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Government of Nepal

Ministry of Communications and Information Technology

Minimum Wages Fixation Committee

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By: L. Pakwan, MD

Assistant Professor, Icahn School of Medicine at Mount Sinai

They resemble the bacteria in their shape and resemble the viruses in their strict growth requirements for living host cells hair loss treatment usa buy discount dutasteride 0.5mg line. Rickettsiae are transmitted to man and animals by vectors such as ticks hair loss treatment uk cheap dutasteride amex, lice hair loss yahoo article discount 0.5mg dutasteride fast delivery, fleas hair loss cure your own bacon 0.5 mg dutasteride with visa, and mites. The rickettsiae have a selective affinity for specific types of cells of the human and animal bodies. Sheep, goats, cattle, dogs, cats, some wild mammals, birds, and ticks serve as reservoirs. Infected animals usually do not develop the disease, but shed large numbers of organism in placental tissues and body fluids. Airborne particles containing organisms may be carried downwind for a considerable distance (one-half mile or more); also by direct contact with infected animals and other contaminated materials such as wool, straw, fertilizer, and laundry. Raw milk from infected cows contains organisms and may be responsible for some cases, but this has not been proven. Symptoms include fever, fatigue, chills, sweats, muscular pain, and severe headache in 75 percent of cases. At least 4 to 6 hours of attachment and feeding on blood by the tick are required before the rickettsiae become reactivated and infectious for people. Contamination of breaks in the skin or mucous membranes with crushed tissues or feces of the tick may also lead to infection. This disease is characterized by sudden onset of moderate to high fever (which ordinarily persists 2 to 3 weeks in untreated cases), significant malaise, deep muscle pain, severe headache, and chills. A rash generally appears on the extremities on about the third to fifth day; this soon includes the palms and soles and spreads rapidly to much of the body. The fatality rate ranges between 13 to 25 percent in the absence of specific therapy. Measures that can be taken to reduce the opportunity for exposure include good field sanitation and use of insect repellents. Humans serve as reservoirs; the intermediate host and vector is the body louse, Pediculus humanus corporis. The infected louse excrete rickettsiae in their feces and usually defecate at the time of feeding; people are infected by rubbing feces or crushed lice into the bite or into superficial abrasions. Trench Fever is typically a nonfatal, bacterial disease varying in manifestations and severity. It is characterized by headache, malaise, and pain and tenderness-especially on the shins. Onset is either sudden or slow, with a fever that may be relapsing, typhoid-like, or limited to a single episode lasting for several days. Organisms may circulate in the blood (by which lice are infected) for weeks, months, or years and may recur with or without symptoms. In colder areas where people may live under unhygienic conditions and are louse-infested; enormous and explosive epidemics may occur during war and famine. Humans are the reservoirs and are responsible for maintaining the infection between epidemic periods. The body louse, Pediculus humanus corporis, is infected by feeding on the blood of a patient with acute typhus fever. Infected lice excrete rickettsiae in their feces and usually defecate at the time of feeding. People are infected by rubbing feces or crushed lice into the bite or into superficial abrasions. Symptoms have variable onsets, often are sudden, and are marked by headache, chills, exhaustion, fever, and general pains. A macular eruption appears on the fifth to sixth day, initially on the upper trunk, followed by spreading to the entire body (but usually not to the face, palms, or soles). The case-fatality rate increases with age and varies from 10 to 40 percent in the absence of specific therapy. Patients are infective for lice during the febrile illness and possibly for 2 to 3 days after the temperature returns to normal. The louse invariably dies within 2 weeks after infection; rickettsiae may remain viable in the dead louse for weeks. Viral Agents of Potential Concern the groups of microorganisms called viruses are all parasites that live in the cells of their selected hosts.

