Lingering Problems[23]
The complexity of community health and its various problems can make it difficult for researchers to
assess and identify solutions. Community-based participatory research (CBPR) is a unique
alternative that combines community participation, inquiry, and action. [24] Community-based
participatory research (CBPR) helps researchers address community issues with a broader lens and
also works with the people in the community to find culturally sensitive, valid, and reliable methods
and approaches.[24]
Other issues involve access and cost of medical care. A great majority of the world does not have
adequate health insurance.[25] In low-income countries, less than 40% of total health expenditures are
paid for by the public/government.[25] Community health, even population health, is not encouraged
as health sectors in developing countries are not able to link the national authorities with the local
government and community action.[25]
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In the United States, the Affordable Care Act (ACA) changed the way community health centers
operate and the policies that were in place, greatly influencing community health.[26] The ACA directly
affected community health centers by increasing funding, expanding insurance coverage for
Medicaid, reforming the Medicaid payment system, appropriating $1.5 billion to increase the
workforce and promote training.[26] The impact, importance, and success of the Affordable Care Act is
still being studied and will have a large impact on how ensuring health can affect community
standards on health and also individual health.
Community health in the Global South[edit]

Access to community health in the Global South is influenced by geographic accessibility (physical
distance from the service delivery point to the user), availability (proper type of care, service
provider, and materials), financial accessibility (willingness and ability of users to purchase services),
and acceptability (responsiveness of providers to social and cultural norms of users and their
communities).[27] While the epidemiological transition is shifting disease burden from communicable
to non communicable conditions in developing countries, this transition is still in an early stage in
parts of the Global South such as South Asia, the Middle East, and Sub-Saharan Africa.[28] Two
phenomena in developing countries have created a "medical poverty trap" for underserved
communities in the Global South — the introduction of user fees for public healthcare services and
the growth of out-of-pocket expenses for private services.[29] The private healthcare sector is being
increasingly utilized by low and middle income communities in the Global South for conditions such
as malaria, tuberculosis, and sexually transmitted infections.[30] Private care is characterized by more
flexible access, shorter waiting times, and greater choice. Private providers that serve low-income
communities are often unqualified and untrained. Some policymakers recommend that governments
in developing countries harness private providers to remove state responsibility from service
provision.[30]
Community development is frequently used as a public health intervention to empower communities
to obtain self-reliance and control over the factors that affect their health. [31] Community health
workers are able to draw on their firsthand experience, or local knowledge, to complement the
information that scientists and policy makers use when designing health
interventions.[32] Interventions with community health workers have been shown to improve access to
primary healthcare and quality of care in developing countries through reduced malnutrition rates,
improved maternal and child health and prevention and management of HIV/AIDS. [33] Community
health workers have also been shown to promote chronic disease management by improving the
clinical outcomes of patients with diabetes, hypertension, and cardiovascular diseases. [33]
Slum-dwellers in the Global South face threats of infectious disease, non-communicable conditions,
and injuries due to violence and road traffic accidents.[34] Participatory, multi-objective slum
upgrading in the urban sphere significantly improves social determinants that shape health
outcomes such as safe housing, food access, political and gender rights, education, and
employment status. Efforts have been made to involve the urban poor in project and policy design
and implementation. Through slum upgrading, states recognize and acknowledge the rights of the
urban poor and the need to deliver basic services. Upgrading can vary from small-scale sector-
specific projects (i.e. water taps, paved roads) to comprehensive housing and infrastructure projects
(i.e. piped water, sewers). Other projects combine environmental interactions with social programs
and political empowerment. Recently, slum upgrading projects have been incremental to prevent the
displacement of residents during improvements and attentive to emerging concerns regarding
climate change adaptation. By legitimizing slum-dwellers and their right to remain, slum upgrading is
an alternative to slum removal and a process that in itself may address the structural determinants of
population health. [34]
DETERMINANTS OF HEALTH
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Social determinants of health

The social determinants of health are the economic and social conditions that influence individual
and group differences in health status.[1] They are the health promoting factors found in one's living
and working conditions (such as the distribution of income, wealth, influence, and power), rather
than individual risk factors (such as behavioral risk factors or genetics) that influence the risk for
a disease, or vulnerability to disease or injury. The distributions of social determinants are often
shaped by public policies that reflect prevailing political ideologies of the area.[2] The World Health
Organization says, "This unequal distribution of health-damaging experiences is not in any sense a
'natural' phenomenon but is the result of a toxic combination of poor social policies, unfair economic
arrangements [where the already well-off and healthy become even richer and the poor who are
already more likely to be ill become even poorer], and bad politics." [3]
Contents
Commonly accepted determinants[edit]
Social Determinants of Health visualization
There is no single definition of the social determinants of health, but there are commonalities, and
many governmental and non-governmental organizations recognize that there are social factors
which impact the health of individuals.
In 2003, the World Health Organization (WHO) Europe suggested that the social determinants of
health included:[4]
• The social gradient

• Stress
• Early life
• Social exclusion
• Work
• Unemployment
• Social support
• Addiction
• Food
• Transportation
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In Canada, these social determinants of health have gained wide usage. [5]
1. Income and income distribution

2. Education
3. Unemployment and job security
4. Employment and working conditions
5. Early childhood development
6. Food insecurity
7. Housing
8. Social exclusion/inclusion
9. Social safety network
10. Health services
11. Aboriginal status
12. Gender
13. Race
14. Disability
The list could be much longer. A recently published article identified several other social
determinants.[6] These social determinants of health are related to health outcomes, public policy,
and are easily understood by the public to impact health. They tend to cluster together – for
example, those living in poverty experience a number of negative health determinants.[5]
In 2008, the WHO Commission on Social Determinants of Health published a report entitled "Closing
the Gap in a Generation." This report identified two broad areas of social determinants of health that
needed to be addressed.[3] The first area was daily living conditions, which included healthy physical
environments, fair employment and decent work, social protection across the lifespan, and access to
health care. The second major area was distribution of power, money, and resources,
including equity in health programs, public financing of action on the social determinants, economic
inequalities, resource depletion, healthy working conditions, gender equity, political empowerment,
constitution of reserves[7] and a balance of power and prosperity of nations.[3]
The 2011 World Conference on Social Determinants of Health brought together delegations from
125 member states and resulted in the Rio Political Declaration on Social Determinants of Health.
This declaration involved an affirmation that health inequities are unacceptable, and noted that these
inequities arise from the societal conditions in which people are born, grow, live, work, and age,
including early childhood development, education, economic status, employment and decent work,
housing environment, and effective prevention and treatment of health problems. [8]
The United States Centers for Disease Control defines social determinants of health as "life-
enhancing resources, such as food supply, housing, economic and social relationships,
transportation, education, and health care, whose distribution across populations effectively
determines length and quality of life".[9] These include access to care and resources such as food,
insurance coverage, income, housing, and transportation.[9] Social determinants of health
influence health-promoting behaviours, and health equity among the population is not possible
without equitable distribution of social determinants among groups. [9]
Steven H. Woolf, MD of the Virginia Commonwealth University Center on Human Needs states, "The
degree to which social conditions affect health is illustrated by the association between education
and mortality rates".[10] Reports in 2005 revealed the mortality rate was 206.3 per 100,000 for adults
aged 25 to 64 years with little education beyond high school, but was twice as great (477.6 per
100,000) for those with only a high school education and 3 times as great (650.4 per 100,000) for
those less educated. Based on the data collected, the social conditions such as education, income,
and race were dependent on one another, but these social conditions also apply to independent
health influences. [10]
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Marmot and Bell of the University College London found that in wealthy countries, income and
mortality are correlated as a marker of relative position within society, and this relative position is
related to social conditions that are important for health including good early childhood development,
access to high quality education, rewarding work with some degree of autonomy, decent housing,
and a clean and safe living environment. The social condition of autonomy, control, and
empowerment turns are important influences on health and disease, and individuals who lack social
participation and control over their lives are at a greater risk for heart disease and mental illness. [11]
International health inequalities[edit]

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Health gap in England and Wales, 2011 Census
Even in the wealthiest countries, there are health inequalities between the rich and the
poor.[4] Researchers Labonte and Schrecker from the Department of Epidemiology and Community
Medicine at the University of Ottawa emphasize that globalization is key to understanding the social
determinants of health, and as Bushra (2011) posits, the impacts of globalization are
unequal.[12] Globalization has caused an uneven distribution of wealth and power both within and
across national borders, and where and in what situation a person is born has an enormous impact
on their health outcomes. The Organization for Economic Cooperation and Development found
significant differences among developed nations in health status indicators such as life
expectancy, infant mortality, incidence of disease, and death from injuries.[13] Migrants and their
family members also experience significant negatives health impacts. [14]
These inequalities may exist in the context of the health care system, or in broader social
approaches. According to the WHO's Commission on Social Determinants of Health, access to
health care is essential for equitable health, and it argued that health care should be a common
good rather than a market commodity.[3] However, there is substantial variation in health care
systems and coverage from country to country. The Commission also calls for government action on
such things as access to clean water and safe, equitable working conditions, and it notes that
dangerous working conditions exist even in some wealthy countries.[3][15] In the Rio Political
Declaration on Social Determinants of Health, several key areas of action were identified to address
inequalities, including promotion of participatory policy-making processes, strengthening global
governance and collaboration, and encouraging developed countries to reach a target of 0.7%
of gross national product (GNP) for official development assistance.[8]
Theoretical approaches[edit]
The UK Black and The Health Divide reports considered two primary mechanisms for understanding
how social determinants influence health: cultural/behavioral and materialist/structuralist[16] The
cultural/behavioral explanation is that individuals' behavioral choices (e.g., tobacco and alcohol use,
diet, physical activity, etc.) were responsible for their development and deaths from a variety of
diseases. However, both the Black and Health Divide reports found that behavioral choices are
determined by one's material conditions of life, and these behavioral risk factors account for a
relatively small proportion of variation in the incidence and death from various diseases.
The materialist/structuralist explanation emphasizes the people's material living conditions. These
conditions include availability of resources to access the amenities of life, working conditions, and
quality of available food and housing among others. Within this view, three frameworks have been
developed to explain how social determinants influence health. [17] These frameworks are: (a)
materialist; (b) neo-materialist; and (c) psychosocial comparison. The materialist view explains how
living conditions – and the social determinants of health that constitute these living conditions –
shape health. The neo-materialist explanation extends the materialist analysis by asking how these
living conditions occur. The psychosocial comparison explanation considers whether people
compare themselves to others and how these comparisons affect health and wellbeing.
A nation's wealth is a strong indicator of the health of its population. Within nations, however,
individual socio-economic position is a powerful predictor of health.[18]Material conditions of life
determine health by influencing the quality of individual development, family life and interaction, and
community environments. Material conditions of life lead to differing likelihood of physical
(infections, malnutrition, chronic disease, and injuries), developmental (delayed or
impaired cognitive, personality, and social development), educational (learning disabilities, poor
learning, early school leaving), and social (socialization, preparation for work, and family life)
problems.[19] Material conditions of life also lead to differences in psychosocial stress. [20] When the
fight-or-flight reaction is chronically elicited in response to constant threats to income, housing, and
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food availability, the immune system is weakened, insulin resistance is increased, and lipid and
clotting disorders appear more frequently.
The materialist approach offers insight into the sources of health inequalities among individuals and
nations. Adoption of health-threatening behaviours is also influenced by material deprivation and
stress.[21] Environments influence whether individuals take up tobacco, use alcohol, consume poor
diets, and have low levels of physical activity. Tobacco use, excessive alcohol consumption, and
carbohydrate-dense diets are also used to cope with difficult circumstances.[22][21] The materialist
approach seeks to understand how these social determinants occur.
The neo-materialist approach is concerned with how nations, regions, and cities differ on how
economic and other resources are distributed among the population. [23]This distribution of resources
can vary widely from country to country. The neo-materialist view focuses on both the social
determinants of health and the societal factors that determine the distribution of these social
determinants, and especially emphasizes how resources are distributed among members of a
society.
The social comparison approach holds that the social determinants of health play their role through
citizens' interpretations of their standings in the social hierarchy.[24]There are two mechanisms by
which this occurs. At the individual level, the perception and experience of one's status in unequal
societies lead to stress and poor health. Feelings of shame, worthlessness, and envy can lead to
harmful effects upon neuro-endocrine, autonomic and metabolic, and immune
systems.[20] Comparisons to those of a higher social class can also lead to attempts to alleviate such
feelings by overspending, taking on additional employment that threaten health, and adopting health-
threatening coping behaviours such as overeating and using alcohol and tobacco. [24] At the
communal level, widening and strengthening of hierarchy weakens social cohesion, which is a
determinant of health.[25] The social comparison approach directs attention to the psychosocial
effects of public policies that weaken the social determinants of health. However, these effects may
be secondary to how societies distribute material resources and provide security to its citizens,
which are described in the materialist and neo-materialist approaches.[citation needed]
Life-course perspective[edit]
Life-course approaches emphasize the accumulated effects of experience across the life span in
understanding the maintenance of health and the onset of disease. The economic and social
conditions – the social determinants of health – under which individuals live their lives have a
cumulative effect upon the probability of developing any number of diseases, including heart disease
and stroke.[26][27] Studies into the childhood and adulthood antecedents of adult-onset diabetes show
that adverse economic and social conditions across the life span predispose individuals to this
disorder.[28][29]
Hertzman outlines three health effects that have relevance for a life-course perspective.[30] Latent
effects are biological or developmental early life experiences that influence health later in life. Low
birth weight, for instance, is a reliable predictor of incidence of cardiovascular disease and adult-
onset diabetes in later life. Nutritional deprivation during childhood has lasting health effects as well.
Pathway effects are experiences that set individuals onto trajectories that influence health, well-
being, and competence over the life course. As one example, children who enter school with
delayed vocabulary are set upon a path that leads to lower educational expectations, poor
employment prospects, and greater likelihood of illness and disease across the lifespan. Deprivation
associated with poor-quality neighbourhoods, schools, and housing sets children off on paths that
are not conducive to health and well-being.[31][citation needed]
Cumulative effects are the accumulation of advantage or disadvantage over time that manifests itself
in poor health, in particular between women and men.[32] These involve the combination of latent and
pathways effects. Adopting a life-course perspective directs attention to how social determinants of
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health operate at every level of development – early childhood, childhood, adolescence, and
adulthood – to both immediately influence health and influence it in the future.[33][34][citation needed]
Chronic stress and health[edit]

Stress is hypothesized to be a major influence in the social determinants of health. There is a
relationship between experience of chronic stress and negative health outcomes. [35] This relationship
is explained through both direct and indirect effects of chronic stress on health outcomes.
The direct relationship between stress and health outcomes is the effect of stress on human
physiology. The long term stress hormone, cortisol, is believed to be the key driver in this
relationship.[36] Chronic stress has been found to be significantly associated with chronic low-grade
inflammation, slower wound healing, increased susceptibility to infections, and poorer responses to
vaccines.[35] Meta-analysis of healing studies has found that there is a robust relationship between
elevated stress levels and slower healing for many different acute and chronic conditions [37] However,
it is also important to note that certain factors, such as coping styles and social support, can mitigate
the relationship between chronic stress and health outcomes. [38][39]
Stress can also be seen to have an indirect effect on health status. One way this happens is due to
the strain on the psychological resources of the stressed individual. Chronic stress is common in
those of a low socio-economic status, who are having to balance worries about financial security,
how they will feed their families, housing status, and many other concerns. [40] Therefore, individuals
with these kinds of worries may lack the emotional resources to adopt positive health behaviours.
Chronically stressed individuals may therefore be less likely to prioritize their health.
In addition to this, the way that an individual responds to stress can influence their health status.
Often, individuals responding to chronic stress will develop potentially positive or negative coping
behaviors. People who cope with stress through positive behaviors such as exercise or social
connections may not be as affected by the relationship between stress and health, whereas those
with a coping style more prone to over-consumption (i.e. emotional eating, drinking, smoking or drug
use) are more likely to be see negative health effects of stress.[38]
The detrimental effects of stress on health outcomes are hypothesised to partly explain why
countries that have high levels of income inequality have poorer health outcomes compared to more
equal countries.[41] Wilkinson and Picket hypothesise in their book The Spirit Level that the stressors
associated with low social status are amplified in societies where others are clearly far better off. [41]
Improving health conditions worldwide[edit]

Reducing the health gap requires that governments build systems that allow a healthy standard of
living for every resident.
Interventions[edit]
Three common interventions for improving social determinant outcomes as identified by the WHO
are education, social security and urban development. However, evaluation of interventions has
been difficult due to the nature of the interventions, their impact and the fact that the interventions
strongly affect children's health outcomes.[42]
1. Education: Many scientific studies have been conducted and strongly suggests that
increased quantity and quality of education leads to benefits to both the individual and
society (e.g. improved labor productivity).[43] Health and economic outcome improvements
can be seen in health measures such as blood pressure,[44][45] crime,[46] and market
participation trends.[47] Examples of interventions include decreasing size of classes and
providing additional resources to low-income school districts. However, there is currently
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insufficient evidence to support education as an social determinants intervention with a cost-

benefit analysis.[42]
2. Social Protection: Interventions such as “health-related cash transfers”, maternal education,
and nutrition-based social protections have been shown to have a positive impact on health
outcomes.[48][49]However, the full economic costs and impacts generated of social security
interventions are difficult to evaluate, especially as many social protections primarily affect
children of recipients.[42]
3. Urban Development: Urban development interventions include a wide variety of potential
targets such as housing, transportation, and infrastructure improvements. The health
benefits are considerable (especially for children), because housing improvements such as
smoke alarm installation, concrete flooring, removal of lead paint, etc. can have a direct
impact on health.[50] In addition, there is a fair amount of evidence to prove that external
urban development interventions such as transportation improvements or improved
walkability of neighborhoods (which is highly effective in developed countries) can have
health benefits.[42] Affordable housing options (including public housing) can make large
contributions to both social determinants of health, as well as the local economy. [51]
The Commission on Social Determinants of Health made recommendations in 2005 for action to
promote health equity based on three principles: "improve the circumstances in which people are
born, grow, live, work, and age; tackle the inequitable distribution of power, money, and resources,
the structural drivers of conditions of daily life, globally, nationally, and locally; and measure the
problem, evaluate action, and expand the knowledge base."[52] These recommendations would
involve providing resources such as quality education, decent housing, access to affordable health
care, access to healthy food, and safe places to exercise for everyone despite gaps in affluence.
Expansion of knowledge of the social determinants of health, including among healthcare workers,
can improve the quality and standard of care for people who are marginalized, poor or living in
developing nations by preventing early death and disability while working to improve quality of life. [53]
Challenges of measuring value of interventions[edit]
Many economic studies have been conducted to measure the effectiveness and value of social
determinant interventions but are unable to accurately reflect effects on public health due to the
multi-faceted nature of the topic. While neither cost-effectiveness nor cost-utility analysis is able to
be used on social determinant interventions, cost-benefit analysis is able to better capture the effects
of an intervention on multiple sectors of the economy. For example, tobacco interventions have
shown to decrease tobacco use, but also prolong lifespans, increasing lifetime healthcare costs and
is therefore marked as a failed intervention by cost-effectiveness, but not cost-benefit. Another issue
with research in this area is that most of the current scientific papers focus on rich, developed
countries, and there is a lack of research in developing countries.[42]
Policy changes that affect children also present the challenge that it takes a significant amount of
time to gather this type of data. In addition, policies to reduce child povertyare particularly important,
as elevated stress hormones in children interfere with the development of brain circuitry and
connections, causing long term chemical damage.[54] In most wealthy countries, the relative child
poverty rate is 10 percent or less; in the United States, it is 21.9 percent.[55] The lowest poverty rates
are more common in smaller well-developed and high-spending welfare states like Sweden and
Finland, with about 5 or 6 percent. [55] Middle-level rates are found in major European countries where
unemployment compensation is more generous and social policies provide more generous support
to single mothers and working women (through paid family leave, for example), and where social
assistance minimums are high. For instance, the Netherlands, Austria, Belgium and Germany have
poverty rates that are in the 7 to 8 percent range.[56]
Public policy[edit]
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The Rio Political Declaration on Social Determinants of Health embraces a transparent, participatory
model of policy development that, among other things, addresses the social determinants of health
leading to persistent health inequalities for indigenous peoples.[8] In 2017, citing the need for
accountability for the pledges made by countries in the Rio Political Declaration on Social
Determinants of Health, the World Health Organization and United Nations Children's Fund called for
the monitoring of intersectoral interventions on the social determinants of health that improve health
equity.[57]
The United States Department of Health and Human Services includes social determinants in its
model of population health, and one of its missions is to strengthen policies which are backed by the
best available evidence and knowledge in the field [58] Social determinants of health do not exist in a
vacuum. Their quality and availability to the population are usually a result of public policy decisions
made by governing authorities. For example, early life is shaped by availability of sufficient material
resources that assure adequate educational opportunities, food and housing among others. Much of
this has to do with the employment security and the quality of working conditions and wages. The
availability of quality, regulated childcare is an especially important policy option in support of early
life.[59] These are not issues that usually come under individual control but rather they are socially
constructed conditions which require institutional responses. [60] A policy-oriented approach places
such findings within a broader policy context. In this context, Health in All Policies has seen as a
response to incorporate health and health equity into all public policies as means to foster synergy
between sectors and ultimately promote health.
Yet it is not uncommon to see governmental and other authorities individualize these issues.
Governments may view early life as being primarily about parental behaviours towards their children.
They then focus upon promoting better parenting, assist in having parents read to their children, or
urge schools to foster exercise among children rather than raising the amount of financial or housing
resources available to families. Indeed, for every social determinant of health, an individualized
manifestation of each is available. There is little evidence to suggest the efficacy of such approaches
in improving the health status of those most vulnerable to illness in the absence of efforts to modify
their adverse living conditions.[61]
A team of the Cochrane Collaboration conducted the first comprehensive systematic review of the
health impact of unconditional cash transfers, as an increasingly common up-stream, structural
social determinant of health. The review of 21 studies, including 16 randomized controlled trials,
found that unconditional cash transfers may not improve health services use. However, they lead to
a large, clinically meaningful reduction in the likelihood of being sick by an estimated 27%.
Unconditional cash transfers may also improve food security and dietary diversity. Children in
recipient families are more likely to attend school, and the cash transfers may increase money spent
on health care.[62]
One of the recommendations by the Commission on the Social Determinants of Health is expanding
knowledge – particularly to health care workers.[53]
Although not addressed by the WHO Commission on Social Determinants of Health, sexual
orientation and gender identity are increasingly recognized as social determinants of health. [63]
CAUSATION OF DISEASE
CAUSATION OF DISEASES
Introduction
Health and diseases have always been matters of concern of the society. This resulted in constant
search for improvement in the quality of living and maintenance of a healthy society. In that process
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various concepts on health, diseases and treatment emerged, thereby the practice of medicine got
refined on scientific basis. The emergence of biomedicine with the advent of Germ theory completely
changed the outlook towards health and diseases and efforts in scientific investigation started finding
correlation with material cause to every diseases. Though this helped in rational explanation to certain
group of diseases, it opened up more questions on causation of several other diseases. In spite of
development in more theories and concepts, there is a consensus that health and well-being does not
simply mean the absence of pain and suffering or the lack of disease, disability, defect and death, but
has a positive dimension. This call for holistic approach in health care.
Understanding the cause of disease is the key to begin the process of finding remedies that could cure
them. Every medical system has its own models of identifying the reason of diseases. Based on those
concepts they develop models of treatment. The biomedicine uses the knowledge of pathogens as the
root cause of the infectious diseases and therefore, uses antibiotics and anti viral therapies to
overcome such diseases. Based on the theory of Tridosha, Ayuveda explore treatment to bring
harmony of the doshas. Homeopathy considers all chronic diseases due to miasms. Though all
these models are divergent in nature, the goal of every medical system has been to provide rational
treatment to the diseases. The basic effort of every medical system is to bring homeostasis (balance)
with one’s surroundings based on their medical philosophy to extend a healthy state to the sick and
tackle diseases.
Factors of disease causation
Predisposing factors are the factors which create a state of susceptibility, making the host vulnerable
to the agent. These are age, sex and previous illnesses.
Enabling factors are those which assist in the development of (or in recovery from) the disease; e.g.
housing conditions, socio-economic status.
Precipitating factors are those which are associated with immediate exposure to the disease agent or
onset of disease, e.g. drinking contaminated water, close contact with a case of pulmonary TB.
Reinforcing factors are those which aggravate an already existing disease, e.g. malnutrition, repeated
exposures.
Risk factors are the conditions, quality or attributes, the presence of which increases the chances of
an individual to have, develop or be adversely affected by a disease process. The risk factor need not
necessarily cause the disease but does increase the probability that the person exposed to the factor
may get the disease easily.
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CHAIN OF INFECTION
There are many different germs and infections inside and outside of the healthcare
setting. Despite the variety of viruses and bacteria, germs spread from person to person
through a common series of events. Therefore, to prevent germs from infecting more
people, we must break the chain of infection. No matter the germ, there are six points at
which the chain can be broken and a germ can be stopped from infecting another
person. The six links include: the infectious agent, reservoir, portal of exit, mode of
transmission, portal of entry, and susceptible host.
▪ Infectious agent is the pathogen (germ) that causes diseases
▪ Reservoir includes places in the environment where the pathogen lives (this includes
people, animals and insects, medical equipment, and soil and water)
▪ Portal of exit is the way the infectious agent leaves the reservoir (through open wounds,
aerosols, and splatter of body fluids including coughing, sneezing, and saliva)
▪ Mode of transmission is the way the infectious agent can be passed on (through direct or
indirect contact, ingestion, or inhalation)
▪ Portal of entry is the way the infectious agent can enter a new host (through broken skin,
the respiratory tract, mucous membranes, and catheters and tubes)
▪ Susceptible host can be any person (the most vulnerable of whom are receiving
healthcare, are immunocompromised, or have invasive medical devices including lines,
devices, and airways)
The way to stop germs from spreading is by interrupting this chain at any link. Break the
chain by cleaning your hands frequently, staying up to date on your vaccines (including
the flu shot), covering coughs and sneezes and staying home when sick, following the
rules for standard and contact isolation, using personal protective equipment the right
way, cleaning and disinfecting the environment, sterilizing medical instruments and
equipment, following safe injection practices, and using antibiotics wisely to prevent
antibiotic resistance.
LEVELS OF PREVENTION
Three Levels of Health Promotion/Disease Prevention
Levels of Prevention
Three broad categories of determinants of human behavior will be discussed in this

study session and you will have an opportunity to learn about the influence of these
factors in determining human behavior.
Prevention, as it relates to health, is really about avoiding disease before it starts. It has
been defined as the plans for, and the measures taken, to prevent the onset of a
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disease or other health problem before the occurrence of the undesirable health event.
There are three distinct levels of prevention.
Primary prevention—those preventive measures that prevent the onset of illness or

injury before the disease process begins.
• Examples include immunization and taking regular exercise.
Secondary prevention—those preventive measures that lead to early diagnosis and

prompt treatment of a disease, illness or injury to prevent more severe problems
developing. Here health educators such as Health Extension Practitioners can help
individuals acquire the skills of detecting diseases in their early stages.
• Examples include screening for high blood pressure and breast self-examination.
Tertiary prevention—those preventive measures aimed at rehabilitation following

significant illness. At this level health services workers can work to retrain, re-educate
and rehabilitate people who have already developed an impairment or disability.
Read the list of the three levels of prevention again. Think about your experience of
health education, whether as an educator or recipient of health education.
• How do you think health education can help with the prevention of disease?
• Do you think it will operate at all these levels?
• Note an example of possible health education interventions at each level where
you think health education can be applied.
Health Education can be applied at all three levels of disease prevention and can be of
great help in maximizing the gains from preventive behavior.
• For example at the primary prevention level — you could educate people to
practice some of the preventive behaviors, such as having a balanced diet so that
they can protect themselves from developing diseases in the future.
• At the secondary level, you could educate people to visit their local health center
when they experience symptoms of illness, such as fever, so they can get early
treatment for their health problems.
• At the tertiary level, you could educate people to take their medication
appropriately and find ways of working towards rehabilitation from significant
illness or disability.
You have learned that:
• Primary prevention includes those preventive measures that come before the
onset of illness or injury and before the disease process begins. Examples include
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immunization and taking regular exercise to prevent health problems developing in

the future.
• Secondary prevention includes those preventive measures that lead to early
diagnosis and prompt treatment of a disease, illness or injury. This should limit
disability, impairment or dependency and prevent more severe health problems
developing in the future.
• Tertiary prevention includes those preventive measures aimed at rehabilitation
following significant illness. At this level health educators work to retrain, re-
educate and rehabilitate the individual who has already had an impairment or
disability.
EPIDEMIOLOGY OF BLOOD BORNE

DISEASES
A bloodborne disease is a disease that can be spread through contamination by blood and
other body fluids. Bloodborne pathogens are microorganisms such as viruses or bacteria. The most
common examples are HIV, hepatitis B (HVB), hepatitis C (HVC) and viral hemorrhagic fevers.[citation
needed][1]
Diseases that are not usually transmitted directly by blood contact, but rather by insect or other
vector, are more usefully classified as vector-borne disease, even though the causative agent can
be found in blood. Vector-borne diseases include West Nile virus, zika fever and malaria.
Many bloodborne diseases can also be contracted by other means, including high-risk sexual
behavior or intravenous drug use. These diseases have also been identified in sports medicine.[2]
Since it is difficult to determine what pathogens any given sample of blood contains, and some
bloodborne diseases are lethal, standard medical practice regards all blood (and any body fluid) as
potentially infectious. Blood and Body Fluid precautions are a type of infection control practice that
seeks to minimize this sort of disease transmission.
Occupational exposure[edit]
Blood poses the greatest threat to health in a laboratory or clinical setting due to needlestick
injuries (e.g., lack of proper needle disposal techniques and/or safety syringes). These risks are
greatest among healthcare workers, including: nurses, surgeons, laboratory assistants, doctors,
phlebotomists, and laboratory technicians.[3] These roles often require the use of syringes for blood
draws or to administer medications.
The Occupational Safety and Health Administration (OSHA) prescribes 5 rules that are required for a
healthcare facility to follow in order to reduce the risk of employee exposure to bloodborne
pathogens. They are:
• Written exposure control plan

• Engineering controls (Sharps containers, detachable and retractable needles, syringe caps, etc.)
• Safe Work Practices and Safety Devices
• Hepatitis B vaccine available to employees
• Education and post-exposure follow up
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These controls, while general, serve to greatly reduce the incidence of bloodborne disease
transmission in occupational settings of healthcare workers.
There are 26 different viruses that have been shown to present in healthcare workers as a result of
occupational exposure.[4] The most common bloodborne diseases are hepatitis B (HBV), hepatitis
C (HCV), and human immunodeficiency virus (HIV).[5] Exposure is possible through blood of an
infected patient splashing onto mucous membranes; however, the greatest exposure risk was shown
to occur during percutaneous injections performed for vascular access. These include blood draws,
as well as catheter placement, as both typically use hollow bore needles. [3] S Preventative measures
for occupational exposure include standard precautions (hand washing, sharp disposal containers),
as well as additional education and preventative measures. Advancements in the design of safety
engineered devices have played a significant role in decreasing rates of occupational exposure to
bloodborne disease.[5] According to the Massachusetts Sharps Injury Surveillance System, needle
devices without safety features accounted for 53% of the 2010 reported sharps injuries. [6] Safer
sharps devices now have engineering controls, such as a protective shield over the needle, and
sharps containers that have helped to decrease this statistic. These safer alternatives are highly
effective in substantially reducing injuries. For instance, almost 83% of injuries from hollow bore
needles can be prevented with the use of safer sharps devices.[7]
Blood transfusions[edit]
Blood for blood transfusion is screened for many bloodborne diseases. Additionally, a technique that
uses a combination of riboflavin and UV light to inhibit the replication of these pathogens by altering
their nucleic acids can be used to treat blood components prior to their transfusion, and can reduce
the risk of disease transmission.[8][9][10]
A technology using the synthetic psoralen, amotosalen HCl, and UVA light (320–400 nm) has been
implemented in European blood centers for the treatment of platelet and plasma components to
prevent transmission of bloodborne diseases caused by bacteria, viruses and protozoa.[11][12]
Needle exchange programs[edit]

