Guys!

Can we compile this week's anatomy practical answers next week? Just bring your respective answers next Mon and we can compile them together! :)

Summary for Alan & Bill =)

AIDS VS HIV
AIDS
Official criteria- HIV-infected people who have fewer than 200 CD4 T cells.
HIV infection
Case definition- Adults, adolescents, or children aged ≥ 18 months, Children aged ≤ 18 months
Notifiable diseases
These are some of the notifiable diseases: AIDS, HIV infection, Cholera, Malaria, Measles, severe acute respiratory syndrome
Incidence and Prevalence
The number of cases reported in the world increases by year. In Malaysia, majority of the cases reported are male. (more will be shown during presentation)
Etiology
There are 3 major routes of transmission of the HIV(Sexual Transmission, Transmission via blood or blood products, Mother to Child Transmission)
The risk of transmission via tears, urine and saliva is considered to be negligible
Pathophysiology
• Entry to host cells (CD4+ lymphocytes, macrophages and monocytes) using gp120 with the help of chemokine co-receptors.
• Life cycle of HIV (8 stages):
1. Viral binding
2. Entry and Uncoating
3. Reverse transcription
4. Integration into host chromosomal DNA
5. Synthesis of viral DNA
6. Translation and production of Viral proteins
7. Assembly of virus and budding from the host cell
8. Maturation
• Then the virus is ready for infection
Investigation and Diagnosis
• HIV Antibody Testing :
-Detects HIV antibodies in blood or other body fluids
weeks after exposure or an HIV RNA test (viral load)
>detects the presence of the virus
• ELISA - (Enzyme-linked Immunosorbent Assay Test)
-A common serological test for the presence of particular antigens or antibodies (Serum)
-Direct and indirect
• Western Blot Test
• Home Collection Kit
• HIV Viral Load
• p24 Antigen Count Test
• CD4 Count
-measurement of how many functional CD4 T-cells are circulating in the blood.
Modes of transmission
• Having vaginal or anal sex without a condom with someone who is infected.
• Having contact with the blood of someone who has HIV. This could be having a blood transfusion from someone who is infected with HIV
• From a mother who has HIV to her baby: HIV can pass to the baby during pregnancy, during the birth of the baby, or through breast-feeding. Only about one in three babies born to HIV-positive mothers get HIV.
• Receiving an injection from an unsterilized needle that was previously used by someone with HIV.
• Heterosexual transmission is the route by which most people with AIDS have become infected with HIV worldwide
This category of AIDS cases is also among the most rapidly increasing.
Signs and Symptoms of HIV infection
Symptoms Early After Infection - Acute HIV : fever, headache, muscle and joint pain, sore throat, rash, diarrhea.
Later Symptoms Of HIV Infection
it takes about eight to nine years between the time of infection and the appearance of later symptoms, although this varies from person to person.
These symptoms signal that immune system function is deteriorating, due to declining numbers of CD4+ T cells
Symptoms of the Immune System: Swollen lymph nodes in the neck, axilla, or groin (lymphadenopathy), fever / night sweats
Symptoms of the GI Tract : Rapid weight loss, Diarrhea, Poor appetite, Profound fatigue
Respiratory Symptoms
usually occur later in course of the disease
Any cough or shortness of breath could be a sign of bacterial pneumonia or pneumocystis (carinii) jiroveci pneumonia (PCP).
Shortness of breath
Dry cough / productive cough
Symptoms of the Skin and Mucous Membranes
result of infection by other viruses, fungi or bacteria. Often, these infections involve the skin or mucous membranes (for example, inside the mouth).
HIV Effects on Dental Health
Skin rash
Genital sores (sores around the penis or vagina)
Red, brown, pink or purple lesion on the skin - suggestive of Kaposi's sarcoma
White patches on the tongue, inside of the mouth, or gums - could be signs of thrush, candida, or hairy oral leukoplakia
Canker sores / apthous ulcers
Neurological / Emotional Symptoms
Depression
Numbness, tingling, or burning in the feet, hands, or face. (peripheral neuropathy)
Confusion, weakness, or changes in level of consciousness
memory loss
Blurred vision
Complications
Bacterial
- Pneumonia
- Mycobacterium avium complex
- Tuberculosis
- Salmonellosis
Viral
- Cytomegalovirus
- Viral hepatitis
- Herpes simplex virus
- Human papillomavirus
Fungal infections
- Candidiasis
- Cryptococcal meningitis
Parasitic
- Pneumocystis carinii pneumonia
- Toxoplasmosis
- Cryptosporidiosis
Cancers
- Kaposi’s sarcoma
- Non-Hodgkin’s lymphoma
Neurological complications
Management and Treatment
Counsellingproper counselling before and after testing with informed consent especially patients tested positive to address issues such as stigma and the fear of disclosure of one's HIV status
Support Groups
Initiation of Antiretroviral Therapy (Antiretroviral drug treatment)
Combination Therapy (combination of 2 or more drugs)
Home based care (patient staying at homeable to work and do daily chores)
Traditional/Alternative Medicine
Prevention
Effective HIV prevention interventions include
• Condom use, Male circumcision, Provision of clean injecting equipment, Opioid substitution therapy, treatment of sexually transmitted infections, HIV testing and counselling, A set of interventions to prevent mother-to-child transmission of HIV, Sex education
In health care settings, transmission of HIV can be prevented through
• primary prevention measures
• secondary prevention measures
In addition, there is increasing evidence indicating that
• antiretroviral therapy programmes
• Current research on new prevention technologies such as microbicides, topical and oral antiretroviral pre-exposure prophylaxis
HIV prevention - combination behavioural change approach has been
• Abstinence, including delay of sexual initiation or debut
• Being safer by being faithful to one’s partner or reducing the number of sexual partners, and
• correct and consistent Condom use.
Legal and Ethical Issues
o Consent for medical examination and treatment
o Prenatal HIV Testing
 Recommended by Institute of Medicine Panel:
o Confidentiality
 Exception
o The Doctor & The Law Courts
o Release of Information to a third party

Signs and Symptoms of HIV infection

Symptoms Early After Infection - Acute HIV

fever, 

headache, 

muscle and joint pain, 

sore throat, 

Rash,

Diarrhea.

Later Symptoms Of HIV Infection

it takes about eight to nine years between the time of infection and the appearance of later symptoms, although this varies from person to person.

These symptoms signal that immune system function is deteriorating, due to declining numbers of CD4+ T cells

Symptoms of the Immune System 

Swollen lymph nodes in the neck, axilla, or groin (lymphadenopathy)

Fever / night sweats 

Symptoms of the GI Tract 

Rapid weight loss

Diarrhea

Poor appetite

Profound fatigue

Respiratory Symptoms

usually occur later in course of the disease

Any cough or shortness of breath could be a sign of bacterial pneumonia or pneumocystis (carinii) jiroveci pneumonia (PCP).

Shortness of breath

Dry cough / productive cough

Symptoms of the Skin and Mucous Membranes 

result of infection by other viruses, fungi or bacteria. Often, these infections involve the skin or mucous membranes (for example, inside the mouth).

HIV Effects on Dental Health

Skin rash

Genital sores (sores around the penis or vagina)

Red, brown, pink or purple lesion on the skin - suggestive of Kaposi's sarcoma

White patches on the tongue, inside of the mouth, or gums - could be signs of thrush, candida, or hairy oral leukoplakia

Canker sores / apthous ulcers

Neurological / Emotional Symptoms

Depression

Numbness, tingling, or burning in the feet, hands, or face. (peripheral neuropathy)

Confusion, weakness, or changes in level of consciousness

memory loss

Blurred vision

What Symptoms Signal The Onset Of AIDS?

A CD4+ T cell count of less than 200, and/or

At least one of more than two dozen opportunistic infections and conditionsIn the United States, the most common AIDS-defining condition in both women and men is a lung infection called Pneumocystis carinii pneumonia, abbreviated PCP.

Other AIDS-defining conditions include severe body wasting and Candida infection of the esophagus, windpipe, or lungs.

Reference:

CDC

http://www.cdc.gov/hiv/resources/qa/qa5.htm

About.com

http://aids.about.com/od/newlydiagnosed/a/hivsymptom.htm

ehealthMD

http://www.ehealthmd.com/library/aids/ads_symptoms.html 

AIDS Etiology and Pathophysiology Summary

Summary

Etiology

There are 3 major routes of transmission of the HIV:

• Sexual Transmission
• Transmission via blood or blood products
• Mother to Child Transmission

The risk of transmission via tears, urine and saliva is considered to be negligible

Pathophysiology

• Entry to host cells (CD4+ lymphocytes, macrophages and monocytes) using gp120 with the help of chemokine co-receptors.
• Life cycle of HIV (8 stages):

1. Viral binding
2. Entry and Uncoating
3. Reverse transcription
4. Integration into host chromosomal DNA
5. Synthesis of viral DNA
6. Translation and production of Viral proteins
7. Assembly of virus and budding from the host cell
8. Maturation

• Then the virus is ready for infection

HIV vs AIDS, NOTIFIABLE DISEASES

AIDS

Official criteria

• HIV-infected people who have fewer than 200 CD4 T cells.
  

