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In a systematic review with meta-analysis acupuncture relieved joint pain associated with breast 274 cancer treatment induced menopause order loratadine with visa allergy medicine make you gain weight. A review on the management of peripheral neuropathy 275 induced by chemotherapy found acupuncture to be among therapies that may be useful order loratadine with mastercard allergy knoxville tn. Massage therapy cancer pain Massage therapy was found in systematic reviews with meta-analyses to be effective for 276 76 pain in cancer patients compared to active comparators or usual care order line loratadine allergy hair loss. Massage therapy was 277 278 also effective for metastatic bone pain, for pain in children with cancer and those 278,279 undergoing stem cell transplantation. Mind body directed therapy cancer pain 280 Mindfulness-based courses including web-based mindfulness interventions (eHealth) are supportive for cancer patient’s symptom burden. In a large systematic review with meta-analysis, music therapy showed statistical improvements in cancer pain, emotional distress from pain and a small but statistical effect on 259 anesthetic use, opioid and non-opioid intake. Music therapy in a palliative care setting found 77 significant improvement in pain, anxiety, depression, shortness of breath and mood. Evidence-Based Nonpharmacologic Therapies for Chronic Pain Nonpharmacologic therapies are well studied and effective for chronic pain. Acupuncture therapy chronic pain Acupuncture has accrued the most evidence in the treatment of chronic pain. In a systematic review with meta-analysis, acupuncture was associated with greater, immediate relief of chronic pain compared to sham acupuncture or 287 analgesic injection. In a meta-analysis on long term impact, the effects of a course of acupuncture treatment for patients with chronic pain persisted significantly following care; 90% of acupuncture benefit persisted at 12 months in trials using wait list or usual care controls. Trials comparing acupuncture to sham found 50% persistence of benefit at 12 months for the 208 verum groups. An updated individual patient meta-analysis of acupuncture for chronic nonspecific back pain, neck pain, shoulder pain, chronic headache or osteoarthritis included an additional 7 years 288 of trials evaluating 39 trials (20,827 patients). Acupuncture was superior to both sham and no acupuncture controls for each pain condition. The effects of acupuncture were found to persist over time with only a small decrease, approximately 15%, in treatment effect at one year after randomization or 9-10 months after the completion of treatment. A novel finding was additional confirmation of benefit for acupuncture over sham on upper body musculoskeletal pain, neck and shoulder pain. Simple pressure sustained by seeds or small magnets taped to ear points, a form of auricular treatment, showed benefit in acute and chronic pain in systematic reviews with meta 217,290 analysis. In a large multicenter trial of 14,161 patients with chronic neck pain, acupuncture (15 sessions over 3 months) added to routine care was associated with improvements in neck pain 291 and disability maintained through 6 months compared to routine care alone. Although acupuncture care increased cost of treatment, the health benefits lasted well beyond the three month study duration; per international cost-effectiveness threshold values, acupuncture was 292 determined to be a cost-effective treatment strategy. A systematic review and meta-analysis of manual acupuncture for myofascial pain syndrome found treatment of myofascial trigger points reduced pain and improved pain 295 threshold in studies using a single treatment or a course of 8 treatments. Further research is needed to clarify the longitudinal impact of myofascial trigger point treatments as single or multiple sessions. A network meta-analysis of acupuncture needling alone and combined with Gua sha, moxibustion, or e-stim are effective in decreasing pain and in improving physical 296 function in myofascial pain syndrome. In a military population, acupuncture treatment given at least 4 times within a year was associated with improved symptoms, ability to 29 Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care the Consortium Pain Task Force White Paper © www. In a systematic review and meta-analysis, acupuncture therapies with prokinetics were 305 more effective than prokinetics alone for functional dyspepsia. Acupuncture therapy is recommended for functional dyspepsia in patients contraindicated for prokinetics. As stated above, acupuncture therapy has a ‘relative risk’ that is low when provided by qualified trained practitioners. Sixty high quality and seven low quality studies included in a systematic review with meta-analysis on pain and function across all pain populations found massage therapy effectively 308 treats pain compared to sham, no treatment, and active comparators. A systematic review for upper and lower extremity conditions found soft tissue therapy effective for the management of 309 heel pain and lateral epicondylitis. Stiffness and physical function showed significant improvement with treatment duration of more than 4 weeks. As indicated above, massage therapy has a low risk of adverse events when provided by a trained practitioner. A systematic review found