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Normal caliber of the cecum is up to 9 cm hair loss in men zara dutasteride 0.5mg cheap, with the rest of the large bowel up to 6 cm in diameter hair loss 9 year old purchase dutasteride online pills. Abdominal Radiography · Should be the initial imaging modality in a patient with suspected bowel ence of gallstone disease hair loss university of pennsylvania buy dutasteride 0.5 mg cheap. Table 11-1 the Revised Cardiac Risk Index Factor Adjusted Odds Ratio for Cardiac Complications 1 hair loss knoxville tn purchase dutasteride visa. High-risk surgery Ischemic heart disease History of congestive heart failure History of cerebrovascular disease Insulin therapy for diabetes mellitus Preoperative serum creatinine 2. Additional testing is dictated by specific underlying cardiovascular disease and nature of the planned operation. For those with highrisk results or very limited functional capacity, consider coronary angiography. Perioperative beta-blocker therapy reduces incidence of coronary events and should be included in medical regimen if no contraindications. Indications for antiarrhythmic therapy or pacemakers are same as in nonsurgical situations (Chap. Notably, asymptomatic ventricular premature beats generally do not require suppressive therapy preoperatively. Ensure adequate ventricular rate control in mitral stenosis with atrial fibrillation (using beta blocker, digoxin, verapamil, or diltiazem). Endocarditis prophylaxis is indicated for operations associated with transient bacteremias (Chap. If pheochromocytoma is a possibility, surgery should be delayed for evaluation because of high anesthetic risk. Perioperative beta blockers reduce risk of cardiac complications in pts with two or more of the following risk factors: age 65 yrs, hypertension, current cigarette use, diabetes mellitus, and total cholesterol 240 mg/dL. Postoperative lung expansion, deep breathing exercises, and pain control reduce complications in pts with chronic pulmonary disease. Caused by many medical and surgical disorders (Table 12-1), but 80% of cases caused by sepsis, bacterial pneumonia, trauma, multiple transfusions, gastric acid aspiration, and drug overdose. Risk factors include older age, chronic alcohol abuse, metabolic acidosis, and severity of critical illness. Exudative phase- Marked by disruption of normally tight alveolarcapillary membrane with consequent collection of protein-rich alveolar wall and airspace edema with collection of cytokines in edema fluid. Exudative phase duration is typically 7 days, marked by dyspnea, tachypnea, and severe hypoxemia; differential includes cardiogenic pulmonary edema, diffuse pneumonia, alveolar hemorrhage. Proliferative phase- If recovery does not occur, some pts will develop progressive lung injury and evidence of pulmonary interstitial inflammation and fibrosis. Fibrotic phase- Although the majority of patients recover within 3­ 4 weeks of the initial insult, some experience progressive fibrosis, necessitating prolonged ventilatory support predisposing to complications of long-term intensive care. This finding has prompted the introduction of ventilator strategies aimed at limiting alveolar distention while still ensuring adequate tissue oxygenation. Current practice is to use low tidal volumes (6 mL/kg predicted body weight); see. Other techniques that may improve oxygenation while limiting alveolar distention include extending the time of inspiration on the ventilator and placing the patient in the prone position. There is no survival advantage to increasing oxygen delivery by overresuscitation, and fluids should be given only in sufficient volumes to maintain adequate organ function as assessed by urine output, acid-base statues, arterial pressure. If there is respiratory stridor, consider aspiration of a foreign body and perform Heimlich maneuver. The lungs should be inflated twice in rapid succession for every 15 chest compressions. For one rescuer, 15 compressions are performed before returning to ventilating twice. Use 80­100 compressions/min with two lung inflations in rapid succession for every 15 compressions.