Case definition

• Tested positive for HIV antibody
  
• And have one or more of the following:
  • 10%body weight loss or cachexia, with diarrhea or fever, or both, intermittent or constant, for at least 1 month, not known to be due to a condition unrelated to HIV infection
  • Cryptococcal meningitis
    
  • Pulmonary or extra-pulmonary tuberculosis
    
  • Kaposi sarcoma
    
  • Neurological impairment that is sufficient to prevent independent daily activities not known to be due to a condition unrelated to HIV infection
    
  • Candidiasis of the eosophagus
    
  • Clinically diagnosed life-threatening or recurrent episodes of pneumonia, with or without etiological confirmation
    
  • Invasive cervical cancer
    

HIV infection

Case definition

• Adults, adolescents, or children aged ≥ 18 months
  
  • Must meet at least one the following criteria:
    
    • Laboratory criteria
      
      • Detection of antibody to HIV virus
        
      • Detection of HIV virus (viral antigen)
        
  • Clinical or other criteria
    
    • Condition that meet criteria included in the case definitions of AIDS
      
• Children aged ≤ 18 months
  
  • Must meet at least one of the following criteria
    
    • Laboratory criteria
      
      • Definitive
        
        • Positive result or report of detectable quantity on any of the following HIV virology (non-antibody) test
          
          • HIV nucleic acid detection
            
          • HIV p24 antigen test including neutralization assay
            
          • HIV isolation (viral culture)
            
      • OR
      • Presumptive
        
        • Does not meet criteria for definitive HIV infection
          
        • Has a positive result on only one specimen (excluding cord blood) using the above HIV virology tests
          
    • OR
      
    • Clinical or other criteria
      
      • If the laboratory criteria are not met and no other causes of immune suppression
        
      • Condition that meet the criteria included in 1987 pediatric surveillance case definition for AIDS which are
        
      • Candidiasis of the oesophagus, trachea, bronchi, or lungs
        
      • Cryptococcosis, extrapulmonary
        
      • Cryptosporidiosis with diarrhea persisting > 1 month
        
      • Cytomegalovirus diseases of an organ other than liver, spleen, or lymph nodes in patients > 1 month of age
        
      • Herpes simplex virus infection causing a mucotaneous ulcer persisting > 1 month; or bronchitis, pneumonitis, or oesophagitis for any duration in a patient >1 month of age
        
      • Kaposi sarcoma
        
      • Lymphoma of the brain ( primary)
        
      • Mycobacterium avium complex of M. kansasii disease, disseminated (site other than/in addition to lungs, skin, cervical, or hilar lymph nodes)
        
      • Pneumocystis carinii pneumonia
        
      • Progressive multifocal leukoencephalopathy
        
      • Toxoplasmosis of the brain in a patient >1 month of age
        
      • ≥2 bacterial infections within a 2-year period (septicaemia, pneumonia, meningitis, bone or joint infections) or abscess of an internal organ orr body cavity – excluding otitis media or superficial abscesses
        

Notifiable diseases

Other diseases:

• Acute flaccid paralysis (AFP)
  
• Rubella (adult type)
  
• Rubella (congenital syndrome)
  
• Haemophilus influenza disease
  
• Mumps
  
• Influenza-like illness
  
• Avian influenza
  
• Severe acute respiratory syndrome (SARS)
  

References:

http://www.dph.gov.my/survelans/Guidelines%202008/Case%20definition%20update.pdf

http://www.pharmacy.gov.my/self_care_guide/miscellaneous/Hiv%20infection%20And%20Aids.pdf

Modes of Trasmission

Having vaginal or anal sex without a condom with someone who is infected.

Having contact with the blood of someone who has HIV. This could be having a blood transfusion from someone who is infected with HIV

From a mother who has HIV to her baby: HIV can pass to the baby during pregnancy, during the birth of the baby, or through breast-feeding. Only about one in three babies born to HIV-positive mothers get HIV.

Receiving an injection from an unsterilized needle that was previously used by someone with HIV.

Heterosexual transmission is the route by which most people with AIDS have become infected with HIV worldwide
This category of AIDS cases is also among the most rapidly increasing.

Investigation and Diagnosis of HIV

Who needs HIV testing ?
- sexually active
* ≥3 sexual partners in the last 12 months
-a male who has had sex with another male
-Drug addicts who take drugs by injection
*sharing needles and/or other equipment.
-STD patients
-Pregnant woman / woman who wants to make sure she is not infected by HIV before getting pregnant
-Patients who received a blood transfusion prior to 1985, or a sexual partner received a transfusion and later tested positive for HIV
-Health care worker with direct exposure to blood on the job

HIV Antibody Testing :
-Detects HIV antibodies in blood or other body fluids
-can be detected about 3 to 8 weeks after exposure to the virus
-Sample collected for testing:
*Blood
>inserting a needle into a vein in the arm
*Oral sample
>swab completely once around the outer part of the upper and lower gums
*Urine
-Screening tests available :
*ELISA
*Confirmatory test : Western Blot
*Home collection kit
-If you are tested too soon, result may be negative despite the fact that you are infected (false negative).
*may be tested using a p24 antigen test that can detect actual viral protein in the blood 1 to 3-4 weeks after exposure or an HIV RNA test (viral load) 
>detects the presence of the virus

ELISA - (Enzyme-linked Immunosorbent Assay Test)
-A common serological test
-For the presence of particular antigens or antibodies (Serum)
-Direct and indirect
*Direct : Employs monoclonal antibodies to detect the presence of particular antigens in a sample
*Indirect :To determine the presence of specific antibody (eg.HIV antibodies)

Indirect ELISA :
Appropriate antigen is first absorbed to the walls of a microtiter plate.
If serum contains antibodies against the antigens – bind to antigens (form complex)
Rinsing removes any antibodies that do not specifically attach to antigen
Addition of an antibody-enzyme conjugate
*Enzyme-conjugated anti-human IgG antibodies as reporter.
Enzyme-conjugated antibody will bind to the complex
Sample is rinsed again to remove any unbound antibodies
Substrate for the enzyme is added
Colour change – indicates the presence of antibodies that react against the antigens

-If test is taken right after the exposure and the result is negative
(False positive)
-If result is negative after “window period”
(HIV negative)
-If result is positive
*Confirmatory test is required
> WESTERN BLOT TEST

Western Blot Test :
HIV proteins are extracted.
Proteins are electrophoresed into a gel.
Proteins migrate through the gel when they are separated based upon size and charge. smaller proteins migrate through the gel faster than larger proteins.
Sufficiently separated proteins can be transferred to a solid membrane for WB analysis.
electric current is applied to the gel
All sites on the membrane which do not contain blotted protein from the gel can then be non-specifically "blocked"
*so that antibody (serum) will not non-specifically bind to them
*causing a false positive result.
membrane is cut into strips
*to facilitate testing of a large number of samples for antibodies directed against the blotted protein (antigen).
Procedure continues similar to ELISA.

Home Collection Kit :
-Approved by the US Food and Drug Administration (FDA)
-Take a sample of your blood from a finger at home and mail it to a testing center
-Hear your results later over the phone, along with appropriate counseling.

HIV Viral Load :
-the amount (viral load) of RNA (nucleic acid) of the human immunodeficiency virus (HIV) in blood.
-It is measured during the “window period” before the antibodies present
-Sample is collected from blood
*drawn by needle from a vein in your arm
-Can be measured after the therapy has started
*To evaluate whether the therapy is effective
-Test result:
*tests are reported as the number of HIV copies in a milliliter (copies/mL) of blood
*high viral load: from 5,000 to 10,000 copies/mL
*low viral load: between 40 to 500 copies/mL
>risk of disease progression is low.
-Tests available :
*p24 antigen count testing
>Followed by CD4 count
*Polymerase Chain Reaction (PCR)

p24 Antigen Count Test :
-p24 is a protein "shell" on the surface of HIV.
-help diagnose HIV viral protein in blood during early HIV infection.
*before HIV antibody is produced
-Result is positive : 1 week to 3-4 weeks after infection with HIV.
-Not detected until about 1 week after infection with HIV
*the virus haven’t multiplied to sufficient numbers to be detected.
-About 3-8 weeks after initial exposure, antibodies are produced.
*results of the p24 test will usually be negative although the person may be infected with HIV.
*antibodies bind to the p24 protein
>P24 protein no longer be detected in the blood.
 *HIV antibody test is used
-Later in the course of HIV, p24 protein become detectable if the disease is untreated.

CD4 Count :
-measurement of how many functional CD4 T-cells are circulating in the blood.
-CD4 cells - host cells that aid HIV in replication.
*HIV attaches to the CD4 cells
*allowing the virus to enter and infect the CD4 cells
*Damage the CD4 cells
-The lower the absolute CD4 count, the weaker the immune system.
-is measured by a simple blood test
-is reported as the number of CD4 cells per cubic millimeter of blood.
-Normal value :
*600 to 1200 cells per cubic millimter of blood
-Between 600 and 350 :
*In an HIV+ person, this range is considered "very good".
-Between 350 and 200 :
*The immune system is weakened
*HIV+ person may be at increased risk for infection and illness.
-Less that 200 :
*The immune system is severely weakened
*HIV+ person is at a much greater risk of opportunistic infections.