Needle exchange programs (NEPs) are an attempt to reduce the spread of bloodborne diseases
between intravenous drug users. They often also provide addiction counseling services, infectious
disease testing, and in some cases mental health care and/or other case management. NEPs
acquired their name as they were initially places where intravenous (IV) illicit substance users were
provided with clean, unused needles in exchange for their used needles. This allows for proper
disposal of the needles.[13] Empirical studies confirm the benefits of NEPs.[14] NEPs can affect
behaviors that result in the transmission of HIV. These behaviors include decreased sharing of used
syringes, which reduces contaminated syringes from circulation and replaces them with sterile ones,
among other risk reductions.
Prevention[edit]
Follow standard precautions to help prevent the spread of bloodborne pathogens and other diseases
whenever there is a risk of exposure to blood or other bodily fluids. Standard precautions include
maintaining personal hygiene and using personal protective equipment (PPE), engineering controls,
and work practice controls among others.[15] Always avoid contact with blood and other bodily fluids.
Wear disposable gloves when providing care, particularly if you may come into contact with blood or
bodily fluids. Dispose properly of gloves and change gloves when providing care to a new patient.
Use needles with safety devices to help prevent needlestick injury and exposure to bloodborne
pathogens.
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A hierarchy of controls can help to prevent environmental and occupational exposures and
subsequent diseases. These include:
Elimination: Physically remove hazards, including needles that lack a safety device. Additionally,
eliminate the use of needle devices whenever safe and effective alternatives are available.
Substitution: Replace needles without safety devices with ones that have a safety feature built in.
This has been shown to reduce bloodborne diseases transmitted via needlestick injuries.
Engineering controls: Isolate people from the hazard by providing sharps containers for workers to
immediately place needles in after use.
Administrative controls: Change the way people work by creating a culture of safety such as
avoiding recapping or bending needles that may be contaminated and promptly disposing of used
needle devices and other sharps.
Personal protective equipment: Protect workers with PPE such as gloves and masks to avoid
transmission of blood and other bodily fluids.
VACCINOLOGY
Although the demonstration in 1796 by Edward Jenner that vaccinia virus could protect against
smallpox was epochal, he was following the path opened by the ancients who had used the
smallpox virus itself in the practice of variolation. The work of Louis Pasteur on chicken cholera
opened the way to vaccine development in the laboratory. In April 1880, Pasteur reported to the
French Academy of Science that “…chicken cholera is produced by a microscopic parasite [now
known as Pasteurella multocida], that there exists an attenuated virus [Pasteur was using
“virus” in the ancient sense of the word] of that disease, and that one or more inoculations of this
attenuated virus can preserve the animals from the mortal effects of a later inoculation … let me
be permitted to use the word ‘vaccinate’ to express the act of inoculating a chicken with the
attenuated virus” [1]. Thus, the word “vaccinate” was extended beyond vaccinia and came to
have its modern meaning
Today, epidemic infectious diseases of children for which there are vaccines have virtually
disappeared from industrialized countries such as the United States. These are remarkable
successes, which together with clean water and antibiotics have profoundly affected human
society [2]. In addition, a new field of microbiology and immunology has evolved, called
“vaccinology,” that comprises not only vaccine development but also the use of vaccines and
their effects on public health [3]. Here, I will briefly cover some aspects of the past, discuss 5
current issues in vaccinology, and then turn to the future
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Classic Methods of Vaccine Development
Since the time of Pasteur until recently, there have been 2 paths of vaccine development:
attenuation and inactivation [4]. With regard to attenuation (figure 1), heat, oxygenation,
chemical agents, or aging were the first methods used, notably by Pasteur for rabies and anthrax
vaccines. Passage in animal hosts, such as the embryonated hen's egg, was the next method, as
practiced by Theiler for yellow fever vaccine. After the development of cell culture in the 1940s,
attenuation in vitro was accomplished by a variety of means, including selection of chance
mutants, adaptation to growth at low temperatures, chemical mutation to induce inability to grow
at high temperature (temperature sensitivity), or induction of auxotrophy in bacteria
For viruses with segmented genomes, such as influenza virus and rotavirus, reassortment has
been used to combine genetic material coding for protective antigens of pathogens, with genes
coding for attenuated behavior in the host (figure 2). The resultant reassortants can immunize
without causing illness. Reassortants have been fundamental to the preparation of both killed and
live virus influenza vaccines
The second set of strategies is the inactivated organism or subunit path (figure 3). Late in the
19th century, Theobald Smith in the United States and Pasteur's colleagues independently
showed that whole organisms could be killed without losing immunogenicity, which soon
became the basis of vaccines for typhoid and cholera and later for pertussis, influenza, and
hepatitis A. In the 1920s, the exotoxins of Corynebacterium diphtheriae and Clostridium
tetani were inactivated by formalin to provide antigens for immunization against diphtheria and
tetanus. Later in the 20th century, influenza vaccine progressed to subunit preparations, and
pertussis vaccine progressed from bacterial soup to the extracted proteins that we use today in
acellular vaccines. Extracted native polysaccharides from the capsules of Haemophilus
influenzae type b, pneumococci, meningococci, and typhoid bacilli proved useful in immunizing
older children and adults, and more recently, the conjugation of these polysaccharides with
proteins have provided us with immunogens that generate T cell memory and are effective even
in young infants. Although peptide subunits of proteins have not thus far been successful against
infectious diseases, they do offer hope for vaccines against melanoma and other cancers, and
both lipidated and multiepitope peptides show greater immunogenicity against microbes [5, 6]
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Some Current Issues in Vaccinology
RotavirusThe most significant debacle in the recent history of vaccination was that of the rhesus
rotavirus vaccine. The vaccine was composed of reassortants between a type 3 rhesus rotavirus
and 1 gene from each of human rotavirus types 1, 2, and 4. Rhesus rotavirus vaccine was highly
effective against severe rotavirus diarrhea both in trials before licensure and in actual use after
licensure. However, after licensure, intussusception was found to be a serious adverse reaction to
the vaccine, and the vaccine was withdrawn [7]. The attributable risk (i.e., the risk to vaccine
recipients minus the background risk of intussusception in the infant population) may have been
only ∼1 per 10,000 or 20,000 vaccinations, but rotavirus diarrhea is seldom fatal in the United
States, and the risk/benefit calculation was not favorable to the vaccine. On the contrary, in
developing countries, the same calculation probably would have been favorable, but the
difficulties in accepting a product rejected by the United States were insuperable, and those
countries refused to adopt the rhesus rotavirus vaccine
One lesson from this experience is that, if a vaccine has potential to be used in developing
countries, trials should be done in those countries before licensure, so that if a problem occurs,
the benefits as well as the risks can be weighed in varying circumstances. Another lesson is that
rare events cannot be ascertained in prelicensure studies and that careful surveillance in the
period just after licensure of a vaccine is mandatory
Fortunately, alternative live oral rotavirus vaccines are in development: a set of bovine
reassortants and an attenuated human strain. The bovine reassortant vaccine was developed in
my former laboratory in Philadelphia by Fred Clark and Paul Offit and is based on reassortants
of a virus called “WC-3” [8]. The human strain was developed in Cincinnati by Richard Ward et
al. [9]. In a phase II efficacy trial, the efficacy of the bovine reassortant vaccines appeared to be
equal to that of rhesus rotavirus vaccine, with 75% protection against all rotavirus diarrhea and
100% protection against hospitalization [10]. It is now being tested in 60,000 children, including
some in developing countries. As of October 2002, 30,000 children have been vaccinated, with
only 4 cases of intussusception, none after the first dose or within 42 days of vaccination. The
human strain has also demonstrated efficacy in a clinical trial [11]. Thus, new rotavirus vaccines
may soon become available for worldwide use
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PoliomyelitisEradication of pathogens and cessation of vaccination have long been goals of

public health, achieved in the case of smallpox and sought for in the case of polio. Wild
polioviruses are now limited to 2 parts of the world—sub-Saharan Africa and the Indian
subcontinent [12]—but some disturbing findings will inhibit us from ceasing to vaccinate even if
eradication is accomplished (table 1)
Although the attenuated poliovirus strains were passaged ∼70 times in animals or cell culture,
the property of attenuation rests on a small number of mutations [13]. Those mutations change
only 1% of amino acids, and most of the changes have nothing to do with attenuation. Moreover,
after oral administration to humans, reversion of the few attenuating mutations is a constant
feature of replication in the intestine, where neurovirulent viruses have a selective advantage. To
show this, we infected explants of fetal intestine with an attenuated type 3 poliovirus and a
reverted mutant of the same virus [14]. Although both substrains grew in the explants, and
maintained their virological markers, mixing the 2, even at a 20:1 ratio in favor of the attenuated
strain, resulted in overgrowth of the revertant virus
The other facet of the problem is that recombination between poliovirus serotypes and between
poliovirus and enteroviruses is a regular phenomenon during replication in the intestine. When
the 5′ end of a reverted poliovirus combines with the 3′ end of another enterovirus, the result is a
virus that not only is neurovirulent but also can be transmitted easily and become epidemic [15].
In fact, epidemic vaccine-derived polio has happened in the past in Egypt, China, Israel, the
Dominican Republic, Haiti, the Philippines, and Madagascar, undoubtedly accompanied by
hundreds of asymptomatic infections. In addition, rarely persons with B cell deficiencies
chronically excrete reverted vaccine virus, for periods of ⩾10 years [16, 17]
Moreover, as soon as one stops vaccinating against a pathogen, it becomes a potential weapon.
The synthesis of a replicating virulent poliovirus from chemical constituents by Eckard
Wimmer's laboratory [18] removes all doubt about this danger. Poliovirus is far from the ideal
bioweapon, but it becomes more attractive as unvaccinated populations increase in size. Thus,
even if eradication is achieved, and vaccination with oral polio vaccine stopped, many countries
will choose to continue vaccination with inactivated poliovirus vaccine
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Lyme diseaseThe Lyme disease Borrelia burgdorferi outer surface protein A (OspA) vaccine
was recently taken off the market by the manufacturer. The reasons for this are multiple and
probably include lawsuits arising from unsubstantiated claims that the vaccine induced
autoimmunity. However, more important, in my opinion, were 2 errors. The first was the
lukewarm recommendation issued by the Centers for Disease Control and Prevention [19]. In
effect, they proposed that the vaccine was only “to be considered” for people at risk and
indicated preference for attempts to reduce tick exposure and use antibiotics for prophylaxis,
despite weak evidence that Lyme disease cases can actually be reduced by such measures
[20, 21]. The second error was made by the manufacturer's marketing department, which
predicted a high demand by the public in states with endemic Lyme disease. Such patient
demand never materialized, despite an annual and continuing total of >17,000 reported
cases/year of Lyme disease, because the manufacturer did not convince physicians of the value
of vaccination. Consequently, the vaccine did not prove profitable and was withdrawn. Whereas
the efficacy of the OspA vaccine was only moderate, in view of this experience, the likelihood
that manufacturers will seek to develop a better vaccine against Lyme disease is small. Beyond
the issue of Lyme disease, this experience will have a negative effect on development of so-
called lifestyle vaccines for other nonfatal diseases [22]. These are vaccines for nonfatal diseases
in high-risk groups, such as anti-dental caries and anticontraceptive vaccines [22]
Measles and rubellaThe control of measles and congenital rubella in developing countries is
an important program. Vaccination coverage against measles in children must be extraordinarily
high to prevent the virus from spreading, and it must also be high against rubella to prevent a
paradoxical increase in the susceptibility of women because of decreased exposure to natural
infection. Mass vaccination by injection is difficult and risky in some settings. Years ago, Albert
Sabin showed that aerosol administration of measles vaccine is feasible [23], and during the
development of RA 27/3 rubella vaccine, we showed that its administration by nose drops, no
less than injection, resulted in successful vaccination [24]. Recently, Mexican researchers led by
Sepulveda-Amor and Valdespino-Gomez [25–27 ] have administered a combined measles-
rubella vaccine to children by means of a simple aerosol apparatus and have succeeded in
immunizing against both infections in >90% of cases. This opens the way to simpler mass
vaccination campaigns and to the simultaneous control of both measles and congenital rubella
syndrome
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Combination vaccinesThere is currently a gap between Europe and the United States in the use
of combination vaccines. Two hexavalent vaccines covering diphtheria, tetanus, pertussis, polio,
hepatitis B, and H. influenzae type b (Hib) are licensed in Europe for routine pediatric
vaccination. Compared with monovalent Hib vaccine, they give lower responses to the Hib
polysaccharide, and the US Food and Drug Administration (FDA) has been reluctant to license
them. Although vaccine recipients obtain higher levels of antibodies to Hib after receipt of
combined vaccines containing Hib capsular polysaccharide (PRP) coupled to tetanus toxoid than
after licensed vaccine containing Hib PRP coupled to an outer membrane complex of Neisseria
meningitidis group B [28], as well as show immune memory and anamnestic responses [29], the
FDA has insisted on “noninferiority” with respect to geometric mean titers. The absence of
combinations in the United States created the need for numerous separate injections, which in
my opinion was a situation inimical to public health. Fortunately, the FDA very recently licensed
a combination diphtheria, tetanus, acellular pertussis, inactivated poliovirus, and hepatitis B
vaccine. However, a more general question that needs discussion is whether regulation and
public health are now in conflict, without malicious intent on either side
New Tools for Vaccine Development
Genetic engineeringThere are still many important diseases that are not controlled by
vaccination. Why is this so? One reason is that we are now seeking to prevent infections that do
not have extracellular, viremic, bacteremic, mucosal or toxemic phases, during which
pathogenicity can be neutralized by antibodies in the serum or on the mucosae [30]. Second,
although molecular biology permits us to construct just about any antigen, in many cases we
know little about the pathogenesis of the target disease and therefore do not know which antigen
to choose. More young investigators are needed in the field of pathogenesis
Nevertheless, molecular biology and its tool, genetic engineering, have now provided additional
paths to vaccine development. Although induction of antibodies is still a major goal, a particular
aim of much of these efforts is to induce cytotoxic T cell responses and other T cell functions for
prevention of diseases in which cellular immunity is crucial
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Knowledge of the base sequences of genes of microbes and the ability to manipulate them has
been useful in many ways, starting from DNA, cDNA, or even RNA [31] (table 2). Several
recombinant strategies are possible. To develop live recombinants, genes from heterotypic
viruses can be inserted into an attenuated virus. As examples, to produce a candidate dengue
vaccine, the envelope genes from 3 dengue virus serotypes have been inserted into a fourth
attenuated serotype [32, 33]. Also, dengue virus genes have been inserted into the attenuated
17D yellow fever virus as a carrier [34]. A candidate West Nile virus vaccine also is based on the
17D carrier [35]
Recombination also has been used for respiratory agents. The laboratory of Brian Murphy at the
National Institutes of Health created a recombinant parainfluenza virus types 1, 2, and 3 by
inserting the hemagglutinin-neuraminidase gene from parainfluenza virus types 1 and 2 in an
attenuated parainfluenza virus type 3. This recombinant prevented all 3 parainfluenza viruses
from replicating in the lungs of hamsters (figure 4) [36]
Effect of immunization with recombinant parainfluenza virus (hemagglutinin-neuraminidase genes of PIV-1

and PIV-2 each inserted into attenuated PIV-3) on response to subsequent challenge with PIV. Monovalent
viruses provided protection against homotypic challenge, but triple recombinant protected hamsters against
all 3 PIV serotypes [36]
Genes also can be inserted into animal, plant, bacterial, viral, or yeast cells for expression of
proteins, as is the case for hepatitis B surface antigen produced in yeast. In some cases, the
proteins so produced will self-assemble into viruslike particles that are useful for immunization,
despite the absence of a nucleic acid. For example, the L1 protein of human papillomaviruses
will form noninfectious particles, which are the basis of a preventive vaccine against human
papillomavirus infection of the cervix and subsequent cervical cancer; this vaccine gave high
efficacy in a phase II clinical trial [37, 38]. Particles of hepatitis B surface antigen genetically
manipulated to carry circumsporozoite antigen of malarial parasites have shown efficacy against
malaria [39]. Other forms of infection-defective virus particles are being tried for herpes and
even influenza [40]
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In addition, cDNA copies of alphavirus RNA genomes can be split to permit insertion of a gene
for a foreign protein into a segment that also codes for replicase enzymes, whereas the genes for
the viral structural proteins are contained in another helper construct from which the packaging
signal for RNA is deleted. Cotransfection enables the replicon to be incorporated into an
alphavirus particle that can enter cells, in which the foreign gene is then expressed. The particle
is immunogenic but unable to replicate [41, 42]
Remarkably, as was discovered >10 years ago, bacterial DNA plasmids containing foreign genes
can induce antigen production in muscle cells; this antigen is carried by antigen-presenting cells
to the bone marrow, where immune responses are generated [43, 44]. However, the passage from
mice to humans has been difficult: DNA vaccines have given only transient and low-level
antibody responses in primates and humans. Nevertheless, as illustrated by an experiment in a
chimpanzee inoculated with a plasmid containing the gene for hepatitis B surface antigen [45],
such vaccines may protect. Antibodies at a low level developed in the chimpanzee after 3
injections of the plasmid and then disappeared, but were recalled by the challenge and protected
the chimpanzee against infection
Despite low antibody induction in humans, DNA vaccination is of interest for several reasons
(table 3): It often produces good cellular immune responses [46]; it may prime the neonatal
immune system despite the presence of maternal antibodies [47, 48]; DNA coding for vaccine
antigens appears to induce excellent immunologic memory, which can be reawakened by later
immunization or exposure to the pathogen; priming by DNA might conceivably be used to orient
the immune system in a Th1 direction to reduce allergic disease, particularly if the gene for a
cytokine is incorporated [49]; and, finally, in situations such as the appearance of a pandemic
strain of influenza virus, DNAs from conserved nucleoprotein and matrix genes of influenza
virus have been shown in animals to generate some heterologous immunity against the new
strain [50]. The efficacy of DNA immunization may be enhanced by administration through the
skin or by adjuvantation [51, 52]. Codon optimization for expression in mammalian cells is also
critical [53]
Reverse genetics, the technique of inducing specific genetic lesions and then observing the
phenotypic changes, is being applied, particularly to negative-stranded RNA respiratory viruses
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such as influenza virus, parainfluenza virus, and respiratory syncytial virus [25, 54–57 ]. This
technique depends on inducing mutations at specific sites in cDNA and reconstituting a new
virus by furnishing nonstructural enzymes, in a cotransfection with the modified genome
segments. The rescued virus can then be examined for its phenotypic qualities
Another powerful strategy to induce cellular responses uses vectors, microbes that are naturally
or artificially attenuated for humans, in which foreign genetic information has been inserted [58].
Experimental vectors include a wide range of viruses and bacteria, but the ones most explored
are poxviruses, alphaviruses, flaviviruses, adenoviruses, bacille Calmette-Guérin,
and Shigella and Salmonellaspecies. The enteric bacterial vectors are given orally and depend
for their action on the injection into intestinal cells of DNA plasmids carrying foreign genes
[59, 60]
An example of vector use for vaccination comes from experimental cytomegalovirus (CMV)
vaccines [61]. Intrauterine infection with CMV is the most common infectious cause of deafness
and mental retardation in countries that have eliminated rubella. In view of the importance of
cellular immunity to control CMV infections, we placed the gene for the matrix protein pp65, a
principal target of cytotoxic T cell responses against the virus, in a canarypox vector. Strong
pp65-specific cytotoxic T cell response was elicited in all CMV-susceptible human volunteers
after 2 injections [62] (table 4
Induction of cytomegalovirus-specific cytotoxic T cells by canarypox vector carrying gene for pp65 major
matrix protein of cytomegalovirus
The success of this experiment justifies a digression. Over many years, my colleagues and I, as
well as other laboratories, have tried to develop a vaccine against CMV to protect women during
pregnancy [63]. Safety and moderate efficacy were demonstrated with an attenuated live virus
vaccine. Also, workers at Chiron generated a line of Chinese hamster ovary cells transfected with
the gene for the principal viral surface glycoprotein, gB. When the glycoprotein was combined
with an adjuvant, it was highly immunogenic and generated neutralizing antibodies [64]
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Questions remain about the ideal composition of a vaccine against CMV, but although there are
experimental antigens that produce neutralizing antibodies and cell-mediated immunity, vaccine
development has been slow. The perception of marketing departments was that a CMV vaccine
to prevent intrauterine infection would not be used. However, a committee of the Institute of
Medicine recently published an analysis of priorities for new vaccines [65]. They put CMV in
the highest category of need and concluded that a successful vaccine would save society money
as well as suffering. The report by the Institute of Medicine has changed the picture, and now at
least 4 different manufacturers have CMV vaccine development programs. This history
illustrates the necessity for public health authorities and opinion leaders to clearly indicate to
manufacturers what vaccines are wanted. Manufacturers can then avoid investing millions of
dollars in developing a vaccine that will not be welcomed by the public health community, such
as the Lyme disease vaccine, or worse, to ignore a public health need, such as a CMV vaccine
Prime-boost strategiesAlthough immune responses and protection afforded by DNA vaccines

or vectors alone are often insufficient, the combination of modalities in a prime-boost
configuration is more promising [66]. The prime-boost approach works both for generating
antibodies and for generating cell-mediated immunity. For example, one of the earliest trials of
the prime-boost concept involved priming with canarypox vectors containing human
immunodeficiency virus (HIV) genes and boosting with injections of the envelope glycoprotein
120 of the virus (table 5) [67]
Neutralizing antibody responses to human immunodeficiency virus (HIV-1MN) 2 weeks after prime with
canarypox-HIV vector or control vector and second boost with recombinant glycoprotein (rgp) 120
Enhancement of cellular immunity can also be achieved by priming with DNA containing an
HIV gene and boosting with the same gene carried by a vector. In experiments in monkeys by
Harriett Robinson's group [68], the prime was DNA coding for several proteins of HIV that
induce cellular immune responses, and the boost was an attenuated vaccinia virus vector strain
called “MVA,” coding for the same proteins. In contrast to the high HIV loads developed after
challenge by control monkeys, vaccinated monkeys showed no or low virus loads. Human
clinical trials are now being conducted in England and Africa making use of a similar DNA-
MVA prime-boost sequence. Workers at Merck have also achieved efficacy in monkeys with use
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of a DNA prime but followed by a boost with an adenovirus vector [69]. Two different vectors
carrying the same genes can also be combined in a prime-boost format. The prime-boost
approach may also work for other diseases; in fact, clinical trials of a malaria vaccine that use
DNA priming followed by boosting with MVA are now in progress [70]
However, a major problem with vectors is that they are usually good producers of immunity
against themselves as well as against proteins of inserted genes. This so-called vector immunity
may make it problematic to use as vectors agents to which populations are naturally exposed.
Ertl and her colleagues at the Wistar Institute have come up with an ingenious way to circumvent
this difficulty [71, 72]. They have isolated and characterized chimpanzee adenoviruses, which
are antigenically distinct from human adenoviruses. In 1 experiment, monkeys immune to human
adenovirus type 5 or naive to that virus were vaccinated either with the human virus or with a
chimpanzee adenovirus, both carrying the gene for rabies virus glycoprotein. Whereas immune
animals barely responded with rabies antibodies to the human adenovirus vector, the chimpanzee
adenovirus vector was equivalently immunogenic in immune and naive animals (figure 5) [72]
Effect of preimmunization against human adenovirus type 5 (AdHu5) on response to challenge with
106 TCID50 of either human or chimpanzee (Ch) adenovirus type 5 vector containing gene for rabies
glycoprotein. Rabies virus neutralizing antibodies (VNA) were measured after challenge. Monkeys immune to
human virus responded poorly to rabies protein produced by gene carried by same virus but as well as naive
monkeys when gene was carried by chimpanzee virus [72]
Miscellaneous strategiesNew technologies that will help vaccine development are microarray
analysis [73] to define virulence genes and in silico epitope analysis to predict T cell epitopes
[74, 75]. In addition, the burgeoning of proteomics, the field of protein analysis that parallels
genomics, is promising to help define proteins that are important to pathogenesis [76]
Among the important proteins frequently identified by proteomics are bacterial adhesion
proteins, antibodies against which prevent bacteria from attaching to mucosal cells [77]. This is
the basis for an experimental vaccine against recurrent urinary tract infections [78, 79].
Immunization against T cell receptors may help us to decrease immune responses in situations in
which they are pathological [80]
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Although there is insufficient space to discuss the important subject of adjuvants, it is

noteworthy that an entire arm of the immune system, the heretofore-neglected innate immunity,
can be brought into play through the use of unmethylated cytosine-phosphorothiolated guanine
(CpG) oligodinucleotide motifs from bacteria [3]. The stimulation of both innate and acquired
immunity is particularly attractive as a method to protect against agents of bioterrorism. Figure
6 [81] illustrates the concept that although adaptive immunity would arrive too late to prevent
replication of a pathogen, innate immunity stimulated by CpG could act to restrict the growth of
a pathogen until the subject could develop adaptive immunity from vaccination [81]
Combination of innate immunity stimulated by CpG oligodinucleotides (ODN) with adaptive immunity
stimulated by DNA vaccine to provide rapid protection against agent of bioterrorism [81]. Innate immunity
can temporarily suppress replication of pathogen but ultimately fails to control it. Vaccination with DNA or by
other means can protect but develops too late to prevent pathology. Combination may act synergistically to
provide both rapid and persistent protection
Routes of Administration
In addition to new strategies for vaccine development, to avoid injections there will also be new
delivery technologies and routes of administration. Transcutaneous, oral, and even rectal routes
of immunization are under active investigation [82, 83]. Transcutaneous vaccination can be aided
by adjuvants, a low electric current, or simply application to the skin of a sufficient dose, as
shown by studies of adenovirus vectors [84, 85] (table 6)
Transcutaneous immunization of mice against Clostridium tetani with adenovirus vector carrying tetanus
toxin gene
In the category of oral vaccination is the feeding of vaccine antigens produced in transgenic
plants, as illustrated by hepatitis B surface antigen in lettuce [86–88 ]. Chimeric plant viruses
containing genes from animal pathogens also provide an approach to oral immunization [89]
New Targets
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As vaccine development progresses, the target diseases and populations (table 7) are broadening
beyond the traditional pediatric targets to adults in specific risk groups (such as hospitalized
patients) or to adults in general (e.g., for pertussis) [90]
Noninfectious diseases will also become the target of immunization strategies [91]. Cancer
prevention is already provided by hepatitis B vaccine, which is reducing the incidence of hepatic
neoplasms [92], and the recent preliminary success of a human papillomavirus vaccine in
preventing infection [93] augurs well for specific protection of cervical carcinoma. In addition,
the isolation of antigens specific for transformed cells allows for the possible development of
vaccine therapy for cancer
Immunization may also be useful in situations in which infection plays no role, such as to
prevent conception [94] or to neutralize drugs in the bloodstream to treat addiction [95]
The application of vaccines to pregnant women has been inhibited by medicolegal concerns.
Vaccination in pregnancy has as goals either to protect the newborn (e.g., group B streptococcal
disease) or to protect the woman herself (e.g., influenza). Candidate vaccines that might be used
late in pregnancy to protect the neonate during the early months of life include those against
respiratory syncytial virus, pertussis, pneumococcal polysaccharide, and group B streptococcus
[96]
Therapeutic vaccination against chronic infections is an entirely new field of vaccinology [97].
Therapeutic immunization protocols are currently being tested in at least 4 viral diseases (table
8), on the basis of the idea that whereas in chronic infection the host is unable to mount an
effective immune response, external administration of antigens may induce cellular responses
that suppress viral replication [98]. Therapeutic immunization may also be useful in chronic
bacterial infections, such as that due to Helicobacter pylori
Social Issues for the New Century
Finally, we must not forget that the 21st century must deal with 3 major social issues in
vaccinology: safety and the rise of antivaccinationism, cost for developing countries, and
adequacy of supply. These issues could be the subject of a separate article. Although solutions
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have been proposed, considerable wisdom will have to be exercised to put those solutions into
place
Despite these many problems, vaccinology continues to advance through its peculiar
combination of fundamental research and empiricism. As W. H. Auden remarked in a wider
context, “We may not know very much, but we do know something.” Vaccination has come a
long way since Jenner, and we can be confident that vaccinologists will continue to extract
beautiful melodies from the orchestra of the immune system.
4) FORENSIC MEDICINE
BLOOD MODULE
MEDICO-LEGAL IMPORTANCE OF BLOOD
GROUPS
The most important blood groups are the ABO blood system and the RhD blood group system. The blood
groups are defined by the presence or absence of a specific antigen on the surface of a red blood cell.
The 4 Blood Groups

There are four ABO blood groups: A, B, AB and O which all refer to the presence of different antigens on the
red blood cells. Blood group A means you have the A antigen, while blood group B means you have the B
antigen. Blood group AB has both the A and B antigens present on the surface, but blood group O has
neither antigen present. People that have the D antigen on their red blood cells are RhD positive, while
those people that don’t have the D antigen are Rh negative.
The importance of grouping

The grouping is very important when it comes to having a blood transfusion. If blood is given to a patient
that has a blood type that is incompatible with the blood type of the blood that the patient receives, it can
cause intravenous clumping in the patient’s blood which can be fatal. The patient’s body can start
producing antibodies that attack the antigens on the blood cells in the blood that was given to the patient.
For example, a patient who is blood group B has naturally occurring Anti-A antibodies in the blood. If this
(blood group B) patient receives blood group A blood, the Anti-A antibodies in the blood of the patient will
cause the blood group A blood cells to clump intravenously which is life threatening. Similarly, a patient
who is blood group A has naturally occurring Anti-B antibodies in the blood. If this (blood group A) patient
receives blood group B blood, the Anti-B antibodies in the blood of the patient will cause the blood group B
blood cells to clump intravenously which is life threatening. Blood group O can be given safely to any other
blood group is there are no naturally occurring antibodies in the blood of someone who is blood group O.
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Considering that a person can be either blood group A, B, AB or O and is either blood group RhD positive
(also denoted as +) or RhD negative (also denoted as -), this means that a person can be one of eight blood
groups: A+ (A RhD positive), A- (A RhD negative), B+, B-, AB+, AB-, O+, O-. The rarest blood groups amongst
the population that donate blood in the UK are AB-, whereas the most common are O+. People who are
blood group RhD positive, can be given either RhD positive or RhD negative blood, but people with RhD
negative blood can only receive RhD negative blood.
Pregnant women and blood grouping

Blood typing is particularly important for pregnant women, where the father of the baby has the RhD
positive blood group and the mother of the baby has the RhD negative blood group. If the baby has the RhD
positive blood group, it may cause medical complications. In this case a special drug is administered to the
mother to stop the mother’s body producing antibodies against the baby’s blood cells.
5) PRIME
FOUNDATION MODULE
INTRODUCTION TO PROFESSIONALISM
AND ITS ATTRIBUTES
Endorsed by the Accreditation Council on Graduate Medical Education
(ACGME), one of the six general competencies medical residents must
exhibit prior to graduating from their training programs is professionalism.
The definition of professionalism has evolved from the six elements initially
adopted by the American Board of Internal Medicine (ABIM) in 1990, to the
six key attributes currently defined by the ACGME: respect, compassion,
integrity, responsiveness, altruism, accountability, commitment to excel end,
sound ethics and sensitivity to diversity. 1
In efforts to uphold these important attributes, the COM-PHX developed

educational program objectives which correspond to Professionalism, as
defined in their 2012 LCME Self Study report.2 These objectives require
graduates to exemplify a professional behavior that exhibits:
• Compassionate treatment of patients

• Respect for the confidentiality, privacy, dignity and diversity of patients,
peers and faculty
• Integrity in all interactions with patients, their families and professional
colleagues
• Responsiveness to the needs of patients that supersedes self-interest.
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• Active contribution and participation in promoting the awareness of

healthcare
• Commitment to excellence and life-long learning, recognizing their own
limitations and developing and implementing plans to successfully overcome
these limitations.
• Knowledge of and a commitment to uphold ethical principles
• Knowledge of and respect for the contributions of other health care
disciplines and professionals, and appropriate participation, initiative and
cooperation as a member of the health care team
• The ability to credit sources, admit error, and improve behavior
• Teachable attitude, including giving and receiving constructive criticism,
being present and accountable, prepared and engaged.
• Ongoing reflection on the standards of medical practice
These characteristics are assessed throughout the curriculum using
measurable objectives by the outcomes listed below:
• Objective Structured Clinical Examinations (OSCEs)

• Clinical encounter assessment
• Capstone journals
• Case-based Instruction (CBI) Facilitator Assessment
• Block director student feedback
• Longitudinal Clinical Experience (LCE) student assessment
• Student performance assessment in clerkship
• Mid-clerkship feedback
• Faculty assessment of student progress in electives
• Scholarly project student assessment
Within the context of medical school, professionalism at the College of
Medicine - Phoenix is modeled and promoted within various clinical,
academic, and community settings and may be reviewed through
the Professionalism Review Module.
Clinical Care
In any clinical setting, a physician must exhibit and maintain professional

decorum when interaction with administrative personnel, colleagues,
patients, and their families. Demonstration of integrity and truthfulness must
pervade documentation in all medical records. An understanding and respect
for the contributions of others is also upheld to the highest standard when
interacting with and caring for patients regardless of age, ethnicity, and
diversity. Characteristics of professionalism that illustrate dedication to
clinical care are: honor, integrity, accountability, altruism, and commitment
to service.
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Scholarly Research
Professionalism in scholarly research is demonstrated through the pursuit of

significance, innovation, and contribution to a field of study. Physicians
pursue novel approaches through collaborative endeavors addressing
important problems or identifying critical barriers to progress in the field.
The ability to articulate ideas in an understandable manner, engage diverse
audiences, and effectively respond to questions with confidence,
compassion, and integrity, gauge the progression of the ability to act
professional within an academic environment. Key tenets of professionalism
in an academic research setting include: ethical behavior, significance to the
field, pledge of purpose, application to diverse populations, and high
standards of excellence.
Community Engagement
As contributors of the medical community, physicians are obligated to serve

as examples for students, faculty, and other members of the community.
Participationin professional and community organizations, as well as
institutional committees, provides physicians the opportunity to support an
active and involved community.
Attributes that characterize professionalism in a community setting include:

awareness of conflicts of interest, continuous self-improvement, service to
societal goals, respect for others, and a commitment to life-long learning.
INTODUCTION TO BIOETHICS; DESCRIBE

