medical review made easy: 2009

Sense of Sight

Orbital Fascia
forms the periosteum of the orbit.
It is loosely connected to the bones and can readily be separated from them.

The Fascia Bulbi (capsule of Ténon) is a thin membrane which envelops the bulb of the eye from the optic nerve to the ciliary region, separating it from the orbital fat and forming a socket in which it plays

diagram of the eye & orbit muscles

- pierced behind by the optic nerve, and is
continuous through the fibrous sheath of this nerve with the dura mater.

lamina cribrosa scleræ:
a thin cribriform lamina formed by the sclera at the point where the optic nerve passes thru the minute orifices in this lamina
serves for the transmission of the nervous filaments
One of these openings occupying the center of the lamina transmits the central artery and vein of the retina.

- in front, the sclera is directly continuous with
the cornea, the line of union being termed the
sclero-corneal junction.

- in the inner part of the sclera close to this junction is a circular canal, the sinus venosus scleræ (canal of Schlemm). The sinus is lined by endothelium and communicates externally with the anterior ciliary veins.
- The aqueous humor drains into the scleral sinuses by passage through the “pectinate villi” which are analogous in structure and function to the arachnoid villi of the cerebral meninges.

The Cornea
— the projecting transparent part of the external tunic
- convex anteriorly and projects like a dome in front of the sclera
- degree of curvature varies in different individuals, and in the same individual at
different periods of life, being more pronounced in youth than in advanced life
- dense and of uniform thickness throughout
- Immediately in front of the sclero-corneal junction the cornea bulges inward as a thickened rim, and behind this there is a distinct furrow between the attachment of the iris and the sclero-corneal junction, the sulcus circularis corneæ.

filtration angle of the eye:
-an angular recess between the trabecular tissue that forms the inner wall of the sinus venosus sclerae and the anterior surface of the attached margin of the iris.
scleral spur:
-a projecting rim of scleral tissue immediately outside of the filtration
non-vascular structure; the capillary vessels ending in loops at its circumference
are derived from the anterior ciliary arteries
nerves are numerous and are derived from the ciliary nerves

The Vascular Tunic
~ formed from behind forward by:
the choroid- invests the posterior 5/6 of
the eyeball
- extends as far forward as the ora
serrata of the retina.
the ciliary body - connects the choroid to the
circumference of the iris.
the iris- a circular diaphragm behind the
cornea, and presents near its center a
rounded aperture, the pupil.

Choroid: a thin, highly vascular membrane, consisting
mainly of a dense capillary plexus, and of
small arteries and veins carrying blood to
and from this plexus
: dark brown or chocolate color, investing
the posterior five-sixths of the globe
: pierced behind by the optic nerve
: outer surface is loosely connected with the
sclera;
: its inner surface is attached to the pigmented
layer of the retina.
: One of the functions is to provide nutrition for
the retina, and to convey vessels and
nerves to the ciliary body and iris.

Ciliary Body: comprises the orbiculus ciliaris,
the ciliary processes,
the Ciliaris muscle.

orbiculus ciliaris: a zone of about 4 mm. in width, directly
continuous with the anterior part of the
choroid;
: it presents numerous ridges arranged in
a radial manner
ciliary processes : formed by the inward folding of the various
layers of the choroid i.e., the choroid proper
and the lamina basalis,
: received between corresponding foldings of
the suspensory ligament of the lens
: arranged in a circle, and form a sort of
frill behind the iris, around the margin
of the lens

Ciliary Body
The ciliary body lies just behind the iris. Attached to the ciliary body are tiny fiber "guy wires" called zonules. The crystalline lens is suspended inside the eye by the zonular fibers.  Nourishment for the ciliary body comes from blood vessels which also supply the iris.
One function of the ciliary body is the production of aqueous humor, the clear
fluid that fills the front of the eye. It also controls accommodation by changing
the shape of the crystalline lens. When the ciliary body contracts, the zonules relax. This allows the lens to thicken, increasing the eye's ability to focus up close. When looking at a distant object, the ciliary body relaxes, causing the zonules to contract. The lens becomes thinner, adjusting the eye's focus for distance vision.
Angle Structures
The area in the anterior chamber where the cornea and iris join is known as the angle. This is comprised of several structures that make up the eye's drainage system. The angle structures include: the outermost part of the iris, the front of the ciliary body, the trabecular meshwork, and the Canal of Schlemm.