for adults with ‘whiplash-associated disorders’ and ‘neck pain associated disorders’, 320 nonpharmacologic therapies including manual therapy are cost-effective. Manipulation therapy safety Adverse events associated with spinal manipulation include muscle soreness or transient 141 increases in pain. Rare serious adverse events include cervical artery dissection, stroke and 322 neck injury. The most recent review of systematic reviews confirms that though rare, there is 323 some risk of significant adverse events. Mind body directed therapies for chronic pain Mindfulness, meditation and relaxation therapies chronic pain Mindfulness and meditation-based therapies focus training on moment to moment awareness of breathing and attention without judgment to transform perception and relationships to pain and the larger environment. Mindfulness and relaxation-based eHealth interventions have evidence of positive effects on health outcomes for patients with chronic pain including headache, fibromyalgia, and irritable 280 bowel syndrome. A review of patients with arthritis, chronic back or neck pain, or two or more comorbid pain conditions experienced the largest average improvement from a mindfulness 332 program in pain severity and functional limitations. Greater home meditation practice was significantly associated with greater improvements in psychological distress and self-rated general health. In a large meta-analysis, music therapy showed a reduction of chronic pain, emotional distress due to pain, and a small but statistically significant reduction in opioid and non-opioid 259 intake. Systematic reviews of guided imagery were found encouraging but inconclusive for 337,338 musculoskeletal and non-musculoskeletal pain. A more recent systematic review of guided imagery in fibromyalgia, arthritis and rheumatologic disorders found statistically significant improvement in pain and function, with several trials demonstrating reduction in medication 339 use. These approaches are safe, with rare adverse reactions in psychiatric patients, people with epilepsy or those who have suffered abuse or trauma where 141,324,339,340 relaxation may trigger a rare paradoxical reaction. Biofeedback chronic pain Biofeedback utilizes techniques in which a signal generated by a device trains the patient to manipulate an aspect of their physiology not typically directed (e. A meta-analysis of trials also found biofeedback effective for tension headache with stable benefit over an average follow-up phase of 15 months. Biofeedback with relaxation 342 therapy was most effective for children and adolescents with headache. A meta-analysis of 343 biofeedback for fibromyalgia found significant reduction of pain, with less effect established 344 in another systematic review due to variability of measures across trials. Biofeedback has low risk of harms with rare side effects of headache, fatigue or sleep 343 problems. No adverse events are reported in a meta-analysis of biofeedback for chronic back 341 pain. Yoga practice combines attention and meditation (dhyana), breathing (pranayama), and physical postures (asanas). Early intervention of ‘medical yoga’, group sessions of guided Kundalini yoga individualized to each medically screened patient with low back pain, was found to be cost 211,347 effective.

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Cut the suture above the Knot 17 Essential Surgical Skills Figure 1:11 Reference 1 order genuine loratadine on-line allergy medicine non drowsy over the counter. Local anesthetics Drugs which produce reversible block to the transmission of peripheral nerve impulse purchase loratadine 10mg with amex allergy shots birth control. Topical anesthesia – Local anesthetic agents are applied topically to such diverse sites as skin purchase loratadine online allergy symptoms rhinitis, eye, gingival mucosa, tympanic membrane, tracheobronchial tree, and rectum. Forms of topical anesthetic preparation include ointment spray solution suppository Example of topical preparations of lidocaine 4% aqueous solutions for endotracheal installations 2% Jelly for intra urethral use 10% aerosol for anesthesia of gingival mucosa 2. Infiltration anesthesia produced by intra dermal and subcutaneous injection of local anesthetics in the area of the intended surgery. Upper dose limits for commonly used local anesthetics agents Plain solution with adrenaline mg /kg mg/ kg prilocaine 6 9 lidocaine 3 7 bupivacaine 2 2 N: B 1 % local anesthesia is 1 gm /100ml Addition of adrenaline reduces the peak concentration in blood. Peripheral nerve block Local anesthetic agent is injected through a needle which is passed percutaneously in the area of the nerve to be blocked. Then pull back without removing the needle from the skin and fan the needle dorsally. Pull the needle back a second time and, without removing it from the skin, fan the needle in a palmar direction. There, the connective tissue is looser, and the needle need not be fanned into digital septae as described above. The digital arteries are end arteries that can spasm and provide prolonged anesthesia, ischemia of the fingertip, and potentially, necrosis. Figure 2:1 digital nerve block b) Major nerve block -involve blockade of major trunks or plexus such as brachial plexus blockade. Central neural blockade 22 Essential Surgical Skills the local anesthetic agents interrupt the conduction