DIFFERENT TYPES AND COMPONENTS OF
BIOETHICS
Bioethics is the study of the ethical issues emerging from advances in biology and medicine. It is
also moral discernment as it relates to medical policy and practice. Bioethics are concerned with the
ethical questions that arise in the relationships among life
sciences, biotechnology, medicine and medical ethics, politics, law, theology and philosophy. It
includes the study of values relating to primary care and other branches of medicine ("the ethics of
the ordinary"). Ethics also relates to many other sciences outside the realm of biological sciences.
PRINCIPLES
Bioethicists often refer to the four basic principles of health care ethics when
evaluating the merits and difficulties of medical procedures. Ideally, for a medical
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practice to be considered "ethical", it must respect all four of these principles:

autonomy, justice, beneficence, and non-maleficence. The use of reproductive
technology raises questions in each of these areas.
• Autonomy
Requires that the patient have autonomy of thought, intention, and action when
making decisions regarding health care
procedures. Therefore, the decision-making process must be free of coercion or
coaxing. In order for a patient to
make a fully informed decision, she/he must understand all risks and benefits of
the procedure and the likelihood of
success. Because ARTs are highly technical and may involve high emotions, it
is difficult to expect patients to be
operating under fully-informed consent.
• Justice
The idea that the burdens and benefits of new or experimental treatments must
be distributed equally among all groups in
society. Requires that procedures uphold the spirit of existing laws and are fair
to all players involved. The health care provider must consider four main areas
when evaluating justice: fair distribution of scarce resources, competing needs,
rights and obligations, and potential conflicts with established
legislation. Reproductive technologies create ethical dilemmas because
treatment is not equally available to all people.
• Beneficence
Requires that the procedure be provided with the intent of doing good for the
patient involved. Demands that health care providers develop and maintain
skills and knowledge, continually update training, consider individual
circumstances of all patients, and strive for net benefit.
• Non-maleficence
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Requires that a procedure does not harm the patient involved or others in
society. Infertility specialists operate under the assumption that they are doing
no harm or at least minimizing harm by pursuing the greater good. However,
because
assistive reproductive technologies have limited success rates uncertain overall
outcomes, the emotional state of the patient may be impacted negatively. In
some cases, it is difficult for doctors to successfully apply the do no harm
principle.
As medical technology advances at a rapid pace, health care professionals are tasked
with examining the resulting ethical dilemmas. This is where bioethics comes in. By
applying the principles of ethics to the field of medicine, bioethics aims to investigate
and study how health care decisions are made. It is a core component of ensuring that
medical practices and procedures benefit society as a whole.
According to the Center for Practical Bioethics, those who are concerned with
bioethics ask questions such as the following, within the context of modern medicine
and health care:
• What is the right thing to do?
• What is worthwhile?
• What are our obligations to one another?
• Who is responsible, to whom and for what?
• What is the fitting response to this moral dilemma, given the context?
• On what moral grounds are such claims made?
Bioethics is a multidisciplinary field, combining philosophy, theology, history and law
with medicine, nursing, health policy and the medical humanities. Because the health
care system is so complex, it is important to consider relevant issues from multiple
points of view.
The term “bioethics” was first introduced in 1971 to reference “the combination of
biology and bioscience with humanistic knowledge,” the Center for Practical Bioethics
explains. However, its application has become much broader today, including clinical
decision-making, controversial new research, the implications of emerging technologies,
global concerns, public policy and more. In fact, bioethics has played a central role in
influencing policy changes and legislation in recent years. Its relevance for medical
professionals is difficult to overstate, as the modern health care system continues to
change at a rapid pace.
Bioethics has applications ranging from birth to the end of life, and it directly
affects both patients and care providers. “Bioethics has an impact on every level of
human community from the local nursing home to the huge international conferences on
issues like the Human Genome … [It] is full of difficult ethical questions for everybody:
families, hospitals, governments and civilization,” the Adelaide Centre for Bioethics and
Culture explains.
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The following are some of the most relevant bioethical issues faced by the health care
industry.
End-of-Life Care
Elderly individuals and their families face a variety of difficult decisions as they near
the end of life. Whether legal, practical, spiritual or medical in nature, the American
Psychological Association notes that health care professionals overseeing these
decisions “should ideally [consider them] in terms of the relief of suffering and the
values and beliefs of the dying individual and his or her family.”
Advancements in medical treatment may prolong life, but quality of life can decrease
once an individual becomes too ill. Then it is time to consider the level of pain
management offered, whether to deliver care at home or in a hospital setting, what kind
of caregiver is needed and more.
Medical Resource Allocation

When medical resources are limited or scarce, it is difficult to meet all health care needs
due to a limited supply. This is why, in some cases, there is some degree of
rationing in the health care system. One good example of this is intensive care units
(ICUs). Patients might need to be transferred out of the ICU when they could still derive
a small amount of benefit from ongoing monitoring, according to “The Ethics and Reality
of Rationing in Medicine.” Decisions like this might be made to accommodate the needs
of more seriously ill patients who need access to limited space in the unit.
Resource allocation could also apply to something as simple as physician time. Leaders
and other stakeholders must determine which patients should be seen first and how
much time should be dedicated.
Eugenics
With modern advances in technology, it is possible to improve genetic quality through
selective reproduction, gene selection and gene manipulation. But just because more
choice exists, does that mean we should take advantage of it? That’s the ethical
question behind eugenics. Options like embryo selection can allow parents to choose
the sex of their child, for example. “Such possibilities raise important ethical questions –
questions about which of these choices, if any, are morally wrong – along with closely
related questions about the extent to which law and regulation should restrict these
areas of medicine,” according to Eugenics and the Ethics of Selective Reproduction.
Euthanasia
One of the most controversial topics in bioethics is euthanasia. According to the BBC,
“Euthanasia is the termination of a very sick person’s life in order to relieve them of their
suffering. A person who undergoes euthanasia usually has an incurable condition.” In
some cases, it may be done at the patient’s request, but when a patient is
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incapacitated, the decision can be made by others, such as family members or medical
professionals.
In the medical community, there are two categories of euthanasia. Active euthanasia
occurs when a medical professional does something that allows the patient to die.
Passive euthanasia occurs when “medical professionals either don’t do something
necessary to keep the patient alive, or when they stop doing something that is keeping
the patient alive,” according to the BBC. It is important to note that in both cases this is
done at the patient or family member’s request. The American Medical Association
Code of Ethics makes a distinction between “withdrawing life-sustaining treatment”
and euthanasia, which indicates just how complex this issue is.
Organ Donation
The importance of organ transplantation in modern medicine can’t be overstated. It
helps patients by prolonging their lives after the failure of vital organs. For organ
transplantation to work, of course, it requires donation from deceased or living
individuals. According to “Ethical Issues in Organ Transplantation,” “The increasing
incidence of vital organ failure and the inadequate supply of organs … has created a
wide gap between organ supply and organ demand.” This means that patients often
have long wait times before they receive an organ — and this can result in death. The
ethical questions surrounding this issue are complex, including whether organ donation
should continue to be voluntary and whether minors should be allowed to donate
organs.
Bioethics and Health Care Management
For leaders in the health care field, it is important to create an ethical environment in
which to deal with the daily challenges that arise. According to the National Center for
Ethics in Health Care (NCEHC), ethical leadership can be achieved when managers
prioritize ethics, communicate clear expectations to their employees and practice ethical
decision-making.
According to the NCEHC, ethical health care organizations create a culture where
individuals:
• Appreciate the importance of ethics

• See ethics as part of quality
• Recognize and discuss ethical concerns
• Understand what is expected of them
• Seek consultation on ethics cases when needed
• Feel empowered to behave ethically
• Work to resolve ethics issues on a systems level
• View organizational decisions as ethical
BIOPSYCOSOCIAL MODEL OF HEALTH CARE

The Biopsychosocial Model is an interdisciplinary model that looks at the interconnection
between biology, psychology, and socio-environmental factors. The model specifically examines
how these aspects play a role in topics ranging from health and disease models to human
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development. This model was developed by George L. Engel in 1977 and is the first of its kind to
employ this type of multifaceted thinking. The Biopsychosocial Model has received criticism about its
limitations, but continues to carry influence in the fields of psychology, health, medicine, and human
development.
History[edit]
The biopsychosocial model was first proposed by George L. Engel and Jon Romano of Rochester
University in 1977.[1] As opposed to the biomedical approach, Engel strived for a more holistic
approach by recognizing that each patient has his or her own thoughts, feelings, and history. [2][non-primary
source needed] In developing the model, Engel framed this model for both illnesses and psychological
problems. The biopsychosocial model reflects the development of illness through the complex
interaction of biological factors (genetic, biochemical, etc.), psychological factors (mood, personality,
behavior, etc.) and socialfactors (cultural, familial, socioeconomic, medical, etc.).[3][non-primary source
needed][4][non-primary source needed] For example, a person may have a genetic predisposition for depression, but
he or she must have social factors such as extreme stress at work and family life and psychological
factors such as a perfectionistic tendencies which all trigger this genetic code for depression. A
person may have a genetic predisposition for a disease, but social and cognitive factors must trigger
the illness. Specifically, Engel revolutionized medical thinking by re-proposing a separation of body
and mind. The idea of dualism goes back to Rene Descartes, but was forgotten during the
biomedical approach. Engel emphasized that the biomedical approach is flawed because the body
alone does not contribute to illness.[5] Instead, the individual mind (psychological and social factors)
plays a significant role in how a illness is caused and how it is treated. Engel proposes a dialogue
between the patient and the doctor in order to find the most effective treatment solution. [6] Similarly,
materialistic and reductionist ideas proposed with the biomedical model are flawed because they
cannot be verified on a cellular level (according to Engel). [7] Instead, the proposed model focuses on
the research of past psychologists such as Urie Bronfenbrenner, popularized by his belief that social
factors play a role in developing illnesses and behaviors. Simply, Engel used Bronfenbrenner’s
research as a column of his biopsychosocial model and framed this model to display health at the
center of social, psychological, and biological aspects. After Engel’s publication, the biopsychosocial
model was adopted by the World Health Organization as a basis for the International Classification
of Function (ICF).[8]
Current Model[edit]
Twenty-five years after Engel’s publication, the biopsychosocial model is still widely used as a
psychological model. The biological, psychological, and social categories have expanded into bigger
categories: specifically, the social aspect has greatly expanded through ideas such as spirituality
and culture. Even though many psychologists may not completely accept this model as their own, it
is known for interconnecting three important categories.[9] Even if all aspects do not apply to the
situation, the biopsychosocial model is widely used to organize one’s thoughts. It shows that a
person’s problems are all connected, and they may be more complex than previously imagined.
Relevant theories and theorists[edit]

George L. Engel who originally developed the Biopsychosocial model is often considered a primary
theorist associated with the model. Engel used this model to offer an alternative to the more readily
used biomedical model of the time. Engel felt the biopsychosocial model allows physicians to better
understand their patients' subjective view of their illness and suffering. [9]
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Potential applications[edit]
When Engel first proposed the biopsychosocial model it was for the purpose of better understanding
health and illness. While this application still holds true for the model it now also holds sway for
topics such as health, medicine, & development.
The biopsychosocial model has many uses in health and medicine. Firstly, as proposed by Engel, it
helps physicians better understand their whole patient. Considering not only physiological & medical
aspects but also psychological & sociological well being. [9] Furthermore this model is closely tied
to health psychology. Health Psychology examines the reciprocal influences of biology, psychology,
behavioral, & social factors on health & illness.
The developmental applications of this model are equally relevant. One particular advantage of
applying the biopsychosocial model to developmental psychology is that it allows for an intersection
within the Nature versus Nurture debate. This model allows developmental psychologists a
theoretical basis for the interplay of both hereditary & psychosocial factors on an individuals'
development.[9]
Criticisms and Achievements[edit]

There have been a number of criticisms of the biopsychosocial model. Benning summarized the
arguments against the model including that it lacked philosophical coherence, was insensitive to
patients' subjective experience, was unfaithful to the general systems theory that Engel claimed it be
rooted in, and that it engendered an undisciplined eclecticism that provides no safeguards against
either the dominance or the under-representation of any one of the three domains of bio, psycho, or
social.[7] Really, how can each category be perfectly represented, and how does one define what falls
into which category? For example, a person would most likely put “chemistry of the brain” under
biological; but if the wording is revised to “thoughts,” it would then be considered psychological even
if they are essentially the same. Others argue that these categories are pointless, since all can be
boiled down to just the physical.[3][non-primary source needed] Some have argued that the approach borders on
anarchy because of the suggestion that the target and focus on intervention is determined by the
practitioner based on personal preference.[10] Some became reductionistic about the model itself,
attempting to predict small parts of one aspect to predict the functioning in one field of medicine, for
example psychiatry.[11] Other limitations include the probability of bias within a doctor-patient
relationship, the presumed superiority of psychiatric problems to others, and the current debate of
dualism.[12]
Other criticisms include the abuse of the model, doubts of the scientific basis. [13]
In 2002, the World Health Organization adopted the biopsychosocial model for the basis of its
publication: The International Classification of Health, Disability and Functioning. [13]
IMPORTANCE OF BEHAVIORAL SCIENCES

TO HEALTH
The ultimate goal of public health is to achieve and sustain healthy populations and
environments. In order to reach this goal, however, we must be able to understand the role
behavior and social factors play and how they contribute to public health solutions and policies.
The study of social and behavioral health sciences involves how human behavior affects human
interaction, decision making, and group processes.
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The social and behavioral health sciences play an important role in public health
policies and decisions, as the work professionals in this field do is focused on identifying
and analyzing the social determinants and behavioral risk factors associated with any
number of public health issues. They then use this information to better understand how
to promote and achieve healthy behaviors within certain communities and populations.
The Science Behind Social and Behavioral

Health
Our world is constantly being driven by advances in our understanding of human
behavior— socially, politically, and economically. Psychology and neuroscience have
given us an increasingly complex understanding about how people think and feel, and
how they make decisions. This has allowed us to better design and deliver products,
services, and policies. It comes as no surprise, then, that classical approaches to areas
such as finance, economics, and public policy are now being influenced by behavioral
finance, behavioral economics, and behavioral public policy.
These insights have greatly changed public health policies and programs by allowing
public health professionals to understand how behaviors, social factors, and
environmental factors affect the way public health programs are best administered and
delivered.
Therefore, social and behavioral health sciences involve:
• Understanding the psychosocial, behavioral, community, and societal influences

on the health of a specific population, including those who are disadvantaged
• Creating interventions that eliminate specific barriers to health across the lifespan
• Understanding how biological factors influence health, illness, and recovery
• Identifying risk factors that result in adverse health outcomes and strategies for
promoting health and preventing disease
Jobs in the Social and Behavioral Health

Sciences
Professionals in the social and behavioral health sciences must find effective solutions
to widespread public health problems, which require planning, implementing, and
administering programs that take into account individual behaviors and existing
disparities. These researchers, administrators, and program developers use both
quantitative and qualitative research methods to help them make decisions with regard
to program planning and evaluation.
Typical duties of professionals in the social and behavioral health sciences include:
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• Accessing and analyzing data to assess specific public health problems

• Applying social and behavioral theories to develop effective public health
intervention programs
• Developing evaluation trials that assess the efficacy of public health interventions
• Communicating their findings to policymakers and to the public
• Advocating for the implementation of evidence-based public health programs
Most professionals working in the social and behavioral health sciences focus their
careers on research related to contemporary public health issues, such as:
• Obesity
• Diabetes
• Tobacco cessation
• Mental health
• HIV/AIDS
• Domestic violence
• Substance abuse
• School health
• Health equity
• Adolescent health
• Maternal and child health
• Physical activity and wellness
• Injury prevention
Research and related programs in this field of public health are completed in a variety of
organizations and systems, such as:
• Healthcare organizations
• Colleges and universities
• Non-governmental organizations
• Applied health research programs
• Federal agencies (CDC, NIH, FDA, etc.)
• State and county health organizations
Some of the more widely recognized careers in the social and behavioral health
sciences within the realm of public health include:
Evaluation Specialists
Evaluation specialists are responsible for collecting and analyzing data and
developing/writing grant proposals, papers, research materials, and presentations on
the results of their findings. The majority of their work involves managing the collection
and interpretation of data and building models based on that data so as to make it
available to other teams.
These professionals are required to interpret often-complex data and recognize the
concerns or issues associated with it. Upon conducting in-depth analyses of both
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quantitative and qualitative data, evaluation specialists make recommendations and

publish the results of their findings.
Evaluation specialists partner with project directors, lead the development and
implementation of evaluation plans, and oversee a variety of data collection methods,
such as logic models and survey and assessment instruments.
Intervention Researchers
Population health interventions are policies or programs designed to address underlying
social, economic, and environmental conditions. Interventions may be programs or
policies designed and developed in the health sector, or they may involve education,
housing, or employment. Intervention researchers are responsible for capturing the
value of these interventions, how they bring about change, and the contexts in which
they work best.
Intervention researchers are responsible for developing programs and theories based
on the gathering of information and the synthesis of data. Their work also includes
formulating and testing evidence-based intervention programs and publishing their
findings in peer-reviewed journals and other publications.
Intervention researchers develop theories based on the results of interventions and
established protocols and determine how to best measure the outcomes of those
interventions. These professionals also compare intervention methods as a way to
guide their research.
Addiction Treatment Program Developers
Addiction treatment program developers design treatment programs that help
individuals suffering from addictions. The ultimate goal of the work these professionals
do is to improve the quality of life of addicted individuals by implementing specific
treatment methods and customizing programs that are in line with patient needs.
These professionals are called upon to ensure the coordination of all addiction
treatment efforts; ensure that patient success rates are optimized; hire, train, and
manage counselors and other treatment specialists, and oversee the financial stability
of the program.
Degree Programs for Public Health

Professionals in the Social and Behavioral
Health Sciences
Professionals in the social and behavioral health sciences possess the research,
analysis, and leadership skills to drive key decisions in the field of public health. These
specialists may focus their work on health communications, health disparities, or
intervention planning, and they may work for public agencies, private organizations, and
academic institutions, among others.
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Many times, undergraduate work for these professionals is in business, public

administration, epidemiology, public health, psychology, behavioral science, and other
applicable disciplines. They may also focus their undergraduate study on applied
research methods and data analysis. Like many other areas of public health, the social
and behavioral health sciences often requires professionals who possess graduate
degrees, such as the interdisciplinary Master of Public Health (MPH).
The MPH, the most widely recognized master’s degree for public health professionals,
may be focused on Social and Behavioral Health Sciences, which is designed to
address the behavioral, social, and environmental factors related to individual and
population health and health disparities over the lifespan.
Students of these programs study social and behavioral theories, models, and methods
of design for interventions meant to increase healthy behaviors and prevent/reduce
disease and illness.
Departmental coursework requirements for an MPH in Social and Behavioral Health
Sciences often includes:
• Principles of Epidemiology
• Applied Analytic Methods in Epidemiology
• Health Promotion and Disease Prevention Interventions
• Interdisciplinary Research Methods
• Qualitative Research Methods
• Quantitative Research Methods
ATTITUDES IN HEALTH PROFESSIONALS

AND FACTORS AFFECTING THEM
Background: Faculty members play crucial roles as facilitators of learning for effective
interprofessional education (IPE). However, faculty attitudes are reported to be barriers to
successful implementation of IPE initiatives within health care education settings. This study
aimed to investigate the following: 1) health care faculty members’ attitudes toward
interprofessional collaboration (IPC) and IPE; 2) factors affecting faculty members’
perception toward IPC and IPE; and 3) health care professionals’ perceptions toward factors
that hamper the quality of IPC, and whether IPE is a possible remedy for the situation.
Methods: A survey was administered to medicine, nursing, midwifery, and dentistry faculty
members at 17 institutions in Central Java Province, Indonesia. Respondents were asked to
rate their attitudes toward IPC and IPE using a previously validated “Attitude toward
Interprofessional Health care Collaboration and Education” scale. To help interpretation of
the survey results, 4 monoprofessional focus groups (FGs) were conducted and 3 key
participants who could not be present at the FG meetings were interviewed. We conducted a
statistical analysis on the quantitative data and performed a thematic content analysis of
the qualitative data using ATLAS Ti (version 7).
Results: The total response rate was 74.1%. Nurses’ mean scores for attitudes toward IPC
and IPE were higher than those of other health care professionals. The main problems of
IPC identified from the FG were as follows: 1) differing perceptions of the needs of patients
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among professionals; 2) unequal participation in decision-making; 3) lack of face-to-face

interaction; and 4) overlapping of roles and responsibilities. Faculty members agreed that
IPE has the potential to remedy these challenges as long as opportunities are provided to
inculcate equal power and contribution in meeting patients’ needs.
Conclusion: These findings indicate the necessity of convening faculty development
programs regarding IPC and IPE. Additionally, innovative strategies must be developed for
the implementation of IPC and IPE in a variety of academic settings.
Keywords: attitude of health care professionals, interprofessional education,

interprofessional health care collaboration
DEFINITION OF ATTENTION AND

CONCENTRATION AND FACTORS
AFFECTING THEM
ATTENTION
Attention is the behavioral and cognitive process of selectively concentrating on a discrete aspect of
information, whether deemed subjective or objective, while ignoring other perceivable information. It
is a state of arousal. It is the taking possession by the mind in clear and vivid form of one out of what
seem several simultaneous objects or trains of thought. Focalization, the concentration
of consciousness, is of its essence. Attention has also been described as the allocation of limited
cognitive processing resources.[1]
Attention remains a major area of investigation
within education, psychology, neuroscience, cognitive neuroscience, and neuropsychology. Areas of
active investigation involve determining the source of the sensory cues and signals that generate
attention, the effects of these sensory cues and signals on the tuningproperties of sensory neurons,
and the relationship between attention and other behavioral and cognitive processes like working
memory and psychological vigilance. A relatively new body of research, which expands upon earlier
research within psychopathology, is investigating the diagnostic symptoms associated with traumatic
brain injury and its effects on attention. Attention also varies across cultures. [2]
The relationships between attention and consciousness are complex enough that they have
warranted perennial philosophical exploration. Such exploration is both ancient and continually
relevant, as it can have effects in fields ranging from mental health and the study of disorders of
consciousness to artificial intelligence and its domains of research
FACTORS AFFECTING ATTENTION
It is true that the attention is a selective activity and volition of our

mind is very important to determine our attention. But despite this,
there are some factors in the objects as well as in the individual
himself which can influence our attention.
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These factors which determine our attention are divided

into two types:
ADVERTISEMENTS:
(a) Objective factors and
(b) Subjective factors,
1. Objective Factors:
These factors pertain to particular aspects of objects which are
inherent in objects.
a. Movement:
A moving object draws our attention more easily than a stationary
object. For example, flickering lights draw our attention than non-
flickering lights. A moving vehicle draws our attention more than a
stationed vehicle.
b. Intensity:
More intense light, sound or smell draws our attention more easily
than less intense one. For example, a high voltage bulb will be
observed quicker than low voltage bulb, very bright colour than dim
colour, or a very loud sound than a normal sound.
c. Novelty:
New kinds of objects draw our attention quickly. Advertising agencies
adopt this technique very effectively. For example, latest fashion dress,
shoes, pen, etc.
d. Size:
A bigger or a smaller object draws the attention of people very easily
than average level size of any object, For example, a 7′ taller man, a 2′
dwarf, a very fat man, a very huge multistoried building can draw our
attention quickly.
e. Change:
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A change in our environment draws our attention quickly. For

example, regular sound of a moving clock does not draw our attention,
but the movement it stops, our attention is diverted.
A show piece placed in a new place, a radio playing a song stops due to
electricity failure draws our attention.
f. Repetition:
When a stimulus is presented repeatedly our attention is diverted, For
example, repeated horn of a fire brigade or ambulance.
g. Clarity:
An object or sound which can be experienced clearly draws our
attention than the stimuli which are not clear. For example, during
night times stars and planets which are seen clearly draw our
attention.
h. Colours:
Colourful objects draw our attention more easily than black or white
objects.
i. Contrast:
An object that is strikingly different from its background draws our
attention. For example, a black spot on a white shirt
2. Subjective Factors:
These factors refer to individuals. These are inherent in people. There
are many subjective factors which determine our attention.
They are:
a. Interest:
Objects of our interest draw our attention immediately. For example,
while moving on a road a sportsman is attracted towards the shop
where sports materials are placed. A person who is interested in a
particular singer will immediately divert his attention the moment he
listens his voice.
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b. Motives:
Motives are powerful forces which make us to divert our attention. For
example, a hotel will draw the attention of a hungry person because he
has a drive for food.
c. Mental set:
Our set or readiness of mind is very important in attending to any
stimulus. For example, when a person is in fantasy he may not listen
to any call. On the other hand, if he is waiting for a phone call eagerly,
he will listen to that immediately.
d. Emotional state:
Attention is disturbed during emotional state. It also affects our
perception. For example, when a person is highly excited due to fear,
he may not listen or understand what others say.
e. Habits:
Our attention is diverted automatically towards the things to which we
are habituated. For example, a smoker remembers smoking even if he
is otherwise busy in some work. A person habituated to take food at a
particular time remembers food at correct time. Attention of a nurse is
automatically diverted towards a serious patient.
CONCENTRATION
Concentration is the ability to direct one’s attention in accordance with one’s will.
It means control of the attention. It is the ability to focus the mind on one subject,
object or thought, and at the same time exclude from the mind every other
unrelated thoughts, ideas, feelings and sensations.
It also means the ability to do one thing at a time, instead of jumping from one
subject to another and losing attention, time, and energy.
Concentration is a state, in which one’s whole attention is engrossed in one thing

only, and being oblivious to everything else. During concentration, the mind
focuses on the object of concentration, and only one thought occupies the mind.
The whole energy of the mind becomes concentrated on this one thought.
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The ability to command the mind and control the attention is not common, and
requires training. Most people lack the ability to control their attention and focus
the mind exclusively on one subject for any length of time. They can’t command
their mind to concentrate, whenever they want to. However, concentration is not
uncommon activity. It happens almost everyday, to almost everyone, but it is
more of a spontaneous and uncontrolled ability.
FACTORS AFFECTING CONCENTRATION
FACTORS THAT AFFECT FOCUS AND

CONCENTRATION
Our ability to focus and concentrate lets us accomplish amazing things — when it’s
working well. Distractions are the main reason we lose focus, but often these aren’t as
obvious as you might imagine. Instead you may feel scattered or “fuzzy,” or blame
yourself for not having more control.
As we get older, focus and concentration can change, as can memory and other
cognitive functions, but this is not inevitable. In fact, some studies with older people
show no decline in decision-making capabilities, and the capacity for strategic learning
— using specific methods to understand something — can get even better with age.
People in their 70s can be “more conscientious and vigilant, without being hyper-
vigilant” than those in their 50s.
If you have poor focus, you may feel as if you simply have to try harder but this strategy
probably won’t help. Instead, you can have better focus by taking action to promote
improvements in the specific brain functions that drive concentration and awareness. By
creating the conditions that make it easier to concentrate and complete your work, you
can feel sharper and more focused especially when you have a specific task to
accomplish.
Look through these factors that affect focus — for better or worse — and take note of
how many apply to you. Starting at any of these points can be your first step toward
having better focus and concentration for everything you do.
FACTORS THAT IMPAIR FOCUS

Poor diet and nutrition
Weight loss diets are notoriously bad for focus and concentration. Low-fat diets can ruin
focus because the brain needs certain essential fatty acids. But not getting enough
protein is bad too. The amino acids in protein are crucial for creating key brain
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chemicals used for focus. Processed foods lead to blood sugar spikes and crashes that
destroy focus. And if you don’t get essential vitamins (particularly B vitamins and vitamin
D) and minerals, including adequate iron, your ability to concentrate will suffer, and it
will worsen over time.
Hunger
Hunger is a distraction we’ve all had. Many studies show the negative effects that
hunger has on school-aged children and young adults. Hunger is tied directly to low
blood sugar which quickly leads to fatigue and low energy levels — and all wreak havoc
on your ability to focus.
Dehydration
Loss of focus is a definite side effect of not drinking enough water and studies prove it.
Dehydration can also lead to other symptoms that in turn reduce focus, including
headache symptoms, fatigue and low mood. Even having just 1% lower than optimal
hydration can cause lack of focus.
Hormonal changes
Normal hormonal fluctuations and shifts, like those during pregnancy or menopause,
can affect how well women concentrate. This is so common during the midlife transition
that loss of concentration is considered a symptom of menopause by many healthcare
practitioners.
Lack of sleep
This is a big one because if you don’t get enough sleep — even for just one night—
your thought processes can slow down, you’re less alert than normal and your ability to
concentrate suffers. You can become so confused that you can’t perform tasks requiring
complex thought. It’s also hard to remember and learn new things if you’re sleepy and
that also affects focus negatively. Inadequate sleep also cuts into working memory, an
important part of focusing. It makes you less vigilant and reduces both your accuracy
and speed on mental tasks. If your sleep problems become chronic and long-term —
something so many people struggle with — your reduced ability to focus can become
your new normal, which can negatively affect your employment, relationships and
personal growth.
Stress
Stress is inevitable but it can have dire consequences on focus and concentration if it
becomes chronic. Ongoing stress churns up deep internal distress that short-circuits
important cognitive functions. But emotional stress can be just as bad. Job worries,
relationship issues and health concerns can make it hard to concentrate, though lots of
people don’t notice this happening until they become totally overwhelmed. When you
become mentally exhausted, you eventually will have difficulties with concentration and
attention. If you have to reread things a lot because you can’t focus, your work may not
get done, and of course, that alone causes even more stress.
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Medical, emotional and psychological problems

Any serious issue that affects your health, mental or physical, can hurt your focus,
including sleep apnea, toxicity from heavy metals, traumatic brain injury, stroke, ADHD,
learning disabilities, visual disorders, dementia, anxiety, depression, bipolar disorder, and
emotional trauma.
Lack of physical activity
If you don’t exercise, you won’t know how deeply your ability to focus is affected until
you actually get moving. As an example of how the brain benefits from exercise, one
study showed that three months of aerobic exercise was linked to the creation of new
neurons, and broader and deeper interconnections between them. These types of
neuronal improvements can increase and strengthen concentration.
Your environment
Is it too loud or too quiet when you’re trying to concentrate? Is your environment filled
with distractions like ringing phones, humming light fixtures, rattling heater vents, or
visual disruptions? Maybe it’s too hot — or too cold. How about your comfort level
(chair, desk height, lighting)? Are people always interrupting you? All of these elements
can affect focus.
Quality of information
It’s very hard to harness your focus if you don’t have the right information to work with.
An incomplete email, a misleading phone message or a skipped step along the way can
muddle your focus as you try to make sense of the inadequate information.
FACTORS THAT IMPROVE FOCUS
Good Diet
You can improve your ability to focus exponentially by shifting your diet toward eating
healthy foods from the Mediterranean-style of eating. Consistently eating foods that
support healthy brain function increases concentration and can even help you have
more patience with distractions. In addition to moderate amounts of lean protein, fill
your plate with lots of vegetables and fruit. Add whole grains and use olive oil to cook
instead of butter. Eat a good breakfast to send a message to your body that it’s going to
get the fuel it needs — you will be less stressed physically and better able to remain
focused.
Targeted supplemental nutrition
Research has already identified many of the important nutrients and ingredients that
directly fuel brain functions like focus and concentration. The range of B vitamins, and
particularly B6, B9 and B12, are absolutely essential for good focus. Vitamin D is also key
nutrient, and choline has great science behind it for brain health. The latest discovery
with solid research supporting it is curcumin, a plant ingredient derived from turmeric
that has powerful anti-inflammatory properties. Antioxidant ingredients like quercetin
can also help with inflammation.
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Plenty of water
Having enough water in your system throughout the day is one of the most basic steps
you can take to help ensure good focus. Thirst isn’t the best measure of fluid status so
lack of focus can be an important early indicator of dehydration. Dr. Sharon Stills, ND,
has a great way to know how much water is right for you: drink half your weight in
ounces every day.
Right environment
It’s important to set yourself up for good focus by choosing and adapting your
surroundings as needed. Find the best place in your home to concentrate, or move to
the library or a coffee shop if that fits your style better. Too much silence can drive a lot
of people crazy — think solitary confinement. And if it is too quiet, you’ll hear every little
distracting sound, so aim for a little background noise. Conversely, if you’re fighting too
much noise, try noise-cancelling headphones or create white noise with a fan. Listening
to non-distracting music can help — try classical or gentle electronic tunes.
Weird but wonderful
Three unusual ways to improve focus
1. PRACTICE focusing when you don’t have to: read in a noisy spot or drive without the
radio on.
2. WIGGLE
your toes — this mindfulness trick brings you back to the present if your concentration
drifts.
3. AIM HIGH: Perform tasks that require intense focus, like learning a language, to turn on
the nucleus basalis — your brain’s mechanism for creating new neural pathways and
strengthening existing ones, also known as neuroplasticity.
Good sleep every night
Just as important as the food you eat, is sleep — both are basic components of good
brain function. Get seven hours of sleep per night, or up to 9 hours on occasion. For
most of us, anything less than 7 hours eats into a specific stage known as delta, or slow-
wave sleep, which will make it hard to focus when we’re awake. If you feel drowsy at the
wrong times it may mean you’re not getting enough sleep. Take naps only when
necessary, especially if you have trouble getting to sleep at night. If you haven’t slept
well for a long period, use the weekend to catch up by heading to bed earlier and
letting yourself wake up naturally. If you continue to have challenges with sleep, speak
with your doctor.
Exercise
Exercise can do wonderful things for focus: just one session can improve mental focus
and cognitive performance for any task you’re trying to complete. One study showed
that even if people have attention deficits, they can sharpen their focus with physical
activity because it releases brain chemicals associated with learning and memory.
Aerobic exercise can improve functioning in the brain areas related to attention. Need to
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concentrate immediately? A short, intense session of running in place speeds circulation

to the brain and improves focus fast. And for a good focus workout, learn a new sport
that depends on hand-eye coordination, like tennis.
Stress reduction
You can limit the effects of stress on your ability to focus by simply taking a break at
midday and doing absolutely nothing for a solid five minutes. Taking a break physically
disrupts the pattern of stress-building and can help you recover your focus, or prevent it
from being lost.
Good breathing
Pay attention to your breathing throughout the day. Do you subconsciously hold your
breath, especially when focusing intensely on a detailed project or fine-motor work? Is
your normal breathing pattern shallow and irregular? You can feed your brain more
oxygen with regular breathing that’s steady and complete, with full inhales and exhales.
Make even more powerful changes to your focus with deep belly breathing: place one
hand on your stomach and inhale for three full seconds and feel your belly expand, and
then exhale for three seconds pushing the air out with your stomach muscles, feeling
your belly drop. At first, perform this exercise for just 60 seconds total. When you’re
ready, keep going for another minute or two — or even longer if you like. Add
meditation to your deep breathing practice — even for just 30 seconds — to re-focus
your brain in the face of distractions.
DEFINITION OF PERSONALITY AND