Ciliaris muscle (Bowman’s muscle)
: consists of unstriped fibers forming a
grayish, semitransparent, circular band,
on the outer surface of the fore-part of the
choroid
: the chief agent in accommodation, i. e., in
adjusting the eye to the vision of near
objects. When it contracts it draws forward
the ciliary processes, relaxes the
suspensory ligament of the lens, and thus
allows the lens to become more convex

Iris: received its name from its various colors in
different individuals
: a thin, circular, contractile disk, suspended
in the aqueous humor between the cornea
& lens, and perforated a little to the nasal
side of its center by a circular aperture, the
pupil
: by its periphery it is continuous with the
ciliary body, & is also connected with the
posterior elastic lamina of the cornea by
means of the pectinate ligament
: divides the space between the lens and
the cornea into an anterior and a posterior
chamber

anterior chamber
: bounded in front by the posterior surface of
the cornea behind by the front of the iris and
the central part of the lens.

posterior chamber
: a narrow chink behind the peripheral part of
the iris, and in front of the suspensory
ligament of the lens and the ciliary processes

.

The Retina
~ a delicate nervous membrane, upon which the
images of external objects are received
~ outer surface is in contact with the choroid
its inner with the hyaloid membrane of the vitreous
body;
behind, it is continuous with the optic nerve.
~ extends nearly as far as the ciliary body, where it
appears to end in a jagged margin, the ora serrata

The arteria centralis retinæ and its accompanying vein pierce the optic nerve.

The Refracting Media: Aqueous humor.
Vitreous body.
Crystalline lens.

Aqueous Humor: fills the anterior and posterior chambers
of the eyeball
: small in quantity, has an alkaline reaction,
: consists mainly of water,
: less than 1/5 of its weight being solid
matter, chiefly chloride of sodium.
Vitreous Body: forms about four-fifths of the bulb of the eye
: fills the concavity of the retina,
: hollowed in front, forming a deep concavity,
the hyaloid fossa, for the reception of the lens
: transparent, of the consistency of thin jelly,
composed of an albuminous fluid enclosed in
a delicate transparent membrane, the hyaloid
membrane.

in the center, running from the entrance of the optic nerve to the posterior surface of the lens, is a canal, the hyaloid canal, filled with lymph and lined by prolongation of the hyaloid membrane.
the fluid from the vitreous body is nearly pure water; it contains, however, some salts, and a little albumin.

The hyaloid membrane envelopes the vitreous body. The portion in front of the ora serrata is thickened by the accession of radial fibers and is termed the zonula ciliaris (zonule of Zinn).

: splits into two layers, one of which is thin and lines the hyaloid fossa; the other is named the suspensory ligament of the lens

Crystalline lens: enclosed in its capsule which is a
transparent & a structureles membrane
: immediately behind the iris,
in front of the vitreous body
encircled by the ciliary processes,
: transparent, biconvex body
: in the fetus, the lens is nearly spherical,
has a slightly reddish tint; is soft and
breaks down readily on the slightest
pressure.
: In the adult, the lens is colorless,
transparent, firm in texture, and devoid
of vessels.
: In old age it becomes flattened on both
surfaces, slightly opaque, of an amber
tint, & increased in density

Vessels and Nerves.
The arteries of the bulb of the eye are the
long, short, and anterior ciliary arteries, and
the arteria centralis retinæ.
The ciliary veins are seen on the outer surface of the choroid, and are named, from their arrangement, the venæ vorticosæ;
Another set of veins accompanies the anterior ciliary arteries. All of these veins open into the ophthalmic veins.
The ciliary nerves are derived from the nasociliary nerve and from the ciliary ganglion.

The Accessory Organs of the Eye
~ include:
the ocular muscles,
the fasciæ,
the eyebrows,
the eyelids,
the conjunctiva,
and the lacrimal apparatus.