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Workers bring several liters of water and bolis with them into the fields and if they run out of either hair loss treatment vancouver purchase generic dutasteride canada, they can get more on the transport bus hair loss in men 20s dutasteride 0.5mg generic. The planting of seed occurs prior to the application of herbicides such that potential for herbicide exposure among planters is minimal hair loss lyme disease buy 0.5mg dutasteride with amex. Consideration of Past Practices the primary change to this job is that the cane is now cut by the seed cutters and then delivered to the planters in packages hair loss 9gag discount dutasteride 0.5mg free shipping, whereas in the past planters had to both cut the cane stalks and plant the seeds simultaneously. After experimentation with different techniques, the company has found that spacing the seeds in two rows approximately 10 cm apart seems to provide optimal germination (whereas they used to be planted together). Also in the past, planters were hired directly by the company, instead of through a contractor, and provided their own footwear and shovel. Overview of Current Process All irrigation workers are employed directly by the company. The irrigation process is primarily conducted during the zafra season, November to May, and sometimes from mid-July to midAugust. The irrigation cycle depends on soil type, irrigation phase, and developmental stage of the cane. The first irrigation cycle requires more water and is more labor intensive, but during subsequent irrigation cycles more land can be irrigated with less time and water. In the rainy season, some of the 18 workers will continue to work in the fields to monitor drainage. During the site visit, the gravity irrigation method and the sprinkler methods were observed. A typical workday lasts from 6:00 am to 3:00 pm, except on Sunday when the day ends at noon. At the beginning of each day, employees are picked up by a bus, dropped off in a central location, and given their daily task by the supervisor. Each worker controls the gravity irrigation for one field per day, and a supervisor oversees workers in multiple fields. During field preparation, the topography of the field is assessed and the field is graded so that water flows from one side to the other. A main conductor (dug using a tractor) runs along the perimeter of the field where the water is allowed to flow into the furrows and throughout the field. The worker controls the flow of water on a field by opening or closing sections of the conductor using sticks and plastic, and by opening or closing connections between the conductor and the furrows through the removal or addition of soil. The amount of water handled by an irrigation worker is ~1000 gallons/manzana/day but depends on the total area of the plot, type of soil, first or second irrigation, and the growth stage of the cane. This method uses the least amount of water and can cover a greater amount of land, but is the most expensive. A crew consists of three workers, and two crews are typically used to irrigate a field, one during a 12-hour day shift and the other during a 12-hour night shift. Water is diverted from a primary source, such as Tres Rios or the factory, pressurized through a mechanized pump, and then dispersed onto the fields through a series of aluminum pipes and sprinklers. As different areas of the field need to be irrigated, one worker moves the sprinklers while two other workers move the sections of pipe. The number of sprinklers in a field is typically 6-8, but depends on the capacity of the engine and the pump. Evaluation of Hazards and Controls Irrigation workers are paid a daily rate and not by amount of land irrigated or water handled. A gallon of drinking water, bolis, and cookies are distributed at the beginning of the work day, but given that workers spend most of the day working alone, it is unclear whether additional supplies continue to be available or provided throughout the day. The supplies given to each gravity irrigation worker are reported to be: a shovel, machete, polaina, limas (sharpener), rubber boots, and hat with neck covering. Additionally, at the beginning of each workday, each worker is given a supply of water, bolis, and cookies. The 19 shovel is used to open/close the conductors and clear debris from the furrows. The machete is used to create wooden sticks, which hold the plastic in place for opening or closing a furrow. There is potential for heat stress among gravity irrigation workers due to the high temperatures; however, given the nature of the work environment (shade from cane that still has leaves, working close to water) and the fact that workers are not compensated per unit of production, the potential for heat stress among irrigation workers is likely lower than among other field workers. For sprinkler irrigation, approximately five days is needed to completely irrigate a field with this method such that crews construct makeshift canvas shelters to provide shade. Additional equipment includes: bolis, cookies, a 200 liter water tank ("rotoplast"), and antibacterial soap; and for the night shift: flashlights, 2 pairs of batteries every 7 days, sugar, and coffee.