FACTORS AFFECTING THEM
PERSONALITY
Personality is defined as the characteristic set of behaviors, cognitions,

and emotional patterns that evolve from biological and environmental factors.[1] While there is
no generally agreed upon definition of personality, most theories focus
on motivation and psychological interactions with one's environment.[2] Trait-based
personality theories, such as those defined by Raymond Cattell define personality as the
traits that predict a person's behavior. On the other hand, more behaviorally based
approaches define personality through learning and habits. Nevertheless, most theories view
personality as relatively stable.
FACTORS AFFECTING PERSONALITY
Personality is often broken into statistically-identified factors called the Big Five, which are openness
to experience, conscientiousness, extraversion, agreeableness, and neuroticism (or emotional
stability). These components are generally stable over time, and about half of the variance appears
to be attributable to a person's genetics rather than the effects of one's environment. [6][7]
Some research has investigated whether the relationship between happiness and extraversion seen
in adults can also be seen in children. The implications of these findings can help identify children
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that are more likely to experience episodes of depression and develop types of treatment that such
children are likely to respond to. In both children and adults, research shows that genetics, as
opposed to environmental factors, exert a greater influence on happiness levels. Personality is not
stable over the course of a lifetime, but it changes much more quickly during childhood, so
personality constructs in children are referred to as temperament. Temperament is regarded as the
precursor to personality.[8] Whereas McCrae and Costa's Big Five model assesses personality traits
in adults, the EAS (emotionality, activity, and sociability) model is used to assess temperament in
children. This model measures levels of emotionality, activity, sociability, and shyness in children.
The personality theorists consider temperament EAS model similar to the Big Five model in adults;
however, this might be due to a conflation of concepts of personality and temperament as described
above. Findings show that high degrees of sociability and low degrees of shyness are equivalent to
adult extraversion, and correlate with higher levels of life satisfaction in children.
Another interesting finding has been the link found between acting extraverted and positive affect.
Extraverted behaviors include acting talkative, assertive, adventurous, and outgoing. For the
purposes of this study, positive affect is defined as experiences of happy and enjoyable
emotions.[9] This study investigated the effects of acting in a way that is counter to a person's
dispositional nature. In other words, the study focused on the benefits and drawbacks of introverts
(people who are shy, socially inhibited and non-aggressive) acting extraverted, and of extraverts
acting introverted. After acting extraverted, introverts' experience of positive affect
increased[9] whereas extraverts seemed to experience lower levels of positive affect and suffered
from the phenomenon of ego depletion. Ego depletion, or cognitive fatigue, is the use of one's
energy to overtly act in a way that is contrary to one's inner disposition. When people act in a
contrary fashion, they divert most, if not all, (cognitive) energy toward regulating this foreign style of
behavior and attitudes. Because all available energy is being used to maintain this contrary
behavior, the result is an inability to use any energy to make important or difficult decisions, plan for
the future, control or regulate emotions, or perform effectively on other cognitive tasks. [9]
One question that has been posed is why extraverts tend to be happier than introverts. The two
types of explanations attempt to account for this difference are instrumental theories and
temperamental theories.[6] The instrumental theory suggests that extraverts end up making choices
that place them in more positive situations and they also react more strongly than introverts to
positive situations. The temperamental theory suggests that extraverts have a disposition that
generally leads them to experience a higher degree of positive affect. In their study of extraversion,
Lucas and Baird[6] found no statistically significant support for the instrumental theory but did,
however, find that extraverts generally experience a higher level of positive affect.
Research has been done to uncover some of the mediators that are responsible for the correlation
between extraversion and happiness. Self-esteem and self-efficacy are two such mediators.
Self-efficacy is one's belief about abilities to perform up to personal standards, the ability to produce
desired results, and the feeling of having some ability to make important life decisions.[10] Self-
efficacy has been found to be related to the personality traits of extraversion and subjective well-
being.[10]
Self-efficacy, however, only partially mediates the relationship between extraversion (and
neuroticism) and subjective happiness.[10] This implies that there are most likely other factors that
mediate the relationship between subjective happiness and personality traits. Self-esteem may be
another similar factor. Individuals with a greater degree of confidence about themselves and their
abilities seem to have both higher degrees of subjective well-being and higher levels of
extraversion.[11]
Other research has examined the phenomenon of mood maintenance as another possible
mediator. Mood maintenance is the ability to maintain one's average level of happiness in the face of
an ambiguous situation – meaning a situation that has the potential to engender either positive or
negative emotions in different individuals. It has been found to be a stronger force in
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extraverts.[12] This means that the happiness levels of extraverted individuals are less susceptible to
the influence of external events. This finding implies that extraverts' positive moods last longer than
those of introverts.
INTRODUCTION TO RESEARCH ITS

PURPOSE AND BACKGROUND
RESEARCH
Research is "creative and systematic work undertaken to increase the stock of knowledge,
including knowledge of humans, culture and society, and the use of this stock of knowledge
to devise new applications."[1] It is used to establish or confirm facts, reaffirm the results of
previous work, solve new or existing problems, support theorems, or develop new theories. A
research project may also be an expansion on past work in the field. Research projects can
be used to develop further knowledge on a topic, or in the example of a school research
project, they can be used to further a student's research prowess to prepare them for future
jobs or reports. To test the validity of instruments, procedures, or experiments, research may
replicate elements of prior projects or the project as a whole. The primary purposes of basic
research (as opposed to applied research) are documentation, discovery, interpretation, or
the research and development (R&D) of methods and systems for the advancement of human
knowledge. Approaches to research depend on epistemologies, which vary considerably
both within and between humanities and sciences. There are several forms of
research: scientific, humanities, artistic, economic, social, business, marketing, practitioner
research, life, technological, etc. The scientific study of research practices is known as meta-
research.
PURPOSE
The purpose of research can be a complicated issue and varies across

different scientific fields and disciplines. At the most basic level, science
can be split, loosely, into two types, 'pure research' and 'applied research'.
Both of these types follow the same structures and protocols for propagating and testing
hypothesesand predictions, but vary slightly in their ultimate purpose.
An excellent example for illustrating the difference is by using pure and applied mathematics. Pure
maths is concerned with understanding underlying abstract principles and describing them with
elegant theories. Applied maths, by contrast, uses these equations to explain real life phenomena,
such as mechanics, ecology and gravity.
Pure Scientific Research

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Some science, often referred to as 'pure science', is about explaining the world around us and trying
to understand how the universe operates. It is about finding out what is already there without any
greater purpose of research than the explanation itself. It is a direct descendent of philosophy, where
philosophers and scientists try to understand the underlying principles of existence.
Whilst offering no direct benefits, pure research often has indirect benefits, which can contribute
greatly to the advancement of humanity.
For example, pure research into the structure of the atom has led to x-rays, nuclear power and
silicon chips.
Applied Scientific Research
Applied scientists might look for answers to specific questions that help humanity, for example
medical research or environmental studies. Such research generally takes a specific question and
tries to find a definitive and comprehensive answer.
The purpose of research is about testing theories, often generated by pure science, and applying
them to real situations, addressing more than just abstract principles.
Applied scientific research can be about finding out the answer to a specific problem, such as 'Is
global warming avoidable?' or 'Does a new type of medicine really help the patients?'
Generating Testable Data

However, they all involve generating a theory to explain why something is happening and using the
full battery of scientific tools and methods to test it rigorously.
This process opens up new areas for further study and a continued refinement of the hypotheses.
Observation is not accurate enough, with statistically testable and analyzable data the only results
accepted across all scientific disciplines. The exact nature of the experimental process may vary, but
they all adhere to the same basic principles.
Scientists can be opinionated, like anybody else, and often will adhere to their own theories, even if
the evidence shows otherwise. Research is a tool by which they can test their own, and each others'
theories, by using this antagonism to find an answer and advance knowledge.
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The purpose of research is really an ongoing process of correcting and refining hypotheses, which
should lead to the acceptance of certain scientific truths.
Whilst no scientific proof can be accepted as ultimate fact, rigorous testing ensures that proofs can
become presumptions. Certain basic presumptions are made before embarking on any research
project, and build upon this gradual accumulation of knowledge.
BACKGROUND
So you have carefully written your article and probably ran it through your colleagues ten to
fifteen times. While there are many elements to a good research article, one of the most
important elements for your readers is the background of your study. The background of your
study will provide context to the information discussed throughout the research paper.
Background information may include both important and relevant studies. This is particularly
important if a study either supports or refutes your thesis.
In addition, the background of the study will discuss your problem statement, rationale, and
research questions. It links introduction to your research topic and ensures a logical flow of
ideas. Thus, it helps readers understand your reasons for conducting the study.
Providing Background Information

The reader should be able to understand your topic and its importance. The length and detail of
your background also depend on the degree to which you need to demonstrate your
understanding of the topic. Paying close attention to the following questions will help you in
writing background information:
• Are there any theories, concepts, terms, and ideas that may be unfamiliar to the target
audience and will require you to provide any additional explanation?
• Any historical data that need to be shared in order to provide context on why the current
issue emerged?
• Are there any concepts that may have been borrowed from other disciplines that may be
unfamiliar to the reader and need an explanation?
What Makes the Introduction Different from

the Background?
Your introduction is different from your background in a number of ways. First, the introduction
contains preliminary data about your topic that the reader will most likely read. Secondly, the
background of your study discusses in depth about the topic, whereas the introduction only
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gives an overview. Lastly, your introduction should end with your research questions, aims, and
objectives, whereas your background should not (except in some cases where your background
is integrated into your introduction). For instance, the C.A.R.S. (Creating a Research Space)
model, created by John Swales is based on his analysis of journal articles. This model attempts to
explain and describe the organizational pattern of writing the introduction in social sciences.
Points to Note
Your background should begin with defining a topic and audience. It is important that you
identify which topic you need to review and what your audience already knows about the topic.
You should proceed by searching and researching the relevant literature. In this case, it is
advisable to keep track of the search terms you used and the articles that you downloaded. It is
helpful to use one of the research paper management systems such as Papers, Mendeley,
Evernote, or Sente. Next, it is helpful to take notes while reading. Be careful when copying
quotes verbatim and make sure to put them in quotation marks and cite the sources. In
addition, you should keep your background focused but balanced enough so that it is relevant
to a broader audience. Aside from these, your background should be critical, consistent, and
logically structured.
Writing the background of your study should not be an overly daunting task. Many guides that
can help you organize your thoughts as you write the background. The background of the study
is the key to introduce your audience to your research topic and should be done with strong
knowledge and thoughtful writing.
DIFFERENT TYPES OF RESEARCH

Types of scientific research
Research is a logical and systematic search for new and useful information on a particular topic. Research is
important both in scientific and nonscientific fields. In our life new problems, events, phenomena and
processes occur every day. Practically, implementable solutions and suggestions are required for tackling new
problems that arise. Scientists have to undertake research on them and find their causes, solutions,
explanations and applications.
The research is broadly classified into two main classes: 1. Fundamental or basic research and 2. Applied
research. Basic and applied researches are generally of two kinds: normal research and revolutionary research.
In any particular field, normal research is performed in accordance with a set of rules, concepts and procedures
called a paradigm, which is well accepted by the scientists working in that field. In addition, the basic and
applied researches can be quantitative or qualitative or even both (mixed research).
1.Fundamental or basic research:

Basic research is an investigation on basic principles and reasons for occurrence of a particular event or
process or phenomenon. It is also called theoretical research. Study or investigation of some natural
phenomenon or relating to pure science are termed as basic research. Basic researches sometimes may not
lead to immediate use or application. It is not concerned with solving any practical problems of immediate
interest. But it is original or basic in character. It provides a systematic and deep insight into a problem and
facilitates extraction of scientific and logical explanation and conclusion on it. It helps build new frontiers of
knowledge. The outcomes of basic research form the basis for many applied research.
Basic research
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• Seeks generalization
• Aims at basic processes
• Attempts to explain why things happen
• Tries to get all the facts
• Reports in technical language of the topic
2.Appliedresearch:
In an applied research one solves certain problems employing well known and accepted theories and principles.
Most of the experimental research, case studies and inter-disciplinary research are essentially applied
research. Applied research is helpful for basic research. A research, the outcome of which has immediate
application is also termed as applied research. Such a research is of practical use to current activity.
Applied research
• Studies individual or specific cases without the objective to generalize

• Aims at any variable which makes the desired difference
• Tries to say how things can be changed
• Tries to correct the facts which are problematic
• Reports in common language
Basic and applied research, further divided into three types of research bearing some characteristics feature
as follows:
Quantitative research
• It is numerical, non-descriptive, applies statistics or mathematics and uses numbers.

• It is an iterative process whereby evidence is evaluated.
• The results are often presented in tables and graphs.
• It is conclusive.
• It investigates the what, where and when of decision making.
Qualitative research
• It is non-numerical, descriptive, applies reasoning and uses words.

• Its aim is to get the meaning, feeling and describe the situation.
• Qualitative data cannot be graphed.
• It is exploratory.
• It investigates the why and how of decision making.
Mixedresearch
Mixed research- research that involves the mixing of quantitative and qualitative methods or paradigm
characteristics. Nature of data is mixture of variables, words and images.
Other types of research

ExploratoryResearch
Exploratory research might involve a literature search or conducting focus group interviews. The exploration
of new phenomena in this way may help the researcher’s need for better understanding, may test the
feasibility of a more extensive study, or determine the best methods to be used in a subsequent study. For
these reasons, exploratory research is broad in focus and rarely provides definite answers to specific research
issues.
The objective of exploratory research is to identify key issues and key variables.
Descriptiveresearch
The descriptive research is directed toward studying “what” and how many off this “what”. Thus, it is directed
toward answering questions such as, “What is this?”.
Explanatory research
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• Its primary goal is to understand or to explain relationships.

• It uses correlations to study relationships between dimensions or characteristics off individuals,
groups, situations, or events.
• Explanatory research explains (How the parts of a phenomenon are related to each other).
• Explanatory research asks the “Why” question.
LongitudinalResearch
Research carried out longitudinally involves data collection at multiple points in time. Longitudinal studies may
take the form of:
• Trend study- looks at population characteristics over time, e.g. organizational absenteeism rates
during the course of a year
• Cohort study- traces a sub-population over time, e.g. absenteeism rates for the sales department;
• Panel study- traces the same sample over time, e.g. graduate career tracks over the period 1990 –
2000 for the same starting cohort.
While longitudinal studies will often be more time consuming and expensive than cross-sectional studies, they
are more likely to identify causal relationships between variables.
Cross-sectionalResearch
One-shot or cross-sectional studies are those in which data is gathered once, during a period of days, weeks
or months. Many cross-sectional studies are exploratory or descriptive in purpose. They are designed to look
at how things are now, without any sense of whether there is a history or trend at work.
Action research
• Fact findings to improve the quality of action in the social world
Policy-Oriented Research
• Reports employing this type of research focus on the question ‘How can problem ‘X’ be solved or
prevented ?’
Classification research
• It aims at categorization of units in to groups

• To demonstrate differences
• To explain relationships
Comparative research
• To identify similarities and differences between units at all levels
Causal research
• It aims at establishing cause and effect relationship among variable
Theory-testing research
• It aims at testing validity of a unit
Theory-building research
• To establish and formulate the theory

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Last of all, it is needless to say that scientific research helps us in many ways:
• A research problem refers to a difficulty which a researcher or a scientific community or an industry

or a government organization or a society experiences. It may be a theoretical or a practical situation.
It calls for a thorough understanding and possible solution.
• Research provides basis for many government policies. For example, research on the needs and
desires of the people and on the availability of revenues to meet the needs helps a government to
prepare a budget.
• It is the fountain of knowledge and provide guidelines for solving problems.
• Only through research inventions can be made; for example, new and novel phenomena and
processes such as superconductivity and cloning have been discovered only through research.
• It is important in industry and business for higher gain and productivity and to improve the quality of
products.
• Research leads to a new style of life and makes it delightful and glorious.
• It leads to the identification and characterization of new materials, new living things, new stars, etc.
• Mathematical and logical research on business and industry optimizes the problems in them.
• Social research helps find answers to social problems. They explain social phenomena and seek
solution to social problems.
DIFFERENCES BETWEEN LEADERSHIP AND

MANAGEMENT
What is Leadership? What is Management?
The words “leader” and “manager” are among the most commonly used words in
business and are often used interchangeably. But have you ever wondered what the
terms actually mean?
What Do Managers Do?
A manager is the member of an organization with the responsibility of carrying out the
four important functions of management: planning, organizing, leading, and controlling.
But are all managers leaders?
Most managers also tend to be leaders, but only IF they also adequately carry out the
leadership responsibilities of management, which include communication, motivation,
providing inspiration and guidance, and encouraging employees to rise to a higher level
of productivity.
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Unfortunately, not all managers are leaders. Some managers have poor leadership
qualities, and employees follow orders from their managers because they are obligated
to do so—not necessarily because they are influenced or inspired by the leader.
Managerial duties are usually a formal part of a job description; subordinates follow as a
result of the professional title or designation. A manager’s chief focus is to meet
organizational goals and objectives; they typically do not take much else into
consideration. Managers are held responsible for their actions, as well as for the actions
of their subordinates. With the title comes the authority and the privilege to promote,
hire, fire, discipline, or reward employees based on their performance and behavior.
What Do Leaders Do?
The primary difference between management and leadership is that leaders don’t
necessarily hold or occupy a management position. Simply put, a leader doesn’t have to
be an authority figure in the organization; a leader can be anyone.
Unlike managers, leaders are followed because of their personality, behavior, and
beliefs. A leader personally invests in tasks and projects and demonstrates a high level
of passion for work. Leaders take a great deal of interest in the success of their
followers, enabling them to reach their goals to satisfaction—these are not necessarily
organizational goals.
There isn’t always tangible or formal power that a leader possesses over his followers.
Temporary power is awarded to a leader and can be conditional based on the ability of
the leader to continually inspire and motivate their followers.
Subordinates of a manager are required to obey orders while following is optional when
it comes to leadership. Leadership works on inspiration and trust among employees;
those who do wish to follow their leader may stop at any time. Generally, leaders are
people who challenge the status quo. Leadership is change-savvy, visionary, agile,
creative, and adaptive.
BLOOD MODULE
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DEFINITION OF MOTIVATION AND ITS

TYPES
Definitions:
The following three definitions cover all aspects of the meaning of the term ‘Motivation’. ‘Motivation is
driving force which stimulates an individual to initiate and sustain a behavior.’ ‘Motivation is a biological,
social or psychological state that drives a person towards a specific action’. ‘Motivation is a desire that
fuels an individual to perform or continue an action based on needs and wants of the individual’.
Meaning:
Human beings engage in various actions. For example, a student studies his books, a man is striving to
get a job, a man is taking an injured from a road to a hospital to save his life, a person is eating a meal
and so on. Behind each of these actions, there is a driving force which compels the person to engage in
that action – which is called motivation. For example, a student studies his books because he wants to
get high marks in his exam. The aim of getting high marks is a motivation for the students studying his
books. Similarly, a man is striving to get a Job because he wants to earn money – the aim of earning
money is a motivation for the main striving to get a job. Every action has an aim. Every action has certain
good and bad consequences. These aims, rewards or punishments serve as a motivation for engaging in
an action. These aims, rewards or punishments create a driving force which stimulates an individual
towards an action. For example, ‘hunger’ is a biological drive that compels an individual to eat some
food. Similarly, ‘relief from pain’ is a driving force compelling an individual to act to relieve the pain, e.g.
by eating medicine etc. Apart from the above naturally existing motivation, a purposeful motivation is
also offered to fuel an individual to initiate and sustain certain behavior. For example, incentives,
bonuses, allowances, awards, appreciation certificates, prizes, promotion and demotion; and rewards
and punishments are purposeful motivation mostly offered at an organization to improve the efficiency
and productivity of its employees. Similarly, merit certificates, distinction certificates, silver and gold
medals, achievement-shields, and other prizes are designed at educational institutions to motivate
students towards their studies. Being motivated means to have an impetus or inspiration to behave
actively towards a goal. MOTIVATION & MOTIVES
The terms ‘Motivation’ and ‘Motives’ are sometimes used interchangeably but there is a difference in
meaning of both terms. ‘Motivation’ is a generalized term while ‘motive’ is a specific term. A motive is
an agent of motivation. A motive is a goal, an aim, ambition, a need, a want, an interest, or a desire that
motivates an individual towards an action. On the other hand, the term ‘Motivation’ refers to the
process in which motives motivates an individual towards an action.
TYPES OF MOTIVATION
There are two major types of Motivation.
Intrinsic Motivation
It is a type of motivation in which the motives originates from inside the human body. It refers to the
internal driving state stimulating an individual to behave in a specific way. It includes all biological drives
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such as hunger, thirst, sleep, relief from pain, temperature regulation, need for oxygen and so on. For
example, the hunger is driving force coming from inside to compel an individual to eat food. Similarly,
after doing all day activities, the individual feels tired and requires a good amount of sleep to relax for
the next day. Our curiosity, internal fears, psychological needs and desires also serve as intrinsic
motives. It includes the following motives: Biological drives: e.g. hunger, thirst, relief from pain, sleep,
temperature regulation, Curiosity Internal fears e.g. fear of rejection Psychological needs e.g. need for
being accepted and appreciated by others. Internal desires e.g. desire to gain power or dominance.
Extrinsic Motivation
In this type of motivation, the motives originate from outside the human body. The driving force exists
outside the human body that stimulates the individual for certain actions. Though these motives are
external to the human body but they have a rewarding or punishing impact for the individual. It includes
the following motives: Incentives Bonuses Allowances Promotion and demotion Rewards and
punishment Merit and Distinction certicates Appreciation certicates and prizes.
POSITIVE & NEGATIVE INCENTIVES

Motivation by Negative Incentives Incentives are external rewards and punishment which stimulate an
individual towards an action.
Motivation by Positive Incentives It is a type of motivation that is resulted from positive incentives –
rewards. The positive incentives give a feeling of pleasure and satisfaction. These are rewards. For
example, Increase in pay, promotion in job, carbonus, house-allotment, achievement awards and other
benefits offered to employees at an organization.
Motivation by Negative Incentives It is a type of motivation that is resulted from negative incentives –
punishments. The negative incentives give a feeling of pain, displeasure or dissatisfaction. These are
punishments. It includes demotion in job, penalties and fines imposed on employees due to their low
performance.
STRESS AND ITS MANAGEMENT

STRESS
Stress is the body's natural defense against predators and danger. It flushes the body with hormones to
prepare systems to evade or confront danger. This is known as the "fight-or-flight" mechanism.
When we are faced with a challenge, part of our response is physical. The body activates resources to
protect us by preparing us either to stay and fight or to get away as fast as possible.
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The body produces larger quantities of the chemicals cortisol, adrenaline, and noradrenaline. These
trigger an increased heart rate, heightened muscle preparedness, sweating, and alertness. All these
factors improve the ability to respond to a hazardous or challenging situation.
Factors of the environment that trigger this reaction are called stressors. Examples include noises,
aggressive behavior, a speeding car, scary moments in movies, or even going out on a first date. The
more stressors we experience, the more stressed we tend to feel.
STRESS MANAGEMENT
Stress management' is a wide spectrum of techniques and psychotherapies aimed at controlling a

person's level of stress, especially chronic stress, usually for the purpose of and for the motive of
improving everyday functioning. In this context, the term 'stress' refers only to a stress with
significant negative consequences, or distress in the terminology advocated by Hans Selye, rather
than what he calls eustress, a stress whose consequences are helpful or otherwise. Stress produces
numerous physical and mental symptoms which vary according to each individual's situational
factors. These can include physical health decline as well as depression. The process of stress
management is named as one of the keys to a happy and successful life in modern
society.[1] Although life provides numerous demands that can prove difficult to handle, stress
management provides a number of ways to manage anxiety and maintain overall well-being.
Despite stress often being thought of as a subjective experience, levels of stress are readily
measurable, using various physiological tests, similar to those used in polygraphs.
Many practical stress management techniques are available, some for use by health
professionals and others, for self-help, which may help an individual reduce their levels of stress,
provide positive feelings of control over one's life and promote general well-being. Other stress
reducing techniques involve adding a daily exercise routine, finding a hobby, writing your thoughts,
feelings, and moods down and also speaking with a trusted one about what is bothering you. It is
very important to keep in mind that not all techniques are going to work the same for everyone, that
is why trying different stress managing techniques is crucial in order to find what techniques work
best for you. An example of this would be, two people on a roller coaster one can be screaming
grabbing on to the bar while the other could be laughing while their hands are up in the air (Nisson).
This is a perfect example of how stress effects everyone differently that is why they might need a
different treatment. These techniques do not require doctors approval but seeing if a doctors
technique works better for you is also very important.
Evaluating the effectiveness of various stress management techniques can be difficult, as limited
research currently exists. Consequently, the amount and quality of evidence for the various
techniques varies widely. Some are accepted as effective treatments for use in psychotherapy, while
others with less evidence favoring them are considered alternative therapies. Many professional
organizations exist to promote and provide training in conventional or alternative therapies.
There are several models of stress management, each with distinctive explanations of mechanisms
for controlling stress. Much more research is necessary to provide a better understanding of which
mechanisms actually operate and are effective in practice.
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COPING SKILLS AND DEFENCE

MANAGEMENT
Apart from personality traits, people also tend to develop habitual modes and methods of managing
stress and coping with upsetting emotions. By and large, these habitual methods do help people to
manage and defuse stressful situations they find themselves in, but they are not all equally efficient
at this task. Some work better than others. While some really do succeed in helping people to
manage upsetting emotion, the lesser quality methods generally end up causing more problems than
they solve.
Perhaps not surprisingly, there is a relationship between people's emotional maturity and the sort of
coping methods they prefer. Less emotionally mature people tend to prefer rather primitive and often
inefficient coping methods , while more mature folks lean towards more sophisticated and more
useful methods. The less mature methods also tend to have in common that their use is not
premeditated or conscious in nature, but rather fairly reactive, not well thought out, and unconscious.
As coping methods increase in maturity and sophistication, they become correspondingly more
deliberate and conscious in nature, and also tend to be used more proactively, rather than simply
reactively.
The study of coping methods has a long history. The topic was originally described by
psychodynamic psychotherapists (including Dr. Freud) who called them defense mechanisms. The
defense mechanism literature was largely focused on mental illness and the ways that various
primitive mechanisms served largely to maintain serious illness rather than help reduce it. Later,
more cognitively oriented researchers began a separate study of coping that focused more on
mental health, and ways that mature coping methods could be taught to enhance health. Though
some authors suggest that the term defense mechanisms should be reserved for describing
primitive, immature coping strategies, and the term "coping methods" for more mature, useful coping
efforts, it doesn't really matter what label is used to describe the different coping methods from our
perspective; they are all just people's attempts at coping.
The most primitive of the defense mechanisms are considered to be primitive because they
fundamentally rely on blatant misrepresentation or outright ignoring of reality in order to function.
These mechanisms flourish in situations (and minds) where emotion trumps reason and impulsivity
rules the day. Children use them naturally and normally, but then again, children are by definition
emotionally immature and not held to a higher standard as are adults. When adults use these
methods on a regular basis, it is an indication that their emotional development is at some level
delayed.
• Denial; an outright refusal or inability to accept some aspect of reality that is troubling. For example:
"this thing has not happened" when it actually has.
• Splitting; a person cannot stand the thought that someone might have both good and bad aspects,
so they polarize their view of that person as someone who is "all good" or "all bad". Any evidence to
the contrary is ignored. For example: "My boss is evil", after being let go from work, when in reality,
the boss had no choice in the matter and was acting under orders herself. Splitting functions by way
of Dissociation, which is an ability people have in varying amounts to be able to wall off certain
experiences and not think about them.
• Projection; a person's thought or emotion about another person, place or thing is too troubling to
admit, and so, that thought or emotion is attributed to originate from that other person, place or thing.
For example: "He hates me", when it is actually the speaker who hates. A variation on the theme of
Projection is known as "Externalization". In Externalization, you blame others for your problems
rather than owning up to any role you may play in causing them.
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• Passive-aggression; A thought or feeling is not acceptable enough to a person to be allowed direct

expression. Instead, that person behaves in an indirect manner that expresses the thought or
emotion. For example: Failing to wash your hands before cooking when you normally would, and
happen to be cooking for someone you don't like.
• Acting out; an inability to be thoughtful about an impulse. The impulse is expressed directly without
any reflection or consideration as to whether it is a good idea to do so. For example: a person
attacks another person in a fit of anger without stopping to consider that this could seriously wound
or disfigure that other person and/or possibly result in legal problems.
• Fantasy; engaging in daydreams about how things should be, rather than doing anything about how
things are. For example: Daydreaming of killing a bully, instead of taking concrete action to stop the
bully from bothering you.
An intermediate level of defense mechanisms (the "neurotic" mechanisms) are defined by a more
ambivalent relationship with reality. Reality is recognized here to a larger extent, even if it is put off
or avoided.
• Displacement; An unacceptable feeling or thought about a person, place or thing is redirected

towards a safer target. For example, it may feel unsafe to admit anger towards a parent, but it is
perfectly safe to criticize the neighborhood he or she lives in.
• Isolation/Intellectualization; Overwhelming feelings or thoughts about an event are handled by
isolating their meaning from the feelings accompanying the meaning, and focusing on the meaning
in isolation. For example, you cope with the recent death of a parent by reading about the grieving
process.
• Repression; A milder form of denial; You manage uncomfortable feelings and thoughts by avoiding
thinking about them. You are able to admit that you feel a certain way (unlike in denial), but you can't
think of what might have led up to that feeling, and don't really want to think about it anyway.
• Reaction Formation; You react to uncomfortable, unacceptable feelings or ideas that you have (but
aren't quite conscious of really), by forming the opposite opinion. For example; you unconsciously
hate your parent, but your experience is to the contrary; you are only aware of loving feelings for
your parent.
To this historical list of intermediate, "neurotic" mechanisms, we can add a few modern ones as well:
• Rationalization; where you choose to do something on emotional grounds (because it feels good)
but you don't want to admit that, so you make up reasons after the fact to justify your choice.
• Workaholism; where you avoid dealing with problems by burying yourself in work. Workaholism
could be considered a form of Distraction (see below), but distraction is something you choose to do,
and many workaholics don't perceive their devotion to the office as a choice so much as a duty.
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PAPER-B
MUSCLOSKELETAL MODULE
1) PATHOLOGY
INTRODUCTION TO BONE PATHOLOGY
Diseases of the bone include non-neoplastic disorders such as genetic defects (e.g.,
achondroplasia), osteoporosis, infections of the bone (i.e., osteomyelitis), and Paget disease.
The age of the patient and the location of the tumor are very important considerations in the
diagnosis of bone tumors. For example, most chondrosarcomas occur in older adults and
almost never occur in the bones of the hands, whereas most Ewing sarcomas occur in the
diaphysis of long bones of children.
Diseases of the joints include inflammatory and noninflammatory arthritides. The two major
types of arthritis are osteoarthritis and rheumatoid arthritis. Wear and tear is one of the major
etiologic agents for the development of osteoarthritis, whereas rheumatoid arthritis is
considered to be an autoimmune condition. An important molecular topic regarding bone
pathology is the receptor for nuclear factor-κβ (RANK), which is expressed on macrophages,
monocytes, and preosteoclasts. The binding of RANK ligand (RANKL) to RANK stimulates
osteoclastogenesis. RANKL is produced by osteoblasts and marrow stromal cells.
Osteoprotegerin binds to RANK and blocks the binding of RANKL; therefore, it is inhibitory.
This chapter will discuss non-neoplastic bone diseases (including those caused by genetic
defects, osteoporosis, osteonecrosis, osteomyelitis, Paget disease, renal osteodystrophy, and
fractures), bone neoplasms, and joint disorders, primarily osteoarthritis, rheumatoid arthritis,
and gout.
Overview: There are many inherited conditions that result in abnormalities of bone
structure. Three of the more common types, achondroplasia, osteogenesis imperfecta, and
osteopetrosis, will be discussed below.
Achondroplasia
Inheritance pattern: Autosomal dominant; 80% of new cases are the result of spontaneous
mutations.
Mutation: Gene for FGF receptor 3 (FGFR3) on the p arm of chromosome 4.