The Ocular Muscles:

Levator palpebræ superioris
Superior oblique
Inferior oblique
Medial rectus
Superior rectus
Lateral rectus.
Inferior rectus

Levator palpebræ superioris
: thin, flat, and triangular in shape
: arises from the under surface of the
small wing of the sphenoid, above and in
front of the optic foramen, from which it
is separated by the origin of the Rectus
superior.
: inserted into the upper margin of the superior tarsus

Levator palpebrae superior - raises the upper eyelid, and is the direct antagonist of the Orbicularis oculi.

L orbicularis oculi

The four Recti
= arise from a fibrous ring which surrounds
the upper medial, and lower margins of the
optic foramen and encircles the optic nerve.
Two specialized parts of this fibrous ring may be made out:
1) a lower, the ligament or tendon of Zinn
- gives origin to the Rectus inferior,
part of the Rectus internus, and the
lower head of origin of the Rectus
lateralis;

2) an upper, which gives origin to the
Rectus superior,
the rest of the Rectus medialis,
the upper head of the Rectus
lateralis.

This upper band is sometimes
termed the superior tendon of
Lockwood..
.

Although these muscles present a
common origin and are inserted in a
similar manner into the sclera, there are
certain differences to be observed in them
as regards their length and breadth. The
Medial Rectus is the broadest, the Lateral
Rectus is the longest, and the Superior
Rectus the thinnest and narrowest.

muscle movements

A given extraocular muscle moves an eye in a specific manner, as follows:

medial rectus (MR)—moves the eye toward the nose

lateral rectus (LR)—moves the eye away from the nose

superior rectus (SR)—primarily moves the eye upward and secondarily rotates the top of the eye toward the nose

inferior rectus (IR)—primarily moves the eye downward and secondarily rotates the top of the eye away from the nose

superior oblique (SO)—primarily rotates the top of the eye toward the nose and secondarily moves the eye downward

inferior oblique (IO)—primarily rotates the top of the eye away from the nose and secondarily moves the eye upward

Muscle innervations
Each extraocular muscle is innervated by a specific cranial nerve (C.N.):
medial rectus (MR)—cranial nerve III
lateral rectus (LR)—cranial nerve VI
superior rectus (SR)—cranial nerve III
inferior rectus (IR)—cranial nerve III
superior oblique (SO)—cranial nerve IV
inferior oblique (IO)—cranial nerve III

The following can be used to remember the cranial nerve innervations of the six extraocular muscles:
LR6(SO4)3.
That is, the lateral rectus (LR) is innervated by C.N. 6, the superior oblique (SO) is innervated by C.N. 4, and the four remaining muscles (MR, SR, IR, and IO) are innervated by C.N. 3.

eyelashes (cilia): attached to the free edges of the eyelids
: short, thick, curved hairs, arranged in a double or triple row
: near their attachment are the openings of a number of glands, the ciliary glands, arranged in several rows close to the free margin of the lid regarded as enlarged and modified sudoriferous glands.

The lateral palpebral commissure ( external canthus) is more acute than the medial, and the eyelids here lie in close contact with the bulb of the eye: but the medial palpebral commissure ( internal canthus) is prolonged for a short distance toward the nose, and the two eyelids are separated by a triangular space, the lacus lacrimalis At the basal angles of the lacus lacrimalis, on the margin of each eyelid, is a small conical elevation, the lacrimal papilla, the apex of which is pierced by a small orifice, the punctum lacrimale, the commencement of the lacrimal duct.
punctum lacrimale