Prevention

Effective HIV prevention intervention includes

• Condom use
  Condoms, when used correctly and consistently, are highly effective in preventing HIV and other sexually transmitted infections (STIs). A large body of scientific evidence shows that male latex condoms have an 80% or greater protective effect against the sexual transmission of HIV and other STIs. Latex condoms are the best way to keep from getting HIV during sex. If you or your partner is allergic to latex, there are condoms made of polyurethane that can protect against HIV, too. But natural membrane condoms, also called lambskin condoms, do not prevent HIV because the virus can pass through them. If a man can’t or won’t use a condom, a woman can use the Reality female condom. It may protect against HIV, but it’s not as good as the latex condom a man uses. Do not use a Reality female condom along with a male condom. Both condoms will not stay in place when used together

• Male circumcision
  Male circumcision is the surgical removal of some or all of the foreskin (or prepuce) from the penis. This can reduce the risk of HIV infection in heterosexual men. However, the individual must continue to use other forms of protection(male condoms/female condoms).

• Provision of clean injecting equipment

• Opioid substitution therapy
  Opioid: analgesic that works by binding to opioid receptors, which are found principally in the central nervous system and the gastrointestinal tract
  Reduce transmission of blood-borne viruses

• Treatment of sexually transmitted infections
  Sexually transmitted infections (STI) have been shown to be important cofactors in the transmission and acquisition of HIV infection. For example, in Rakai, Uganda, research has shown an emergence of genital herpes simplex virus (HSV) in areas with mature HIV epidemics (i.e., areas with a high prevalence of HIV). Investigators found a nearly fivefold association of HSV with HIV-1 acquisition
  Genital ulcers, such as those associated with HSV-2, are potent cofactors in both HIV transmission and acquisition

• HIV testing and counselling
• A set of interventions to prevent mother-to-child transmission of HIV
• Sex education

To educate youth and society of

• Abstinence
• Use of condoms
  In Malaysia
  Reproduction – Form 3
  E.g. in Thailand
  “Condom King”
  Captain Mandela- HIV computer game
  

In health care settings, transmission of HIV can be prevented through

• Primary prevention measures such as blood safety, standard precautions, injection safety, and safe waste disposal

Standard precautions:

• Handwashing (or using an antiseptic handrub)
• Gloves, Masks, goggles, face masks, Gowns, Linen
• Patient care equipment
• Environmental cleaning
• Sharps
• Patient resuscitation
• Patient placement
• Use physical barriers (protective goggles, face masks and aprons)
• Use antiseptic agents for cleansing the skin or mucous membrane
• Use safe work practices such as not recapping or bending needles,
• Safely dispose of infectious waste materials to protect those who
  handle them and prevent injury or spread of infection to the
  community.
• Process instruments, gloves and other items after use by first
  decontaminating and thoroughly cleaning them, then either sterilizingor high-level disinfecting them using the recommended procedures

• Secondary prevention measures, such as post-exposure prophylaxis for occupational or certain non-occupational exposures to HIV such as in health-care settings, post-rape, and in case of condom breakage.

o Post-exposure prophylaxis (PEP) is short-term antiretroviral treatment to reduce the likelihood of HIV infection after potential exposure, either occupationally or through sexual intercourse.
o If you are within 72 hours of an incident of possible exposure to HIV, ask for PEP (Post Exposure Prophylaxis) treatment
o PEP treatment can help stop you becoming infected with the virus after you have been exposed to HIV. The sooner treatment is begun the higher the probability the treatment will be effective

In addition, there is increasing evidence indicating that

• ART programmes can be implemented in a way that emphasizes HIV prevention
• Current research on new prevention technologies such as microbicides, topical and oral antiretroviral pre-exposure prophylaxis in preventing the transmission of HIV and AIDS vaccines is ongoing.

Microbicides: compounds that can be applied inside the vagina or rectum to protect against sexually transmitted infections (STIs) including HIV.

HIV prevention - combination behavioural change approach has been
labelled as ABC—i.e.,

>Abstinence, including delay of sexual initiation or debut

>Being safer by being faithful to one’s partner or reducing the number of sexual partners

>correct and consistent Condom use

References:

1. Centers World Health Organization
http://www.who.int/hiv/topics/prevention/en/

2. Malaysian Aids Council
http://www.mac.org.my/hmtct.htm

3. Food and Drug Administration
http://www.fda.gov/opacom/lowlit/aids.pdf

4. Centers for Disease Control and Prevention
http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm
http://www.reproline.jhu.edu/english/4morerh/4ip/IP_manual/02_StandardPrecaution.pdf

Normal Process of Healing 2

To continue after WaiKit's.
Am posting up the whole story of the process.
For a brief summary, please get ppt slides from me. =)

The proliferative phase

Collagen deposits, angiogenesis, granulation, tissue development, wound contraction

Ideal repair is complete restoration of normal anatomy and function by regeneration of the anatomy and specialized functional (parenchymal) cells of the organ.
Healing is a process that occurs when regeneration is not possible or is incomplete and additional mending of the site is required by fibrous repair – the production of a scar. Occurs under following circumstances:
- The damage to tissue is extensive that the supporting framework is destroyed.
- The injured tissue is composed of permanent cells such as myocardium, skeletal muscle or brain.

Fibrous repair
1. Fibrocyte migration and proliferation – to provide raw material for repair
2. Angiogenesis – growth of new blood vessels to nourish the process
3. Scar development – the synthesis of extracellular matrix proteins and deposition of collagen followed by contraction (shrinking), reshaping (remodelling) and strengthening of the fibrous tissue

Cell migration
Leucocytes produce cytokines that stimulate migration and proliferation of fibroblasts
Fill space not occupied by regenerating parenchymal cells, synthesize collagen fibers to knit back together the disrupted tissue
Provide permanent structure to support additional cell growth
Endothelial cells fr nearby bv sprout angioblast

Angioneogenesis
Vascular endothelial growth factor and other factors stimulate new vessels to sprout fr existing veesels
1. Normal capillary with intact basement membrane and endothelial cells
2. Dissolution of the basement membrane of the parent vessels in the injured site by proteolytic enzymes released by inflammatory cells
3. Migration and proliferation of angioneoblastic endothelial cells through the defect and up the gradient of cytokines released by inflammatory cells and injred cells
4. Organization of a new capillary branch as the tube of endothelial cells generates a basement membrane.

Scar development
Follows angioneogenesis
1. Migration and proliferation of fibroblasts and new blood vessels into the injured site
2. Deposition of an extracellular matrix of collagen and other supportive proteins
3. Maturation, remodelling, contraction and strengthening of fibrous tissue

Granulation tissue
= mixture of capillaries, fibroblasts, residual edema, small no of leucocytes
 
Fibroblast contract, pulling edges of the wound inwards, decreasing the volume to be healed
At the same time, fibroblast produce collagen and other extracellular components to bind the wound firmly and give strength
Fluid is resorbed, inflammatory cells disappear, site becomes more collagenous tissue.
Blood vessels shrink or disappear as workload decreases.
More collagen accumulates to bind the wound tightly, fibroblast shrink and disappear


Healing by first intention
Day 1 : Neutrophils accumulate at the margin of the fibrinous clot in the cut. Stem cells in the epidermis (near basement membrane) begin to proliferate
Day 2-3: Neutrophils are gradually replaced by macrophages, new capillaries begin to appear. Fibroblasts and endothelial cells begin to migrate into the wound
Days3-7: Angiogenesis peaks and richly vascular granulation tissue fills the incision space.
Fibroblasts produce large amounts of collagen to bridge the space between the edges of the wound. Growth of epidermal stem cells has produced a thin layer of epithelium to cover the wound

Second week: Fibroblastic proliferation continues and collagen accumulates. Inflammatory cells, edema fluid, and blood vessels are disappearing rapidly.
End of first month: Pink (vascularised) scar is present. It is composed largely of collagen, is devoid of imflammatory cells, has a declining number of blood vessels, and is covered by normal epidermis. The tensile strength of the wound countinues to improve as fibroblasts contract and continue to add collagen.
After several months or a year: A narrowed, white, fitted scar is present. Skin tensile strength has returned to near normal.

Freshly sutured wound has about 70% of normal tensile strength if sutures are placed After sutured removal at one week, tensile strength is about 10%. Strength improves to about 75% at three months and after a year has returned to near normal.

Healing by second intention is much the same as healing by first intention: inflammation first, followed by macrophage clean-up, neovascularization and scarring. However, the volume of necrotic tissue to be removed is greater, the reepithelialisation of the surface is slower because the wound is wider. Healing by second intention is characteristic of ulcers, infarcts, abscesses, or other wounds where the defect is largeand wound edges are not close together. A greater volume of necrotic and inflammatory debris must be removed, and a large amount of granulation tissue is required to fill the gap. The granulation tissue is replaced by scar tissue, which in turn contracts so that the filnal volume of the scar may be as little as 10% of the original defect. In tissue covered by epithelium, new epithelial cells advanced inward from the edges, first forming a thin membrane of immature cells that rest on underlying granulation tissue and then differentiate into mature epithelium as the wound below matures into scar.

Maturation Phase

 Remodelling of scar occurs
- structural modifications of collagen
eg. Cross linking
Increasing fiber size
 Recovery of tensile strength results from collagen synthesis exceeding degradation during the first 2 months.
 Wound strength reaches 70%-80% of normal by 3 months.