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Effect of mutation: FGF receptor 3 (FGFR3) is an inhibitor of cartilage proliferation. The

mutation places the receptor in a constant state of activation.
Manifestations of achondroplasia
• Gross: Disproportionate dwarfism with normal trunk length and short extremities,
varus and valgus deformities of legs, short fingers and toes, and large head with
prominent forehead.
• Microscopic: Narrow and disorganized zones of proliferation and hypertrophy.
Important points: Achondroplasia accounts for 70% of cases of dwarfism. Less commonly,
dwarfism may be due to pituitary dysfunction or secondary to a mutation in the growth
hormone receptor (Laron dwarfism).
Osteogenesis Imperfecta
Overview: There are several different types of osteogenesis imperfecta, each one caused by
one of several different mutations. Some of the mutations have an autosomal dominant
inheritance pattern. Only type I and type II osteogenesis imperfecta, two of the more
common forms of the disease, will be discussed in detail here.
Mutations: Gene for α1 and α2 chains of type I collagen.
Effect of mutation: Varies, depending upon mutation. The results vary from phenotypically
normal collagen produced in decreased amounts to absence of collagen production.
2) PHARMACOLOGY
DRUG USED IN MSK
• Medications play a key role in helping you manage your musculoskeletal condition
• They work alongside other treatments such as exercise, sleep, aids and equipment and a healthy diet
• The medications your doctor prescribes will depend on your condition and your symptoms
If you live with a musculoskeletal condition (e.g. arthritis, back pain, osteoporosis) it’s likely that you use
medication to help you manage your condition and symptoms (e.g. pain, inflammation).
Together with other strategies such as exercise, weight management, learning different ways to manage your
pain, aids and equipment and getting a good night’s sleep, medications can help you live well.
There are many types of medication that you may use to help you at different times and in different ways.
Medications can help control symptoms (e.g. pain, swelling and stiffness) and some can slow the progress of
your condition.
In most cases, when prescribing medications your doctor will start with the simplest medications at the
smallest doses and work their way up to more complex medications and larger doses depending on how your
condition responds to treatment.
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Depending on your particular symptoms, and how much pain and inflammation you have, you may take one
medication or a combination of different medications.
This information resource will look at the types of medications that you may use – regularly and occasionally
– depending on your condition and symptoms.
Note: It’s important to remember that all medications can have side effects (or unwanted effects). Together
with your doctor or specialist you should weigh up the risks and benefits of medications for your specific
situation.
Topicals
Some quick and temporary forms of pain relief are rubs, gels, ointments, sprays and creams that are applied
directly to your skin (topically). There are a lot of them available, in many different forms and using different
ingredients.
When you apply these products you’re actually benefiting from two things – the first is the product itself, the
second is the mini-massage you enjoy when applying the product.
Topical products work in a variety of ways and use different ingredients.
Note: Be careful when using topicals that you read the instructions carefully, wash your hands thoroughly and
avoid contact with your eyes and other sensitive areas.
Counterirritants – these products have ingredients such as menthol, methyl salicylate, eucalyptus oil and
camphor. They’re called counterirritants because they create a burning or cooling sensation that distracts you
from your pain. You may know some of these by their distinctive smell, however, you can now get some that
have little or no smell.
NSAIDs – many topical products contain non-steroidal anti-inflammatory drugs (NSAIDs). You can rub the
NSAID into the skin directly over the joint to relieve pain. They may be an option for you if you can’t take oral
NSAIDs due to other health issues (e.g. high blood pressure) or the risk of complications (e.g. stomach
problems), as less medication is absorbed into the bloodstream.
Capsaicin – is the main ingredient of chili peppers. Applied to the skin as a cream, it works by interfering
with the pain signals between your nerve endings and brain. It may provide temporary pain relief.
Analgesics (pain killers)

These medications provide temporary pain relief. They can range in strength from mild to very strong. You
can purchase many of these over-the-counter at your pharmacy or supermarket, however stronger
medications, including those containing codeine require a prescription from your doctor.
Analgesics are generally used as a short-term measure to help you get through a flare, or a period of time
when your pain is particularly bad. They’re not meant to be a long-term strategy for pain management.
Oral non-steroidal anti-inflammatory drugs (NSAIDs)

NSAIDs provide temporary pain relief, specifically pain associated with inflammation. There are over-the-
counter NSAIDs that you can buy at the pharmacy or supermarket, as well as prescription NSAIDs.
NSAIDs block the action of specific enzymes (cyclooxygenase or COX) that are involved in inflammation.
However COX also protects the lining of your stomach and intestines. That means that when taking NSAIDs
you may experience stomach problems – pain, nausea, diarrhoea, ulcers. This risk is increased if you take
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NSAIDs frequently, if you have a history of stomach ulcers, if you’re over 65, and if you take other medications
that interact with NSAIDs. Before you start taking NSAIDs discuss it with your doctor or pharmacist to make
sure it’s safe for you to do so.
Opioids
Opioids are used to treat severe pain associated with cancer or acute pain (e.g. following surgery). They may
be helpful for some people with severe, persistent non-cancer pain, however their long-term benefit is
controversial. Opioids can have serious side effects (including constipation, breathing difficulties). They will
also produce physical dependence over time and have the potential to produce addiction. Long-term use of
strong opioids are used cautiously; before prescribing an opioid you and your doctor will discuss the risks
and benefits for you.
Anti-neuropathic pain medications

These medications act on the nervous system to reduce neuropathic (nerve) pain associated with injury,
disease, dysfunction or where the nervous system itself is ‘over-sensitised’. These include the older type anti-
depressants, anti-epilepsy medications, and some blood pressure medications. These medications typically
have significant side effects (e.g. reduced concentration, sleepiness, weight gain), however, sometimes they
may be prescribed for these effects (e.g. to improve sleep).
Corticosteroids
Corticosteroids are used to rapidly control or reduce inflammation. They can be injected or swallowed.
Corticosteroid liquid or tablets – may be used in the early days of your condition, or if you’re going through
a flare, to help get inflammation and pain under control. They do have side effects if used for long periods, so
your doctor will closely monitor you while you’re taking them.
Corticosteroid injections – if a joint is particularly painful and swollen, an injection directly into the joint
can help to relieve your pain and inflammation.
Disease modifying anti-rheumatic drugs (DMARDs)

Your immune system is designed to identify foreign bodies (e.g. bacteria, viruses) and attack them to keep
you healthy. However with some musculoskeletal conditions, the immune system mistakenly attacks healthy
tissue – in and around the joints – causing ongoing inflammation and pain.
DMARDs work by controlling your overactive immune system. They help relieve pain and inflammation, and
can also reduce or prevent joint damage. They’re a long-term treatment for many types of musculoskeletal
conditions.
As their name suggests, they work on modifying the disease process, not just managing your symptoms. It can
take several weeks to months before you begin to notice any effect, so you may also need to take other
medications to help control pain and inflammation until then.
There are a number of different DMARDs on the market and your doctor will discuss your options with you,
as well as the risk and benefits of each. You may find you try a few before you find one that works best for
you.
While taking DMARDs you’ll have regular blood tests to monitor the effects of the medication on your
condition, and to watch for possible side effects before they have the potential to become serious.
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Biologics and biosimilars (bDMARDs)

These newer medications are also a type of disease modifying drug, and they also work to control your
immune system. However unlike other disease modifying drugs, biologics and biosimilars target specific cells
and proteins that are causing the inflammation and tissue damage, rather than suppressing your entire
immune system.
Biologics (or biologicals) have been created from a biological source (e.g. human cells). They’re usually made
of proteins that occur naturally in our bodies.
The patents on many biologics have expired, so other companies can make a similar, slightly cheaper version
– which has led to the appearance of biosimilars. They’re very similar to biologics, but not the same as the
original medication.
Biologics and biosimilars aren’t prescribed to everyone due to the high costs associated with developing
them. They also may not be the best choice in terms of side effects and the availability of other effective
medications.
Osteoporosis medications
Bones are living tissue and are constantly growing, rebuilding, replacing and repairing. When you’re young,
you build more bone than you lose to create a strong skeleton. As people get older, they begin to lose more
bone than they rebuild.
If this effects overall bone density and strength, bones can break more easily. This is osteoporosis.
If you have osteoporosis, the type of medication chosen by your doctor will depend on factors such as your
age, general health, and fracture risk.
Osteoporosis medicines work by:
• slowing down bone loss and slow the progression of osteoporosis- antiresorptives
• increasing the amount of bone that’s made – anabolic medicines.
Antiresorptives – are the most commonly prescribed medication for treating osteoporosis. They include the
group of medications called bisphosphonates.
Anabolic medicines are used to treat people with severe osteoporosis.
These medications may be taken as a tablet, an injection under the skin or an infusion into the vein. How
often you take them (e.g. daily, weekly, monthly) will depend on the medication.
Hormone replacement therapy (HRT) – may be an option for some women around the time of menopause.
It’s a synthetic version of the hormones oestrogen and progesterone. Oestrogen plays an important role in
maintaining bone strength, however during menopause, oestrogen levels drop significantly and women
experience a period of rapid bone loss. HRT is most commonly prescribed as a combination of oestrogen and
progestogen, however some women may take oestrogen on its own.
Supplements – calcium and vitamin D are important for bone health. Your doctor may prescribe a
supplement if you’re not getting enough through diet or exposure to sunlight.
Gout medications
Gout occurs when uric acid, a normal waste product, builds up in your bloodstream and forms urate crystals
in a joint. It can happen if your body makes too much uric acid, or your kidneys can’t clear enough of it out,
and it builds up in your blood. This is called hyperuricaemia.
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If you have gout, the first step in treatment is getting the pain and inflammation under control. This may
involve anti-inflammatories and/or analgesics), cold packs on the swollen joint, and rest.
Once the painful attack is under control, depending on the underlying cause of your hyperuricaemia, your
doctor may prescribe medications that:
• reduce the amount of uric acid your body produces, or

• increase the amount of uric acid you pass through your urine.
Fibromyalgia medications
Combined with other strategies, medication may be used to manage your pain, reduce stress and help you
sleep.
There are different types of medication that your doctor may recommend depending on your symptoms:
• analgesics – for temporary pain relief

• anti-inflammatory or analgesic creams and gels – may provide some temporary pain relief
• anti-depressant medications – may be used in small doses to reduce pain and help you sleep
• anti-epileptic medications – may also be used in small doses to reduce pain and improve sleep, however they
aren’t listed on the Pharmaceutical Benefits Scheme (PBS) for fibromyalgia.
Medication tips
• Before buying any over-the-counter medications talk with your doctor or pharmacist about the benefits and
harms of these medications and how to use them most effectively.
• Be aware of the active ingredients in all of your medications to prevent accidentally taking too much, e.g. be
careful not to use other medications that contain paracetamol (e.g. some cold and flu remedies) while you’re
taking paracetamol for pain relief. If you’re unsure of the active ingredients, talk with your doctor or
pharmacist.
• Always take your medications as prescribed, and organise regular review appointments with your doctor.
• If you have difficulty remembering to take your medications, set up a reminder alert on your phone, use a pill
dispenser or link your medications to a daily routine (e.g. cleaning your teeth).
• All medications have side effects. Discuss these with your doctor or pharmacist and read the consumer
medicine information that comes with any new medication.
• Let your doctor know about any other medications or supplements you’re taking. This includes over-the-
counter medications, supplements and products you’ve purchased from a supermarket or health food store,
or products prescribed by a complementary therapist (e.g. naturopath, homeopath). They may interact with
medications you’re taking for your musculoskeletal or other health condition.
• Keep track of your medications. Write down all of the medications, supplements etc that you take. There are
many medication apps you can download to help you keep all of this information in one place.
• Don’t stop taking any medications without first discussing it with your doctor. Some medications need to be
gradually reduced, rather than simply stopped, to avoid side effects.
• Consider a Home Medicines Review by an accredited pharmacist. If you’re eligible, they‘re particularly useful
if you’re taking many medications, or if you have other health conditions. They help make sure you’re using
your medicines effectively and will help you avoid any unwanted side effects. Your doctor or pharmacist can
give you more information about a Home Medicines Review.
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BACK PAIN
Overview
Back pain is one of the most common reasons people go to the doctor or miss work,
and it is a leading cause of disability worldwide. Most people have back pain at least
once.
Fortunately, you can take measures to prevent or relieve most back pain episodes. If
prevention fails, simple home treatment and proper body mechanics often will heal your
back within a few weeks and keep it functional. Surgery is rarely needed to treat back
pain.
Symptoms
Signs and symptoms of back pain can include:
• Muscle ache
• Shooting or stabbing pain
• Pain that radiates down your leg
• Pain that worsens with bending, lifting, standing or walking
• Pain that improves with reclining
When to see a doctor
Most back pain gradually improves with home treatment and self-care, usually within a
few weeks. If yours doesn't improve in that time, see your doctor.
In rare cases, back pain can signal a serious medical problem. Seek immediate care if
your back pain:
• Causes new bowel or bladder problems
• Is accompanied by fever
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• Follows a fall, blow to your back or other injury
Contact a doctor if your back pain:
• Is severe and doesn't improve with rest
• Spreads down one or both legs, especially if the pain extends below the knee
• Causes weakness, numbness or tingling in one or both legs
• Is accompanied by unexplained weight loss
Also, see your doctor if you start having back pain for the first time after age 50, or if you
have a history of cancer, osteoporosis, steroid use, or excessive drug or alcohol use.
Causes
Low back pain caused by spinal degeneration and injury.e

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Back pain that comes on suddenly and lasts no more than six weeks (acute) can be
caused by a fall or heavy lifting. Back pain that lasts more than three months (chronic) is
less common than acute pain.
Back pain often develops without a cause that your doctor can identify with a test or an
imaging study. Conditions commonly linked to back pain include:
• Muscle or ligament strain. Repeated heavy lifting or a sudden awkward movement can
strain back muscles and spinal ligaments. If you're in poor physical condition, constant
strain on your back can cause painful muscle spasms.
• Bulging or ruptured disks. Disks act as cushions between the bones (vertebrae) in your
spine. The soft material inside a disk can bulge or rupture and press on a nerve. However,
you can have a bulging or ruptured disk without back pain. Disk disease is often found
incidentally when you have spine X-rays for some other reason.
• Arthritis. Osteoarthritis can affect the lower back. In some cases, arthritis in the spine can
lead to a narrowing of the space around the spinal cord, a condition called spinal stenosis.
• Skeletal irregularities. A condition in which your spine curves to the side (scoliosis) also
can lead to back pain, but generally not until middle age.
• Osteoporosis. Your spine's vertebrae can develop compression fractures if your bones
become porous and brittle.
Risk factors
Anyone can develop back pain, even children and teens. These factors might put you at
greater risk of developing back pain:
• Age. Back pain is more common as you get older, starting around age 30 or 40.
• Lack of exercise. Weak, unused muscles in your back and abdomen might lead to back
pain.
• Excess weight. Excess body weight puts extra stress on your back.
• Diseases. Some types of arthritis and cancer can contribute to back pain.
• Improper lifting. Using your back instead of your legs can lead to back pain.
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• Psychological conditions. People prone to depression and anxiety appear to have a

greater risk of back pain.
• Smoking. This reduces blood flow to the lower spine, which can keep your body from
delivering enough nutrients to the disks in your back. Smoking also slows healing.
Prevention
You might avoid back pain or prevent its recurrence by improving your physical
condition and learning and practicing proper body mechanics.
To keep your back healthy and strong:
• Exercise. Regular low-impact aerobic activities — those that don't strain or jolt your back
— can increase strength and endurance in your back and allow your muscles to function
better. Walking and swimming are good choices. Talk with your doctor about which
activities you might try.
• Build muscle strength and flexibility. Abdominal and back muscle exercises, which
strengthen your core, help condition these muscles so that they work together like a
natural corset for your back. Flexibility in your hips and upper legs aligns your pelvic bones
to improve how your back feels. Your doctor or physical therapist can tell you which
exercises are right for you.
• Maintain a healthy weight. Being overweight strains back muscles. If you're overweight,
trimming down can prevent back pain.
• Quit smoking. Talk to your doctor about ways to quit.
Avoid movements that twist or strain your back. Use your body properly:
• Stand smart. Don't slouch. Maintain a neutral pelvic position. If you must stand for long
periods, place one foot on a low footstool to take some of the load off your lower back.
Alternate feet. Good posture can reduce the stress on back muscles.
• Sit smart. Choose a seat with good lower back support, armrests and a swivel base.
Placing a pillow or rolled towel in the small of your back can maintain its normal curve.
Keep your knees and hips level. Change your position frequently, at least every half-hour.
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• Lift smart. Avoid heavy lifting, if possible, but if you must lift something heavy, let your
legs do the work. Keep your back straight — no twisting — and bend only at the knees.
Hold the load close to your body. Find a lifting partner if the object is heavy or awkward.
Buyer beware
Because back pain is so common, numerous products promise prevention or relief. But
there's no definitive evidence that special shoes, shoe inserts, back supports, specially
designed furniture or stress management programs can help.
In addition, there doesn't appear to be one type of mattress that's best for people with
back pain. It's probably a matter of what feels most comfortable to you.
4) PRIME
LITERATURE REVIEW
BACKGROUND
A literature review or narrative review is a type of review article. A literature review is a scholarly
paper, which includes the current knowledge including substantive findings, as well as theoretical
and methodological contributions to a particular topic. Literature reviews are secondary sources, and
do not report new or original experimental work. Most often associated with academic-oriented
literature, such reviews are found in academic journals, and are not to be confused with book
reviews that may also appear in the same publication. Literature reviews are a basis for research in
nearly every academic field.[1]A narrow-scope literature review may be included as part of a peer-
reviewed journal article presenting new research, serving to situate the current study within the body
of the relevant literature and to provide context for the reader. In such a case, the review usually
precedes the methodology and results sections of the work.
Producing a literature review may also be part of graduate and post-graduate student work, including
in the preparation of a thesis, dissertation, or a journal article. Literature reviews are also common in
a research proposal or prospectus (the document that is approved before a student formally begins
a dissertation or thesis).
KEYWORDS
Keyword search
During your literature search, especially when you search for articles in databases, you will
rely very much on keyword searching. To conduct a keyword search, you need
to formulate a search statement.
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Below are the basic steps to develop a search statement. After going through these steps,
try to build up your own search statement using this worksheet [pdf]
Here is a diagram to help you understand:
1. Identify the keywords or the main concepts of your research topic.
• For example, for the topic Globalization of Chinese companies, the keywords
are Globalization, Chinese and Companies.
2. Think of similar terms (synonyms) or phrases that might also be used to describe these
concepts, to ensure that you do not miss out any relevant information. You can use a
thesaurus to help you find synonyms. For example, you can first arrange the main concepts
in columns. Then under each column write down similar terms or phrases that may also be
used to represent that concept:
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3. Combine your search terms in a way that a database can understand. To do this, you
need to use the words AND, OR, NOT(Boolean operators).
• AND combines different concepts (e.g. Globalization and Chinese listed in different
columns of the table above are different concepts).
• OR combines similar concepts (e.g. Chinese and China listed in the same column
above are similar concepts).
• NOT excludes the undesirable concepts
4. Make use of truncation, wildcards, parentheses and phrase searching for more
productive searching. Symbols commonly used in many search tools including
catalogues and databases are:
5. A search statement can then be developed
RESEARCH; TITLE, RATIONALE, PURPOSE

TITLE
The title summarizes the main idea or ideas of your study. A good title contains the fewest possible
words that adequately describe the contents and/or purpose of your research paper.
The title is without doubt the part of a paper that is read the most, and it is usually read first. If
the title is too long it usually contains too many unnecessary words, e.g., "A Study to Investigate the...."
On the other hand, a title which is too short often uses words which are too general. For example,
"African Politics" could be the title of a book, but it does not provide any information on the focus of a
research paper.
Structure and Writing Style
The following parameters can be used to help you formulate a suitable research paper title:
1. The purpose of the research

2. The narrative tone of the paper [typically defined by the type of the research]
3. The methods used
The initial aim of a title is to capture the reader’s attention and to draw his or her attention to the
research problem being investigated.
Create a Working Title
Typically, the final title you submit to your professor is created after the research is complete
so that the title accurately captures what was done. The working title should be developed early
in the research process because it can help anchor the focus of the study in much the same way the
research problem does. Referring back to the working title can help you reorient yourself back to the
main purpose of the study if you feel yourself drifting off on a tangent while writing.
The Final Title
Effective titles in academic research papers have several characteristics.
• Indicate accurately the subject and scope of the study.

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• Avoid using abbreviations.

• Use words that create a positive impression and stimulate reader interest.
• Use current nomenclature from the field of study.
• Identify key variables, both dependent and independent.
• May reveal how the paper will be organized.
• Suggest a relationship between variables which supports the major hypothesis.
• Is limited to 10 to 15 substantive words.
• Do not include "study of," "analysis of" or similar constructions.
• Titles are usually in the form of a phrase, but can also be in the form of a question.
• Use correct grammar and capitalization with all first words and last words capitalized, including
the first word of a subtitle. All nouns, pronouns, verbs, adjectives, and adverbs that appear
between the first and last words of the title are also capitalized.
• In academic papers, rarely is a title followed by an exclamation mark. However, a title or
subtitle can be in the form of a question.
The Subtitle
Subtitles are quite common in social science research papers. Examples of why you may include
a subtitle:
1. Explains or provides additional context, e.g., "Linguistic Ethnography and the Study of
Welfare Institutions as a Flow of Social Practices: The Case of Residential Child Care
Institutions as Paradoxical Institutions."
2. Adds substance to a literary, provocative, or imaginative title, e.g., "Listen to What I Say,
Not How I Vote: Congressional Support for the President in Washington and at Home."
3. Qualifies the geographic scope of the research, e.g., "The Geopolitics of the Eastern
Border of the European Union: The Case of Romania-Moldova-Ukraine."
4. Qualifies the temporal scope of the research, e.g., "A Comparison of the Progressive Era
and the Depression Years: Societal Influences on Predictions of the Future of the Library,
1895-1940."
5. Focuses on investigating the ideas, theories, or work of a particular individual, e.g., "A
Deliberative Conception of Politics: How Francesco Saverio Merlino Related Anarchy and
Democracy."
RATIONALE
You know from SOM 491A/B that proposals (see Proposal Writing Assignment
listed under SOM 310A/B at this website) are usually documents that define and
describe a problem and then define and defend a solution to the problem. Proposals
are persuasive, but they are also "speculative" -- that is, they tell readers how you'll
carry out your plan -- costs, timetable, facilities, training, and so forth. Proposals also
list reasons for acting, and the outcomes expected as a result of action. The details of a
proposal may be technical, but the arguments (see Arguments in the SOM Writing
Lab under SOM 310A/B at this website) in a proposal must be persuasive -- selling
your idea, your competence.
A rationale is a kind of sub-proposal within a proposal: it offers the reasons for

proceeding to address a particular problem with a particular solution. A rationale for
research is a set of reasons offered by a researcher for conducting more research into a
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particular subject -- either library research, descriptive research, or experimental

research. Since you have already conducted library research (your literature review),
you are now ready to propose to your Honors Advisor that s/he authorize you to
conduct further study and write a Thesis on your subject.
Your rationale (for this assignment) should cover the following "sub-arguments":
1. your objectives in conducting further research -- What do you hope to find

out?
2. the significance of the subject in your field -- Why is this subject important?
3. ) reasons why more or better research is needed -- a summary of your
concluions from your literature review -- the gaps in our knowledge, flawed
prior research, etc.) -- What was wrong or incomplete about prior efforts and
what is needed to address these probems?
4. your proposed research method -- Will you want to do qualitative (descriptive)
or quantitative (experimental) research?
You may also want to share with your reader the following:
1. your expected outcomes or hypotheses about the research you hope to

conduct (if you are ready to articulate these)
2. your credentials or strengths as a student and researcher
3. your expectations about how you'd like your future research to be evaluated
Revised 8-15-97/EdC
PURPOSE
As you probably already know, there are many reasons why research is done. But, what are its
purposes? Why bother with all the different styles, techniques, experiments and measurements?
Why did the first sailors, the ones before Columbus and Magellan, hop on their little canoes and
paddle out? Humans naturally explore the world around them, wanting to learn about the planet we
have labeled Earth.
Why did Hippocrates and Galen examine and write about the maladies of man? The need to describe
and understand our world is found in even the youngest children.
Why did we develop an entire group of sciences to understand humans? Because what good is being
human if you cannot explain why we do something. Maybe I am being a little to 'meta' about all this.
The purpose of psychology is to explore, to describe and to explain how and why a person thinks,
feels and acts.
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PAPER-C
1) PATHOLOGY
CARDIOVASCULAR MODULE
RISK FACTORS AND LAB DIAGNOSIS OF CAD
Coronary artery disease (CAD) causes impaired blood flow in the arteries that
supply blood to the heart. Also called coronary heart disease (CHD), CAD is
the most common form of heart disease and affects approximately 16.5
million Americans over the age of 20.
It’s also the leading cause of death for both men and women in the United
States. It’s estimated that every 40 seconds, someone in the United States
has a heart attack.
A heart attack can come from uncontrolled CAD.
Causes of coronary artery disease

The most common cause of CAD is vascular injury with cholesterol plaque
buildup in the arteries, known as atherosclerosis. Reduced blood flow occurs
when one or more of these arteries becomes partially or completely blocked.
The four primary coronary arteries are located on the surface of the heart:
• right main coronary artery

• left main coronary artery
• left circumflex artery
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• left anterior descending artery
These arteries bring oxygen and nutrient-rich blood to your heart. Your heart
is a muscle that’s responsible for pumping blood throughout your body.
According to the Cleveland Clinic, a healthy heart moves approximately 3,000
gallons of blood through your body every day.
Like any other organ or muscle, your heart must receive an adequate,
dependable supply of blood in order to carry out its work. Reduced blood flow
to your heart can cause symptoms of CAD.
Other rare causes of damage or blockage to a coronary artery also limit blood
flow to the heart.
Symptoms of CAD
When your heart doesn’t get enough arterial blood, you may experience a
variety of symptoms. Angina (chest discomfort) is the most common symptom
of CAD. Some people describe this discomfort as:
• chest pain
• heaviness
• tightness
• burning
• squeezing
These symptoms can also be mistaken for heartburn or indigestion.
Other symptoms of CAD include:

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• pain in the arms or shoulders

• shortness of breath
• sweating
• dizziness
You may experience more symptoms when your blood flow is more restricted.
If a blockage cuts off blood flow completely or almost completely, your heart
muscle will start to die if not restored. This is a heart attack.
Don’t ignore any of these symptoms, especially if they are excruciating or last
longer than five minutes. Immediate medical treatment is necessary.
Symptoms of CAD for women
Women may also experience the above symptoms, but they’re also more
likely to have:
• nausea
• vomiting
• back pain
• jaw pain
• shortness of breath without feeling chest pain
Men have a higher risk of developing heart disease

than premenopausal women. Postmenopausal women by age 70 have the
same risk as men.
Due to decreased blood flow, your heart may also:
• become weak
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• develop abnormal heart rhythms (arrhythmia) or rates

• fail to pump as much blood as your body needs
Your doctor will detect these heart abnormalities during diagnosis.
Risk factors for CAD

Understanding the risk factors for CAD can help with your plan to prevent or
decrease the likelihood of developing the disease.
Risk factors include:
• high blood pressure

• high blood cholesterol levels
• tobacco smoking
• insulin resistance/hyperglycemia/diabetes mellitus
• obesity
• inactivity
• unhealthy eating habits
• obstructive sleep apnea
• emotional stress
• excessive alcohol consumption
• history of preeclampsia during pregnancy
The risk for CAD also increases with age. Based on age alone as a risk factor,
men have a greater risk for the disease beginning at age 45 and women have
a greater risk beginning at age 55. The risk for coronary artery disease is also
higher if you have a family history of the disease.
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Diagnosing CAD
Diagnosing CAD requires a review of your medical history, a physical
examination, and other medical testing. These tests include:
• Electrocardiogram:This test monitors electrical signals that travel through

your heart. It may help your doctor determine whether you’ve had a
heart attack.
• Echocardiogram: This imaging test uses ultrasound waves to create a

picture of your heart. The results of this test reveal whether certain
things in your heart are functioning properly.
• Stress test:This particular test measures the stress on your heart during
physical activity and while at rest. The test monitors your heart’s
electrical activity while you walk on a treadmill or ride a stationary bike.
Nuclear imaging may also be performed for a portion of this test. For
those unable to perform physical exercise, certain medications can be
used instead for stress testing.
• During this procedure, your

Cardiac catheterization (left heart catheterization):
doctor injects a special dye into your coronary arteries through a
catheter inserted through an artery in your groin or forearm. The dye
helps enhance the radiographic image of your coronary arteries to
identify any blockages.
• Heart CT scan:Your doctor may use this imaging test to check for calcium
deposits in your arteries.
What is the treatment for CAD?

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It’s important to reduce or control your risk factors and seek treatment to lower
the chance of a heart attack or stroke, if you’re diagnosed with
CAD. Treatment also depends on your current health condition, risk factors,
and overall wellbeing. For example, your doctor may
prescribe medication therapy to treat high cholesterol or high blood pressure,
or you may receive medication to control blood sugar if you have diabetes.
Lifestyle changes can also reduce your risk of heart disease and stroke. For
example:
• quit smoking tobacco

• reduce or stop your consumption of alcohol
• exercise regularly
• lose weight to a healthy level
• eat a healthy diet (low in fat, low in sodium)
If your condition doesn’t improve with lifestyle changes and medication, your
doctor may recommend a procedure to increase blood flow to your heart.
These procedures may be:
• to widen blocked arteries and smoosh down the

balloon angioplasty:
plaque buildup, usually performed with insertion of a stent to help keep
the lumen open after the procedure
• coronary artery bypass graft surgery: to restore blood flow to the heart in
open chest surgery
• to stimulate the formation of new small

enhanced external counterpulsation:
blood vessels to naturally bypass clogged arteries in a noninvasive
procedure
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What is the outlook for CAD?