Structure of the Eyelids (palpebrae)
~ composed of the following structures taken in their order from without inward: integument, areolar tissue, fibers of the Orbicularis oculi, tarsus, orbital septum, tarsal glands and conjunctiva.
The upper eyelid has the aponeurosis of the Levator palpebræ superioris.
integument - extremely thin, and continuous at the margins of the eyelids with the conjunctiva.
subcutaneous areolar tissue - very lax and delicate, and seldom contains any fat.
palpebral fibers of the Orbicularis oculi: thin, pale in color, and possess an involuntary action

tarsi (tarsal plates)
- two thin, elongated plates of dense connective
tissue
- one is placed in each eyelid, and contributes to its form and support
a) superior tarsus (superior tarsal plate)
= larger, a semilunar form
= to the anterior surface of this plate
the aponeurosis of the Levator palpebræ superioris is attached
b) inferior tarsus (inferior tarsal plate)
= smaller, is thin, elliptical in form

tarsi and ligaments

Tarsal Glands (Meibomian glands)
~ situated upon the inner surfaces of the
eyelids, between the tarsi and conjunctiva,
and may be distinctly seen through the latter on
everting the eyelids, presenting an
appearance like parallel strings of pearls.
~ there are about thirty in the upper eyelid, fewer in
the lower
~ imbedded in grooves in the inner surfaces of the tarsi,
and correspond in length with the breadth of these
plates
~ longer in the upper than in the lower eyelid. Their ducts
open on the free magins of the lids by minute foramina.

tarsal glands

orbital septum (septum orbitale; palpebral ligament)
- a membranous sheet, attached to the edge of the orbit, where it is continuous with the periosteum.
- perforated by the vessels and nerves which pass from the orbital cavity to the face and scalp.
The eyelids are richly supplied with blood

Conjunctiva
~ the mucous membrane of the eye
~ lines the inner surfaces of the eyelids
~ reflected over the forepart of the sclera and cornea.

1) Palpebral Portion (tunica conjunctiva palpebrarum)
- thick, opaque, highly vascular, and covered with numerous
papillæ,
- at the lateral angle of the upper eyelid the ducts of the
lacrimal gland open on its free surface
- at the medial angle it forms a semilunar fold, the plica
semilunaris

The line of reflection of the conjunctiva from the upper eyelid on to the bulb of the eye is named the superior fornix, and that from the lower lid the inferior fornix.

2) Bulbar Portion (tunica conjunctiva bulbi)
- upon the sclera the conjunctiva is
loosely connected to the bulb of the
eye;
- thin, transparent, destitute of papillæ,
and only slightly vascular

Lymphatics arise in the conjunctiva in a delicate zone around the cornea, and run to the ocular conjunctiva.

Conjunctiva
The conjunctiva is the thin, transparent tissue that covers the outer surface of the eye. It begins at the outer edge of the cornea, covering the visible part of the sclera, and lining the inside of the eyelids. It is nourished by tiny blood vessels that are nearly invisible to the naked eye.
The conjunctiva also secretes oils and mucous that moisten and lubricate the eye.

Caruncula lacrimalis
~ a small, reddish, conical-shaped body, situated at the medial palpebral commissure, and filling up the lacus lacrimalis
~ consists of a small island of skin containing sebaceous and sudoriferous glands, and is the source of the whitish secretion which constantly collects in this region.
~ lateral to the caruncula is a slight semilunar fold of conjunctiva, the concavity of which is directed toward the cornea & is called the plica semilunaris.
The nerves in the conjunctiva are numerous and form rich plexuses. According to Krause they terminate in a peculiar form of tactile corpuscle, which he terms “terminal bulb.”

punctum lacrimale

The Lacrimal Ducts (lacrimal canals)
~ one in each eyelid, commence at minute orifices, termed puncta lacrimalia, on the summits of the papillæ lacrimales
~ seen on the margins of the lids at the lateral extremity of the lacus lacrimalis.
superior duct
inferior duct

lacrimal apparatus
The Bony Orbit
Roof of orbit
1.Orbital plate of frontal bone
2.Lesser wing of sphenoid

Floor of orbit
1.Orbital plate of maxilla
2.Orbital surface of zygomatic bone
3.Orbital process of palatine bone

Medial wall of orbit
1.Frontal process of maxilla
2.Lacrimal bone
3.Orbital plate of ethmoid
4.Body of sphenoid

Lateral wall of orbit
1.Zygomatic bone
2.Greater wing of sphenoid

Foramina of the Orbit
Supraorbital notch/foramen
Infraorbital foramen
Superior orbital fissure
Inferior orbital fissure
Optic canal
Ethmoidal foramina

Supraorbital foramen – supraorbital vessels & nerves

Infraorbital foramen – infraorbital vessels & nerves

Supraorbital fissure
Lacrimal n. Frontal n.
Trochlear n. Oculomotor n.
Nasociliary n. Abducens n.
Sup. Ophthalmic v.

