- Grading of Murmurs.

Grading of Murmurs

- Intensity of murmur refers to the amplitude of sound of murmur (i.e loudness of the murmur)
- Murmurs are classified ("graded") depending on their ability to be heard by the examiner.

- It is graded on a scale from I to VI (1-6/6).

-Grades:-

• Grade I:- very faint,not heard in all positions,no thrill.
• Grade II:- Soft,heard in all positions,no thrill.
• Grade III:- loud,no thrill.
• Grade IV:- Loud,with palpable thrill (i.e a tremor or vibration felt on palpation).
• Grade V:- Very loud, with thrill,heard with only the edge of the stethoscope touching the chest wall.
• Grade VI:- loudest, with thrill,heard with the stethoscope just above the precordium, not touching the skin.

Dr Ibrahim

Return to list of medical grades (click here)

- Influenza virus.

- Influenza virus belongs to Orthomyxoviridae family (single-stranded, negative-sense RNA,enveloped viruses and replicate by nuclear replication).

- Genera which are identified by antigenic differences in their nucleoprotein and matrix protein :-

• Influenza A virus.
• Influenza B virus.
• Influenza C virus.

*Influenza Virus Morphology*

- The particles are mostly spherical, 80-120 nm diameter,its core diameter 9 nm and has helical nucleoprotein.

-Nucleoprotein(RNA + nucleoprotein, NP)is any protein which is structurally associated with nucleic acid.

-Matrix proteins(M1,M2)are structural proteins linking the viral envelope with the virus core.

- The virus has a lipid envelope from which project 500 prominent glycoprotein spikes 10 - 14 nm from the surface and are of two types:-

1. Haemagglutinin (HA or H)"the major" which is a sugar-binding protein that mediates binding of the virus to target cells and entry of the viral genome into the target cell.

2. Neuraminidase (NA or N) which is an enzyme involved in the release of virus progeny from infected cells, by cleaving sugars that bind the mature viral particles.

-Ratio of HA to NA is about 4-5 to 1.

(Simplified cartoon showing structure of influenza virus image from Nature)

*Virus Mutation*

-Every 10 - 15 years a major new pandemic strain appears in man, with a totally new H and sometimes a new N as well (Antigenic Shift) which means complete change in HA and NA.

-This new variant may cause a major epidemic around the world.

- Over the subsequent years this strain undergoes minor changes (Antigenic Drift) every two to three years which means incomplete change in HA and NA.

*serotypes:-

- Influenza A viruses are further classified, based on the viral surface proteins (HA or H) and (NA or N) into 16 H subtypes (or serotypes) and 9 N subtypes giving a large number of subtypes due to different associations.

-Influenza B: Known only in man and seals and is less common than influenza A Undergoes relatively slow change in HA with time,consequently is less genetically diverse, with only one influenza B serotype as a result of this lack of antigenic diversity, a degree of immunity to influenza B is usually acquired at an early age.

-Influenza C: Uncommon strain, known only in man and pigs and can cause severe illness and local epidemics.

-Influenza A viruses have an importance nowadays due to lack of specificity to a single host tissue and genome re-assortment which leaded to a panic in the world as for example human Influenza A H1N1 was causing seasonal flu in man and Swine Influenza A H1N1 was causing endemic flu in pigs,swine H1N1 made re-assortment in pig to be transmitted to man leading to pandemic of swine flu in world.

Dr Ibrahim...

- Integrated Management of Childhood Illness (Imci).

- Def:-
An integrated approach to child health which focuses on the well being of whole child.

- Aims (Broad goals-الأهداف العامة):-

• Reduce death, illness and disability
• Promote improved growth and development among children under five years of age.
• Includes both preventive and curative elements implemented by families,communities and health facilities.

-Objectives(الأهداف الصغيرة-underlying goals):-

1- In Health facilities,IMCI strategy promotes:-

• The accurate diagnosis of childhood illnesses in outpatient clinics.
• Appropriate combined treatment of all major illnesses.
• Improving skills of PHC staff.
• Speeding up the referral of severely ill children.

2- In the home setting,IMCI strategy promotes:-

• Appropriate care seeking behaviours
• Improved nutrition and preventative care.
• Correct implementation of prescribed care/and drugs.

- Why is IMCI better than single-condition approaches?

• Children brought for medical treatment in the developing world are often suffering from more than one condition, making a single diagnosis impossible.
• IMCI ensures the combined treatment of the major childhood illnesses, emphasizing prevention of disease through immunization and improved nutrition.

-Rationale of IMCI in developing countries:-

1-More than10million deaths/year among children under 5 years of age in developing countries.