Summary

Summary :
Types of burns :
• Chemical burns
• Electrical burns
• UV light burn
• Radiation injury

Signs and Symptoms :
Burn
• First-degree burns:
red, swollen, and painful. The burned area whitens (blanches) when lightly touched but does not develop blisters.
• Second-degree burns:
pink or red, swollen, and painful, and they develop blisters that may ooze a clear fluid. The burned area may blanch when touched.
• Third-degree burns :
usually are not painful. The skin becomes leathery and may be white, black, or bright red. The burned area does not blanch when touched, and hairs can easily be pulled from their roots.

Infection
• Change in color of the burnt area or surrounding skin
• Purplish discoloration, particularly if swelling is also present
• Change in thickness of the burn (the burn suddenly extends deep into the skin)
• Greenish discharge or pus
• Fever

Severity of Wound
• Depth
• Surface Area (Rule of nine, Rule of palm)
• Body part
• Pre-existing medical problem
• Age

Classification of Wound :
• 1st degree (epidermis)
• 2nd degree (epidermis + part of dermis)
• 3rd degree (epidermis + dermis)

Investigations for wound infection :
Wound culture:
• help determine whether wound infected
• identify bacteria
• prepare sample for susceptibility testing
• steps
o collecting sample
o stimulating growth (media)
o identification (e.g. gram stain)
o antimicrobial susceptibility testing (for treatment)

Complications:
Minor burns :
• usually superficial and do not cause complications.
Severe burns and some moderate burns :
• Dehydration
o Cause shock if dehydration is severe
• Chemical imbalances
• Destruction of muscle tissue (rhabdomyolysis)
• Infection cause severe illness or death.
• Thick, crusty surfaces (eschars)
o cutting off blood supply to healthy tissues or impairing breathing.

Normal process of healing :
Hemostasis
• growth factors are released.
• Constriction of blood vessels
• Adherence of platelets to damaged epithelium
• Discharge of adenosine diphosphate – promote thrombocyte clumping
• Clot forms to close blood vessels
• Cytokines initiate inflammatory phase

Inflammation
• Polymorphonuclear leukocytes released
• Activation of complement
• Macrophage formation

The proliferative phase
-collagen deposits
-angiogenesis
-granulation
-tissue development
- wound contraction

Maturation Phase
-remodelling of the scar
- strength of scar tissue

Treatment and Management :
• Wound Management.
• First Aid
o CPR
o Airway
 Check airways that may cause breathing problems.
o Breathing
o Circulation
 Fluid resuscitation (IV therapy)
• Chemical Burns
• Electrical Burns
• Skin Grafts
o Types – (Pinch Grafts, Split-thickness grafts, Full thickness grafts , Pedicle grafts)
• Skin Treatment Medication
• Follow-Up
o Physiotherapy
o Counseling and Support Groups
o Rehabilitative Care

Complementary medicine :
• Nutrition and diet supplement
• Herbs
• Acupuncture
• Massage therapy
• Physical therapy
• Homeopathy
• Mind-body Medicine
• Therapeutic Touch
• Maggot Therapy

Diseases spread by food handlers:
Agents of Food-borne diseases:
• Microorganisms, including:
o bacteria
o viruses
o parasitic protozoa
o worms
• natural toxins
• chemical residues
• prions.

List of potential diseases:
• Typhoid fever
• Gastroenteritis - norovirus, rotavirus, adenovirus, astrovirus, Helicobactor pylori
• Hepatitis A
• Cholera
• Listeriosis
• Hemolytic uremic syndrome
• hemorrhagic colitis
• Septicaemia
• Bovine Spongiform Encephalopathy (BSE)
• Strep throats
• Foodborne botulism
• Hemorrhagic colitis
• Salmonellosis
• Meningitis

Route of transmission (main diseases only)
Typhoid fever - stool of persons infected with typhoid fever or carriers, water
Gastroenteritis - fecal/oral, oral/oral, or gastric/oral pathways.
Campylobacter - from the consumption of undercooked meat, unpasteurized milk
Shigella - typically spread from person to person
Hepatitis A- by the fecal-oral route of transmission.
Cholera - through contamination of water sources and contamination of food.
Bovine Spongiform Encephalopathy (BSE)
–through an agent related to scrapie in sheep, which contaminated recycled bovine carcasses used to make meat and bone meal additives for cattle feed.
-contaminated bovine-based food products
Listeria - bacteria found in soil and water, raw foods as well as in processed foods and foods made from unpasteurized milk

Prevention of burns
• keep hot liquids away from table & counter edges
• don't hold or pass hot liquids over children
• keep cups & bowls with hot contents out of reach
• keep children out of kitchen while cooking
• keep iron or curling iron cords out of child's reach
• Never leave candles unattended. Blow them out when you leave the room.
• Test the water temperature before you or your children get into the tub or shower.
Preventing Radiation Burns
• Use a sunscreen
• Avoid exposure to UV (ultraviolet) radiation from sunlamps or tanning beds.
Preventing Chemical Burns
• Wear gloves and other protective clothing when you handle chemicals. Store chemicals, including gasoline, out of the reach of children.
• Store Chemicals in Locked Cabinet
• Purchase Potentially Dangerous Chemicals in Safety Containers
• Avoid Prolonged Chemical Exposure
Preventing Electrical Burns
• keep electrical outlets covered from children
• put covers on any electrical outlets that are within children's reach.


Public Health Issue :
General Requirement for food premises
• Location
• General design
• Water supply
• Cleanliness of food premises
• Pest control in food premises
• Disposal of refuse

Specific Requirements for Food premises
• Floor surfaces
• Wall surfaces
• Lighting
• Ventilation
• Ceiling
• Door
• Furniture, fitting and food contact surfaces
• Food storage
• Changing room
• Wash basin
• Toilet room
• Drainage facility

Food Handler
• Food handlers training
• Clothing of food handler
• Medical examination and health condition of food handler
• Personal hygiene of food handler
• Duty to keep food premises clean

Severity of Wounds + Investigation (Summary)

Summary

Severity of Wounds

• Depth
• Surface Area (Rule of nine, Rule of palm)
• Body part
• Pre-existing medical problem
• Age

Classification of Wounds

• 1st degree (epidermis)
• 2nd degree (epidermis + part of dermis)
• 3rd degree (epidermis + dermis)

Investigation for Wound Infection

Wound culture:

• help determine whether wound infected
• identify bacteria
• prepare sample for susceptibility testing
• steps
• collecting sample
• stimulating growth (media) 
• identification (e.g. gram stain)
• antimicrobial susceptibility testing (for treatment)

PUBLIC HEALTH ISSUE (FOOD HYGIENE REGULATIONS 2009 – will be enforced in 1st March 2010)

General Requirement for food premises

Location

• Food premises shall be located away from sources of contamination including aeration ponds, septic tanks and waste disposal sites
  

General design

• Food premises shall be designed and constructed as such to facilitate cleaning and disinfection
  

Water supply

• There shall be ample supply of potable water and adequate facilities for its storage and distribution, where necessary.
  
• The water supply shall be adequately protected against any contamination
  

Cleanliness of food premises

• Food premises shall be maintained at all times in a good, clean, and tidy condition
  
• Food premises shall be free from any accumulation of boxes, tin, empty bottles, rubbish or any other article not connected with the business of the food business to prevent the entrance and harbourage of pest
  
• The cleaning of food premises shall be carried out at least once daily and includes the removal of food residues and dirt, whenever necessary
  
• There shall be provided an adequate facilities for the cleaning, disinfecting, and storing of appliances used in food premises and such facilities shall be constructed from corrosion resistant materials and easily cleaned and, where necessary, have an adequate supply of hot and cold potable water
  
• There shall be provided and made available at all times an adequate supply of suitable cleaning agents, disinfectant and tools to enable regular and proper cleaning of food premises and all appliances used in the food premises
  
• Every cleaning agent and disinfectant used in the food premises shall be adequately labelled and not to be stored in areas where food is stored or handled
  
• The Director or an officer authorised by him may, for the purpose of maintaining the cleanliness of the food premises, require any proprietor, owner, or occupier of food premises to make any structural alteration, repair, renovation, plumbing or drainage work in the premises within such time as may be specified by the Director or an officer authorised by him
  

Pest control in food premises

• A proprietor, owner or occupier of food premises shall, at all times, keep the food premises free from any pest.
  
• A proprietor, owner or occupier of food premises shall, on becoming aware of the presence of any pest in the premises, forthwith take all practicable measures to destroy the pest and to prevent reinfestation.
  
• A pest control treatment shall only be carried out by using a suitable chemical, physical or biological agent and without posing a threat to the safety of food.
  

Disposal of refuse

• All food waste, non edible by-products and other refuse shall be
  
  • removed from any room where food is present as soon as possible to avoid their accumulation;
    
  • 
    deposited in closable containers or other types of containers of an appropriate construction and kept in a good condition, easily cleaned and where necessary, disinfected; and
    
  • 
    eliminated in a hygienic and environmentally friendly way in accordance with the relevant law applicable to that effect, and is not to constitute a direct or indirect source of contamination.
    
• There shall be adequate provision for the storage and disposal of food waste, non edible by-products and other refuse.
  
• All food waste, non edible by-products and other refuse stores shall be designed and managed in such a way as to enable them to be kept clean and, where necessary, free of animals and pests.
  