Infraorbital fissure
Maxillary n.
Zygomatic n.
Branchesof pterygopalatine ganglion
Inf. ophthalmic v.

Optic canal: optic n.
ophthalmic artery

Ethmoidal foramina:
Ant. ethmoidal foramen :ant. ethmoidal n. & a.
Post. ethmoidal foramen: post. ethmoidal n. & a.
- End -
Sense of Hearing

External Ear

1. Auricle:
Single elastic cartilage.
Covered by skin.
Continuous medially with external auditory meatus.
Innervation:
auriculotemporal nerve,
great auricular nerve.

The External Ear
~ consists of:
1) auricula/pinna: the expanded portion
: projects from the side of the
head
: serves to collect the vibration
of the air by w/c sound is
produced
2) external acoustic meatus
:leads inward from the bottom
of the auricula
:conducts the vibrations to the
tympanic cavity

The Auricula or Pinna
= ovoid form, with its larger end directed
upward.
= the prominent rim of the auricula is
called the helix
Where the helix turns downward behind, a small tubercle, the auricular tubercle of Darwin, is frequently seen; this tubercle is very evident about the sixth month of fetal life.
Another curved prominence, parallel with and in front of the helix, is called the antihelix
The narrow-curved depression between the helix and the antihelix is called the scapha;

In front of the concha, and projecting backward over the meatus, is a small pointed eminence, the tragus, so called from its being generally covered on its under surface with a tuft of hair, resembling a goat’s beard.

The muscles of the auricula
- consist of two sets:
(1) the extrinsic: connect it with the skull and scalp and move the auricula as a whole
(2) the intrinsic: extend from one part of the auricle to another

- The Auricularis anterior, the smallest of the three, is thin, fan-shaped, and its fibers are pale and indistinct. It arises from the lateral edge of the galea aponeurotica, and its fibers converge to be inserted into a projection on the front of the helix.
- The Auricularis superior , the largest of the three, is thin and fan-shaped. Its fibers arise from the galea aponeurotica, and converge to be inserted by a thin, flattened tendon into the upper part of the cranial surface of the auricula.
- The Auricularis posterior consists of two or three fleshy fasciculi, which arise from the mastoid portion of the temporal bone by short aponeurotic fibers. They are inserted into the lower part of the cranial surface of the concha.
Actions.—In man, these muscles possess very little action: the Auricularis anterior draws the auricula forward and upward; the Auricularis superior slightly raises it; and the Auricularis posterior draws it backward.
muscles of external ear
The intrinsic muscles are the:
Helicis major.
Antitragicus.
Helicis minor.
Transversus auriculæ.
Tragicus.
Obliquus auriculæ.

External auditory meatus:
Outer 1/3:
S-shaped,
cartilaginous,
skin contains hairs, sebaceous and ceruminous glands.
Inner 2/3:
bony,
narrower (isthmus).
Inferior wall about 5 mm longer than superior wall due to obliquity of tympanic membrane.
Innervation:
auriculotemporal nerve,
auricular branch of vagus.

The External Acoustic Meatus
= extends from the bottom of the concha to the tympanic membrane
tympanic membrane: closes the inner end of the meatus
= formed partly by cartilage and membrane, and partly by bone, and is lined by skin

~ consists of two parts:
1) the tympanic cavity proper: opposite the tympanic membrane
2) attic or epitympanic recess: above the level of the membrane;
: contains the upper half of the malleus and the greater part of the incus.
~ bounded laterally by the tympanic membrane
medially by the lateral wall of the
internal ear
communicates behind, with the tympanic antrum and through it with the mastoid air
cells, in front with the auditory tube

The Tegmental Wall or Roof (paries tegmentalis):
~ formed by a thin plate of bone, the tegmen tympani, which separates the cranial and tympanic cavities
~ situated on the anterior surface of the petrous portion of the temporal bone close to its angle of junction with the squama temporalis

The Jugular Wall or Floor (paries jugularis)
~ narrow, and consists of a thin plate of bone (fundus tympani) which separates the tympanic cavity from the jugular fossa
~ presents, near the labyrinthic wall, a small aperture for the passage of the tympanic branch of the glossopharyngeal nerve.