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It divides the maxillary sinus into a superoposterior part and an inferoanterior part hair loss low testosterone purchase dutasteride 0.5 mg without a prescription. Malignant tumors of the nose and paranasal sinuses: a retrospective review of 291 cases hair loss testosterone cheap dutasteride online american express. The diagnosis must be excluded in patients with asymptomatic cervical lymphadenopathy and unilateral serous otitis media hair loss cure july 2013 buy generic dutasteride line. N Anatomy the nasopharynx is bounded superiorly by the basiocciput and basisphenoid hair loss keratin treatment generic 0.5mg dutasteride amex, posteriorly by the C1 and C2 cervical bodies, anteriorly by the choanae, and inferiorly by the soft palate. There is an intermediate incidence in Inuit Eskimos and in the populations of the Mediterranean basin. N Clinical Signs and Symptoms Early signs and symptoms are subtle and variable, and are often initially ignored by both patient and physician. Five to 7% of all patients have systemic metastases at presentation, most often to bone. Symptoms include unilateral nasal obstruction, unilateral hearing loss and otalgia, diplopia, facial or neck pain, and paresthesia. Differential Diagnosis G G G G G G G G G G G Minor salivary gland tumors Juvenile nasopharyngeal angiofibroma Adenoid hypertrophy Tornwaldt cysts Fibromyxomatous polyps Choanal polyps, fibromas Papillomas Osseous/fibroosseous tumors Craniopharyngiomas Extracranial meningiomas Chordomas N Evaluation History History should include questions about epistaxis, nasal obstruction and discharge, hearing loss or clogged ear, headache, diplopia, facial pain, and numbness. A chest x-ray, liver ultrasound, and a bone scan are recommended for all patients with nodal disease. Other Tests A dental examination is required before instituting radiotherapy to reduce the development of postradiotherapy complications. Type 1 may have an association with cigarette and alcohol consumption and accounts for up to 30% of cases in nonendemic areas and 5% in endemic areas. External beam is most commonly delivered by opposed lateral fields to encompass the primary tumor and upper neck. Because there is a high incidence of subclinical neck disease, radiation doses between 50 and 60 Gy are used to electively treat the neck. Recent data shows a clear role for concomitant chemoradiotherapy followed by adjuvant chemotherapy, which provides statistically significant improvement in overall survival and disease free survival. Neck dissection for postradiation residual or recurrent nodal disease is the most common indication for surgery. For these patients, radiotherapy delivered in combination with chemotherapy has become the standard of care. A first complete evaluation should be performed 2 to 3 months after completion of treatment. The next evaluations should be scheduled for 6 months after this first posttherapeutic workup and on a yearly basis thereafter. State-of-the-art management of nasopharyngeal carcinoma: current and future directions. The oral cavity extends from the skin­vermilion junctions of the anterior lips to the junction of the hard and soft palates superiorly and to the line of circumvallate papillae posteriorly. N Epidemiology Thirty thousand people are diagnosed yearly with oral cancer in the United States, and it will cause 8000 deaths. For all stages combined, 370 Handbook of Otolaryngology­Head and Neck Surgery the 5-year relative survival rate is 59% and the 10-year survival rate is 44%. It typically occurs in those over the age of 45, and occurs in men twice as often as women. The number of new cases of this disease has been decreasing during the past 20 years. Smokeless tobacco in the Western world and paan (betel leaf with areca nut) in Asia are also risk factors for oral cancer. Recently there has been a growing number of young patients with oral cancers, particularly involving the tongue. N Clinical Signs Signs may include uncomfortable or poorly fitting dentures, loosening of the teeth, changes in articulation, a mass in the neck, weight loss, and persistent halitosis. Symptoms Symptoms depend on site and stage of the primary tumor and its effect on function of that area. They include a nonhealing white or red (leukoplakia, erythroplasia) patch or sore in the mouth (most common symptom), persistent pain in the mouth, and a thickening in the cheek or floor of mouth. More advanced disease may cause a sore throat, difficulty chewing, dysphagia, trismus or tongue tethering, numbness of the tongue or mouth, and pain around the teeth or jaw.

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