Specific Requirements for Food premises

Floor surfaces

• All floors in food premises shall be–
  
  • maintained in a good condition, easily cleaned and where necessary, disinfected;
    
  • of impervious, non-absorbent, washable and non-toxic materials unless the proprietor, owner or occupier of food premises can satisfy the Director or an officer authorized by him that other materials used are appropriate; and
    
  • Adequately drained.
    

Wall surfaces

• All walls in food premises shall be–
  
  • maintained in a good condition, easily cleaned and where necessary, disinfected; and
    
  • 
    of impervious, non absorbent, washable and non toxic materials and require a smooth surface up to a height appropriate for a food process unless the proprietor, owner or occupier of food premises can satisfy the Director or an officer authorized by him that other materials used are appropriate.
    
  • All angles between a wall and a floor in a food premises shall be sealed and coved to facilitate cleaning, where necessary.
    

Lighting

• Every food premises shall be provided with adequate natural or artificial lighting which does not lead, or cause any contamination of food.
  

Ventilation

• A ventilation system in food premises shall be–
  
  • suitable and sufficient which does not lead to, or cause any contamination of food; and
    
  • constructed to enable filters and other parts requiring cleaning or replacement be readily accessible.
    
• A mechanical airflow of a ventilation system shall not flow from a contaminated area to a clean area.
  

Ceiling

• All ceilings or where there is no ceiling, the interior surface of the roofs and overhead fixtures of food premises shall be constructed and in finish form which able to prevent the accumulation of dirt and shedding of particles and to reduce condensation and growth of undesirable mould.
  

Door

• All doors in food premises shall be–
  
  • easily cleaned and where necessary, disinfected; and
    
  • of smooth, non absorbent surface and self closing.
    

Furniture, fitting and food contact surfaces

• All furniture, fittings and food contact surfaces used or to be used for the preparation, serving, storage, conveyance or distribution of food in any food premises shall be well maintained and kept clean at all times.
  
• All furniture, fittings and food contact surfaces used or to be used in any processing area of food premises shall be of impervious material and easily cleaned.
  

Food storage

• There shall be a suitable storeroom of adequate size for the storage of food in all food premises.
  
• There shall be a different storeroom for the storage of raw food materials and ingredients, and for the storage of processed food materials in all food premises.
  
• All fittings or equipments used or to be used for storage of food in all food premises shall–
  
  • be made of suitable material;
    
  • be designed and constructed to permit adequate cleaning and disinfection; and
    
  • 
    Have adequate space to enable proper storage of food.
    
• Where any food needs to be stored in a chilled or frozen condition, the storage facility for such food shall comply with the following requirements:
  
  • a separate refrigerated storage for raw food materials and processed food materials is sufficiently provided;
    
  • the facility is defrosted whenever necessary to maintain refrigeration efficiency;
    
  • 
    the inner layer of the facility is made of a smooth and non-toxic metal or other impervious material, and of is light coloured and easily cleaned;
    
  • any device used to record temperature in the facility is accurate to a plus or minus 1C; and
    
  • the air vent of the facility is sited away from excessive light, warm air, oven or air-conditioning outlets.
    
• If the storage facility referred to in subregulation (4) is a cold room, the doors to such facility shall be fitted with an air curtain or other effective means to avoid loss of cold air or any sudden rise in temperature.
  

Changing room

• There shall be provided a changing room, where necessary, for the use of a food handler in food premises.
  

Wash basin

• There shall be provided an adequate number of wash-basin suitably located and designated for washing hand.
  
• wash-basin shall, at all times, be—
  
  • 
    supplied with adequate running water;
    
  • supplied with soap or suitable liquid detergent in a dispenser;
    
  • 
    supplied with paper towel or automatic hand dryer;
    
  • 
    kept clean and maintained in a good condition; and
    
  • 
    equipped with non-hand operated taps for the use of food handler.
    
• There shall be different wash-basin for washing hand and washing food in food premises.
  

Toilet room

• There shall be provided an adequate number of toilet room in food premises.
  
• The toilet room shall—
  
  • be provided with running water, toilet paper, soap or suitable liquid detergent in a dispenser, hand drying facility or clean roller towels or paper towels at all times;
    
  • be kept clean and free from malodour at all times: and
    
  • not directly open to any room or compartment used for the storage, production and serving of food.
    

Drainage facility

• A drainage facility in food premises shall be adequate, designed and constructed to avoid any risk of contamination to food.
  
• A drainage facility in a kitchen or food preparation areas of food premises shall be made of smooth type material, fitted with food trap and connected to the main outlet drain of the food premises.
  
• The drainage channels in food premises shall be fully or partially open and appropriately designed to ensure that waste does not flow from a contaminated area towards or into a clean area.
  

Food Handler

Food handlers training

• All food handlers shall undergo a food handlers training in, and obtain a Certificate of Food Handlers Training from, an institution specified by the Director.
  
• The Minister may, if he thinks necessary, require any food handler to attend any additional food handlers training in any institution specified by the Director.
  
• Any food handler who works in any food premises fails to undergo a training or obtain a certificate referred to in subregulation (1) or fails to attend any additional training referred to in subregulation (2) commits an offence and shall, on conviction, be liable to a fine not exceeding ten thousand ringgit or to imprisonment for a term not exceeding two years.
  

Clothing of food handler

• A food handler shall wear―
  
  • 
    a clean, suitable and proper clothing which shall not contribute to any contamination of food; and
    
  • a clean, suitable and light-coloured outer overall or a light-coloured apron, head cover and footwear, or any other clothing which is suitable to the opinion of the Director or an officer authorized by him.
    
• The clothing specified in paragraph (1)(b) shall not be worn other than in food premises and shall be kept in a suitable cupboard or locker when not in use.
  
• Any food handler who fails to comply with subregulation (1) or (2) commits an offence and shall, on conviction, be liable to a fine not exceeding one thousand ringgit.
  

Medical examination and health condition of food handler

• A food handler shall be medically examined and vaccinated by a registered medical practitioner.
  
• Any food handler who suffers from, or is a carrier of food-borne diseases or suspected to be suffering from, or to be a carrier of food-borne diseases shall—
  
  • not be allowed to enter food premises or handle food;
    
  • 
    immediately report to the management of food premises pertaining to his health condition; and
    
  • be suspended from working in food premises until he is certified cured from the disease and medically fit to work by a registered medical practitioner before he is allowed to enter the food premises or handle food.
    
• Any food handler who fails to comply with subregulations (1) or (2) commits an offence and shall, on conviction, be liable to a fine not exceeding ten thousand ringgit or to imprisonment for a term not exceeding two years.
  

Personal hygiene of food handler

• A food handler while handling, preparing, packing, carrying, storaging, displaying and serving of food shall―
  
  • maintain a high degree of personal cleanliness which includes the keeping of short and clean fingernails;
    
  • remove his overall or head cover or apron before visiting toilet;
    
  • wash his hands before commencing work, immediately after using the toilet and after handling raw food or any contaminated material;
    
  • 
    not engage in any behaviour or action that could result in contamination of food;
    
  • not place any articles in the pocket of any garment or apron which may contribute to any contamination of food; and
    
  • not wear jewelleries, watches, pins or other accessories.
    
• Any food handler who fails to comply with subregulation (1) commits an offence and shall, on conviction, be liable to a fine not exceeding ten thousand ringgit or to imprisonment for a term not exceeding two years.
  

Duty to keep food premises clean

• A food handler shall ensure that food premises where the food is handled are kept clean and free from rubbish, pest, dirt or soot, sweepings, ashes, wastes and cobwebs at all time.
  
• Any food handler who fails to comply with subregulation (1) commits an offence and shall, on conviction, be liable to a fine not exceeding ten thousand ringgit or to imprisonment for a term not exceeding two years.
  

References:

http://fsq.moh.gov.my/uploads/Peraturan2_Kebersihan_Makanan_2009__BI_%5B1%5D.pdf

Signs and symptoms of burns and infection

Burn

• First-degree burns are red, swollen, and painful. The burned area whitens (blanches) when lightly touched but does not develop blisters.
• Second-degree burns are pink or red, swollen, and painful, and they develop blisters that may ooze a clear fluid. The burned area may blanch when touched.
• Third-degree burns usually are not painful because the nerves have been destroyed. The skin becomes leathery and may be white, black, or bright red. The burned area does not blanch when touched, and hairs can easily be pulled from their roots without pain.

Infection

• Change in color of the burnt area or surrounding skin
• Purplish discoloration, particularly if swelling is also present
• Change in thickness of the burn (the burn suddenly extends deep into the skin)
• Greenish discharge or pus
• Fever

Summary for Hemostasis and Inflammation

Hemostasis
When injury occurs, chemical mediators and intercellular messengers called growth factors are released.
-next, blood leaking from inflamed, dilated or broken veselss, begin to coagulate.