Everyone’s outlook for CAD is different. You have better chances of
preventing extensive damage to your heart the earlier you can start your
treatment or implement lifestyle changes.
It is important to follow your doctor’s instructions. Take medications as

directed and make the recommended lifestyle changes. If you have a higher
risk for CAD, you can help to prevent the disease by reducing your risk
factors.
STAGES OF ATHEROCLEROSIS
The Three Stages of Atherosclerosis
The fatty streak: This first stage of atherosclerosis can sometimes be found in children as young as
10 years of age. In this stage, a yellow streak appears along major arteries, such as the aorta and
carotid artery. This streak is made up of smooth muscle cells, cholesterol, and macrophages (a type
of white blood cell). The fatty streak phase alone does not cause any noticeable symptoms but can
progress into a more dangerous phase of atherosclerosis called a fibrous plaque.
Fibrous plaque: A fibrous plaque develops within the inner layer of the vessel. This plaque is made
up of smooth muscle cells, macrophages, and lymphocytes (a more aggressive type of white blood
cell). These cells have cholesterol inside of them. As the fibrous plaque grows, it begins to protrude
into the vessel where the blood is flowing.
Complicated lesion: The final stage of atherosclerosis is defined when a dangerous series of events
occur. When the fibrous plaque breaks apart, it exposes the cholesterol and connective tissue
underneath it. This event is recognized by the body as an injury, and a team of blood clotting cells
are sent to the scene. This becomes particularly dangerous because now the blood flow is being
restricted by the initial blockage as well as the clot that has formed. The ruptured plaque in
combination with the blood clot is called a complicated lesion.
RESPIRATORY MODULE
PNEUMONIAS
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Pneumonia is an infection in one or both lungs. It can be caused by bacteria,

viruses, or fungi. Bacterial pneumonia is the most common type in adults.
Pneumonia causes inflammation in the air sacs in your lungs, which are called
alveoli. The alveoli fill with fluid or pus, making it difficult to breathe.
Read on to learn more about pneumonia and how to treat it.
What are the symptoms of

pneumonia?
Pneumonia symptoms can be mild to life-threatening. The most common
symptoms of pneumonia can include:
• coughing that may produce phlegm (mucus)

• fever, sweating, and chills
• chest pain
Other symptoms can vary according to the cause and severity of the infection,
as well as the age and general health of the individual.
Symptoms by cause
• Viral pneumonia may start with flu-like symptoms, such as wheezing. A
high fever may occur after 12–36 hours.
• Bacterial pneumonia may cause a fever as high as 105°F along with
profuse sweating, bluish lips and nails, and confusion.
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Symptoms by age
• Children under 5 years of age may have fast breathing.
• Infants may vomit, lack energy, or have trouble drinking or eating.
• Older people may have a lower-than-normal body temperature.
What are the types and causes of

pneumonia?
The major types of pneumonia are classified by the cause of the infection,
where the infection was transmitted, and how the infection was acquired.
Types by germ
Pneumonia can be classified according to the organism that caused the

infection.
Bacterial pneumonia: The most common cause of bacterial pneumonia

is Streptococcus pneumoniae. Chlamydophila pneumonia and Legionella
pneumophila can also cause bacterial pneumonia.
Viral pneumonia: Respiratory viruses are often the cause of pneumonia,

especially in young children and older people. Viral pneumonia is usually not
serious and lasts for a shorter time than bacterial pneumonia.
Mycoplasma pneumonia: Mycoplasma organisms are not viruses or bacteria,

but they have traits common to both. Mycoplasmas generally cause mild
cases of pneumonia, most often in older children and young adults.
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Fungal pneumonia: Fungi from soil or bird droppings can cause pneumonia in
people who inhale large amounts of the organisms. They can also cause
pneumonia in people with chronic diseases or weakened immune systems.
One kind of fungal pneumonia is called Pneumocystis jirovecii pneumonia

(PCP). This condition generally affects people with weakened immune
systems, such as those with AIDS. In fact, PCP can be one of the first signs of
infection with AIDS.
Types by location
Pneumonia is also classified according to where it was acquired.
Hospital-acquired pneumonia (HAP): This type of bacterial pneumonia is

acquired during a hospital stay. It can be more serious than other types,
because the bacteria involved may be more resistant to antibiotics.
Community-acquired pneumonia (CAP): This refers to pneumonia that is

acquired outside of a medical or institutional setting.
Types by how they are acquired
Pneumonia can also be classified according to how it is acquired.
Aspiration pneumonia: This type of pneumonia occurs when you inhale

bacteria into your lungs from food, drink, or saliva. This type is more likely to
occur if you have a swallowing problem or if you become too sedate from the
use of medications, alcohol, or some types of illicit drugs.
Ventilator-associated pneumonia (VAP): When people who are using a

ventilator get pneumonia, it’s called VAP.
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Is pneumonia contagious?
Most kinds of pneumonia are contagious.
Both viral and bacterial pneumonia can spread to others through inhalation of
airborne droplets from a sneeze or cough. But while you can become infected
with fungal pneumonia from the environment, it doesn’t spread from person to
person.
Who is at risk of pneumonia?

Anyone can get pneumonia, but certain people are at higher risk:
• infants from birth to age 2 years, and individuals ages 65 years or older
• people who have had a stroke, have problems swallowing, or are
bedridden
• people with weakened immune systems because of disease or use of
medications such as steroids or certain cancer drugs
• people who smoke, misuse certain types of illicit drugs, or drink
excessive amounts of alcohol
• people with certain chronic medical conditions such as asthma, cystic
fibrosis, diabetes, or heart failure
How is pneumonia diagnosed?

Your doctor will start by asking you questions about when your symptoms first
appeared and about your medical history. They’ll also give you a physical
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exam. This will include listening to your lungs with a stethoscope for any
abnormal sounds, such as crackling.
Your doctor will also likely order a chest X-ray. Typically, pneumonia can be
diagnosed with the physical exam and the chest X-ray. But depending on the
severity of your symptoms and your risk of complications, your doctor may
also order one or more of these tests:
• This test can confirm an infection, but it may not be able to

A blood test.
identify what’s causing it.
• A sputum test. This test can provide a sample from your lungs that may
identify the cause of the infection.
• Pulse oximetry. An oxygen sensor placed on one of your fingers can
indicate whether your lungs are moving enough oxygen through your
bloodstream.
• This test can identify the bacteria Streptococcus
A urine test.
pneumoniae and Legionella pneumophila.
• A CT scan. This test provides a clearer and more detailed picture of
your lungs.
• A fluid sample. If your doctor suspects there is fluid in the pleural
space of your chest, they may take fluid using a needle placed between
your ribs. This test can help identify the cause of your infection.
• A bronchoscopy. This test looks into the airways in your lungs. It does
this using a camera on the end of a flexible tube that’s gently guided
down your throat and into your lungs. Your doctor may do this test if
your initial symptoms are severe, or if you’re hospitalized and your body
is not responding well to antibiotics.
PULMONARY TUBERCULOSIS
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The bacterium Mycobacterium tuberculosis causes tuberculosis (TB), a

contagious, airborne infection that destroys body tissue. Pulmonary TB occurs
when M. tuberculosis primarily attacks the lungs. However, it can spread from
there to other organs. Pulmonary TB is curable with an early diagnosis and
antibiotic treatment.
Pulmonary TB, also known as consumption, spread widely as an epidemic

during the 18th and 19th centuries in North America and Europe. After the
discovery of antibiotics like streptomycin and especially isoniazid, along with
improved living standards, doctors were better able to treat and control the
spread of TB.
Since that time, TB has been in decline in most industrialized nations.

However, TB remains in the top 10 causes of death worldwide, according to
the World Health Organization (WHO)Trusted Source, with an estimated 95
percent of TB diagnoses as well as TB-related deaths occur in developing
countries.
That said, it’s important to protect yourself against TB. Over 9.6 million people
have an active form of the disease, according to the American Lung
Association (ALA). If left untreated, the disease can cause life-threatening
complications like permanent lung damage.
What is latent TB?

Being exposed to M. tuberculosis doesn’t necessarily mean you’ll get sick.
Among the 2.5 billion people who carry the germ, most have latent TB.
People with latent TB aren’t contagious and have no symptoms because their
immune system is protecting them from getting sick. But it is possible for
latent TB to develop into active TB. Most people with the germ have up to
a 15 percent lifetime riskTrusted Source of getting sick with TB. The risk can be
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far higher if you have conditions that compromise your immune system such
as HIV infection. When you start showing symptoms, you may become
contagious and have pulmonary TB.
If you’re at risk of being exposed to M. tuberculosis (for example, because you

were born in a country where TB is common), you should talk to your doctor
about being tested for latent TB infection and being treated if test results are
positive.
What are the symptoms of

pulmonary TB?
If you or someone you know has pulmonary TB, they will commonly:
• cough up phlegm
• cough up blood
• have a consistent fever, including low-grade fevers
• have night sweats
• have chest pains
• have unexplained weight loss
There may also be other symptoms of pulmonary TB, such as fatigue. Your
doctor will be able to tell you whether you should be tested for TB after
reviewing all your symptoms.
How pulmonary TB spreads

You can’t get pulmonary TB by:
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• shaking hands
• sharing food or drink
• sleeping in the same bed
• kissing
TB is airborne, which means you can become infected with M.

tuberculosis after breathing air exhaled by someone with tuberculosis. This
can be air from:
• coughing
• sneezing
• laughing
• singing
The germs can stay in the air for several hours. It’s possible to inhale them
even when the infected person isn’t in the room. But usually you have to be
close to someone with TB for a long period of time to catch it.
Risk factors for pulmonary TB

The risk for getting pulmonary TB is highest for people who are in close
contact with those who have TB. This includes being around family or friends
with TB or working in places such as the following that often house people
with TB:
• correctional facilities
• group homes
• nursing homes
• hospitals
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• shelters
People also at risk for developing pulmonary TB disease are:
• older adults
• small children
• people who smoke
• people with an autoimmune disorder, such as lupus or rheumatoid
arthritis
• people with lifelong conditions, such as diabetes or kidney disease
• people who inject drugs
• people who are immunocompromised, such as those living with HIV,
undergoing chemotherapy, or taking chronic steroids
How is pulmonary TB diagnosed?

During your examination, your doctor will:
• conduct a physical exam to check for fluid in your lungs

• ask about your medical history
• schedule a chest X-ray
• order a medical test to confirm pulmonary TB
To diagnose pulmonary TB specifically, a doctor will ask a person to perform a

strong cough and produce sputum up to three separate times. The doctor will
send the samples to a laboratory. At the lab, a technician will examine the
sputum under a microscope to identify TB bacteria.
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In addition to this test, a doctor can also “culture” a sputum sample. This
means they take a portion of the sputum sample and put it in a special
material that makes TB bacteria grow. If TB bacteria grow, this is a positive
culture.
Doctors can also order a polymerase chain reaction (PCR) assay to be

performed. This tests the sputum for the presence of certain genes from the
germs that cause TB.
Other exams
These exams can also look for pulmonary TB, which may be hard to diagnose
in children, and in people who have HIV or multidrug-resistant TB (MDR-TB).
Test
CT scan an imaging test to check lungs for signs of an infection
a procedure that involves inserting a scope through your mouth or nose to allow
bronchoscopy
your doctor to see your lungs and airways
a procedure that removes fluid from the space between the outside of your lungs
thoracentesis
and the wall of your chest
lung biopsy a procedure to remove a sample of lung tissue
Treatment for latent TB and

pulmonary TB
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It’s important to get treatment for latent TB even if you have no symptoms.
You can still develop pulmonary TB disease in the future. You may only need
one TB drug if you have latent TB.
If you have pulmonary TB, your doctor may prescribe several medicines.
You’ll need to take these drugs for six months or longer for the best results.
The most common TB medicines are:
• isoniazid
• pyrazinamide
• ethambutol (Myambutol)
• rifampin (Rifadin)
Your doctor might recommend an approach called directly observed therapy

(DOT) to ensure that you complete your treatment. Stopping treatment or
skipping doses can make pulmonary TB resistant to medicines, leading to
MDR-TB.
With DOT, a healthcare professional meets with you every day or several
times a week to administer your medication so that you don’t have to
remember to take it on your own.
If you aren’t on DOT, make a schedule for taking your medicines so that you
don’t miss a dose. Here are some tips to help you remember to take your
medicines:
• Take medicines at the same time every day.

• Make a note on your calendar each day to show that you’ve taken your
medicine.
• Ask someone to remind you to take your medicine every day.
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• Keep your medicines in a pill organizer.
You won’t need to go to the hospital unless you’re unable to take the
medication at home or have a bad reaction to the treatment.
What is multidrug-resistant TB?

Multi-drug resistant TB (MDR-TB) is TB that is resistant to the typical
antibiotics used to treat the condition, which are isoniazid and rifampin. Some
of the factors that contribute to MDR-TB include:
• healthcare providers prescribing an incorrect drug to treat TB

• people stopping treatment early
• people taking poor-quality medications
Improper prescribing is the leading cause of MDR-TB, according

to WHOTrusted Source. However, it’s possible a person who hasn’t ever taken
TB medications can have a strain that is drug-resistant.
People who develop MDR-TB also have fewer options for treatment. The
second-line treatments can be expensive and take as long as two years. It’s
also possible for MDR-TB to develop even further into extensively drug-
resistant TB (XDR-TB). This is why it’s important to finish your medications,
even if you feel better before you finish your dosage.
Outlook for pulmonary TB

Pulmonary TB is curable with treatment, but if left untreated or not fully
treated, the disease often causes life-threatening concerns. Untreated
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pulmonary TB disease can lead to long-term damage to these parts of the

body:
• lungs
• brain
• liver
• heart
• spine
New drugs and treatments are currently being developed to prevent latent TB
and TB, especially as MDR-TB grows. In some countries, this involves a
vaccine called Bacillus Calmette-Guérin (BCG). This vaccine is useful to
prevent severe forms of TB outside the lungs in children, but it doesn’t prevent
development of pulmonary TB.
How to prevent pulmonary TB

It can be difficult to avoid contracting TB if you work in an environment
frequented by people with TB or if you’re caring for a friend or family member
with TB.
Following are a few tips for minimizing your risk for pulmonary TB:
• Provide education on preventing TB like cough etiquette.

• Avoid extended close contact with someone who has TB.
• Air out rooms regularly.
• Cover your face with a mask that is approved for protection against TB.
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Anyone exposed to tuberculosis should be tested, even if they show no

symptoms. The Centers for Disease Control and Prevention has
detailed guidelines and precautionsTrusted Source for people who work or visit
a healthcare setting.
How to protect others
People with latent TB aren’t contagious and can go about their day-to-day
lives as usual.
But if you have pulmonary TB disease, you need to stay home and avoid
close contact with others. Your doctor will tell you when you’re no longer
contagious and can resume a regular routine.
BRONCHIAL ASTHMA
Asthma is an inflammatory disease of the airways to the lungs. It makes
breathing difficult and can make some physical activities difficult or even
impossible.
According to the Centers for Disease Control and Prevention

(CDC), approximately 27 million AmericansTrusted Source have asthma. It’s
the most common chronic condition among American children: 1 child out of
every 12Trusted Source has asthma.
To understand asthma, you need to understand a little about what happens

when you breathe.
Normally, with every breath you take, air goes through your nose and down
into your throat, into your airways, eventually making it to your lungs. There
are lots of small air passages in your lungs that help deliver oxygen from the
air into your bloodstream.
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Asthma symptoms occur when the lining of your airways swell and the
muscles around them tighten. Mucus then fills the airways, further reducing
the amount of air that can pass through.
These conditions then bring on an asthma “attack,” the coughing and

tightness in your chest that is typical of asthma.
Asthma symptoms
Symptoms of asthma include:
• coughing, especially at night, when laughing, or during exercise

• wheezing, a squealing or whistling sound made when breathing
• tightness in the chest
• fatigue
The type of asthma that you have can determine which symptoms you
experience.
Not everyone with asthma will experience these particular symptoms. If you
think the symptoms you’re experiencing could be a sign of a condition such as
asthma, make an appointment to see your doctor.
The first indication that you have asthma may not be an actual asthma
attack. Discover some early symptoms of asthma you may experience
instead.
Cause of asthma
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No single cause has been identified for asthma. Instead, researchers believe
that the breathing condition is caused by a variety of factors. These factors
include:
• Genetics. If a parent has asthma, you’re more likely to develop it.

• History of viral infections. People with a history of viral infections
during childhood are more likely to develop the condition.
• Hygiene hypothesis. This hypothesis proposes that babies aren’t
exposed to enough bacteria in their early months and years. Therefore,
their immune systems don’t become strong enough to fight off asthma
and other conditions.
• Early allergen exposure. Frequent contact with possible allergens and
irritants may increase your risk for developing asthma.
Asthma triggers
Certain conditions and environments may also trigger symptoms of asthma.

These triggers include:
• Illness. Respiratory illnesses such as the flu and pneumonia can trigger
asthma attacks.
• Exercise. Increased movement may make breathing more difficult.
• Irritants in the air. People with asthma may be sensitive to irritants
such as chemical fumes, strong odors, and smoke.
• Allergens. Animal dander, dust mites, and pollen are just a few
examples of allergens that can trigger symptoms.
• Extreme weather conditions. Conditions such as very high
humidity or low temperaturesmay trigger asthma.
• Emotions. Shouting, laughing, and crying may trigger an attack.
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The list of possible causes and triggers is extensive. Check out even more
examples here.
Treatment of asthma
Treatments for asthma fall into three primary categories: breathing exercises,
rescue or first aid treatments, and long-term asthma control medications.
Your doctor will determine the right treatment or combination of treatments for
you based on the type of asthma you have, your age, and your triggers.
Breathing exercises
These exercises can help you get more air into and out of your lungs. Over
time, this may help increase lung capacity and cut down on severe asthma
symptoms. Your doctor or an occupational therapist can help you learn
these breathing exercises for asthma.
Rescue or first aid treatments
These medications should only be used in the event of an asthma attack.

They provide quick relief to help you breathe again. Examples include:
• rescue inhalers and nebulizers, which are used with medicine that
needs to be inhaled deep into the lungs
• bronchodilators, which work to relax the tightened muscles in your lung
• anti-inflammatories, which target inflammation in your lungs that could
be preventing your breathing
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If you think that someone you know is having an asthma attack, you should sit
them upright and assist them in using their rescue inhaler or nebulizer. Two to
six puffs of medication should help ease their symptoms.
If symptoms persist for more than 20 minutes, and a second round of

medication doesn’t help, seek medical attention.
Long-term asthma control mediations
These medications should be taken daily to prevent symptoms. Some rescue

treatments, such as inhalers and nebulizers, can be used daily. However, your
doctor will need to adjust your dosages.
Several types of medications are used to treat asthma. Read more about each
one to understand their risks and benefits.
Asthma home remedies

In general, over-the-counter (OTC) medicines and alternative remedies aren’t
encouraged as treatments for asthma. If not treated properly, asthma can be
life-threatening.
However, these home remedies may help stop symptoms from escalating and
may be effective in an emergency:
Coffee or caffeinated tea
A chemical in caffeine acts similarly to the asthma drug theophylline. It opens

up airways and may ease symptoms of asthma for up to four hours.
Purchase coffee and tea online.

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Essential oils
Inhaling eucalyptus essential oil may ease breathing difficulties brought on by

asthma. Lavender and basil essential oils also show promise. However, for
some individuals, inhaling essential oils may make asthma worse. Strong
smells and chemicals can trigger asthma or worsen symptoms.
Find eucalyptus, lavender, and basil essential oils online.
Mustard oil
This fatty oil, made from pressed mustard seeds, can be massaged into the
skin to help open airways. Mustard oil is different than mustard essential oil, a
medicinal oil which shouldn’t be applied directly to the skin.
Shop for mustard oil.
Other home remedies may help ease symptoms of an asthma attack. Read
about even more home remedies that can allow you to breathe more
efficiently.
Bronchial asthma
Bronchial asthma is simply another name for the most common type of
asthma. Symptoms include coughing, wheezing, chest tightness, and
shortness of breath.
Unless a specific type of asthma is mentioned, most references made to

asthma are about bronchial asthma.
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Bronchitis vs. asthma
Despite having similar symptoms, bronchitis and asthma aren’t related

conditions. They both lead to inflamed airways that can make breathing
difficult, but key distinctions separate the two conditions.
For example, bronchitis causes a thick mucus when you cough, fever, chills,
and body aches. Asthma doesn’t cause these symptoms.
Like asthma, bronchitis can also be acute — that is, treatment will end the
symptoms — or chronic. Both chronic bronchitis and chronic asthma need to
be treated daily in order to avoid worsening symptoms. Learn more about the
similarities and differences between asthma and bronchitis.
Types of asthma
The most common type of asthma is bronchial asthma, which affects
the bronchi in the lungs.
Additional forms of asthma include childhood asthma and adult-onset asthma.

In adult-onset asthma, symptoms don’t appear until at least age 20.
Other types of asthma are described below.
Allergic asthma (extrinsic asthma)
Allergens trigger this type of asthma. These might include:
• pet dander from animals like cats and dogs

• food
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• mold
• pollen
• dust
Allergic asthma is more likely to be seasonal because it often goes hand-in-

hand with seasonal allergies.
Nonallergic asthma (intrinsic asthma)
Irritants in the air not related to allergies trigger this type of asthma. Irritants
might include:
• burning wood and cigarette smoke

• cold air
• air pollution
• viral illnesses
• air fresheners
• household cleaning products
• perfumes
Occupational asthma
Occupational asthma is a type of asthma induced by triggers in the workplace.

These include:
• dust
• dyes
• gases and fumes
• industrial chemicals
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• animal proteins
• rubber latex
These irritants can exist in a wide range of industries, including farming,

textiles, woodworking, and manufacturing.
Exercise-induced bronchoconstriction (EIB)
Exercise-induced bronchoconstriction (EIB) usually affects people within a few

minutes of starting exercise and up to 10–15 minutes after physical activity.
This condition was previously known as exercise-induced asthma (EIA).
Up to 90 percent of people with asthma also experience EIB, but not everyone
with EIB will have other types of asthma.
Nocturnal asthma
In this type of asthma, symptoms worsen at night.
Triggers that are thought to bring on symptoms at night include heartburn, pet
dander, and dust mites. The body’s natural sleep cycle may also trigger
nocturnal asthma.
Cough-variant asthma (CVA)
Cough-variant asthma doesn’t have classic asthma symptoms of wheezing

and shortness of breath. CVA is characterized by a persistent, dry cough.
Cough-variant asthma can lead to full-blown asthma flares that include the
other more common symptoms. Find out how to identify an asthma cough
here.
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Asthma diagnosis
There’s no single test or exam that will determine if you or your child has
asthma. Instead, your doctor will use a variety of criteria to determine if
symptoms are the result of asthma.
The following can help diagnose asthma:
• Health history. If you have family members with the breathing disorder,
your risk is higher. Alert your doctor to this genetic connection.
• Physical exam. Your doctor will listen to your breathing with
a stethoscope. They may also conduct a skin test, looking for signs of
an allergic reaction such as hives or eczema. Allergies increase your
risk for asthma.
• Breathing tests. Your doctor may use pulmonary function tests
(PFTs) to measure airflow into and out of your lungs. The most common
test, spirometry, requires you to blow into a device that can measure the
speed of the air.
Doctors don’t typically perform breathing tests in children under 5 years of

age. It’s difficult to get an accurate reading. Instead, they may prescribe
asthma medicines to your child and wait to see if symptoms improve. If they
do, your child likely has asthma.
For adults, your doctor may prescribe a bronchodilator or other asthma

medication if test results indicate asthma. Discover which types of doctors,
from pediatricians to pulmonologists, who are able to diagnose asthma.
If symptoms improve with the use of this medication, your doctor will continue
to treat your condition as asthma.
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Asthma prevention
Because researchers have yet to identify the exact cause of asthma, it’s
challenging to know how a person can prevent the inflammatory condition.
However, more information is known about preventing asthma attacks. These

strategies include:
• Avoiding triggers. Steer clear of chemicals, smells, or products that

have caused breathing problems in the past.
• Reducing exposure to allergens. If you’ve identified allergens, such
as dust or mold, that trigger an asthma attack, avoid them as best you
can.
• Getting allergy shots. Allergen immunotherapy is a type of treatment
that may help alter your immune system. With routine shots, your body
may become less sensitive to any triggers you encounter.
• Taking preventive medication. Your doctor may prescribe medicine
for you to take on a daily basis. This medicine may be used in addition
to the one you use in case of an emergency.
Your doctor can help you put an asthma action plan in place so that you know
which treatments to use and when. Get more information on asthma attack
plans and other prevention techniques here.
Asthma in children
Around 6 million childrenTrusted Source in the United States have asthma.
The majority of them experienced their first symptoms of this chronic
disease by age 5.
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Diagnosing asthma in children is difficult. Their airways are already small due
to their size. Common childhood illnesses such as head and chest colds can
further inflame the tissues in these airways. That can make detecting an
underlying breathing problem such as asthma hard.
Children with asthma may exhibit symptoms such as:
• difficulty eating or sucking

• panting during activities that shouldn’t leave them winded
• a nagging cough
• coughing, especially at night
• labored breathing
• rapid breathing that pulls the skin around their ribs or neck tight
• frequent colds that settle into the chest
Among older children, the most common symptoms include:
• wheezing, or a squealing sound, especially when exhaling

• feeling winded after physical activities
• chest tightness
• cough
These symptoms are easy to mistake for coughs and colds, both of which
young children are prone to in their earliest years.
However, if these symptoms are persistent, talk with your child’s doctor about
the possibility of asthma. Find out more about the symptoms of — and
treatments for — children with asthma.
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COPD vs. asthma

Chronic obstructive pulmonary disease (COPD) and asthma are commonly
mistaken for one another. They result in similar symptoms, including
wheezing, coughing, and trouble breathing. However, the two conditions are
quite different.
COPD is an umbrella term used to identify a group of progressive respiratory

diseases that include chronic bronchitis and emphysema. These diseases
cause reduced airflow due to inflammation in the airways. These conditions
may worsen over time too.
Asthma can occur at any age, with a majority of diagnoses coming in

childhood. Most people with COPD are at least 45Trusted Source at the time
of their diagnosis.
Over 40 percent of people with COPD also have asthma, and the risk for
having both conditions increases with age.
It’s not clear what causes asthma, but we know that asthma attacks are the
result of exposure to triggers such as physical activity or smells. These
triggers can make breathing problems worse.
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The most common cause of COPD is smoking. In fact, smoking accounts for
up to 9 out of 10 COPD-related deaths, according to the National Heart, Lung,
and Blood InstituteTrusted Source.
The goal of treatment for both asthma and COPD is to reduce symptoms so
you can maintain an active lifestyle. Compare and contrast the different
treatments used for asthma and COPD.
Management of asthma
In addition to using maintenance medications, you can take steps each day to
make yourself healthier and reduce your risk for asthma attacks. These
include:
• Eating a healthier diet. Eating a healthy, balanced diet can improve

your overall health, which may reduce the risks for asthma attacks. In
that same vein, research suggests that eliminating processed
foods may cut down on the risk of an asthma attack.
• Maintaining a healthy weight. Asthma tends to be worse in overweight
and obeseindividuals. Losing weight is healthy for your heart, your
joints, and your lungs.
• Quitting smoking. Irritants such as cigarette smoke can trigger
asthma. You also put yourself at greater risk for COPD.
• Exercising regularly. Activity can trigger an asthma attack, but regular
exercise may actually reduce the risk of breathing problems. Aerobic
activity can strengthen your lungs and help you breathe better.
• Managing stress. Stress can be a trigger for asthma symptoms. Stress
can also make stopping an asthma attack more difficult. Find healthy
ways to reduce your stress and anxiety.
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Nutrient-rich foods are vital to reducing symptoms, but food allergies can
trigger asthma symptoms. Get informed on the connection between what you
eat and your asthma symptoms.
Asthma risk factors

A combination of environmental and genetic factors may contribute to the
development of asthma. These risk factors for asthma include:
• Race. African-Americans and Puerto Ricans are more likely to develop

asthma.
• Sex. Boys are more likely than girls to be diagnosed with asthma in
childhood. However, in adulthood, women are more frequently
diagnosed with the condition than men.
• Genetics. Children born to parents with the disease are more likely to
develop it.
• Health history. People diagnosed with certain conditions, including
allergies and eczema, are more likely to also be diagnosed with asthma.
• Age. Asthma can and does develop in adulthood, but the majority of
asthma diagnoses are made while a person is still in childhood.
• Environment. People living in an area with heavy pollution are at a
greater risk for developing asthma.
• Weight. Children and adults who are overweight or obese are more
likely to develop asthma.
Other factors also increase your odds of being diagnosed with asthma. Find
out more about these risk factors here.
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Asthma pregnancy
Asthma affects 8 percent of women in their childbearing years, so it’s no
wonder that asthma is one of the most common diseases that pregnant
women can experience.
There’s no way to know how pregnancy will affect asthma. Some expecting
mothers don’t experience a change. For others, their pregnancy may make
their asthma better or even worse. If symptoms worsen, it’s more likely to
happen in your second and third trimesters.
Some women also experience the onset of asthma while they’re pregnant.
If you have asthma, you should work closely with your doctor during your
pregnancy to reduce risks for you and your growing fetus.
You may need to adjust the dosage of your maintenance medicine. Your
doctor may also want to change the emergency medicine you keep on hand in
the event that your symptoms are worse than they were before your
pregnancy.
It remains vital that you treat your asthma while you’re pregnant. Untreated
asthma can lead to complications, such as:
• severe morning sickness

• preterm labor
• pregnancy-induced high blood pressure
• preeclampsia
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If your baby isn’t getting enough oxygen, they can also experience health
complications. Understand the connection between pregnancy and asthma,
and learn how you can prevent the risks.
Long-term outlook
At the moment. there’s no cure for asthma. However, there are many effective
treatments that can decrease asthma symptoms. Lifestyle changes and
medications can also improve your quality of life.
The key is to become educated. The more you know, the better your lung
function will be and the better you’ll feel. Talk with doctor about:
• your type of asthma

• what triggers your symptoms
• what daily treatments are best for you
• your treatment plan for an asthma attack
PULMONARY EDEMA
Pulmonary edema is a condition in which the lungs fill with fluid. It’s also
known as lung congestion, lung water, and pulmonary congestion. When
pulmonary edema occurs, the body struggles to get enough oxygen and you
start to have shortness of breath.
But timely treatment for pulmonary edema and its underlying cause can
improve possible outcomes.
Causes of pulmonary edema

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There are several possible causes of pulmonary edema.
Congestive heart failure
The most common cause of pulmonary edema is congestive heart failure

(CHF). Heart failure happens when the heart can no longer pump blood
properly throughout the body. This creates a backup of pressure in the small
blood vessels of the lungs, which causes the vessels to leak fluid.
In a healthy body, the lungs will take oxygen from the air you breathe and put
it into the bloodstream. But when fluid fills your lungs, they cannot put oxygen
into the bloodstream. This deprives the rest of the body of oxygen.
Other medical conditions
Other less common medical conditions that can cause pulmonary edema
include:
• heart attack, or other heart diseases

• leaking, narrowed, or damaged heart valves
• sudden high blood pressure
• pneumonia
• kidney failure
• lung damage caused by severe infection
• severe sepsis of the blood, or blood poisoning caused by infection
External factors
Some external factors can also put extra pressure on the heart and lungs and
cause pulmonary edema. These outside factors are:
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• high altitude exposure

• illicit drug use or drug overdose
• lung damage caused by inhalation of toxins
• severe trauma
• major injury
• near drowning
Symptoms of pulmonary edema

In cases of pulmonary edema, your body will struggle to gain oxygen. This is
due to the amount of increasing fluid in the lungs preventing oxygen moving
into the bloodstream. Symptoms may continue to worsen until you get
treatment.
Symptoms depend on the type of pulmonary edema.
Long-term pulmonary edema
The symptoms for long-term pulmonary edema include:
• shortness of breath when being physically active

• difficulty breathing when lying down
• wheezing
• waking up at night with a breathless feeling that goes away when you sit
up
• rapid weight gain, especially in the legs
• swelling in the lower part of the body
• fatigue
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High-altitude pulmonary edema
Pulmonary edema due to altitude sickness, or not getting enough oxygen in

the air, will have symptoms that include:
• headaches
• irregular, rapid heartbeat
• shortness of breath after exertion and during rest
• coughing
• fever
• difficulty walking uphill and on flat surfaces
Get emergency assistance if these symptoms start to get worse. Do not drive
yourself to the hospital.
Diagnosis of pulmonary edema

You doctor will look for fluid in your lungs, or symptoms caused by its
presence. They will perform a basic physical examination and listen to your
lungs with a stethoscope, looking for:
• an increased heart rate

• rapid breathing
• a crackling sound from your lungs
• any abnormal heart sounds
Your doctor may also look at your neck for fluid buildup, legs and abdomen for
swelling, and if you have pale or blue-colored skin. They will also discuss your
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symptoms, and ask about your medical history. If they believe you have fluid
in your lungs, they’ll order additional tests.
Examples of tests used in diagnosing pulmonary edema include:
• complete blood count

• echocardiogram, or an ultrasound, to check for abnormal heart activity
• chest X-ray to see fluid
• blood tests to check oxygen levels
• electrocardiogram (ECG) to look for heart rhythm problems or signs of a
heart attack
Treatment of pulmonary edema

Pulmonary edema is a serious condition that requires quick treatment.
Oxygen is always the first line of treatment for this condition. Your healthcare
team may prop you up and deliver 100 percent oxygen through an oxygen
mask, nasal cannula, or positive pressure mask.
Your doctor will also diagnose the cause of pulmonary edema and prescribe
the appropriate treatment for the underlying cause.
Depending on your condition and the cause of your pulmonary edema, your
doctor may also give:
• Preload reducers. Thesehelp decrease pressures from the fluid going into
your heart and lungs. Diuretics also help reduce this pressure by
making you urinate, which eliminates fluid.
• These medications dilate your blood vessels and take
Afterload reducers.
pressure off your heart.
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• These will control your pulse, reduce high blood

Heart medications.
pressure, and relieve pressure in arteries and veins.
• Morphine. Thisnarcotic is used to relieve anxiety and shortness of
breath. But fewer doctors today use morphine due to the risks.
In severe cases, people with pulmonary edema may need intensive or critical
care.
In other cases of pulmonary edema, you may need treatment to help you
breathe. A machine will deliver oxygen under pressure to help get more air
into your lungs. Sometimes this can be done with a mask or cannula, also
called Continuous Positive Airway Pressure (CPAP).
Your doctor may need to insert an endotracheal tube, or breathing tube, down
your throat and use mechanical ventilation.
Pulmonary edema vs pleural

effusion
Sometimes pulmonary edema is confused with pleural effusion, another
condition that involves fluid buildup in the lungs. However, pleural effusion
specifically causes a buildup of fluids in the pleural tissues. These cover the
outside of each of your lungs as well as the inside of the chest wall.
Pleural effusion can be caused by CHF, poor nutrition, and pneumonia. It’s
also sometimes cancerous (malignant).
With pleural effusion, you may experience:
• breathing difficulties
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• a dry cough
• chest pain and discomfort
A chest x-ray can help diagnose pleural effusion. Your doctor may take a
biopsy from pleural tissues if cancer is suspected. Depending on the cause,
pleural effusion may be treated with a combination of fluid removal techniques
and surgery.
Pulmonary edema vs. pneumonia

Pneumonia is another serious condition of the lungs. Unlike edema,
pneumonia is caused by either a viral, fungal, or bacterial infection. As your
lungs become infected, fluid builds up in the air sacs (alveoli).
While both pulmonary edema and pneumonia cause a form of buildup in the
lungs, the former is primarily caused by CHF. Pneumonia, on the other hand,
is caused by an infection. A weakened immune system can increase your
chances of getting pneumonia from a common cold or flu.
Symptoms of pneumonia may include:
• high fever with chills

• cough with mucus that continues to worsen
• chest pain and discomfort
• nausea and/or vomiting
• diarrhea
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Pneumonia is one of the most common causes of hospitalization in children

and adults, according to the American Lung Association. When left untreated,
this condition can lead to:
• pleural effusion
• lung abscesses
• respiratory failure
• septic shock
• renal failure
Pulmonary edema isn’t a cause of pneumonia. However, the buildup of fluids

from pneumonia can lead to pleural effusion. Pneumonia requires immediate
treatment to prevent complications, which may require antibiotics and oxygen
therapy.
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When is it an emergency?
Call 911 or local emergency services immediately for medical help if you
experience any of these symptoms:
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• extreme breathing difficulties, or shortness of breath, like suffocating or

drowning
• inability to breathe
• anxiety related to trouble breathing
• cough that produces a pink, frothy mix of saliva and mucus
• chest pain
• rapid, irregular heartbeat
• blue or gray skin tone
• sweating along with breathing difficulties
These may be symptoms of acute pulmonary edema. Acute pulmonary

edema develops suddenly. If left untreated, the fluid in your lungs can cause
you to drown.
Risk factors of pulmonary edema

People with heart problems or heart failure are the most at risk for pulmonary
edema. Other factors that may put a person at risk include:
• history of pulmonary edema

• history of lung disease, such as tuberculosis or chronic obstructive
pulmonary disorder (COPD)
• vascular (blood) disorders
Prevention of pulmonary edema

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There is no way to fully prevent pulmonary edema. Those at high risk should
seek immediate attention if they develop symptoms of the disorder.
The best way to try and prevent pulmonary edema is by taking good care of
your health:
• Get a pneumonia vaccine.

