Conversely order celebrex 100mg on line, patients with a widened mediastinum had a higher injury severity score buy celebrex 200 mg without prescription, longer hospital stay (p < 0 buy celebrex 200 mg free shipping. Six patients still had pain 1 month after injury of whom two had injury-related long-term disability because of pain cheap 200 mg celebrex. The early mortality in our study was 2/29 in patients with sternal fractures and 1/7 in patients with widened mediastinum. An aggressive approach including early operative reduction is recommended even for a stable fracture to reduce the overhelming pain. Sternal fracture with or without retrosternal heamatoma is not a reliable indicator of cardiac and aortic injuries, while mediastinal widening is still a fairly reliable clue that should indicate further investigation. Key words: sternal fractures, retrosternal hematoma, mediastinal widening, diagnosis, management, morbidity and mortality, cardiac and aortic injuries. One of our main aims Most chest injuries involve soft tissue, the bone cage, was to Ž nd out if the presence of a sternal fracture and the underlying pleura and lung, and chest wall indicates cardiac and aortic injuries and to clarify the injuries make up a half to two thirds of all thoracic difference between a retrosternal haematoma and injuries that require admission to hospital. The age, sex, should suspect and assess any underlying injuries to the mechanism of injury, comorbidity, clinical diagnosis, heart, bronchus, and great vessels. Reports about radiological diagnosis, associated injuries, complica- sternal fractures are almost always contradictory tions, treatment, length of hospital stay, and follow-up (3, 5, 7, 9, 12, 15). Because most of them are chest trauma of whom 29 patients (range 30–92 years, associated with the steering wheel type of injury the mean age 64, 17 women and 12 men) had a fractured mortality rate may be high because of the severity of sternum (11 with retrosternal haematoma and 18 associated cardiovascular injuries. We therefore con- without) and 389 did not (7 with widened mediastinum ducted this retrospective study to look at the incidence, and 382 without). Upper body 7 2 Three patients initially had echocardiograms and one Manubrium 6 3 Lower body 3 1 a transoesophageal echocardiogram and all were Multiple parts 2 1 inconclusive. Two patients had Adjacent to xiphoid 1 0 displacement by one anteroposterior thickness, four cases were displaced by half an anteroposterior thickness, and 22 cases had stable fractures. The retro- coexisting cardiac diseases, but neither of them had sternal haematomas were found adjacent to many of cardiac problems from the sternal fractures. Electro- fractures and ranged from a few mm to 2 cm in size; cardiographic monitoring with estimation of cardiac they were more common in fractures of the body of enzyme activities were done in nine cases. No patients were recorded There was no signiŽ cant difference in the incidence as having aortic injuries. The incidence of suspected of associated lesions between patients with sternal aortic injury and aortography was 7/29, (3 angiograms fractures with or without a retrosternal haematoma. Differences between patients with sternal fractures and retrosternal haematomas and those with a widened mediastinum alone Sternal fracture and retrosternal Widened mediastinum alone haematoma (n = 11) (n = 18) p Value Associated thoracic lesions 1. A lateral sternal radiograph showing a wide overlapping fracture in the body in which the upper segment separation at the synchondrosis. It is worth emphasising that retrosternal haematomas were more common in fractures of the mid-body and manubrium of the sternum (Table I). The presence of such widening is an indication for urgent aortography to rule out the possibility of concurrent major vascular injury (2). The diagnosis in all cases was based on a history of trauma to the sternum in patients wearing seat belts, with pain and local tenderness. These structures are usually transverse and if displaced the upper segment lies behind the lower fragment (Fig. In the past, immersion in cold water was recommended to reduce the fracture by sudden inspiratory movements, but this is of historical interest only (12). In this series one patient developed a big organised The early mortality in our study was 2/29 in patients haematoma over the fracture. The residual symptom with sternal fractures (one patient died on the 13th day during early follow-up of these patients was usually after injury of multiple organ failure, and one patient pain, which was exaggerated by chest movement. Eur J Surg 167 Cardiovascular injuries 247 However, there are some treatments for sternal showed that pain was the major complication but those fractures: analgesics were taken by all patients and authors did not suggest radical solution such as surgical should be tried Ž rst. A retrosternal haematoma Operative reduction and Ž xation can be done by can be differentiated from real mediastinal widening wiring the proximal and distal fragments together with but our observations are clinical and based on only a 2 or 3 heavy wire sutures (Fig. Like others lessen the unnecessary use of angiograms in a stable (11), we advocate early surgical repair when indicated, patient with a traumatic retrosternal haematoma. Our observations themselves are usually benign if not excessively may make selection easier and avoid unnecessary displaced, they are associated with appreciable mor- angiograms. The sternal haematoma was not associated with cardiac and incidence