-platelets adhere to the damaged epithelium
-discharge adenosine diphosphate to promote thrombocyte clumping
-releases cytokines to initiate inflammatory phase

Alpha granules release growth factors
– PDGF(Platelet-derived growth factor)
– Platelet factor 4
– TGF-b(Transforming growth factor beta)
Serotonin and histamine also released
Thrombin forms , clot forms to close small vessels and stop bleeding
Inflammation
Polymorphonuclear leukocytes released. They clear the debris from the wound.
Activation of complement
C5a-attract neutrophils. Release histamine. Capillary permeability and vasodilation.
C3b-opsonize bacteria-enhance phagocytosis by neutrophils and macrophage.
C5,6,7,8,9-form Membrane Attack Complex that lyse bacteria
Macrophage formation
-cytokine production-TNF,IL-8,IL-1,IL-6.
1) Has chemoattractants that recruit and activate additional macrophages at the site of injury,
2) growth factors that promote cellular proliferation and protein synthesis,

Diseases spread by food handlers, Route of transmission, Prevention of burns

Diseases spread by food handlers

Agents of Food-borne diseases:

Microorganisms, natural toxins, and chemical residues, prions. 

Microorganisms, including:

bacteria (eg Campylobacter), 

viruses (eg Norwalk virus), 

parasitic protozoa (eg Cryptosporidium), 

and worms (eg Trichinella spiralis).

List of potential diseases:

Typhoid fever

Gastroenteritis - norovirus, rotavirus, adenovirus, astrovirus, Helicobactor pylori 

Hepatitis A

Cholera

Listeriosis

Hemolytic uremic syndrome

hemorrhagic colitis 

Septicaemia

Bovine Spongiform Encephalopathy (BSE)

Strep throats 

Foodborne botulism

Hemorrhagic colitis

Salmonellosis

Meningitis

Route of transmission (main diseases only)

Typhoid fever - Salmonella Typhi present in stool of persons infected with typhoid fever or carriers. More common in areas of the world where hand washing is less frequent and water is likely to be contaminated with sewage.  Can be contracted from handling poultry or reptiles such as turtles that carry the germs.

Gastroenteritis - fecal/oral, oral/oral, or gastric/oral pathways. Improper hand washing following a bowel movement or handling a diaper can spread the disease from person to person. 

Viruses:

Adenoviruses

Parvoviruses

Astroviruses 

Bac:

Campylobacter - from the consumption of undercooked meat, unpasteurized milk 

Shigella - typically spread from person to person

Hepatitis A- by the fecal-oral route of transmission. An infected food employee can transmit these pathogens to consumers through the contamination of food or food utensils by Hep A virus present in stool of persons infected with Hep A.

Cholera - V. cholerae is introduced to humans through contamination of water sources and contamination of food. The cycle of transmission is closed when infected humans shed the bacteria into the environment and contaminate water sources and food. V. cholerae survives for up to 14 days in some foods, especially when contamination occurs after preparation of the food.  Cooking and heating the food eliminate the bacteria. Epidemics of cholera associated with the ingestion of leftover rice,  yellow rice in a restaurant,  raw fish,cooked crabs, eafood,  raw oysters,  and fresh vegetables and fruits  have been documented.

Bovine Spongiform Encephalopathy (BSE), a fatal, transmissible, neurodegenerative disease of cattle, was first discovered in the United Kingdom in 1985. The cause of the disease was traced to an agent related to scrapie in sheep, which contaminated recycled bovine carcasses used to make meat and bone meal additives for cattle feed. Recycling of the BSE agent led to a distributed common source epidemic of more than 180,000 diseased animals in the UK alone.  Humans can be infected if exposed to contaminated bovine-based food products

Listeria, caused by Listeria monocytogenes, bacteria found in soil and water. It can be in a variety of raw foods as well as in processed foods and foods made from unpasteurized milk. Listeria is unlike many other germs because it can grow even in the cold temperature of the refrigerator. 

Prevention of burns

keep hot liquids away from table & counter edges 

keep handles on cooking pots turned in 

don't hold or pass hot liquids over children 

keep cups & bowls with hot contents out of reach 

keep children out of kitchen while cooking 

always keep oven door closed 

turn hot water heater temperature down to 120 F 

never place beds or cribs near radiators 

never place torch lamps near curtains & bedding 

never leave hot iron on floor or on top of bed 

keep iron or curling iron cords out of child's reach 

never smoke in bed 

never pour flammable liquids onto a hot BBQ

Never leave candles unattended. Blow them out when you leave the room.

Don't wear clothing with long, loose sleeves when you are cooking.

Test the water temperature before you or your children get into the tub or shower. Don't let young children touch the faucet handles during a bath.

Prevent prolonged exposure to steam

Preventing Radiation Burns

Use a sunscreen that has a sun protection factor (SPF) of at least 30 or higher. Sunscreens that say "broad-spectrum" can protect the skin from ultraviolet A and B (UVA and UVB) rays. Sunscreens come in lotions, gels, creams, and ointments.

Avoid exposure to UV (ultraviolet) radiation from sunlamps or tanning beds.

Preventing Chemical Burns

Wear gloves and other protective clothing when you handle chemicals. Store chemicals, including gasoline, out of the reach of children.

Store Chemicals in Locked Cabinet

Purchase Potentially Dangerous Chemicals in Safety Containers

Avoid Prolonged Chemical Exposure

Preventing Electrical Burns

keep electrical outlets covered from children 

put covers on any electrical outlets that are within children's reach. Throw out electrical cords that are frayed or damaged in any way.

References:

WHO

http://www.who.int/mediacentre/factsheets/fs124/en/

UC San Diego Medical Center

http://health.ucsd.edu/specialties/burn/about.htm

FamilyDoctor.org

http://familydoctor.org/online/famdocen/home/healthy/safety/safety/649.printerview.html

American College of Emergency Physicians

http://www3.acep.org/patients.aspx?id=25990

Healthline

http://www.healthline.com/channel/chemical-burns_prevention

http://www.healthline.com/galecontent/food-borne-diseases

Northwest Burn Foundation

www.nwburn.org

CDC

http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-foodhandlers.htm

http://www.cdc.gov/ncidod/dbmd/diseaseinfo/foodborneinfections_g.htm#mostcommon

http://www.cdc.gov/nczved/dfbmd/disease_listing/salmonellosis_gi.html

http://www.cdc.gov/ncidod/dbmd/diseaseinfo/typhoidfever_g.htm

KidsHealth

http://kidshealth.org/parent/infections/stomach/campylobacter.html

MedlinePlus

http://www.nlm.nih.gov/medlineplus/botulism.html

Merck

http://www.merck.com/mmhe/sec09/ch122/ch122b.html

Complications

Minor burns are usually superficial and do not cause complications. However, deep second-degree and third-degree burns swell and take more time to heal. In addition, deeper burns can cause scar tissue to form. This scar tissue shrinks (contracts) as it heals. If the scarring occurs in a limb or digit, the resulting contracture may restrict movement of nearby joints.

Severe burns and some moderate burns can cause serious complications due to extensive fluid loss and tissue damage. These complications may take hours or days to develop. The deeper and more extensive the burn, the more severe are the problems it tends to cause. Young children and older adults tend to be more seriously affected by complications than other age groups. The following are some complications of some moderate and severe burns:

Dehydration eventually develops in people with widespread burns, because fluid seeps from the blood to the burned tissues and, if burns are deep and extensive enough, to the whole body.
Shock develops if dehydration is severe.
Chemical imbalances can result from extensive burns.
Destruction of muscle tissue (rhabdomyolysis) sometimes occurs with deep third-degree burns. The muscle tissue releases myoglobin, one of the muscle's proteins, into the blood. If present in high concentrations, myoglobin harms the kidneys.
Infection can complicate burn wounds. Sometimes the infection can spread throughout the bloodstream and cause severe illness or death.
Thick, crusty surfaces (eschars) are produced by deep third-degree burns. Eschars can become too tight, cutting off blood supply to healthy tissues or impairing breathing.

Complementary Therapy

Nutrition and Diet Supplement
-Often given high-calorie, high-protein diets to speed recovery
-Eat antioxidant food (beta-carotene, vitamin C and E)
*Fruits : blueberries, tomatoes, cherries, papaya, guava etc.
*Vegetables : broccoli, spinach, green pepper etc.
^neutralize free radicals by offering their own electrons
-Eat fewer red meats and more lean meats, cold-water fish, tofu (soy) or beans for protein.
-Drink 6 - 8 glasses of filtered water daily.
-Avoid fatty food (saturated fats, trans-fats) and processed food
-Avoid refined foods, such as white breads, pastas, and sugar.
-Vitamin C (1,000 mg two to six times per day)
*helps skin heal by enhancing new tissue growth and strength.
-Vitamin E (400 - 800 IU a day) promotes healing.
*May be used topically once the burn has healed and new skin has formed.
*Higher doses may help in healing burns.
-Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tablespoonful oil, one to two times daily
*to help decrease inflammation, and for healing and immunity.
*Cold-water fish, such as salmon or halibut, are good sources.
-Coenzyme Q10
*for antioxidant and immune activity.

Herbs
-Gotu kola (Centella asiatica) as a cream
*contains chemicals called triterpenoids
*In animal and lab studies, these compounds appear to help heal wounds.
*For example, some studies indicate that triterpenoids strengthen the skin, boost antioxidants in wounds, and increase blood supply to the area

-Calendula (Calendula officinalis), or pot marigold
*contains high amounts of flavonoids, plant-based antioxidants
*Animal studies show that calendula does appear to speed wound healing, possibly by increasing blood flow to the wounded area and by helping the body produce collagen proteins, which are used to heal skin and connective tissue.