• Get the flu vaccine, especially if you have heart problems or if you are
an older adult.
• Remain on diuretics after an episode of pulmonary edema to prevent a
reoccurrence.
You can also decrease your risk for heart failure, the most common cause of
pulmonary edema with the following steps:
• Visit your doctor regularly.

• Don’t smoke or use recreational drugs.
• Get regular exercise.
• Eat healthy foods.
• Maintain a normal weight.
Outlook for pulmonary edema

The outlook for pulmonary edema depends on the severity of your case. If you
have a moderate case and receive quick treatment, you will often have a full
recovery. Severe cases can be fatal if you delay treatment.
Be sure to see your doctor regularly, and get immediate help if you experience
any of the symptoms of pulmonary edema.
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2) PHARMACOLOGY
CARDIO-VASCULAR MODULE
GROUPS OF DRUGS USED IN THE
TREATMENT OF CAD
Coronary artery disease (CAD) occurs when the blood vessels can’t carry
enough blood and oxygen to the heart. Typically, this is because the vessels
are damaged, diseased, or blocked by a fatty substance called plaque. A
buildup of plaque causes a condition called atherosclerosis. This can lead to
CAD.
The goals of CAD treatment are to control symptoms and to stop or slow the
progression of the disease. Your doctor’s first treatment suggestion for CAD
might be lifestyle changes such as improved diet and exercise habits. If these
changes alone aren’t enough, your doctor may prescribe medications.
Drugs can play an important role in treating the complications of CAD.

According to the Cleveland Clinic, medication may be the first line of treatment
if artery blockage is less than 70 percent and doesn’t severely limit blood flow.
Read on to learn how drugs can help treat CAD and prevent related problems.
Medications to treat angina

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A common symptom of CAD is angina, or chest pain. If you have angina, your
doctor may prescribe short- or long-acting drugs called nitrates to reduce this
pain. Nitroglycerin, a type of nitrate, dilates blood vessels and allows the heart
to pump blood with less effort. These actions help relieve chest pain.
Beta-blockers are also often prescribed to treat angina. Beta-blockers can

slow your heart rate and lower your blood pressure. These actions decrease
the amount of oxygen your heart needs to work, which can help relieve
angina.
Medications to prevent clots

Plaque buildup in your blood vessels is a common feature of CAD. This
buildup can cause blood clots to form. These clots can block your vessels and
cause a heart attack.
Blood clots are formed by a buildup of platelets, also called thrombocytes, that
circulate in blood. These clotting cells bind together into a clot to help your
body stop bleeding after an injury. Certain drugs suppress the activity of
platelets, making it harder for blood clots to form within your arteries. This
effect reduces your risk of heart attack.
Examples of medications that help keep platelets from forming clots include:
• aspirin
• clopidogrel (Plavix)
• eptifibatide (Integrilin)
• ticlopidine (Ticlid)
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Cholesterol medications
High levels of cholesterol in your blood play a key role in causing
atherosclerosis. If you have high cholesterol and can’t lower it through a
healthy diet and increased physical activity, your doctor may prescribe daily
medications.
Examples of drugs that can help reduce your cholesterol levels include:
Bile acid sequestrants
These drugs help the body get rid of low-density lipoprotein (LDL), or “bad”
cholesterol. They’re also known as bile acid-binding resins. Examples include:
• cholestyramine (Questran)
• colesevelam hydrochloride (Welchol)
• colestipol hydrochloride (Colestid)
Fibrates
Fibrates lower triglycerides and raise high-density lipoprotein (HDL), or “good”

cholesterol. Examples include:
• clofibrate (Atromid-S)
• fenofibrate (Tricor)
• gemfibrozil (Lopid)
Statins
Statins work by decreasing overall cholesterol production. Examples include:

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• atorvastatin (Lipitor)
• fluvastatin (Lescol)
• lovastatin (Mevacor)
• pravastatin (Pravachol)
• rosuvastatin (Crestor)
• simvastatin (Zocor)
Niacin
Niacin increases HDL and decreases LDL. It’s also known as vitamin B-3.
Brand names include Niaspan and Niacor.
Medications that lower blood

pressure
Several types of drugs can help lower your blood pressure. These drugs can
also help your heart function better in other ways. They include:
Beta-blockers
High blood pressure can contribute to CAD because it can damage your blood
vessels. Beta-blockers help by slowing your heart rate and lowering your
blood pressure. These actions also reduce your risk of heart attack, a
complication of CAD.
Examples of beta-blockers include:
• atenolol (Tenormin)
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• carvedilol (Coreg)
• metoprolol (Toprol)
• nadolol (Corgard)
• propranolol (Inderide)
• timolol (Blocadren)
Calcium channel blockers
Calcium channel blockers help increase the amount of oxygen sent to the
heart. They relax the vessels of the heart, allowing oxygen-rich blood to flow
to it more easily. Calcium channel blockers also lower blood pressure and
relax other blood vessels in the body. These effects can decrease the amount
of oxygen the heart needs.
Examples of calcium channel blockers include:
• amlodipine (Norvasc)
• diltiazem (Cardizem)
• felodipine (Plendil)
• isradipine (DynaCirc)
• nicardipine (Cardene)
• nifedipine (Adalat, Procardia)
ACE inhibitors and ARBs
Angiotensin II is a hormone in your body that tightens your blood vessels.

Tightening blood vessels raise your blood pressure and increase the amount
of oxygen your heart needs.
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Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor

blockers (ARBs)reduce the effects of angiotensin II. They work to prevent
increases in blood pressure. These types of medications can lower your risk
of stroke or heart attack.
Examples of ACE inhibitors include:
• benazepril (Lotensin)
• captopril (Capoten)
• enalarpril (Vasotec)
• fosinopril
• lisinopril (Prinivil, Zestril)
• moexipril
• perindopril
• quinapril (Accupril)
• ramipril (Altace)
• trandolapril (Mavik)
Examples of ARBs include:
• irbesartan (Avapro)
• losartan (Cozaar)
• telmisartan (Micardis)
• valsartan (Diovan)
Talk with your doctor

Medications used to treat CAD can:
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• lower your cholesterol levels

• lower your blood pressure
• reduce your heart’s workload
• prevent blood clots
• increase the amount of oxygen sent to your heart
All of these actions can help reduce your CAD symptoms and prevent serious
complications, such as heart attack or stroke.
Your doctor can tell you more about drugs that can help your CAD. Questions
you might ask them include:
• What drugs are best suited for my symptoms and medical history?
• Am I taking any other medications that might interact with a CAD drug?
• Are there nondrug ways I can reduce my CAD symptoms?
MECHANISM OF DRUGS USED IN THE

TREATMENT OF HYPERTENSION
Hypertension can lead to many serious health problems, such as heart attack,
heart failure, stroke, and kidney disease. Treating high blood pressure early is
important in preventing these and other problems.
Dozens of different medications can help treat high blood pressure. These
drugs are called antihypertensives. They’re divided into many different
categories, each of which works differently and causes different side effects.
With so many options available, finding the best one for you may take some
time and patience. Your doctor will work with you to find the best treatment
plan for you, which may include one or more medications.
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Diuretics
Diuretics are some of the most commonly used drugs for treating high blood
pressure. They help the kidneys get rid of excess water and sodium, or salt.
This reduces the volume of blood that needs to pass through your blood
vessels, which lowers your blood pressure.
There are three major types of diuretics: thiazide, potassium-sparing, and loop
diuretics. Thiazide diuretics generally have fewer side effects than the others.
This is especially true when they’re prescribed in the low doses that are
generally used in treating early high blood pressure.
Examples of thiazide diuretics include:
• chlorthalidone (Hygroton)
• chlorothiazide (Diuril)
• hydrochlorothiazide (Hydrodiuril, Microzide)
• indapamide (Lozol)
• metolazone (Zaroxolyn)
Examples of potassium-sparing diuretics include:
• amiloride (Midamor)
• spironolactone (Aldactone)
• triamterene (Dyrenium)
Examples of loop diuretics include:
• bumetanide (Bumex)
• furosemide (Lasix)
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• torsemide (Demadex)
Examples of combination diuretics include:
• amiloride hydrochloride/hydrochlorothiazide (Moduretic)

• spironolactone/hydrochlorothiazide (Aldactazide)
• triamterene/hydrochlorothiazide (Dyazide, Maxzide)
Beta-blockers
Beta-blockers work by blocking the actions of chemicals in your body that
stimulate your heart. This allows your heart to beat with less speed and force.
Your heart pumps less blood through the blood vessels with each beat, so
blood pressure decreases.
Examples of these drugs include:
• acebutolol (Sectral)
• atenolol (Tenormin)
• betaxolol (Kerlone)
• bisoprolol (Zebeta)
• bisoprolol/hydrochlorothiazide (Ziac)
• metoprolol tartrate (Lopressor)
• metoprolol succinate (Toprol-XL)
• nadolol (Corgard)
• pindolol (Visken)
• propranolol (Inderal)
• solotol (Betapace)
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• timolol (Blocadren)
Angiotensin converting enzyme

(ACE) inhibitors
ACE inhibitors keep the body from making a hormone called angiotensin II,
which causes blood vessels to narrow. These medications lower blood
pressure by helping constricted blood vessels expand to let more blood
through.
Examples of ACE inhibitors include:
• benazepril (Lotensin)
• captopril (Capoten)
• enalapril (Vasotec)
• fosinopril (Monopril)
• lisinopril (Prinivil, Zestril)
• moexipril (Univasc)
• perindopril (Aceon)
• quinapril (Accupril)
• ramipril (Altace)
• trandolapril (Mavik)
Angiotensin II receptor blockers

(ARBs)
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This class of drugs also protects the blood vessels from angiotensin II. In
order to tighten blood vessels, angiotensin II must bind with a receptor
site. ARBs prevent that from happening. As a result, blood pressure is
lowered.
Examples of ARBs include:
• candesartan (Atacand)
• eprosartan (Teveten)
• irbesartan (Avapro)
• losartan (Cozaar)
• telmisartan (Micardis)
• valsartan (Diovan)
Calcium channel blockers

To move, all muscles need calcium to flow in and out of the muscle
cells. Calcium channel blockers help block calcium from entering the smooth
muscle cells of the heart and blood vessels.
This makes the heart beat with less force and helps blood vessels relax. As a
result, blood pressure decreases.
• amlodipine (Norvasc, Lotrel)

• diltiazem (Cardizem CD, Cardizem SR, Dilacor XR, Tiazac)
• felodipine (Plendil)
• isradipine (DynaCirc, DynaCirc CR)
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• nicardipine (Cardene SR)

• nifedipine (Adalat CC, Procardia XL)
• nisoldipine (Sular)
• verapamil (Calan SR, Covera HS, Isoptin SR, Verelan)
Alpha-blockers
In certain situations, your body makes hormones called catecholamines.
These hormones can bind to parts of cells called alpha-receptors. When this
occurs, your blood vessels narrow and your heart beats faster and with more
force. These actions cause your blood pressure to rise.
Alpha-blockers work by blocking catecholamines from binding to alpha-

receptors. As a result, blood can flow through the blood vessels more freely,
and your heart beats normally. This helps lower your blood pressure.
Examples of alpha-blockers include:
• doxazosin (Cardura)
• prazosin (Minipress)
• terazosin (Hytrin)
Alpha-beta-blockers
Alpha-beta-blockers have a combined effect. They block the binding of
catecholamine hormones to both alpha- and beta-receptors. Therefore, they
can decrease the constriction of blood vessels like alpha-blockers do. They
also slow down the rate and force of the heartbeat like beta-blockers do.
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Examples of alpha-beta-blockers include:
• carvedilol (Coreg)
• labetalol (Normodyne, Trandate)
Central agonists
These medications keep the brain from sending messages to the nervous
system telling it to release catecholamines. As a result, the heart doesn’t
pump as hard and blood flows more easily, lowering blood pressure.
Examples of central agonists include:
• methyldopa (Aldomet)
• clonidine (Catapres)
• guanfacine (Tenex)
Vasodilators
Vasodilators relax the muscles in the walls of blood vessels, especially in
small arteries called arterioles. This widens the blood vessels and allows
blood to flow through them more easily. As a result, blood pressure falls.
Examples of vasodilators include:
• hydralazine (Apresoline)
• minoxidil (Loniten)
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Aldosterone receptor antagonists

Aldosterone receptor antagonists work by blocking a chemical called
aldosterone. This action reduces the amount of fluids your body retains, which
helps lower your blood pressure.
Examples of aldosterone receptor antagonists include:
• eplerenone (Inspra)
• spironolactone (Aldactone)
Direct renin inhibitors

A newer type of blood pressure medication is called direct renin inhibitors
(DRIs). These drugs block a chemical in your body called renin. This action
helps widen your blood vessels, which lowers your blood pressure.
The only type of DRI that is currently available in the United States is:
• aliskiren (Tekturna)
High blood pressure drug

treatment plans
For most people, the first-choice medication for high blood pressure is a
thiazide diuretic. For other people, a diuretic alone is not enough to control
blood pressure. In these cases, a diuretic may be combined with a beta-
blocker, ACE inhibitor, angiotensin II receptor blocker, or calcium channel
blocker. Adding a second medication may lower your blood pressure more
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quickly than using a diuretic alone. Also, it allows you to take less of each
medication, which may reduce side effects.
Combination drugs
If your doctor thinks you need more than one drug to manage your blood
pressure, they may prescribe a combination medication. For instance, they
may prescribe a beta-blocker with a diuretic, or an ARB with a calcium
channel blocker.
Using these combination medications may be more convenient than taking

several different drugs each day.
Many combination medications to treat high blood pressure are available.

Examples include:
• triamterene/hydrochlorothiazide (Dyazide) — triamterene and

hydrochlorothiazide are both diuretics
• valsartan/hydrochlorothiazide (Diovan HCT) — valsartan is an ARB and
hydrochlorothiazide is a diuretic
Treating for multiple conditions
The type of blood pressure medication your doctor prescribes may depend on
what other health problems you have. For example, if you have coronary
artery disease (CAD) and high blood pressure, your doctor may prescribe a
beta-blocker. If you have had a myocardial infarction due to CAD, a beta-
blocker can lower your blood pressure and decrease your overall risk of
death.
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If you have diabetes, your doctor may choose an ACE inhibitor or an ARB.
That’s because these drugs can help protect the kidneys from diabetic
damage by lowering the blood pressure in your kidneys.
Talk with your doctor

High blood pressure is a serious condition that requires treatment to prevent
more severe health problems.
Don’t worry if you’re confused by all of your medication options. Your doctor
can tell you which drugs might work best for you. Together, you can put
together a treatment plan to get your blood pressure under control.
Some questions to ask your doctor include:
• Do I need medication to control my blood pressure?

• Am I at high risk of certain side effects from blood pressure medication?
• Am I taking any other drugs that might interact with my blood pressure
medication?
• Would a combination blood pressure medication be a good option for
me?
• Do you recommend improved diet and exercise as a way to lower my
blood pressure?
RESPIRATORY MODULE
ANTI-ASTHMATIC DRUGS
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The first step in managing your asthma symptoms is to know and avoid your
personal asthma triggers. Still, avoidance only goes so far, so you may need
an asthma drug to help control your symptoms.
The right medication will depend on a range of factors, including your age,
symptoms, triggers, and response to the drugs. Effective asthma medications,
including those recommended by the American Lung Association, aren’t
available over the counter (OTC). In fact, OTC asthma medications are
generally discouraged. Your doctor can prescribe the medication that’s best
for you.
Knowing what medications are available can help you work with your doctor to
create your treatment plan. Read on to learn about the types of asthma drugs
available today, what they treat, and what side effects they may cause.
Inhalers and nebulizers

Asthma medication comes in various forms, including tablets, liquids,
injections, and inhalers. Many medications come as sprays or powders that
need to be inhaled deep into your lungs. You can take these using either an
inhaler or a nebulizer. Both can deliver fast-acting or long-term medicines.
The device you use won’t change the effectiveness of the drug. It’s a matter of
personal preference, and there are pros and cons to each method.
Inhalers
These handheld devices are used to pump medicine into your lungs. They
require some coordination on the user’s part, because you have to press the
apparatus and then inhale the medication. Inhalers are small, light, and
portable, but that means they can also be easy to lose. If you or your child
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uses an inhaler, be sure to have backups. You don’t want to discover you’ve
lost the inhaler when you’re having a flare-up.
Inhalers come in two types: metered dose inhaler (MDI) and dry powder
inhaler (DPI).
An MDI delivers a measured spritz of medicine when you press the inhaler.
Some MDI inhalers count the doses used, so you know when the medicine is
about to run out. You can also use a spacer with an MDI inhaler to make it
easier to use. A spacer attaches to the inhaler and “holds” the medicine in a
small chamber, so you can inhale it when you’re ready. This works well for
young kids and babies. You can attach either a mouthpiece or a facemask to
the spacer for easy inhalation.
A dry powder inhaler releases medicine in powder form. To use it, you inhale
powder forcibly out of the inhaler. This method requires a bit more work on the
user’s part, and generally isn’t the best choice for young kids.
Nebulizers
Nebulizers are plug-in or battery-powered devices that turn liquid asthma

medicines into a mist that’s easy to inhale. They’re especially good for kids,
because they’re automatic. To receive the medicine, you wear the nebulizer’s
mouthpiece or facemask, and then breathe in the mist slowly. It usually takes
between 5 and 10 minutes to breathe in the medicine from the nebulizer. The
downside is that the machines need a power source and are less portable
than inhalers. They can be bulky and loud.
Bronchodilators and anti-

inflammatories
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Asthma medications typically fall into two groups: bronchodilators and anti-
inflammatories. They work by targeting the two main symptoms of asthma.
Bronchodilators target the tightened muscles in your lungs that are restricting
your airways. These drugs help relax the lung muscles. This widens your
airways and makes it easier for you to breathe. Bronchodilators are used for
quick relief from asthma symptoms.
Anti-inflammatory agents target inflammation in your lungs. They reduce lung

swelling and irritation, which helps improve your breathing. Anti-inflammatory
drugs are used for daily maintenance to help prevent asthma symptoms.
Quick-relief medications
Asthma drugs are further divided between quick-relief and long-term
medications. All quick-relief medications are bronchodilators.
Quick-relief medications are also called rescue therapy. They’re used to

provide rapid relief from asthma flare-ups or more serious attacks.
Short-acting beta agonists
These inhaled medications provide near-instant relief during an asthma

attack, and the relief can last for several hours. Short-acting beta agonists are
the drugs of choice for treating exercise-induced attacks. Examples include:
• albuterol (ProAir HFA, Ventolin HFA)

• levalbuterol (Xopenex HFA)
The more common side effects of these drugs include:

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• shakiness
• excitability
• headache
• throat irritation
• fast heart rate
In rare and serious cases, these drugs may cause heart arrhythmias.
Anticholinergics
Anticholinergics are another class of fast-acting, inhalable bronchodilators that

can provide quick relief from an asthma attack. One example is ipratropium
bromide (Atrovent HFA).
The more common side effects of anticholinergics include:
• trouble breathing
• nosebleed
• nasal dryness
• nasal irritation
• dry mouth
Rare but serious side effects include bronchospasms, which are muscle
spasms in the lungs which narrow your airways. Rare side effects also include
worsening of pre-existing heart arrhythmias.
Long-term asthma control

medications
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Long-term asthma control medications are taken daily. They’re used to

prevent asthma symptoms rather than treat sudden asthma attacks. For long-
term treatment, your doctor may prescribe an anti-inflammatory drug, a
bronchodilator, or a combination of the two.
Long-term asthma control medications are divided into the following groups.
Inhalable corticosteroids
These anti-inflammatory drugs are the strongest and most commonly

prescribed long-term asthma drugs. Examples of these drugs include:
• beclomethasone (QVAR)
• budesonide (Pulmicort Flexhaler)
• flunisolide (Aerospan)
• fluticasone (Flovent Diskus, Flovent HFA)
• mometasone (Asmanex)
The more common side effects of inhalable corticosteroids include:
• throat irritation
• nosebleed
• headache
• nose irritation
Rare but serious side effects can include:
• bronchospasm
• vision problems
• increased blood pressure in the eyes
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• decreased growth in children
Oral corticosteroids
Corticosteroids are systemic drugs, which means they affect your entire body.
They can be used to treat severe asthma symptoms. These drugs are anti-
inflammatories, and they work by relieving swelling and inflammation in your
airways. Oral corticosteroids are taken by mouth.
• prednisone
• methylprednisolone
• hydrocortisone
• weight gain
• high blood sugar levels
• trouble sleeping
• slow wound healing
Long-term use of corticosteroids can cause side effects that may be serious.
Therefore, these drugs should only be used for short-term treatment.
Examples of serious side effects include:
• peptic ulcers
• osteoporosis
• glucose intolerance
• weight gain
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Long-acting beta agonists
Long-acting beta agonists (LABAs) are bronchodilators. They’re used to help

prevent asthma attacks and are typically taken twice per day using an inhaler.
They're always used along with an inhalable corticosteroid. These drugs are
fast-acting and can provide relief for up to 12 hours.
• formoterol (Perforomist)
• salmeterol (Serevent Diskus)
The more common side effects of these drugs include headache and muscle
pain. Rare but serious side effects can include bronchospasm and throat
spasm.
Combination inhalers
Combination inhalers are common prescriptions for asthma. They include a

combination of a corticosteroid and a LABA. Combinations available in the
United States include:
• budesonide and formoterol (Symbicort)

• fluticasone and salmeterol (Advair Diskus)
The more common side effects of these drugs include headache and throat
infection. Rare but serious side effects can include heart arrhythmias,
increased blood pressure, and bronchospasm.
Leukotriene modifiers
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Leukotriene modifiers are considered anti-inflammatory drugs, but they work

differently from corticosteroids. They come in tablet form and work by blocking
the action of leukotrienes. Leukotrienes are substances in your lungs that
cause the air passages to constrict. They also cause your lungs to make
excess mucus.
Examples of leukotriene modifiers include:
• montelukast (Singulair)
• zafirlukast (Accolate)
• zileuton (Zyflo, Zyflo CR)
The more common side effects of these drugs include headache, stomach
pain, and muscle pain. More serious side effects can include liver damage,
blood disorders, and seizures.
Methylxanthines
Methylxanthines are bronchodilators that are also thought to have some anti-
inflammatory effects. These drugs come as pills. One example of a
methylxanthine is theophylline (Theochron, Theo-24, Elixophyllin).
These drugs are rarely prescribed. This is because they require close
monitoring to make sure that the amount of drug in your body stays within a
narrow range. If the amount goes above that range, it puts you at risk of
serious side effects such as heart arrhythmias and seizures.
• headache
• trouble sleeping
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• nausea
• vomiting
Immunomodulators
Immunomodulators are also called biologics. They affect your immune

system, blocking substances that cause asthma attacks. These drugs are
typically only prescribed for people who can’t control their asthma symptoms
with other types of asthma medications. Examples of these drugs include:
• mepolizumab (Nucala)
• omalizumab (Xolair)
• reslizumab (Cinqair)
Each of these drugs can cause different side effects, but the common ones
include:
• headache
• tiredness
• injection site reactions
• muscle and joint pain
• infections
More serious side effects can include:
• hypersensitivity reactions, which can include anaphylaxis

• bronchospasm
• heart attack
• stroke
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Outlook
There are many medication options for treating your asthma symptoms. The
type of medication you take, and how you take it, depends on factors such as
your age, the severity of your symptoms, your triggers, and your lifestyle.
Keeping up to date on the medications available will help you best manage
your asthma. Talk to your doctor regularly about your symptoms and how
each medication is working for you. They can continue to help you tailor your
treatment plan.
ANTI-TUBERCULOSIS DRUGS
Many bacterial infections are treated with antibiotics for a week or two, but TB
is different. People diagnosed with active TB disease generally have to take a
combination of medications for six to nine months. The full treatment course
must be completed. Otherwise, it’s highly likely a TB infection could come
back. If TB does recur, it may be resistant to previous medications and be
much more difficult to treat.
Your doctor may prescribe multiple medications because some TB strains are
resistant to certain drug types. The most common combinations of
medications for active TB disease include:
• isoniazid
• ethambutol (Myambutol)
• pyrazinamide
• rifampin (Rifadin, Rimactane)
• rifapentine (Priftin)
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Some drugs may be used as add-on therapy to the current drug-resistant combination
treatment, including:
• Bedaquiline (Sirturo)
• Linezolid (Zyvox)
Medication side effects
Serious side effects of TB drugs aren't common but can be dangerous when they do
occur. All tuberculosis medications can be highly toxic to your liver. When taking these
medications, call your doctor immediately if you experience any of the following:
• Nausea or vomiting
• Loss of appetite
• A yellow color to your skin (jaundice)
• Dark urine
• A fever that lasts three or more days and has no obvious cause
3) FORENSIC MEDICINE
MEDICO-LEGAL ASPECTS OF SUDDEN
DEATH DUE TO CARDIO-VASCULAR
DISEASES
Abstract
The investigation of sudden or unexpected death has got immense importance where the vital objective
of the investigation is to exclude an unnatural cause of death. Total 2509 autopsies were performed
during January 2001 to December 2002 (2 years), out of which 224(8.92%) were sudden deaths. Most of
the sudden deaths were in the middle age group i.e. 31-50 years of age. Male predominates female
among all sudden deaths with male: female ratio 1:0.178. Cardiovascular causes were the leading causes
of death followed by respiratory causes among all sudden deaths. Death due to coronary artery disease
amounts to almost half of all sudden deaths (42.85%). The role of histopathological examination in
confirmation of cause of death was discussed.
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Key words:
Sudden death, Natural death, Unexpected Death, Autopsy.
Introduction:
Natural deaths undoubtedly constitute a significant portion of deaths, which undergo autopsy for
investigation of death. In most of the natural deaths in such instances, the death has occurred suddenly
or unexpectedly without any obvious disease. There are instances when a healthy person with no
previous history of any disease or precipitating factor, if found dead, creates suspicion of foul play. In
few cases, the physician has not attended at the time of terminal event of death or attending physician
cannot determine a cause of death or death is suspicious. In such cases, after completion of autopsy, the
outcome may often reveal some natural disease, the presence of which may trigger issue like
association of disease with trauma, work, crime etc. and its relative contribution towards death. The
study of sudden death gives systemic view of differential diagnosis of cause of death and to make a
logical choice of most likely cause will help to improve the mortality statistics, assist the legal authorities
and satisfy the bereaved relatives.
Material & Methods:

The present study has been conducted in the Department of Forensic Medicine, Government Medical
College & Hospital, Aurangabad (Maharashtra), during the period of 1st January 2001 to 31st December
2002. The material for the present study consists of the cases where the deceased had died suddenly
and / or unexpectedly and had been subjected to medico-legal autopsy. The criteria for selection of
cases was as per definition of sudden death - 'sudden death is a death which is not known to have been
caused by any trauma, poisoning or violent asphyxia and where death occurs all of a sudden or within 24
hrs of the onset of the terminal symptoms'. A careful autopsy examination was carried out in every case
and the whole organ or pieces of organ showing gross pathologic changes were preserved for
histopathological examination. After the receipt of histopathological report, final opinion as to cause of
death was given. The findings were recorded and analysed statistically.
Observation:
During the period of study, total 2509 medico-legal autopsies were carried out. Out of which 224 cases
(8.92%) were due to sudden death with known natural cause of death. Age wise distribution showed
maximum number of cases belonged to age group 31-40 years (28.50%) and 41-50 years (24.10%) with
male predominance. Sexwise distribution showed male predominance with male: female ratio 1:0178.
(Table No.1) Among the causes of sudden death, 111 cases (49.55%) were due to cardiovascular causes,
61 cases (27.23%) were due to respiratory causes, 27 cases (12.05%) were due to central nervous
system causes, 18 cases (8.03%) were due to gastrointestinal causes, 2 cases (0.89%) were due to
genitourinary causes and in 5 cases (2.23%), no clear-cut cause was established. (TableNo.2) Amongst
the cardiovascular causes, coronary artery disease was the leading cause of death (86.47%) with male
predominance. Out of 61 cases died of respiratory diseases, Pulmonary Koch's (36.06%), Pneumonia
(26.22%) and combinations of two (29.50%) were leading causes of death. (TableNo.3) Recent
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myocardial infarction JIAFM, 2006 : 28 (1) ISSN : 0971-0973 28 was seen in 32 cases (33.33%)and in 14
cases (14.58%), old myocardial infarction was seen on gross examination.
Discussion:
The term "sudden" has no agreed universal definition. In the material for the various studies, the
duration of the death process has ranged from 1-24 hours, but it is difficult to determine exactly how
long the fatal symptoms have been present, as death often occurs before the victim reaches hospital, in
such circumstances no data on the symptoms are available for want of eye witnesses. In the present
study, the incidence of sudden death was 8.92% (224/2509) amongst all the medico-legal autopsies
conducted during the study period. The findings of incidence of sudden death in the present study are
somewhat consistent with the study of T. Sarkoija et al (5%)1 and Anders Siboni et al (4.06%)2 . This
finding is inconsistent with that reported by A. Meina Singh et al (2.66%)3 and Ivar Nordrum et al
(27.8%)4 . The inconsistency is mainly due to differences in selection of cases due to lack of proper
definition of sudden death. Age distribution for the present study showed most of the cases belonged to
age group 31-40 years (28.50%) and 41-50 years (24.10%). (Table No. 1) This finding matches with the
study of A. Meina Singh et al (34.5%)3 , Kagne R.N. et al (19%)5 , R. M. Whitington et al6 , T. Sarkoija et
al1 . From all above these studies, it is seen that the maximum number of sudden deaths are seen in the
middle age (31-50 years). This may be due to westernization of Indian society, sedentary lifestyle with
increased smoking and alcohol consumption habit. Out of 224 cases of sudden death, 190 (84.8%) were
male and 34 (15.1%) were female with male: Female ratio 1:0.178. (TableNo.1) This finding is consistent
with the study of T. Sarkoija et al (82%)1 , Anthony Thomas et al (73.9%)7 , Ivar Nordrum et al (79.67%)4
& A. Meina Singh et al (94.5%)3 . Although there are numerous causes of sudden death, cardiovascular
causes are the principle cause among sudden death in the present study. Out of 224 cases of sudden
death, 111 cases (49.55%) were due to cardiovascular causes, of which 102 (91.89%) were male and 9
(8.10%) were female. (Table No.2) Dr. K.S.Narayan Reddy8 and Apurba Nandy9 stated that most of the
deaths were due to cardiovascular causes about 45-50%. Similar findings were seen in the study of
Kuller Lewis et al (49.50%)10, Anders Siboni et al (46.20%)2 , Di Maio V.J.M. et al11 (60.9%), T. Sarkoija
et al (61%)1 , James Luke et al (38%)12, Ivar Nordrum et al (69.15%)4 , Anthony Thomas et at (69.5%)7 .
Coronary artery disease was not only the principle cause among cardiovascular causes (86.47%) but also
important cause among sudden death amounting to 42.85% with male predominance, which is
consistent with previous studies1, 4,7,11,12,13. In the present study, out of 224 cases of sudden deaths,
61 cases (27.23%) were due to respiratory causes. The important among respiratory causes were
Pulmonary Koch's (36.06%), Pneumonia with pulmonary Koch's (29.50%) and pneumonia (26.22%).
(Table No 2,3) This finding of deaths due to respiratory causes are comparatively higher as compared to
other studies2, 3,4,7,8,9,11,12, . This may be due to cases of pulmonary Koch's and pneumonia are
higher in our studies. This may be due to lower economic status, increased pollution and treatment
defaulter in pulmonary Koch's patients.
Conclusion:
The study reveals that
1. The incidence of sudden death among the total medico-legal autopsies performed is 8.92%.
2. Adults between the ages of 31-50 years are most vulnerable to sudden death.
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3. The marked preponderance of males in the present study is significant.
4. Cardiovascular disease accounts for the greatest number of sudden death.
5. Coronary artery disease is not only the main cause of cardiovascular deaths, but also of all sudden
deaths.
6. Histopathological study helps in confirmation of the cause of death in sudden death cases.
7. The study can be of great help in positively convincing and counseling bereaved relatives of deceased
about cause and manner of death. This is particularly important when relatives complain of negligence
by hospital authorities out of ignorance, trauma of death and suspicion expressed by unrelated persons.
In last few years, medical science has changed a lot due to invention in medical and paramedical
fields. The diseases which were not in position to be diagnosed during life in past, can now be easily
diagnosed. In such cases newer techniques are found to be helpful in diagnosis of cause of death
especially in sudden unexpected deaths in persons without any signs of disease.
RESPIRATORY MODULE
ASPHYXIA
Asphyxia or asphyxiation is a condition of deficient supply of oxygen to the body that arises from
abnormal breathing. An example of asphyxia is choking. Asphyxia causes generalized hypoxia,
which affects primarily the tissues and organs. There are many circumstances that can induce
asphyxia, all of which are characterized by an inability of an individual to acquire sufficient oxygen
through breathing for an extended period of time. Asphyxia can cause coma or death.
In 2015 about 9.8 million cases of unintentional suffocation occurred which resulted in 35,600
deaths.[1][2] The word asphyxia is from Ancient Greek "squeeze" (throb of heart).[3]
Cause
Situations that can cause asphyxia include but are not limited to: the constriction or obstruction of
airways, such as from asthma, laryngospasm, or simple blockage from the presence of foreign
materials; from being in environments where oxygen is not readily accessible: such as underwater,
in a low oxygen atmosphere, or in a vacuum; environments where sufficiently oxygenated air is
present, but cannot be adequately breathed because of air contamination such as excessive smoke.
Other causes of oxygen deficiency include but are not limited to:
• Acute respiratory distress syndrome