of sternal fractures and the associated aortic injuries, while mediastinal widening is still a mortality seems to increase with age. American College of Surgeons, Committee on Trauma Sternal fracture has been reported to be associated with Advanced trauma life support manual. The a sternal fracture following discharge from the A and E associated head injuries decreased with time from 49% department. Cardiac and vascular sequale of reduced speed limits, legislation about seat belts, safer sternal fractures. Diagnostic value appreciable reduction in the number of major head and of ultrasonography and conventional radiography for the assessment of sternal fractures. A prospective study of 413 the use of seat belts increased the incidence of minor consecutive car occupants with chest injuries. Fracture of the sternum in motor vehicle clear, and seldom reported by the patient or ambu- accidents and its association with mediastinal injury. Early operative days, weeks, or even months absence from work or management of isolated sternal fractures. The effects of mandatory seat Submitted December 15, 1999; submitted after revision May belt wearing on the mortality and pattern of injury of car 16, 2000; accepted September 20, 2000 occupants involved in motor vehicle crashes in Victoria. Subjects: 81 patients who presented with pulmonary injuries during the period January 1988–December 1997; 6 were penetrating and 75 blunt. The remaining was divided into 2 groups: those with pulmonary contusion and thoracic lesions (n = 32), and those with pulmonary contusion and extrathoracic lesions (n = 42). Four patients in the penetrating group were shocked and required urgent operations; emergency room thoracotomy (n = 1), urgent thoracotomy (n = 2), and urgent thoracoabdominal exploration (n = 1) were done successfully. The corresponding hospital mortality was 6/42 (19%) mainly as a result of the central nervous system lesions (4/6) compared with 0/32. Conclusions: An excellent outcome can be achieved managing penetrating injuries of the lung by an aggressive approach and urgent surgical intervention even when emergency room thoracotomy is essential. Pulmonary contusion is considered to be a relatively benign lesion that does not add to the morbidity or mortality in patients with blunt chest trauma. These data may help to decrease the obsession with pulmonary contusion in patients with chest trauma, with or without extrathoracic lesions, and avoid many unnecessary computed tomograms of the chest. It is often considered to be inconsequential in patients The earliest known record of thoracic injuries is found with chest trauma, but it is the second most common in the Edwin Smith Surgical Papyrus, written 5000 injury in blunt thoracic trauma and is associated with a years ago. Since that time, the treatment of chest trauma had management and outcome of 81 patients with chest been restricted to closed drainage of empyema during trauma and documented penetrating or blunt injury to World War I (11) and removal of foreign bodies that the lung.

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Ultimately generic 200 mg celebrex with mastercard, all such approaches attempt to optimize over treatment response cheap celebrex 200 mg with amex, side-effects best 200mg celebrex, and costs in achieving best outcomes for individual patients order celebrex 100mg fast delivery. Patients with low viral load and achieve rapid virological response will not beneft from adding the protease inhibitor. This report just presents the fndings without any The goal of the report was to provide a recommendations for the clinicians. Harder, Greifswald Christian Hoffmann, Hamburg Bernd Sebastian Kamps, Paris Stephen Korsman, Tygerberg Wolfgang Preiser, Tygerberg Gustavo Reyes-Terán, Mexico-City Matthias Stoll, Hannover Ortrud Werner, Greifswald Gert van Zyl, Tygerberg Influenza Report 2006 www. The editors and authors of Influenza Report 2006 have made every effort to provide information that is accurate and complete as of the date of publication. However, in view of the rapid changes occurring in medical science, prevention and policy, as well as the possibility of human error, this site may contain technical inaccuracies, typographical or other errors. Readers are advised to check the product information currently provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsibility of the treating physician who relies on experience and knowledge about the patient to determine dosages and the best treatment for the patient. The contributors to this site, including the editors and Flying Publisher, disclaim responsibility for any errors or omissions or for results obtained from the use of information contained herein. Important: The current book is designed for educational purposes only and is not engaged in rendering medical advice or professional services. The information provided herein should not be used for diagnosing or treating a health problem or a disease. Members of the lay public using this site are advised to consult with a physician regarding personal medical care. Tuberculosis was defeated, small pox was about to be eradicated, sexually transmissible diseases could easily be treated, and other scourges of mankind, such as malaria, were expected to disappear one day. Some experts hilariously announced that we would soon be able to close the book of infectious diseases once and for all. A quick look at medical history would have sufficed to understand that infectious diseases have accompanied humans ever since they opted for a sedentary lifestyle. While