-Aloe Vera
*“Burn plant”
*contains over 75 known active ingredients including a wide range Vitamins A,B,C,and E, antioxidant, minerals, calcium, essential Amino Acids, Sugars, Digestive Enzymes, Anti-inflammatory Enzymes, Plant Sterols, Lignin, Saponins, Anthraquinones and more.
stimulate skin growth and repair
*ability to provide essential nutrients needed to promote healthy tissue growth
^by reducing inflammation
^killing bacteria and other foreign organisms
*Aloe Vera’s cooling effect offers instant relief from burns
^prevent, or greatly reduce, blistering when applied immediately after receiving a burn.
*In a review of the scientific literature, researchers found that patients who were treated with aloe vera healed an average of almost 9 days sooner than those who weren't treated with the medicinal plant.

-Honey
*Current interest in medicinal honey focuses largely on its antibacterial effects.
*It is acidic
^prevent infection
*High concentration of sugar
^absorb fluid that weeps from the wound
*Contains natural plant chemicals that are anti-bacterial.
*May help the body remove dead tissue
*Anti-inflammatory activity reduces edema and minimizes scarring
*Stimulates growth of granulation and epithelial tissues to speed healing
*Removes malodor
*Hydrogen Peroxide
^When honey is applied as a wound dressing, it is diluted with fluids from the damaged tissue and
^combines with an enzyme added by the bee to form hydrogen peroxide
^the same antiseptic found in drugstores.
^Diluted honey- an excellent antiseptic
^naturally occurring hydrogen peroxide won’t harm the tissues and no scarring will occur.
*The evidence :
^level 2 evidence that honey is effective for healing superficial burns and scalds.
^unclear what type of honey product (eg, natural honey, medicated dressings) is best for burns.
^not safe or effective as a dressing for more serious burns (level 2 evidence).
^None of the honey-based or other dressings tested were reported to cause adverse effects.
*Ancient Egyptian surgical texts recommended using honey on wounds, and some animal studies and trials suggest the sweet solution may speed up healing.

Acupuncture
-Electrical Stimulation
*Transcutaneous electrical nerve stimulation (TENS) uses controlled, low-voltage electrical stimulation of the skin to relieve pain.
*Recent studies have suggested that TENS applied to acupuncture points (called electroacupuncture) on the ear (auricular acupuncture) may relieve pain for people with burns.

Masssage Therapy
-"hands-on" therapy
-muscles and other soft tissues of the body are manipulated to improve health and well-being.
-electrical signals are transmitted both to the local area and throughout the body
*heal damaged muscle,
*stimulate circulation,
*clear waste products via the lymphatic system,
*boost the activity of the immune system,
*reduce pain and tension, and
*induce a calming effect.
*stimulate the release of endorphins (natural painkillers and mood elevators)
*reducing levels of certain stress hormones.
-People receiving a massage reported significantly less itching, pain, anxiety, and depressed mood compared to those who received standard care only.

Physical Therapy
-to improve movement and function of the areas affected by a burn.
-reduce scar formation.
-Practices include :
*Body and limb positioning
*Splinting
*Help with activities of daily living until normal function and ability are recovered
*Passive (physical therapist moves the person's limbs) and active exercises
*Help with walking

Homeopathy
-important principles : dilution and succussion.
*Remedies are diluted and then "succussed," or shaken,
^to increase their potency.
-act as catalysts that aid the body's inherent healing mechanisms
-Examples:
*Place the burned area in cold water until the pain goes away (at least a few minutes).
*Arnica Montana -- taken orally immediately after the burn.
*Hypericum perforatum -- used on the skin if there are sharp, shooting pains with the burn.
*Causticum -- taken orally for burning pains with great rawness (as from an open wound) or when there are long-term physical or emotional symptoms after a burn.

Mind Body Medicine
-healing that uses the power of thoughts and emotions to positively influence physical health
-Hypnotise
*a person's body relaxes
^thoughts become more focused and attentive -in the state of deep concentration
^people are highly responsive to a hypnotherapist's suggestions.
^reduce pain and anxiety and enhance relaxation

-Therapeutic Touch
*based on the theory that the body, mind, and emotions form a complex energy field
*correct the body's imbalances by moving their hands just over the body.
^"the laying on of hands.“
*studies have shown conflicting results

Maggot Therapy
-For maggots to function optimally :
*require a moist environment;
*saline soaks were therefore applied for 48 hours
*to moisten the wound
^remove excess SSD prior to application of maggots.
-Maggot secretions appear to
*amplify the healing effects of host epidermal growth factor
^allantoin and urea (antimicrobial activity)
^calcium carbonate (stimulation of phagocytosis) and
^proteolytic enzymes (slough/necrotic tissue breakdown)
^The resultant enzymatic degradation products are subsequently ingested and digested by the maggots.
-Micromassage of the wound by maggot movement is thought to
*stimulate the formation of granulation tissue and wound exudate by the host
-accelerated debridement of slough and necrosis
-a reduction in the bacterial load of the wound,
*leading to earlier healing, reduced wound odour and less pain.
-Evidence suggests that maggots can be used successfully in a wide variety of wounds (trauma, vascular, infected, malignant and a single report in an infected burn wound

sites for burns

hey guys and girls i hope these sites will be useful to u all.

http://www.primary-surgery.org/ps/vol2/html/sect0100.html

http://www.merck.com/mmhe/print/sec24/ch289/ch289a.html

http://www.medicinenet.com/burns/article.htm

Types of burns

Burns are usually caused by heat (thermal burns), such as fire, steam, tar, or hot liquids. Burns caused by chemicals are similar to thermal burns, whereas burns caused by radiation , sunlight , and electricity differ significantly. Events associated with a burn, such as jumping from a burning building, being struck by debris, or being in a motor vehicle crash, may cause other injuries.

Thermal and chemical burns usually occur because heat or chemicals contact part of the body's surface, most often the skin.

Chemical burns
Burns can also occur when chemicals are spilled onto the body and generate a reaction that creates heat. Chemical burns may be classified by their pH or acidity.
Acids are those with pH less than 7 and include common household compounds like acetic acid, hydrochloric acid, or sulfuric acid.
Bases or alkali compounds have a pH greater than 7. Ammonia is a common alkali found in the home.

A variety of household products fits this description:
Bleach
Concrete mix
Drain or toilet bowl cleaners
Metal cleaners
Pool chlorinators

Pathophysiology

Agents that cause chemical burns are described by mechanism of injury. The chemical classification scheme includes such categories as desiccants, vesicants, oxidizing agents, protoplasmic poisons, acids, and alkali agents.

Acids act through coagulative necrosis, forming an eschar that limits the penetration of the acid. Strong alkali cause liquefactive necrosis, resulting in saponification of fats and denaturation of proteins, ultimately allowing deeper penetration of the chemical. Oxidizing agents also denature proteins and often cause cell damage via cytotoxic effects. Protoplasmic poisons, such as hydrofluoric acid (HF), can form salts with cellular proteins. Desiccants dehydrate cells through an exothermic reaction. Finally, vesicants are thought to produce physiologic reactions that cause the release of amines along with a variety of other damaging processes. Despite these categories, precise classification of chemical agents remains difficult because agents often cause injury by more than one mechanism.

Tissue damage from chemical burns depends on several factors.
The strength or concentration of the agent
The site of contact (eye, skin, mucous membrane)
Whether swallowed or inhaled
Whether or not skin is intact
With how much of the agent you came into contact
The duration of exposure
How the chemical works

Signs and symptoms of chemical burns include the following:
Redness, irritation, or burning at the site of contact
Pain or numbness at the site of contact
Formation of blisters or black dead skin at the contact site
Vision changes if the chemical gets into your eyes
Cough or shortness of breath

Self-Care at Home
Begin basic first aid. Immediately call 911 if you have a severe injury, any shortness of breath, chest pain, dizziness, or other symptoms throughout your body. If you are aiding an injured person with these symptoms, lay the person down and immediately call 911.
Remove yourself or the victim from the accident area.
Remove any contaminated clothing.
Wash the injured area to dilute or remove the substance, using large volumes of water. Wash for at least 20 minutes, taking care not to allow runoff to contact unaffected parts of your body. Gently brush away any solid materials, again avoiding unaffected body surfaces.
Especially wash away any chemical in your eye. Sometimes the best way to get large amounts of water to your eye is to step into the shower.
Remove contaminated clothing
Brush away any dry powders or particles
Rinse the area with large amounts of water.

Treatment
Before burns are treated, the burning agent must be stopped from inflicting further damage. For example, fires are extinguished. Clothing—especially any that is smoldering (such as melted synthetic shirts), covered with a hot substance (for example, tar), or soaked with chemicals—is immediately removed.

Hospitalization is sometimes necessary for optimal care of burns. For example, elevating a severely burned arm or leg above the level of the heart to prevent swelling is more easily accommodated in a hospital. In addition, burns that prevent people from carrying out essential daily functions, such as walking or eating, make hospitalization necessary. Severe burns, deep second- and third-degree burns, burns occurring in the very young or the very old, and burns involving the hands, feet, face, or genitals are usually best treated at burn centers. Burn centers are hospitals that are specially equipped and staffed to care for burn victims.



Smoke Inhalation
Many people who have been burned in fires have also inhaled smoke. Sometimes people inhale smoke without sustaining skin burns. Smoke inhalation often causes no serious, lasting effects. However, if the smoke contains certain poisonous chemicals, is unusually dense, or inhalation is prolonged, serious problems can develop.