The Membranous or Lateral Wall (paries membranacea; outer wall)
~ formed mainly by the tympanic membrane, partly by the ring of bone into which this membrane is inserted. This ring of bone is incomplete at its upper part, forming a notch (notch of Rivinus), close to which are three small apertures: the iter chordæ posterius,
the petrotympanic fissure, and
the iter chordæ anterius

Tympanic Membrane
= separates the tympanic cavity from the bottom of the external acoustic meatus
= a thin, semitransparent membrane
= directed very obliquely downward and inward
= pars flaccida: the small, somewhat triangular part of the membrane above the anterior & posterior folds w/c is lax and thin
= the manubrium of the malleus is firmly attached to the medial surface of the membrane
= the most depressed part of the concavity is named the umbo.

         Tympanic Membrane (Ear Drum)
Semi-transparent oval membrane.
Separates external and middle ears.
Is obliquely placed.
Handle of malleus attached to its inner side, resulting in concavity towards the external auditory meatus.
Moves in response to air vibrations which are transmitted via middle ear bones to the inner ear.
External surface is innervated mainly by the auriculotemporal nerve.

Labyrinthic or Medial Wall (inner wall)
~ vertical in direction, and presents for examination
the fenestræ vestibuli
cochleæ,
the promontory, and
the prominence of the facial canal

fenestra vestibuli (fenestra ovalis)
= a reniform opening leading from the tympanic cavity into the vestibule of the internal ear
= in the recent state it is occupied by the base of the stapes
fenestra cochleæ
= below and a little behind the fenestra vestibuli, from which it is separated by a rounded elevation, the promontory

The mastoid or posterior wall (paries mastoidea)
~ wider above than below, and presents for examination the entrance to the tympanic antrum, the pyramidal eminence, and the fossa or mastoid antrum which communicates behind and below with the mastoid air cells

pyramidal eminence (pyramid)
= immediately behind the fenestra vestibuli,
and in front of the vertical portion of the
facial canal
= hollow, and contains the Stapedius muscle

The Carotid or Anterior Wall

~ corresponds with the carotid canal, from which it is separated by a thin plate of bone perforated by the tympanic branch of the internal carotid artery, and by the deep petrosal nerve
~ at the upper part of the anterior wall are the orifice of the semicanal for the Tensor tympani muscle and the tympanic orifice of the auditory tube, separated from each other by a thin horizontal plate of bone, the septum canalis musculotubarii

The tympanic cavity contains a chain of three movable ossicles:
malleus, incus, stapes
malleus - attached to the tympanic membrane
- so named from its fancied resemblance
to a hammer
- consists of a head, neck, and three
processes, viz., the manubrium, the
anterior and lateral processes
head (capitulum mallei): the large upper
extremity of the bone
: oval in shape
: articulates posteriorly
with the incus

manubrium mallei (handle): connected by its lateral margin with the
tympanic membrane.
: on its medial side, near its upper end, is a
slight projection, into which the tendon of
the Tensor tympani is inserted.

incus - connected to both by delicate articulations
- received its name from its supposed resemblance to an
anvil, but it is more like a premolar tooth

stapes - attached to the circumference of the fenestra vestibul
- so called from its resemblance to a stirrup
- consists of a head, neck, two crura, and a base.

malleus
incus
stapes

Stapedius - O: wall of a conical cavity, hollowed out of the interior of the pyramida eminence
I: posterior surface of the neck of the
stapes
N.S.: a branch of the facial nerve.
A: pulls the head of the stapes
backward
By the action of the muscle the tension of the fluid within the internal ear is probably increased.