we are today better prepared to prevent and fight off infectious diseases, we are nonetheless condemned to coexist with them. In a world with an increasing potential for the rapid spread of pathogens – overcrowded cities, high mobility – the role of efficient infectious disease task forces can therefore not be overestimated. An avian influenza strain, H5N1, has recently caused multiple outbreaks in poultry on three continents and has infected nearly 200 persons, killing more than half of them. The book is freely available on the Internet and the second edition is scheduled to be published before the end of the year. Influenza Report may be translated into other languages without incurring a license fee (see details on the website). Bernd Sebastian Kamps, Christian Hoffmann, and Wolfgang Preiser Paris, Hamburg, Tygerberg – 24 March 2006 6 7 Contributors Georg Behrens, M. Klinische Immunologie Zentrum Innere Medizin der Medizinischen Hochschule Carl-Neuberg-Straße 1 D – 30625 Hannover Phone: +49 511 532 5393 Fax: +49 511 532 9067 René Gottschalk, M. Leiter der Abteilung Infektiologie Stellvertretender Amtsleiter Stadtgesundheitsamt Frankfurt/Main Braubachstr. Klinische Immunologie Zentrum Innere Medizin der Medizinischen Hochschule Carl-Neuberg-Straße 1 D 30625 Hannover Phone: +49 511 532 3637 Fax: +49 511 532 5324 stoll. Earthquakes in Tokyo or San Francisco last from seconds to a couple of minutes – pandemics spread around the world in successive waves over months or a couple of years. And quite different are the consequences: an influenza pandemic may be a thousand times more deadly than even the deadliest tsunami. The next pandemic may be relatively benign, as it was in 1968 and 1957, or truly malignant, as was the 1918 episode. We don’t know if the next pandemic will be caused by the current bête noire, H5N1, or by another influenza strain. We ignore how the next pandemic will evolve over time, how rapidly it will spread around the world, and in how many waves. The ongoing outbreak of H5N1 influenza among birds with occa- sional transmission to human beings is of major concern because of intriguing par- allels between the H5N1 virus and the 1918 influenza strain. As the threat is global, strategies must be global – a tricky task when our planet is divided into more than two hundred nations. In the following paragraphs, we shall take a look at the various facets of the war on influenza: the global and individual impact of the disease, the virus itself, and the individual and global management of what may one day turn out to be one of the most challenging healthcare crises in medical history. The most important thing to remember when talking about pandemic influenza is that its severe form has little in common with seasonal influenza. Global Impact Epidemics and Pandemics Influenza is a serious respiratory illness which can be debilitating and cause com- plications that lead to hospitalisation and death, especially in the elderly. Every 18 Influenza 2006 year, the global burden of influenza epidemics is believed to be 3–5 million cases of severe illness and 300,000–500,000 deaths. The new variants are able to elude human host defences and there is therefore no lasting immunity against the virus, neither after natural infection nor after vaccination, as is the case with smallpox, yellow fever, polio, and measles. These permanent and usually small changes in the antigenicity of in- fluenza A viruses are termed “antigenic drift” and are the basis for the regular oc- currence of influenza epidemics (Figure 1). In addition, there is now evidence that multiple lineages of the same virus subtype can co-circulate, persist, and reassort in epidemiologically significant ways (Holmes 2005). These major changes in the antigenicity of an influenza virus are called “antigenic shift” (Figure 2). Table 1: Antigenic Shifts and Pandemics* Designation Resulting Pandemic Death Toll 1889 H3N2 Moderate? The new viral strain will eventually reach everywhere, and will infect practically every human being within a period of a few years. Seasonal excess mortality rates due to pneumonia and influenza may remain elevated for many years, as was shown in the A(H3N2)- dominated seasons in the decade after 1968, in persons aged 45–64 years in the United States (Simonsen 2004). Courtesy: National Institute of Allergy and Infectious Disease Global Impact 21 One hallmark of pandemic influenza is a mortality shift towards younger age groups. Half of influenza-related deaths during the 1968 pandemic, and large pro- portions of influenza-related deaths during the 1957 and the 1918 pandemics, oc- curred among persons < 65 years old (Simonson 1998). It was the worst pandemic in history, killing more people than World War I, and it is generally assumed that at least 50 million people died (Johnson 2002). The first wave, which started during the spring of 1918, was highly contagious but not particularly deadly. Symptoms in 1918 were so unusual that, initially, it was misdiagnosed as dengue fever, cholera, or typhoid (Barry 2004). In contrast to subsequent pandemics, most deaths during the 1918 pandemic were among young and healthy persons aged 15 to 35 years old, and 99 % of deaths occurred in people younger than 65 years. According to this investigation, the 1918 virus was not a reassortant virus (like those of the 1957 and 1968 pandemics), but more likely an entirely avian-like virus that adapted to humans. Patients with chronic underlying disease and pregnant women were particularly at risk of developing pulmonary complications (Louria 1957).