of nerve impulse near the site where the nerve roots enter and leave the spinal cord. It includes spinal and epidural anesthesia Spinal Anesthesia Indications o For operations below the umbilicus o For operations on the perineum or genitalia o For operations on the legs Contraindications o Hypovolemia o Increased intracranial pressure o Coagulopathy o Infection at the puncture site o Sepsis (increased risk of meningitis) o Patient refusal (absolute contra indication) o Pre-existing neurologic disease Technique the important points when spinal block is performed are: 1. It should be done under absolute sterile condition Clean patients back with the swabs and antiseptics 4. Locate sites of needle insertion Safe sites of needle insertion are L2-L3, L3-L4, L4-L5, lumbar interspaces Iliac crests are used as a land mark to identify these interspaces the line drawn between the iliac crests crosses L3-L4 interspaces 5. Direction of needle insertion 23 Essential Surgical Skills Spinal needle can be inserted at a direction perpendicular to the saggital plane in the midline. Epinephrine is added to local anesthetic solutions in a dose of 5ug /ml (1:200,000) Contraindication to the inclusion of epinephrine in local anesthetic solutions. Toxicity of local anesthetic agents o Systemic toxicity usually results from an accidental intravascular injection or administration of excessive dose of local anesthetic agents. Objective signs include shivering, muscular twitching, tremors and generalized convulsions. Local anesthetic agents can exert direct effect on the heart and peripheral blood vessels resulting in cardiac dysrhythmias and hypotension. Air way maintenance, administration of O2 by face mask, prevention of aspiration by turning the patient to the side and lower the head. Four basic elements of general anesthesia are o Analgesia o Loss of consciousness o Immobility o Inhibition of noxious reflexes Routes of administration of general anesthetic drugs A. Inhalation Access to the circulation through the lungs For example Nitrous oxide Halothane Enflurane Isofulrane Methods of administration o Face mask o Endotracheal tube o Insufflations anesthetic agent and oxygen delivered into the mouth or trachea 27 Essential Surgical Skills B. Intra muscular Ketamine 5-10 mg/kg Ketamine anesthesia Ketamine produces a state of “Dissociative anesthesia” which implies that the patients are detached from their surroundings. It produces systemic effects that are characteristics of sympathetic nervous system stimulation. The more commonly observed hemodynamic effects include increased heart rate, blood pressure & cardiac out put. The effects of sympathetic stimulation from ketamine anesthesia may be useful in patients with bronchospastic disease or hypovolemia. Ketamine may be used as a sole anesthetic agent for a large number of superficial operations & procedures in both adults & children. The following air way equipments must be available a) Endotracheal tubes Endotracheal tubes are calibrated by internal diameter. The following sizes are used for children Age size(mm internal diameter) Premature 2. Blade sizes Adult men 4 Adult women 3 Children 2 Infant 1 Neonate 0 c) Various aids to tracheal intubation Stylet Syringe Securing tape or bandage Tracheal tube lubricant Face mask Oral airway Suction catheter 30 Essential Surgical Skills Figure 2:3 airway equipments 31 Essential Surgical Skills 2) pre oxygenation Hundred percent oxygen for 3 to 5 minutes should be administered by mask ventilation immediately prior to laryngoscopy. The inspired atmospheric air within the lung mainly contains nitrogen which should be washed out and substituted by o2. Exposure of the laryngeal inlet by means of direct laryngoscope is preformed to facilitate translaryngeal placement of endotracheal tube. Take the laryngoscope with your left hand (see figure 2:5) 32 Essential Surgical Skills Figure 2:5 laryngoscope with left hand An optimal alignment of the operator’s visual axis and patient’s laryngeal axis is desirable for optimal visualization of the glottis opening by direct laryngoscope. An optimal position of the head and the neck for an alignment of these axes can be achieved by flexion of the neck and extension of the head at the atlanto occipital joint (Sniff position). Then, with the sustained axes alignment and the patient’s mouth opened maximally and the lower lip rolled forward, the laryngoscope blade is inserted in the right side of the mouth, displacing the tongue to the left as the blade is advanced into the vallecula. Causes of cardiac arrest o Underlying cardiac or pulmonary diseases o Metabolic and physical abnormalities such as o Hypoxia o Hypovolemia o Acid-base abnormalities o Electrolytes derangement o Adverse drug effects o Pericardial tamponade o Tension pneumothorax 36 Essential Surgical Skills Diagnosis of cardiac arrest o Pulselessness in large arteries (carotid, femoral, brachial) is the most important point in the diagnosis. Airway maintenance Upper airway is obstructed by the tongue in un unconscious patients. Vomit, blood or foreign material in the mouth should be removed manually or with rigid sucker. Techniques of airway maintenance • Head tilt-chin lift Lifting the tongue a way from the posterior pharynx, prevent airway obstruction in an unconscious patient • Jaw – thrust • An oro pharyngeal or nasopharyngeal airway insertion • Tracheal