• Carbon monoxide inhalation, such as that from a car exhaust and the smoke's emission from a
lighted cigarette: carbon monoxide has a higher affinity than oxygen to the hemoglobin in the
blood's red blood corpuscles, bonding with it tenaciously, and, in the process, displacing oxygen
and preventing the blood from transporting oxygen around the body
• Contact with certain chemicals, including pulmonary agents (such as phosgene) and blood
agents (such as hydrogen cyanide)
• Drowning
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• Drug overdose
• Exposure to extreme low pressure or vacuum from spacesuit damage (see space exposure)
• Hanging, whether suspension or short drop hanging
• Self-induced hypocapnia by hyperventilation, as in shallow water or deep water blackout and
the choking game
• Inert gas asphyxiation
• Congenital central hypoventilation syndrome, or primary alveolar hypoventilation, a disorder of
the autonomic nervous system in which a patient must consciously breathe; although it is often
said that persons with this disease will die if they fall asleep, this is not usually the case
• Respiratory diseases
• Sleep apnea
• A seizure which stops breathing activity
• Strangling
• Breaking the wind pipe
• Prolonged exposure to chlorine gas
Smothering
Smothering is the mechanical obstruction of the flow of air from the environment into the mouth
and/or nostrils, for instance, by covering the mouth and nose with a hand, pillow, or a plastic
bag.[4] Smothering can be either partial or complete, where partial indicates that the person being
smothered is able to inhale some air, although less than required. In a normal situation, smothering
requires at least partial obstruction of both the nasal cavities and the mouth to lead to asphyxia.
Smothering with the hands or chest is used in some combat sports to distract the opponent, and
create openings for transitions, as the opponent is forced to react to the smothering.
In some cases, when performing certain routines, smothering is combined with simultaneous
compressive asphyxia. One example is overlay, in which an adult accidentally rolls over onto an
infant during co-sleeping, an accident that often goes unnoticed and is mistakenly thought to
be sudden infant death syndrome.[4] Other accidents involving a similar mechanism are cave-ins or
when an individual is buried in sand or grain.
In homicidal cases, the term burking is often ascribed to a killing method that involves simultaneous
smothering and compression of the torso.[5] The term "burking" comes from the method William
Burke and William Hare used to kill their victims during the West Port murders. They killed the
usually intoxicated victims by sitting on their chests and suffocating them by putting a hand over their
nose and mouth, while using the other hand to push the victim's jaw up. The corpses had no visible
injuries, and were supplied to medical schools for money. [6]
Compressive asphyxia
Compressive asphyxia (also called chest compression) is mechanically limiting expansion of the
lungs by compressing the torso, hence interfering with breathing. Compressive asphyxia occurs
when the chest or abdomen is compressed posteriorly.[7] "Traumatic asphyxia" or "crush asphyxia"
usually refers to compressive asphyxia resulting from being crushed or pinned under a large weight
or force. An example of traumatic asphyxia includes cases where an individual has been using a car-
jack to repair a car from below, and is crushed under the weight of the
vehicle.[5] Pythons, anacondas, and other constrictor snakes kill through compressive asphyxia. In
cases of co-sleeping ("overlay"), the weight of an adult or large child may compress an infant's
chest, preventing proper expansion of the chest. Risk factors include large or obese adults, parental
fatigue or impairment (sedation by drugs or alcohol) of the co-sleeping adult and a small shared
sleeping space (for example, both adult and infant sharing a couch).
In fatal crowd disasters, compressive asphyxia from being crushed against the crowd causes the
large part of the deaths, rather than blunt trauma from trampling. This is what occurred at the Ibrox
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disaster in 1971, where 66 Rangers fans died; the 1979 The Who concert disaster where 11 died;
the Luzhniki disaster in 1982, when 66 FC Spartak Moscow fans died; and at the Hillsborough
disaster in 1989, 96 Liverpool fans were crushed to death in an overcrowded terrace, 95 of the 96
victims died from compressive asphyxia, with 93 dying directly from it and 2 others dying from
related complications.[8] In confined spaces, people push and lean against each other; evidence from
bent steel railings in several fatal crowd accidents have shown horizontal forces over 4500 N
(equivalent to a weight of approximately 450 kg, or 1014 lbs). In cases where people have stacked
up on each other forming a human pile, estimations have been made of around 380 kg (838 lbs) of
compressive weight in the lowest layer.[9]
"Positional" or "restraint" asphyxia is when a person is restrained and left alone prone, such as in a
police vehicle, and is unable to reposition himself or herself in order to breathe. The death can be in
the vehicle, or following loss of consciousness to be followed by death while in a coma, having
presented with anoxic brain damage. The asphyxia can be caused by facial compression, neck
compression, or chest compression. This occurs mostly during restraint and handcuffing situations
by law enforcement, including psychiatric incidents. The weight of the restraint(s) doing the
compression may contribute to what is attributed to positional asphyxia. Therefore, passive deaths
following custody restraint that are presumed to be the result of positional asphyxia may actually be
examples of asphyxia occurring during the restraint process.
Chest compression is also featured in various grappling combat sports, where it is sometimes called
wringing. Such techniques are used either to tire the opponent or as complementary or distractive
moves in combination with pinning holds,[10] or sometimes even as submission holds. Examples of
chest compression include the knee-on-stomach position; or techniques such as leg scissors (also
referred to as body scissors and in budō referred to as do-jime;[11] 胴絞, "trunk strangle" or "body
triangle")[12] where a participant wraps his or her legs around the opponent's midsection and
squeezes them together.[13]
Pressing is a form of torture or execution that works through asphyxia e.g. burking.
Perinatal asphyxia
Perinatal asphyxia is the medical condition resulting from deprivation of oxygen (hypoxia) to a
newborn infant long enough to cause apparent harm. It results most commonly from a drop in
maternal blood pressure or interference during delivery with blood flow to the infant's brain. This can
occur as a result of inadequate circulation or perfusion, impaired respiratory effort, or
inadequate ventilation.[14] There has long been a scientific debate over whether newborn infants with
asphyxia should be resuscitated with 100% oxygen or normal air.[14] It has been demonstrated that
high concentrations of oxygen lead to generation of oxygen free radicals, which have a role
in reperfusion injury after asphyxia.[15] Research by Ola Didrik Saugstad and others led to new
international guidelines on newborn resuscitation in 2010, recommending the use of normal air
instead of 100% oxygen.
CARDIO-VASCULAR MODULE
PREVENTION OF CVD
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Heart disease may be a leading cause of death, but that doesn't mean you have to
accept it as your fate. Although you lack the power to change some risk factors — such
as family history, sex or age — there are some key heart disease prevention steps you
can take to reduce your risk.
You can avoid heart problems in the future by adopting a healthy lifestyle today. Here
are seven heart disease prevention tips to get you started.
1. Don't smoke or use tobacco

Smoking or using tobacco of any kind is one of the most significant risk factors for
developing heart disease. Chemicals in tobacco can damage your heart and blood
vessels, leading to narrowing of the arteries due to plaque buildup (atherosclerosis).
Atherosclerosis can ultimately lead to a heart attack.
Carbon monoxide in cigarette smoke replaces some of the oxygen in your blood. This
increases your blood pressure and heart rate by forcing your heart to work harder to
supply enough oxygen.
Women who smoke and take birth control pills are at greater risk of having a heart
attack or stroke than are those who don't smoke or take birth control pills, because both
can increase the risk of blood clots.
When it comes to heart disease prevention, no amount of smoking is safe. But, the
more you smoke, the greater your risk. Smokeless tobacco, low-tar and low-nicotine
cigarettes, and secondhand smoke also can be risky. Even so-called social smoking —
smoking only while at a bar or restaurant with friends — can be dangerous and increase
the risk of heart disease.
The good news, though, is that your risk of heart disease begins to lower soon after
quitting. Your risk of coronary heart disease significantly reduces one year after quitting
smoking. Your risk of coronary heart disease drops almost to that of a nonsmoker in
about 15 years. And no matter how long or how much you smoked, you'll start reaping
rewards as soon as you quit.
2. Exercise for about 30 minutes on most days of the week

Getting some regular, daily exercise can reduce your risk of heart disease. And when
you combine physical activity with other lifestyle measures, such as maintaining a
healthy weight, the payoff is even greater.
Physical activity can help you control your weight and reduce your chances of
developing other conditions that may put a strain on your heart, such as high blood
pressure, high cholesterol and diabetes.
In general, you should do moderate exercise, such as walking at a brisk pace, for about
30 minutes on most days of the week. That can help you reach the Department of
Health and Human Services recommendations of 150 minutes a week of moderate
aerobic activity, 75 minutes a week of vigorous aerobic activity, or a combination of
moderate and vigorous activity. For even more health benefits, aim for 300 minutes of
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moderate aerobic activity or 150 minutes of vigorous aerobic activity every week. In
addition, aim to do strength training exercises two or more days a week.
However, even shorter amounts of exercise than these recommendations can offer
heart benefits, so if you can't meet those guidelines, don't give up. You can even get the
same health benefits if you break up your workout time into three 10-minute sessions
most days of the week.
And remember that activities such as gardening, housekeeping, taking the stairs and
walking the dog all count toward your total. You don't have to exercise strenuously to
achieve benefits, but you can see bigger benefits by increasing the intensity, duration
and frequency of your workouts.
3. Eat a heart-healthy diet

Eating a healthy diet can reduce your risk of heart disease. Two examples of heart-
healthy food plans include the Dietary Approaches to Stop Hypertension (DASH) eating
plan and the Mediterranean diet.
A diet rich in fruits, vegetables and whole grains can help protect your heart. Aim to eat
beans, low-fat or fat-free dairy products, lean meats, and fish as part of a healthy diet.
Avoid too much salt and sugars in your diet.
Limiting certain fats you eat also is important. Of the types of fat — saturated,
polyunsaturated, monounsaturated and trans fat — try to limit or avoid saturated fat and
trans fat. Aim to keep saturated fat to 5 or 6 percent of your daily calories. And try to
keep trans fat out of your diet altogether.
Major sources of saturated fat include:
• Red meat
• Full-fat dairy products
• Coconut and palm oils
Sources of trans fat include:
• Deep-fried fast foods

• Bakery products
• Packaged snack foods
• Margarines
• Crackers, chips and cookies
If the nutrition label has the term "partially hydrogenated" or "hydrogenated," it means
that product contains trans fat.
But you don't have to cut all fats out of your diet. Healthy fats from plant-based sources
— such as avocado, nuts, olives and olive oil — help your heart by lowering the bad
type of cholesterol.
Most people need to add more fruits and vegetables to their diets — with a goal of five
to 10 servings a day. Eating many fruits and vegetables not only can help prevent heart
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disease, but also may help improve your blood pressure and cholesterol levels, and
improve diabetes.
Eating two or more servings a week of certain fish, such as salmon and tuna, may
decrease your risk of heart disease.
Following a heart-healthy diet also means keeping an eye on how much alcohol you
drink. If you choose to drink alcohol, it's better for your heart to do so in moderation. For
healthy adults, that means up to one drink a day for women of all ages and men older
than age 65, and up to two drinks a day for men age 65 and younger. One drink is
defined as 12 ounces (355 milliliters, or mL) of beer, 5 ounces of wine (148 mL), or 1.5
fluid ounces (44mL) of 80-proof distilled spirits.
At that moderate level, alcohol may have a protective effect on your heart. Too much
alcohol can become a health hazard.
4. Maintain a healthy weight

Being overweight — especially if you carry excess weight around your middle —
increases your risk of heart disease. Excess weight can lead to conditions that increase
your chances of heart disease — including high blood pressure, high cholesterol and
diabetes.
Metabolic syndrome — a combination of fat around your abdomen, high blood pressure,
high blood sugar and high triglycerides — also increases the risk of heart disease.
One way to see if your weight is healthy is to calculate your body mass index (BMI),
which considers your height and weight in determining whether you have a healthy or
unhealthy percentage of body fat. BMI numbers 25 and higher are generally associated
with higher cholesterol, higher blood pressure, and an increased risk of heart disease
and stroke.
The BMI is a good, but imperfect guide. Muscle weighs more than fat, for instance, and
women and men who are very muscular and physically fit can have high BMIs without
added health risks. Because of that, waist circumference also can be a useful tool to
measure how much abdominal fat you have:
• Men are generally considered overweight if their waist measurement is greater than
40 inches (101.6 centimeters, or cm).
• Women are generally overweight if their waist measurement is greater than 35
inches (88.9 cm).
Even a small weight loss can be beneficial. Reducing your weight by just 3 to 5 percent
can help decrease your triglycerides and blood sugar (glucose), and reduce your risk of
diabetes. Losing even more weight can help lower your blood pressure and blood
cholesterol level.
5. Get enough quality sleep

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Sleep deprivation can do more than leave you yawning throughout the day; it can harm
your health. People who don't get enough sleep have a higher risk of obesity, high blood
pressure, heart attack, diabetes and depression.
Most adults need seven to nine hours of sleep each night. If you wake up without your
alarm clock and you feel refreshed, you're getting enough sleep. But, if you're constantly
reaching for the snooze button and it's a struggle to get out of bed, you need more sleep
each night.
Make sleep a priority in your life. Set a sleep schedule and stick to it by going to bed
and waking up at the same times each day. Keep your bedroom dark and quiet, so it's
easier to sleep.
If you feel like you've been getting enough sleep, but you're still tired throughout the
day, ask your doctor if you need to be evaluated for obstructive sleep apnea.
In obstructive sleep apnea, your throat muscles relax and block your airway
intermittently during sleep. This may cause you to stop breathing temporarily. Signs and
symptoms of sleep apnea include snoring loudly; gasping for air during sleep; waking up
several times during the night; waking up with a headache, sore throat or dry mouth;
and memory or learning problems.
Treatments for obstructive sleep apnea may include losing weight if you're overweight
or using a continuous positive airway pressure (CPAP) device that keeps your airway
open while you sleep. CPAP treatment appears to lower the risk of heart disease from
sleep apnea.
6. Manage stress
Some people cope with stress in unhealthy ways — such as overeating, drinking or
smoking. Finding alternative ways to manage stress — such as physical activity,
relaxation exercises or meditation — can help improve your health.
7. Get regular health screenings

High blood pressure and high cholesterol can damage your heart and blood vessels.
But without testing for them, you probably won't know whether you have these
conditions. Regular screening can tell you what your numbers are and whether you
need to take action.
• Blood pressure. Regular blood pressure screenings usually start in childhood. You
should have a blood pressure test performed at least once every two years to screen
for high blood pressure as a risk factor for heart disease and stroke, starting at age
18.
If you're age 40 or older, or you're between the ages of 18 and 39 with a high risk of
high blood pressure, ask your doctor for a blood pressure reading every year.
Optimal blood pressure is less than 120/80 millimeters of mercury (mm Hg).
S T
• Cholesterol levels. Adults should generally have their cholesterol measured at least
once every five years starting at age 18. Earlier testing may be recommended if you
have other risk factors, such as a family history of early-onset heart disease.
• Diabetes screening. Since diabetes is a risk factor for developing heart disease,
you may want to consider being screened for diabetes. Talk to your doctor about
when you should have a fasting blood sugar test or hemoglobin A1C test to check
for diabetes.
Depending on your risk factors, such as being overweight or having a family history
of diabetes, your doctor may recommend early screening for diabetes. If your weight
is normal and you don't have other risk factors for type 2 diabetes, the American
Diabetes Association recommends starting screening at age 45, and then retesting
every three years.
If you have a condition such as high cholesterol, high blood pressure or diabetes, your
doctor may prescribe medications and recommend lifestyle changes. Make sure to take
your medications as your doctor prescribes and follow a healthy lifestyle plan.
PREVENTIVE STRATEGIES OF
HYPERTENSION
If you've been diagnosed with high blood pressure, you might be worried about taking
medication to bring your numbers down.
Lifestyle plays an important role in treating your high blood pressure. If you successfully
control your blood pressure with a healthy lifestyle, you might avoid, delay or reduce the
need for medication.
Here are 10 lifestyle changes you can make to lower your blood pressure and keep it
down.
1. Lose extra pounds and watch your waistline

Blood pressure often increases as weight increases. Being overweight also can cause
disrupted breathing while you sleep (sleep apnea), which further raises your blood
pressure.
Weight loss is one of the most effective lifestyle changes for controlling blood pressure.
Losing even a small amount of weight if you're overweight or obese can help reduce
your blood pressure. In general, you may reduce your blood pressure by about 1
millimeter of mercury (mm Hg) with each kilogram (about 2.2 pounds) of weight you
lose.
Besides shedding pounds, you generally should also keep an eye on your waistline.
Carrying too much weight around your waist can put you at greater risk of high blood
pressure.
In general:
S T
• Men are at risk if their waist measurement is greater than 40 inches (102
centimeters).
• Women are at risk if their waist measurement is greater than 35 inches (89
centimeters).
These numbers vary among ethnic groups. Ask your doctor about a healthy waist
measurement for you.
2. Exercise regularly
Regular physical activity — such as 150 minutes a week, or about 30 minutes most
days of the week — can lower your blood pressure by about 5 to 8 mm Hg if you have
high blood pressure. It's important to be consistent because if you stop exercising, your
blood pressure can rise again.
If you have elevated blood pressure, exercise can help you avoid developing
hypertension. If you already have hypertension, regular physical activity can bring your
blood pressure down to safer levels.
Some examples of aerobic exercise you may try to lower blood pressure include
walking, jogging, cycling, swimming or dancing. You can also try high-intensity interval
training, which involves alternating short bursts of intense activity with subsequent
recovery periods of lighter activity. Strength training also can help reduce blood
pressure. Aim to include strength training exercises at least two days a week. Talk to
your doctor about developing an exercise program.
3. Eat a healthy diet

Eating a diet that is rich in whole grains, fruits, vegetables and low-fat dairy products
and skimps on saturated fat and cholesterol can lower your blood pressure by up to 11
mm Hg if you have high blood pressure. This eating plan is known as the Dietary
Approaches to Stop Hypertension (DASH) diet.
It isn't easy to change your eating habits, but with these tips, you can adopt a healthy
diet:
• Keep a food diary. Writing down what you eat, even for just a week, can shed
surprising light on your true eating habits. Monitor what you eat, how much, when
and why.
• Consider boosting potassium. Potassium can lessen the effects of sodium on
blood pressure. The best source of potassium is food, such as fruits and vegetables,
rather than supplements. Talk to your doctor about the potassium level that's best for
you.
• Be a smart shopper. Read food labels when you shop and stick to your healthy-
eating plan when you're dining out, too.
4. Reduce sodium in your diet
Even a small reduction in the sodium in your diet can improve your heart health and
reduce blood pressure by about 5 to 6 mm Hg if you have high blood pressure.
S T
The effect of sodium intake on blood pressure varies among groups of people. In
general, limit sodium to 2,300 milligrams (mg) a day or less. However, a lower sodium
intake — 1,500 mg a day or less — is ideal for most adults.
To decrease sodium in your diet, consider these tips:
• Read food labels. If possible, choose low-sodium alternatives of the foods and
beverages you normally buy.
• Eat fewer processed foods. Only a small amount of sodium occurs naturally in
foods. Most sodium is added during processing.
• Don't add salt. Just 1 level teaspoon of salt has 2,300 mg of sodium. Use herbs or
spices to add flavor to your food.
• Ease into it. If you don't feel you can drastically reduce the sodium in your diet
suddenly, cut back gradually. Your palate will adjust over time.
5. Limit the amount of alcohol you drink
Alcohol can be both good and bad for your health. By drinking alcohol only in
moderation — generally one drink a day for women, or two a day for men — you can
potentially lower your blood pressure by about 4 mm Hg. One drink equals 12 ounces of
beer, five ounces of wine or 1.5 ounces of 80-proof liquor.
But that protective effect is lost if you drink too much alcohol.
Drinking more than moderate amounts of alcohol can actually raise blood pressure by
several points. It can also reduce the effectiveness of blood pressure medications.
6. Quit smoking
Each cigarette you smoke increases your blood pressure for many minutes after you
finish. Stopping smoking helps your blood pressure return to normal. Quitting smoking
can reduce your risk of heart disease and improve your overall health. People who quit
smoking may live longer than people who never quit smoking.
7. Cut back on caffeine

The role caffeine plays in blood pressure is still debated. Caffeine can raise blood
pressure up to 10 mm Hg in people who rarely consume it. But people who drink coffee
regularly may experience little or no effect on their blood pressure.
Although the long-term effects of caffeine on blood pressure aren't clear, it's possible
blood pressure may slightly increase.
To see if caffeine raises your blood pressure, check your pressure within 30 minutes of
drinking a caffeinated beverage. If your blood pressure increases by 5 to 10 mm Hg,
you may be sensitive to the blood pressure raising effects of caffeine. Talk to your
doctor about the effects of caffeine on your blood pressure.
8. Reduce your stress

S T
Chronic stress may contribute to high blood pressure. More research is needed to
determine the effects of chronic stress on blood pressure. Occasional stress also can
contribute to high blood pressure if you react to stress by eating unhealthy food,
drinking alcohol or smoking.
Take some time to think about what causes you to feel stressed, such as work, family,
finances or illness. Once you know what's causing your stress, consider how you can
eliminate or reduce stress.
If you can't eliminate all of your stressors, you can at least cope with them in a healthier
way. Try to:
• Change your expectations. For example, plan your day and focus on your
priorities. Avoid trying to do too much and learn to say no. Understand there are
some things you can't change or control, but you can focus on how you react to
them.
• Focus on issues you can control and make plans to solve them. If you are
having an issue at work, try talking to your manager. If you are having a conflict with
your kids or spouse, take steps to resolve it.
• Avoid stress triggers. Try to avoid triggers when you can. For example, if rush-
hour traffic on the way to work causes stress, try leaving earlier in the morning, or
take public transportation. Avoid people who cause you stress if possible.
• Make time to relax and to do activities you enjoy. Take time each day to sit
quietly and breathe deeply. Make time for enjoyable activities or hobbies in your
schedule, such as taking a walk, cooking or volunteering.
• Practice gratitude. Expressing gratitude to others can help reduce your stress.
9. Monitor your blood pressure at home and see your doctor
regularly
Home monitoring can help you keep tabs on your blood pressure, make certain your
lifestyle changes are working, and alert you and your doctor to potential health
complications. Blood pressure monitors are available widely and without a prescription.
Talk to your doctor about home monitoring before you get started.
Regular visits with your doctor are also key to controlling your blood pressure. If your
blood pressure is well-controlled, check with your doctor about how often you need to
check it. Your doctor may suggest checking it daily or less often. If you're making any
changes in your medications or other treatments, your doctor may recommend you
check your blood pressure starting two weeks after treatment changes and a week
before your next appointment.
10. Get support

Supportive family and friends can help improve your health. They may encourage you to
take care of yourself, drive you to the doctor's office or embark on an exercise program
with you to keep your blood pressure low.
S T
If you find you need support beyond your family and friends, consider joining a support
group. This may put you in touch with people who can give you an emotional or morale
boost and who can offer practical tips to cope with your condition.
RESPIRATORY MODULE
PREVENTION OF RESPIRATORY DISORDERS
Given the many factors that can have an effect on our lungs, it doesn't come as a surprise that
many Canadians have experience with lung disease. Genetics, air pollution, cleaning solutions,
smoking, and sleep disorders put our lungs at risk. Some risk factors may be unavoidable, but
some basic knowledge and prevention tips can help limit these threats.
• STOP SMOKING. Smoking damages your lungs and increases your risk for a number of diseases
including lung cancer and COPD. This is because combustion of materials releases harmful substances
into your lungs (toxins and carcinogens). If you have never smoked, don't start. If you are still smoking,
it’s never too late to quit. Learn more about how to quit including the many effective medications and
smoking cessation programs that work.
• TEACH KIDS SMOKING STINKS. Make sure kids understand the dangers of smoking and be a role
model by not smoking or by committing to quit.
• AVOID SECOND- AND THIRD-HAND SMOKE. Breathing the smoke from cigarettes and pipes
boosts your risk for the same diseases that affect people who smoke. Don't allow smoking in your home,
in the car, or at work. Also stay away from third-hand smoke—residual tobacco fumes that adhere to
walls and furniture that—along with indoor pollutants to form lung-damaging compounds. Clean your
carpets. Paint the walls with low VOC paints. Rent smoke-free hotel rooms.
• WASH YOUR HANDS. Wash thoroughly with soap and water several times a day to keep germs at
bay and avoid most of the common infectious diseases that are spread by hand. Learn expert
handwashing.
• COVER YOUR COUGHS. To help stop the spread of germs, cover your mouth and nose with a tissue
when you cough or sneeze. Stay away from crowds during peak cold and flu season, get plenty of rest,
eat well and keep your stress levels under control.
• CONVERT YOUR FIREPLACE. The particulate matter in wood and waste can seriously damage your
lungs. If possible, switch to a cleaner burning gas or wood stove or put in an electronic fireplace or gas
insert.
• CLEAN HOUSE. Air fresheners, mould, pet dander, and construction materials all pose a potential
problem. Turn on the exhaust fan when you cook and avoid using aerosol products like hair spray.
Change your furnace air filter seasonally. Learn about indoor air pollution and what you can do to
reduce your exposure.
• CHECK YOUR HOME FOR RADON. Radon gas (a naturally occurring radioactive gas produced by
the breakdown of uranium in the ground) is a hidden killer and the second leading cause of lung cancer
after smoking. Find out if there are high levels of radon in your home or workplace. It may be leaking
into the house through cracks in the foundation and walls.
• WEAR A MASK. Canadian workers may be exposed to an excessive amount of dust, fumes, smoke,
gases, vapors or mists in the workplace. Poor ventilation, closed-in working areas and heat increase are
also disease-causing culprits. Avoid breathing in toxic fumes from chemical, solvents and paints. Wear
protective masks when you work with chemicals and report unsafe working conditions. Go to lung
screening and other health programs offered at work.
S T
• TALK TO YOUR DOCTOR. See your doctor if you experience shortness of breath, pain when
breathing, dizziness with a change of activity, a persistent cough, wheezing or coughing with exercise,
pain in the airway. If you have a chronic lung disease like asthma or COPD, work with your doctor to
manage symptoms and flare-ups.
• TAKE THE STAIRS. Do something active for 30 minutes each day to lighten the load on your lungs
and increase the efficiency of oxygen transportation and metabolism. Walk around the building, bike
around your neighborhood, or even run in place for a bit.
• BE AWARE OF THE AIR. People with lung diseases such as asthma and COPD need to pay particular
attention to the levels of air pollution called particulates — tiny solid or liquid particles — in the
environment and limit their outdoor exposure when levels are high. To learn more about particulates.
• DON’T IDLE. Do your part to curb noxious air and turn off the ignition if you’re waiting more than 10
seconds.
• GET VACCINATED. This is especially important if you have lung disease, though healthy people also
benefit from getting vaccinated. If you have significant lung disease or are over 65, a pneumonia shot
also is recommended.
Germ Control
Follow these steps to cut your risk of catching the common cold, the flu (influenza), and other
viruses.

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SIDE SUBJECTS OF 1ST YEAR

MBBS MODULAR EXAM

MAIN SOURCES: WIKIPEDIA, HEALTHLINE, MAYO CLINIC

Copyright @ 2019 Gomal Medical College

DEDICATED TO ALL GMCITES

PAPER-A PAGE 1-110

PAPER-B PAGE 111-125

PAPER-C PAGE 126-213

• loosening of intercellular attachments

Biochemical changes in cellular injury

• Failure of the ATP dependent pumps (Na+

DNA damage and repair

Structural changes of cells undergoing necrosis and apoptosis

1. Coagulative necrosis is characterized by the formation of a gelatinous (gel-like) substance in

Necrotic leg wound caused by a brown recluse spider bite

Necrosis may occur due to external or internal factors.

Signs and symptoms

• Immune-mediated causes could include transient factors as in Mycoplasma

ROUTES OF DRUG ADMINISTRATION

Oral administration of a liquid

Administration through the gastrointestinal tract is sometimes termed enteral or enteric

A medical professional injects medication into a gastric tube.

Administering medication rectally

• central nervous system

A medical professional applies nose drops.

Administering medication vaginally

Desired target effect[edit]

A dummy wears a nebulizer mask, used to administer inhaled medications.

A peripheral IV placed on the hand.

A medical professional performs an intradermal (ID) injection.

TRANSMEMBRANE DRUG TRANSPORT

Concept of drug cross the cell membrane[edit]

Methods of Drug cross the cell membrane[edit]

RECEPTOR AND CELLULAR BASIS

Structure and mechanism[edit]

Three conformation states of acetylcholine receptor (click to enlarge)

Sketch of an enzyme-linked receptor structure (structure of IGF-1R) (click to enlarge)

Membrane receptor-related disease[edit]

VP4 is myristylated and thus hydrophobic【myristic acid=CH3(CH2)12COOH】. It is proposed that the

Structure-based drug design[edit]

Flow charts of two strategies of structure-based drug design

Main article: Drug design

• Low Affinity Nerve Growth Factor Receptor

▪ Trade Names: erythropoietin, Epo, Epogen, Procrit ®

▪ INCREASED DEATH, SERIOUS CARDIOVASCULAR and THROMBOEMBOLIC

▪ Trade Name: generic

▪ Trade Name: INFeD ®

▪ rxlist.com Infed (Iron Dextran)

▪ Trade Name: Desferal ®

▪ Masters SB (2012): Agents Used in Anemias; Hematopoietic Growth Factors

▪ Trade Name: Folvite ®

▪ Folate deficiency (in pregnant women) is implicated as a cause of congenital

▪ Generic Names: generic, cyanocobalamin, hydroxocobalamin

▪ Vit B12 deficiency symptoms: paresthesias & weakness in peripheral nerves,

COAGULATION MODIFYING DRUG

Indications for drugs that alter coagulation

Ensuring patient safety

Measuring community health[edit]

Categories of community health[edit]

• improving patient responsibility through daily disease-monitoring

• underrepresentation of minority cultures within programs

Relationship limited to the Relationship limited to

Programme-defined disease Comprehensive, continuous and

Responsibility limited to Responsibility for the health of all in the