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These funds are often administered through the hospital rather than the University celebrex 100mg on line, so there is no centralized accounting for these grants buy 200mg celebrex with visa. Collaboration and Networks Diabetes researchers can not and should A Provincial Centre for Diabetes Research not work in isolation discount celebrex 200 mg visa. Most diabetes (modeled discount celebrex 100mg overnight delivery, for example, on the Centre on researchers are already part of an informal Aging at the University of Manitoba) would network of colleagues and collaborators, provide dedicated and long-term nationally and internationally. It would attract Within the province, examples of the formal financial contributions by industry and linkages between researchers include the government and encourage the recruitment following: of high-calibre researchers to the university. It could also play a role in research groups formally recognized by province-wide recruitment of participants in the Faculty in its structural reorganization. Community-Based Diabetes • Health Canada is currently considering a Research and Ethics proposal for a Centre for Innovation in Research should involve the full Aboriginal Diabetes Care, Education and participation of communities, not only with Research to be based in Peguis First community members consenting as Nation. This National Centre would research subjects, but also involving them in consolidate and promote community-based deciding on priorities and playing an active research on diabetes interventions in the role in designing and executing the projects. The result would be a move away from the traditional model of research on While the majority of diabetes researchers communities towards research for are university-based academic researchers, communities and ultimately, research by it should be recognized that research is not communities. There with specific gains beyond contributing to are limited opportunities for practice-based an increase in the knowledge base. Several improve understanding of the research models exist, for example, the one process and scientific method. This concern developed by the Kahnawake Diabetes is jointly shared by the Education Working Education Project in Quebec. Existing guidelines and structures for ethical The media do not always provide accurate approval developed for basic biomedical accounts of research and researchers are and clinical research are not entirely suitable not always proficient in explaining their or appropriate for community-based work in comprehensible language. The basic ethical principles of must make an effort to report their work autonomy, beneficence, non-maleficence clearly and carefully to the popular media. However, there are usually additional requirements such as the need Report of the Support for collective consent, ownership of data, Working Group negative publicity and other issues for Background which a clear consensus does not currently “Support” means to assist individuals with exist. The peer review ensure quality of life within their own process seeks to ensure the quality of communities. Communities The underlying principle is that support also have a role to play in the review should be provided in a holistic manner. This includes: scientific merit and community relevance • co-ordination of and access to services in within the same review committee. The general public is language barriers; often bewildered by the proliferation of • wellness promotion and prevention of research studies, which may contain disease; and contradictory results and confusing • providing culturally sensitive and implications. Both physical and human Support for Individuals with resources are needed to develop this Diabetes and Their Families supportive environment. The support for individuals newly diagnosed community must feel responsible for its with diabetes and those coping with programs and resources. The long-term lifestyle changes for themselves and their success of these initiatives depends on this. It should also include support for individuals who are coping with the long- “Community involvement recognizes the term complications of diabetes. People with diabetes should be included in health care planning when it involves diabetes and health care delivery in their community. These people need to be supported by adequate training, access to resources and attention to the balance of physical and mental well-being in their jobs. Theresa Point Band Office the public, were convened across the Steinbach province during the spring of 1998 as an Bethesda Personal Care Home integral component of the Strategy. A The Pas Steering Committee and Secretariat member Cree Nation Tribal Health Centre were present to provide background to the The Pas Kikiwak Inn Manitoba Diabetes Strategy and identify the Thompson purpose of the public meeting. The format Keewatin Tribal Council Board Room for each meeting varied depending upon Thompson the site and the number of participants. Lions Centre Participants were asked to provide input Winnipeg Franco-Manitoban Cultural Centre regarding their issues, concerns and Winnipeg possible actions related to diabetes Freight House prevention, education, care, research and Winnipeg support. Lions Place The following community consultation sites The following sites were scheduled for the were convened by the Steering Committee: consultation process, but meetings were Arborg not held due to travel weather conditions, Town of Arborg Board Room or other logistical issues: Brandon Churchill Canadian Diabetes Association offices Lac Brochet Dauphin