2-70% of these deaths are due to just 5 preventable and treatable
conditions (pneumonia,diarrhea
malaria,measles and malnutrition).

3-Surveys show that many sick children aren't properly treated by healthcare providers as their parents are poorly advised.

4-In developing countries diagnostic aids (Radiology or lab) are minimal or absent.

5-In developing countries drugs and equipment are limited.

6-These limitations leave doctors helpless,they often rely on history,signs and symptoms to determine the management with least cost.

- Components :-

The strategy includes three main components:-

• Improving case management skills of health-care staff(health-worker component).
• Improving overall health systems(health-service component).
• Improving family and community health practices(community component).

-The department responsible for IMCI in WHO is called "Child and adolescent health department"(CAH) here.

-Benefits of Integrated Management of Childhood Illness (IMCI)(3):-

• Addresses major child health problems by addressing the most important causes of childhood death and illness.
• Responds to demand – Every day millions of parents take their sick children to hospitals and health centres,pharmacists and community health care providers. At least three out of four of these children are suffering from one of the five conditions that are the focus of IMCI.
• Promotes prevention as well as cure .
• Is cost-effective – Investing in Health ranked IMCI among the 10 most cost-effective interventions in both low- and middle-income countries.
• Promotes cost saving – Inappropriate management of childhood illness wastes scarce resources. Although increased investment will be needed initially for training and reorganization, the IMCI strategy will result in cost savings.
• Improves equity – Nearly all children in the developed world have ready access to simple and affordable preventive and curative care which protects them from death due to ARI, diarrhoea, measles, malaria and malnutrition. Millions of children in the developing world, however, do not have access to this same life-savingcare. The IMCI strategy addresses this inequity in global health care.

-Implementation of IMCI:-
(How does IMCI achieve these goals?)
1-Adopting this strategy in the national health policy.
2-Adapting the standard IMCI clinical guidelines to the country's needs,Available drugs,policies,and to local foods.
3-Upgrading care in PHC units by training staff in new methods of management of children.
4-Implementation of the concept of the essential drug list.
5-strengthening the referral system.
6-Implementation of IMCI is done in conjugation with other health strategies (e.g Roll back malaria,Nutrition,EPI,IMPAC).


- Some WHO publications concerned with IMCI:-

*IMCI chart booklet - standard,

• Page here
• Download here.

* Handbook:IMCI integrated management of childhood illness.

• Page here
• Download here.

* Integrated Management of Childhood Illness (Imci) Photographs:-

• Download here.

-References:-

(1)Mohammed Kamel Farag ,community medicine, non communicable disorders & management in health care ,Ch 14 ,Child health care services, p.g 181-183.
(2)About Integrated Management of Childhood Illness (IMCI), Pan American Health Organizationn here.
(3)IMCI information package (here) ,WHO/CHS/CAH/98.1 A-M Rev.1 1999, BOX 1,p.g 4.
(Figer 1)UNICEF:The state of the worlds children 2008: child survival(here)UNICEF/HQ07-0108/Thierry Delvigne Jean
(Figer 2)UNICEF:The state of the worlds children 2008: child survival(here)New York: UNICEF; 2007.

- Pedigree.

-A pedigree:- is a diagram of a family history and illustrates relationships among family members; it shows which family members are affected with specific medical conditions.

-Information for a three-generation pedigree should be obtained from a family being evaluated for a genetic disorder.

- The patient through whom the family is ascertained is called the proband.

(Symbols commonly used in pedigree chart)

-Consanguinty:-

There are Five degrees of Consanguinty:-

*first-degree:-
-First-degree relatives share half of their genetic material with the proband (brothers, sisters, children,parents).

*second degree:-
-Second degre relatives share one fourth of their genetic material (grandparents,aunts,uncles).

*Third degree:-
-Third degree relatives share one eighth of their genetic material with the proband(1st cousin).

*Fourth degree:-
-Fourth degree relatives share one sixteenth of their genetic material with the proband(2nd cousin).

*Fifth degree:-
-Fifth degree relatives are once remote form the proband.


References:-
(1)Richard E Behrman,Nelson Textbook of Pediatrics,17th ed,ch69,(http://www.elsevier.com).
(2)Bennett RL, Steinhaus KA, Uhrich SB, et al: Recommendations for standardized pedigree nomenclature. J Genet Counsel 1995;4:267–79.)

- Cushing's triad.

Cushing's triad

is a late sign of increase intra-cranial tension

and composed of:-

1. Hypertension.
2. Respiratory depression.
3. Bradycardia.

Return to other triads here.