Hot smoke sometimes burns the throat, resulting in swelling. As the swelling narrows this area, airflow into the lungs is obstructed. Breathing hot steam can burn the lungs as well as the throat, causing severe breathing problems.

Inhalation of chemicals released in the smoke, such as hydrogen chloride, phosgene, sulfur dioxide, and ammonia, can cause swelling and damage to the windpipe (trachea) and even the lungs. Eventually, the small airways leading to the lungs narrow, further obstructing airflow. Smoke can also contain chemicals that poison the body's cells, such as carbon monoxide (see Poisoning: Carbon Monoxide Poisoning) and cyanide.

Damage to the trachea or the lungs can cause shortness of breath, which can take up to 24 hours to develop. Obstruction of airflow due to swelling of the airways can produce difficulty breathing air in, wheezing, and shortness of breath. People may have soot in the mouth or nose, singed nasal hairs, or burns around the mouth. Lung damage may cause chest pain, coughing, and wheezing. If the oxygen supply is depleted due to smoke, people may pass out. High levels of carbon monoxide in the blood may cause confusion or disorientation or may even be fatal.

To assess the extent of injury due to smoke inhalation, doctors may pass a flexible viewing tube (bronchoscope) into the trachea. Doctors may assess lung damage with a chest x-ray or with a test that determines the level of oxygen in the blood.

People who have inhaled smoke are given oxygen through a face mask. If a tracheal burn is suspected, a breathing tube is inserted through the nose or mouth in case the trachea later swells and obstructs airflow. If people begin to wheeze, drugs that open small airways such as albuterol may be given, usually as a mist that is combined with oxygen and inhaled through a face mask. If lung damage causes shortness of breath that persists despite use of a face mask and albuterol, a ventilator may be necessary. Relieving the stress of breathing conserves people's energy and usually allows faster recovery.


Electrical burns

Electrical burns may cause serious injury that is not readily apparent. Often the entry and exit points for the electrical shock may not be easily found.

Electricity flows more easily through tissues in the body that are designed to deal with electricity. Nerves and muscles are "wired" for this task and often are damaged. If significant muscle damage occurs, muscle fibers and chemicals can be released into the bloodstream causing electrolyte disturbances and kidney failure.

An electrical injury occurs when a current passes through the body, interfering with the function of an internal organ or sometimes burning tissue.

Often the main symptom is a skin burn, but not all people have visible injuries.
Doctors check the person for abnormal heart rhythms, fractures, dislocations, and spinal cord or other injuries.
Abnormal heart rhythms are monitored, burns are treated, and, if the burn caused extensive internal damage, intravenous fluids are given.
Electrical injury may result from contact with faulty electrical appliances or machinery or inadvertent contact with household wiring or electrical power lines. Getting shocked from touching an electrical outlet in the home or by a small appliance is rarely serious, but accidental exposure to high voltage causes about 400 deaths each year in the United States. 

The severity of the injury ranges from minor to fatal and is determined by the following factors:
Intensity of the current
Type of current
Pathway of the current through the body
Duration of exposure to the current
Electrical resistance to the current

Symptoms
Often, the main symptom of an electrical injury is a skin burn (see Burns), although not all electrical injuries cause external damage. High-voltage injuries may cause massive internal burns. If muscle damage is extensive, a limb may swell so much that its arteries become compressed (compartment syndrome—see Fractures: Compartment Syndrome), cutting off blood supply to the limb. If a current travels close to the eyes, it may lead to cataracts. Cataracts can develop within days of the injury or years later. If large amounts of muscle are damaged (a disorder called rhabdomyolysis), a chemical substance, myoglobin, is released into the blood. The myoglobin can damage the kidneys.

Treatment
First the person must be separated from the current's source. The safest way to do so is to shut off the current—for example, by throwing a circuit breaker or switch or by disconnecting the device from an electrical outlet. No one should touch the person until the current has been shut off, particularly if high-voltage lines could be involved.

High-voltage and low-voltage lines are difficult to distinguish, especially outdoors. Shutting off current to high-voltage lines is done by the local power company. Many well-meaning rescuers have been injured by electricity when trying to free a person.

Once the person can be safely touched, the rescuer should check to see if the person is breathing and has a pulse. If the person is not breathing and has no pulse, cardiopulmonary resuscitation (CPR) should be started immediately (see First Aid: First-Aid Treatment). Emergency medical assistance should be called for any person who has more than a minor injury. Because the extent of an electrical burn may be deceptive, medical assistance should be sought if any doubt exists regarding severity.

People with rhabdomyolysis may receive large amounts of fluids intravenously. A tetanus shot is given if needed.

Skin burns are treated with burn cream (such as silver sulfadiazine, bacitracin,or sterile aloe vera) and sterile dressings. A person with only minor skin burns can usually be treated at home. If the injury is more severe, the person is admitted to the hospital, ideally a burn center. The person is kept in the hospital for 6 to 24 hours if any of the following exists:

The results of an ECG are abnormal
The person has lost consciousness
The person has symptoms of a heart problem (for example, chest pain, shortness of breath, awareness of heartbeats [palpitations])
The person has other severe injuries
The person is pregnant (in many, but not necessarily all, cases)
The person has a known heart problem (in many, but not necessarily all, cases)


UV light burn
Treatment: The key to minimizing the damaging effects of the sun is avoiding further sun exposure. Damage that is already done is difficult to reverse. Moisturizing creams and makeup help hide wrinkles. Chemical peels, alpha-hydroxy acids, tretinoin
creams, and laser skin resurfacing may improve the appearance of thin wrinkles and irregular pigmentation. Deep wrinkles and substantial skin damage, however, require significant treatment to be reversed.


Radiation injury
damage to tissues caused by exposure to ionizing radiation.
Large doses of ionizing radiation can cause acute illness by reducing the production of blood cells and damaging the gastrointestinal tract.
A very large dose of ionizing radiation can also damage the heart and blood vessels (cardiovascular system), brain, and skin.
Ionizing radiation can increase the risk of cancer, and damage to sperm and egg cells can increase the risk of genetic defects in offspring.
In general, ionizing radiation refers to high-energy electromagnetic waves (x-rays, gamma rays) and particles (alpha particles, beta particles, neutrons) that are capable of stripping electrons from atoms (ionization). Ionization changes the chemistry of affected atoms and any molecules containing those atoms. By changing molecules in the highly ordered environment of the cell, ionizing radiation can disrupt and damage cells.
onizing radiation is emitted by radioactive substances (radionuclides), such as uranium, radon, and plutonium. It is also produced by man-made devices, such as x-ray and radiation therapy machines.

Radio waves, such as from cell phones and AM and FM transmitters, and visible light also are forms of electromagnetic radiation. However, because of their lower energy, these forms of radiation are not ionizing, and thus public exposure levels from these common sources do not damage cells. In this discussion, “radiation” refers exclusively to ionizing radiation.

Contamination is contact with and retention of radioactive material, usually as a dust or liquid. External contamination is that on skin or clothing, from which some can fall or be rubbed off, contaminating other people and objects. Internal contamination is radioactive material deposited within the body, which it may enter by ingestion, inhalation, or through breaks in the skin. Once in the body, radioactive material may be transported to various sites, such as the bone marrow, where it continues to emit radiation, increasing the dose, until it is removed or emits all its energy (decays). Internal contamination is more difficult to remove than external contamination.

Irradiation is exposure to radiation but not to radioactive material, that is, no contamination is involved. A common example is diagnostic x-rays, such as for a broken bone. Radiation exposure can occur without direct contact between people and the source of radiation (such as radioactive material or an x-ray machine). When the source of the radiation is removed or turned off, irradiation ends. People who are irradiated but not contaminated are not radioactive, that is, they do not emit radiation, and their dose from that source of radiation does not continue to increase.

Effects of Radiation
The damaging effects of radiation depend on several factors:
The amount (dose)
How rapidly the dose is received
How much of the body is exposed
The sensitivity of particular tissues to radiation

Treatment
Physical injuries are treated before irradiation is treated because they are more immediately life-threatening. Irradiation has no emergency treatment, but doctors closely monitor people for the development of the various syndromes and treat the symptoms as they arise.

Contamination should be removed promptly to prevent the radioactive material from continuing to irradiate the person and to prevent the radioactive material from being taken up by the body. Contaminated wounds are treated before contaminated skin. Doctors decontaminate wounds by flushing them with a salt water solution and wiping them with a surgical sponge. After decontamination, wounds are covered to prevent recontamination as other sites are washed. Contaminated skin should be gently scrubbed with large amounts of soap and warm (not hot) water. Skin folds and nails need extra attention. Harsh chemicals, brushes, or scrubbing that may break the skin surface should be avoided. If hair cannot be decontaminated with soap and water, clipping it off with scissors is preferable to shaving. Shaving may cut the skin and allow contamination to enter the body. Skin and wound decontamination should continue until the Geiger-Muller counter shows that the radioactivity is gone or almost gone, until washing does not substantially reduce the amount of radioactivity measured, or until further cleaning risks damaging the skin. Burns should be gently rinsed but not scrubbed.

http://emedicine.medscape.com/article/1089490-overview
medline
merck.com
http://www.medicinenet.com/burns/page3.htm#tocf