Thunders Restaurant Souris. School summarizing input received from health programs were frequently identified participants at the public meetings, relative as needing more emphasis on nutrition. Three hundred and improved labeling of food products could four people attended the sessions: 231 contribute to healthy eating by identifying members of the general public and 73 appropriate food choices. Site-specific records recommended that restaurants should play have been retained by the Strategy Steering a role in identifying healthy food Committee. Standards for school lunch Prevention programs were recommended in urban and There was general recognition of the need rural settings. Improved food choices in for prevention, heightened by the knowledge public arenas received comment in one that diabetes was increasingly a cause of northern setting. Concerns regarding the increased facilities was identified in rural and First rate of diabetes in children of First Nations Nations communities. It was stated programming in schools was identified as that governments need to identify needing attention in the context of prevention as a priority. Incentive programs were Education recommended for the promotion of The need for more education of the preventive measures. There was concern The most frequent recommendation in expressed in both rural and First Nations northern and First Nations communities was consultations that individuals tend to the need to ensure the availability and develop a fatalistic approach once dia- affordability of appropriate foods. Education was seen as Nations communities made frequent a mechanism for generating hope and reference to the importance of traditional improved self-care. There was a strong foods in the prevention of diabetes and presentation regarding the need for the need to examine hunting regulations attention to literacy levels in the and the impact of such regulations on the development of a public education availability of traditional foods. Rural communities emphasized development of community gardens was the value of “wellness fairs” for public 72 Diabetes A Manitoba Strategy Public Meetings education, in addition to the usual media It was recommended that people living with methods of education. The need for diabetes should receive specific education general public education in traditional about the current standards of diabetes languages was advocated by Aboriginal care. In all sectors of the province, the Issues regarding traditional healing were school health curricula was identified as addressed in First Nations consultations. It was It was recommended that health clearly stated that health professionals need professionals receive education about current information. Specifically, there was traditional healing to promote an interface dismay expressed regarding the knowledge between Western and traditional approaches base of general and family practitioners. Enhanced education for physicians was There was a recommendation that recommended at a majority of public education must also be available in French meetings. The important role of family for individuals with diabetes and their physicians in diabetes care was stressed. The need for increased emphasis on dia- Care betes in nursing education programs was Issues of access to care were essentially identified in one consultation. General concerns included funding meet the education needs of First Nations for travel from rural and northern areas.

Emotional and practical support from the partner order celebrex 200 mg free shipping, family and friends are vital in assisting an affected woman in her recovery celebrex 100 mg generic. If necessary medications are prescribed to control the production of depressing chemicals in the brain (eg best 200 mg celebrex. In developed countries it is very uncommon buy 200mg celebrex with visa, because most women undertake regular antenatal visits and checks. Pre-eclampsia is a condition that precedes eclampsia, and this is detected in about 10% of all pregnant women. The exact cause of pre-eclampsia is unknown, but it is thought to be due to the production of abnormal quantities of hormones by the placenta. Pre-eclampsia normally develops in the last three months of pregnancy, but may not develop until labour commences, when it may progress rapidly to eclampsia if not detected. Doctors diagnose the condition by noting high blood pressure, swollen ankles, abnormalities (excess protein) in the urine due to poor kidney function and excessive weight gain (fluid retention). Blood tests may show a low level of platelets (thrombocytopenia) that are used in blood clot formation. Not until the condition is well established does the patient develop the symptoms of headache, nausea, vomiting, abdominal pain and disturbances of vision. This causes convulsions, coma, strokes, heart attacks, death of the baby and possibly death of the mother. Pre-eclampsia is treated by strict rest (which can be very effective), drugs to lower blood pressure and remove excess fluid, sedatives, and in severe cases, early delivery of the baby. An infusion of magnesium sulphate into a vein may be used while waiting for an emergency delivery if the mother is at high risk of fitting. The correct treatment of pre-eclampsia prevents eclampsia, and the prognosis is very good if detected early and treated correctly. Unfortunately there is no regime that will prevent pre- eclampsia or a recurrence, although low dose aspirin is being used experimentally for prevention in high risk mothers. To facilitate this expansion, the ligaments that normally hold the joints of the pelvis (and other parts of the body) together become