intubation In all cases, the first step is to clear the airway and then maintain clarity while ventilation is carried out. Circulation: An artificial blood flow is provided by external cardiac compression. Venous cut down It is an emergency surgical procedure, which enables access to veins. Practical Session V the incision should follow the broken lines shown on the picture below. After isolation of the vein in the usual manner, a loop of thread is passed under the vein as shown in figure 2:12. Figure 2:12 Loop of thread passed the distal ligature is knotted and the ends of the proximal ligature are held without knotting. A needle (21G needle or the needle of the intravenous cannula which is to be used for the cannulation) is used to transfix the vein at the proposed site of cannulation, as shown in figure 2:13 Figure 2:13 Trance fixation 40 Essential Surgical Skills the circumference of the vein anterior to the needle is almost completely incised with a scalpel as shown in figure 2:14. The needle prevents injury to the posterior wall of the vein and also facilitates a clean-cut incision. Figure 2:14 Vein opening the intravenous cannula without the inner needle is then introduced into the venotomy opening, with the needle steadying the vein (Figure 2:15). The needle is then removed, the proximal ligature tied over the cannula and the wound closed.

Enumerate the sequential steps in both the vascular and cellular responses of acute inflammation 10mg loratadine visa quick allergy treatment. Definition of healing the word healing buy discount loratadine on-line food allergy treatment guidelines, used in a pathological context loratadine 10 mg visa allergy testing st cloud mn, refers to the body’s replacement of destroyed tissue by living tissue. Processes of healing the healing process involves two distinct processes: Regeneration, the replacement of lost tissue by tissues similar in type and Repair (healing by scaring), the replacement of lost tissue by granulation tissue which matures to form scar tissue. Healing by fibrosis is inevitable when the surrounding specialized cells do not possess the capacity to proliferate. Whether healing takes place by regeneration or by repair (scarring) is determined partly by the type of cells in the damaged organ & partly by the destruction or the intactness of the stromal frame work of the organ. Types of cells Based on their proliferative capacity there are three types of cells. Labile cells these are cells which have a continuous turn over by programmed division of stem cells. They are found in the surface epithelium of the gastrointestinal treat, urinary tract or the skin. The cells of lymphoid and haemopoietic systems are further examples of labile cells. Stable cells Tissues which have such type of cells have normally a much lower level of replication and there are few stem cells. However, the cells of such tissues can undergo rapid division in response to injury. For example, mesenchymal cells such as smooth muscle cells, fibroblasts, osteoblasts and endothelial cells are stable cells which can proliferate. Liver, 43 endocrine glands and renal tubular epithelium has also such type of cells which can regenerate. If lost, permanent cells cannot be replaced, because they don not have the capacity to proliferate. Having been introduced to the types of cells, we can go back to the two types of healing processes & elaborate them. Healing by regeneration Definition: Regeneration (generare=bring to life) is the renewal of a lost tissue in which the lost cells are replaced by identical ones. The capacity of a tissue for regeneration depends on its 1) proliferative ability, 2) degree of damage to stromal framework and 3) on the type and severity of the damage. Tissues formed of labile and stable cells can regenerate provided that stromal framework are intact. Repair (Healing by connective tissue) Definition: Repair is the orderly process by which lost tissue is eventually replaced by a scar. A wound in which only the lining epithelium is affected heals exclusively by regeneration. In contrast, wounds that extend through the basement membrane to the connective tissue, for example, the dermis in the skin or the sub-mucosa in the gastrointestinal tract, lead to the 44 formation of granulation tissue and eventual scarring. Tissues containing terminally differentiated (permanent) cells such as neurons and skeletal muscle cells can not heal by regeneration. Phase of inflammation At this phase, inflammatory exudate containing polymorphs is seen in the area of tissue injury. Phase of demolition the dead cells liberate their autolytic enzymes, and other enzymes (proteolytic) come from disintegrating polymorphs. Ingrowth of granulation tissue This is characterized by proliferation of fibroblasts and an ingrowth of new blood vessels into the area of injuty, with a variable number of inflammatory cells. The fibronectin and proteoglycans form the ‘scaffolding’ for rebuilding of the matrix. Fibronectin binds to fibrin and acts as a chemotactic factor for the recruitment of more fibroblasts and macrophages. The synthesis of collagen by fibroblasts begins within 24 hours of the injury although its deposition in the tissue is not apparent until 4 days. This type I collagen is responsible for providing the tensile strength of the matrix in a scar. Coincident with fibroblast proliferation there is angiogenesis (neovascularization), a proliferation and formation of new small blood vessels. Vascular proliferation starts 48 to 72 hours after injury and lasts for several days. Despite an increased collagenase activity in the wound (responsible for removal of built collagen), collagen accumulates at a steady rate, usually reaching a maximum 2 to 3 months after the injury. The tensile strength of the wound continues to increase many months after the collagen content has reached a maximum. As the collagen content of the wound increases, many of the newly formed vessels disappear. This vascular involution which takes place in a few weeks, dramatically transforms a richly vascularized tissue in to a pale, avascular scar tissue. Wound contraction Wound contraction is a mechanical reduction in the size of the defect. Contraction results in much faster healing, since only one-quarter to one-third of the amount of destroyed tissue has to be replaced. Myofibroblasts have the features intermediate between those of fibroblasts and smooth muscle cells. Two to three days after the injury they migrate into the wound and their active contraction decrease the size of the defect. Summary Following tissue injury, whether healing occurs by regeneration or scarring is determined by the degree of tissue destruction, the capacity of the parenchymal cells to proliferate, and the degree of destructon of stromal framework as illustrated in the diagram below (See Fig. In the above discussion, regeneration, repair, and contraction have been dealt with separately. On the contrary, the three processes almost invariably participate together in wound healing. Molecular control of healing process As seen above, healing involves an orderly sequence of events which includes regeneration and migration of specialized cells, angiogenesis, proliferation of fibroblasts and related cells, matrix protein synthesis and finally cessation of these processes. These processes, at least in part, are mediated by a series of low molecular weight polypeptides referred to as growth factors. These growth factors have the capacity to stimulate cell division and proliferation. Some of the factors, known to play a role in the healing process, are briefly discussed below. Sources of Growth Factors: Following injury, growth factors may be derived from a number of sources such as: 1. Lymphocytes recruited to the area of injury the healing process ceases when lost tissue has been replaced. Damaged Blood Macrophages Lymphocytes Epithelial cells platelets Release of growth factors and cytokines Specialized Fibroblast Angiogenesis cell regeneration activation new capillary E. Wound Healing the two processes of healing, described above, can occur during healing of a diseased organ or during healing of a wound. Now, we will discuss skin wound healing to demonstrate the two basic processes of healing mentioned above. Healing of a wound demonstrates both epithelial regeneration (healing of the epidermis) and repair by scarring (healing of the dermis).


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Abnormally high and low temperatures are injurious to the body and their damage are different and have to be discussed separately order cheap loratadine on line quercetin allergy treatment. Injuries due to abnormally high temprature these can be brought by flame order loratadine 10 mg visa allergy forecast gilbert az, boiled water or steam purchase loratadine 10mg allergy medicine hydroxyzine hcl, electricity and etc. Terms like ‘partial thickness’ and ‘full thickness’ burns are applied to describe the degree of burn injury. Epidermis can be fully or partially devitalized and it continues to provide a cover to the burned area. Such burns are characterized by blistering, protinacious fluid exudation from dilated and injured small blood vessels. Inflammatory reaction and regeneration of the epidermis from preserved appendages of dermis are also common features. The epidermal cells may exhibit deranged membrane permeability, with nuclear and cellular swelling or may show clean pyknosis and granular coagulation of cytoplasm. Full thickness burn implies total distraction of the entire epidermis extending into the dermis and even more deeply at times. Regeneration from dermal appendages is scarce and hence healing will result in scarring unless skin grafting is performed. With the epidermis burnt out the dermal collagen may take the appearance of a homogenous gel. The cytologic changes described in partial thickness burn may be seen in deeper structures and the inflammatory reaction seen in the partial thickness burn is greater here. Neurogenic shock can prevail due to the pain and this can be followed by hypovolemic shock when the individual looses fluid from the burned area. Dreadful infection can develop because of a wide area, which is open to infection and due to a media favorable for proliferation of microorganism. The wound infections can progress to regional thrombophllbitis, infective endocarditis, pneumonia, cellulitis, and sepsis. Injuries due to abnormally low temperature the effects of hypothermia depended on whether there is whole body exposure or exposure only of parts. Death may result when the whole body is exposed, with out inducing apparent necrosis of cells or tissues. This is because of the slowing of metabolic process, particularly 246 in the brain and medullary centers, when parts