slightly softer and more elastic which makes them more susceptible to strain. The joints of the spine are particularly at risk because the expanding uterus shifts the centre of balance and changes posture. Standing for any length of time is likely to impose unusual stresses on the back, and this strains the supporting ligaments and results in backache. Slight movements of the vertebrae, one on the other, can cause nerves to be pinched and result in pain such as sciatica. This nerve pinching is further aggravated by the retention of fluid in the whole body, which causes the nerves to be slightly swollen and therefore more easily pinched. The best way to reduce the likelihood of backache is not to gain weight excessively and to avoid all heavy lifting. At antenatal classes, physiotherapists show the correct way to lift, and teach exercises to help relieve the backache. The bleeding may be due to a slight separation of the placenta from the wall of the womb as it grows, and it almost certainly does not involve the baby directly. About 30% of all pregnant women suffer from some degree of bleeding during pregnancy, and some have quite severe bleeds without losing the baby. Other causes of bleeding in pregnancy include an ectopic pregnancy, significant separation of the placenta from the wall of the uterus (placental abruption), vaginal ulcers or erosions or hormonal imbalances. For example, if the last period started on 5 January 2003, she will be due to deliver on 12 October 2003. The most common types of pain are lower abdominal pain due to expansion of the uterus and its attached ligaments, backache and heartburn. Abdominal pain early in pregnancy may also signal significant complications, such as a miscarriage or an ectopic pregnancy. At this early stage, a false negative result is possible, and the tests are more reliable if carried out a couple of days after the missed period. A negative test may mean that the pregnancy is not far enough advanced to be detected, rather than that the woman is not pregnant, while a positive test is almost invariably correct. In a test carried out in a test tube, the mix of urine and chemicals will form a characteristic deposit; but more often the urine is added to one side of a small flat plastic container and as the urine moves across this it interacts with chemicals that will change colour if the test is positive. To ensure a reliable result, the test is generally carried out 2-7 days after the first missed period (ie. A pregnancy test can be carried out at home with a kit purchased from the chemist, but more reliable tests are performed by doctors using a sample of blood. Although pregnancy actually occurs about two weeks after a woman had her last period, for convenience doctors always date a pregnancy from the first day of that last menstrual period. The size, position, maturity, age and sometimes sex of the foetus can all be seen, and some of the internal organs of the baby, particularly the heart, can be checked. Abnormalities such as spina bifida (split spinal cord), hydrocephalus (excess fluid in the brain) and certain other congenital disorders can be identified. A routine scan may be performed between the sixteenth and eighteenth week of pregnancy when the foetus can easily be seen and transformed into an image. Babies under 500g have only a 40% chance of survival, under 1000g a 65% chance, and over 1500g a nearly 100% chance of survival. These figures are for the best hospitals in developed countries, but babies born prematurely in remote areas will have a far lower survival rate. The smaller the baby, the greater the problems, and the more intensive the care required from specialised units in major hospitals. Tubes and leads to and from the infant may appear to overwhelm it but are necessary to monitor the heart and breathing, supply oxygen, assist breathing in some cases, feed the baby, drain away urine, keep the temperature at the correct level, and maintain the correct chemical balance in the blood. Many require oxygen to allow them to breathe, but too much oxygen can cause a condition called retrolental fibroplasia that damages the retina (light sensitive area) at the back of the eye to cause permanent blindness. Premature babies also progress better if their intensive care nursery is darkened and quietened for the twelve night hours. A baby born prematurely will be a little later in reaching the milestones of infancy and should have routine immunisations in the first six months slightly delayed. The delay is halved by the time the child reaches six months of age, and disappears completely by one year of age. It is rare for an infant born before 24 weeks to survive, and only after 30 weeks are the chances of survival considered to be good. There is no apparent cause in over half the cases, but in others, high blood pressure, diabetes, two or more babies, more than six previous pregnancies, foetal abnormalities, polyhydramnios and abnormalities of the uterus may be responsible. Premature labour may now be prevented or controlled in some cases by injections of drugs such as atobisan, ritodrine (Yutopar) or salbutamol (Ventolin, which is also used to treat asthma). Usually this is the back of the head (occiput), but it may be the buttocks (breech), front of the head (brow) or face. The presentation of the baby during labour is very important, as it will determine the ease of labour and its complications. This is a medical emergency, as the start of labour usually follows soon after the waters break, and the cord will be compressed as the baby moves down into the birth canal, cutting off its oxygen supply.

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