of the body are exposed, local changes result depending on the types of exposure to low temperature Local reactions Injury to cells and tissues occur in two ways 1. Indirect effects due to circulatory changes Circulatory changes will be in two ways: slow temperature drop that will result in vasoconstriction and increased permeability leading to edematous changes as in ‘trench foot’, sudden sharp drop that will result in vasoconstriction and increased viscosity of the blood leading to ischemia and degenerative changes. High altitude illness This is encountered in mountain climbers in atmospheres encountered at altitudes above 4000m. The lower oxygen tension produces progressive mental obtundation and may be accompanied by poorly understood increased capillary permeability with systemic and, in particular pulmonary edema. Air or Gas Embolism This may occur as a complication of scuba diving, mechanical positive pressure ventilatory support, and hyperbaric oxygen therapy. In all these occasions there is an abnormal increase in intra-alveolar air or gas pressure, leading to tearing of tissue with entrance of air into the interstitium and small blood vessels. The coalescence of numerous small air or gas emboli that gain access to the arterial circulation may lead acutely to stroke like syndrome or a myocardial ischemic episode. D-Electrical Injuries the passage of an electric current through the body: • May pass without effect • May cause sudden death by disruption of neural regulatory impulse producing, for example, cardiac arrest 247 • Or may cause thermal injury to organs exposed to electric current Although all tissues of the body are conductors, their resistance to flow varies inversely to their water content. Dry skin is particularly resistant, but when skin is wet or immersed in water resistance is greatly decreased. Thus, an electric current may cause only a surface burn of dry skin but, when transmitted through wet skin, may cause death by disruption of regulatory pathways. Summary Environmental pathology deals with diseases that are brought by exposure to harmful substances in the environment. Out door air of industrialized cities is highly polluted with six major pollutants, which affect the health of inhabitants. Organic fumes and particulates taken into the lung cause several types of Neoplastic and non-Neoplastic diseases. Pneumoconioses are a group of non neoplastic lung diseases caused by inhalation of organic and inorganic particulates. Coal dust, asbestos, silicon and beryllium are mineral dusts which cause most of the pneumoconiosis. People affected by different types of pneumoconiosis go through more or less, same kind of steps in to severe forms when exposure continues. In coal workers pneumoconiosis the patient will first have a non symptomatic blackening seen along the lymphatics and lymphnodes which mark coal laden macrophages. Smoking is the single most important pollutant, which affect the health of millions of individuals. Abstinence has a positive impact in progressively lowering the risks imposed by the previous years of smoking. Alcohol, even though taken in small amounts have a health promoting effect, when taken in more amounts it will have short term and long term un healthy impacts. Central and peripheral nerves systems, as well as cardiovascular systems are also its targets. When dealing with environmental diseases injuries caused by physical forces have to be thought about. These could be caused by mechanical forces, extreme high or low temperatures, atmospheric pressure changes or electromagnetic energy. Which one of the following is the most common cause of mortality among cigarette smokers a. This manual has been written with the aim of developing the knowledge, skills and attitudes of nurses and midwives regarding infections and infectious diseases and their prevention and control. A workbook is provided separately, with opportunities for self-assessment through learning activities. A completed workbook is also available for each module to give further guidance to readers. The document may nevertheless be freely reviewed, abstracted, reproduced or translated into any other language (but not for sale or for use in conjunction with commercial purposes) provided that full acknowledgement is given to the source. Any translation should include the words: the translator of this document is responsible for the accuracy of the translation. Any views expressed by named authors are solely the responsibility of those authors. To reduce that burden an integrated approach is required, combining health promotion, disease prevention and patient treatment. The prerequisite for success in this fight is the participation of all health care professionals. Nurses and midwives, as major frontline providers of care, are in a position to contribute significantly to reducing the burden. Mastery of this material will enable nurses and midwives to respond to threats to the community, to teach their patients and members of the community effective ways of preventing infections and infectious diseases, to provide high quality and effective care to people with infectious diseases and to use appropriate measures to ensure safe practice. Each module is in two parts: theory and practice, with opportunities for self-assessment through learning activities and a workbook.

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