~ consists of two parts:
a) the osseous labyrinth - a series of cavities within the petrous part of the temporal bone
- consists of three parts: the vestibule, semicircular canals, and cochlea (cavities hollowed out of the substance of the bone, and lined by periosteum; they contain a clear fluid, the perilymph, in which the membranous labyrinth is situated)
bony labyrinth

The Vestibule = the central part of the osseous labyrinth
= medial to the tympanic cavity, behind the cochlea, and in front of the semicircular canals
= its lateral or tympanic wall is the fenestra vestibuli on its medial wall, at the forepart, is a small circular depression, the recessus sphæricus, which is perforated by several minute holes (macula
cribrosa media) for the passage of filaments of the acoustic nerve to the saccule behind this depression is an oblique ridge, the crista vestibuli, which bifurcates below to enclose a small depression, thefossa cochlearis perforated by a number of holes for the passage of
filaments of the acoustic nerve which supply the vestibular end of the ductus cochlearis

The Bony Semicircular Canals = three in number, superior, posterior, and lateral, = situated above and behind the vestibule
= unequal in length, compressed from side to side, and each describes the greater part of a circle.
= presents a dilatation at one end, called the ampulla, = open into the vestibule by five orifices, one of the apertures being common to two of the canals.

Right osseous labyrinth. Lateral view.
Interior of right osseous labyrinth

The Cochlea = bears some resemblance to a common snail-shell
= forms the anterior part of the labyrinth
= conical in form, and placed almost horizontally in front of the vestibule
= its base corresponds with the bottom of the internal acoustic meatus, perforated by numerous apertures for the passage of the cochlear division of the acoustic nerve

= consists of: a conical shaped central axis, the modiolus;
A canal, the inner wall of which is formed by the central axis, wound spirally around it for two turns and three-quarters, from the base to the apex the osseous spiral lamina, a delicate lamina which projects from the modiolus, and, following the windings of the canal, partially subdivides it into two.
helicotrema: a small opening at the apex of the modiolus connecting the 2 passages of the canal ( the scalae )
modiolus: the conical central axis or pillar of the cochlea.
: perforated by numerous orifices, which transmit filaments of the cochlear division of the acoustic nerve
cupula: where the bony canal terminates and forms the apex of the cochlea

membranous labyrinth

The acoustic nerve (auditory nerve or nerve of hearing)
- divides near the bottom of the internal acoustic meatus into:
a) anterior or cochlear branch: divides into numerous filaments at the base of the modiolus
b) posterior or vestibular branch: supplies the utricle, the saccule, and the ampullæ of the semicircular ducts.

The arteries of the labyrinth:
- the internal auditory, from the basilar: divides at the bottom of the internal acoustic meatus into two branches: cochlear and vestibular.
cochlear branch- subdivides into twelve or fourteen
twigs and are distributed in the
lamina spiralis and basilar
membrane.
vestibular branches - distributed to the utricle, saccule,
and semicircular ducts
- the stylomastoid, from the posterior
auricular

Sense of Smell
Lateral wall of nasal cavity
Sense of Taste

The Tongue (lingua).—The tongue is the principal organ
of the sense of taste, and an important organ of speech; it also assists in the mastication and deglutition of the food. It
is situated in the floor of the mouth, within the curve of the body of the mandible
Its Root is directed backward, and connected with the hyoid bone by the Hyoglossi and Genioglossi muscles and the hyoglossal membrane; with the epiglottis by three folds (glossoepiglottic) of mucous membrane; with the soft palate by the glossopalatine arches; and with the pharynx by the Constrictores pharyngis superiores and the mucous membrane.

Its Apex , thin
and narrow, is directed forward against the lingual surfaces of the lower incisor teeth.
Its Inferior Surface is connected with the mandible by the Genioglossi; in the middle line, it is elevated into a distinct vertical fold, the frenulum linguæ.
On either side lateral to the frenulum is a slight fold of the mucous membrane, the plica fimbriata, the free edge of which occasionally exhibits a series of fringe-like processes

-The Dorsum of the Tongue is convex and marked by a
-median sulcus, which divides it into symmetrical halves; this sulcus ends behind, about 2.5 cm. from the root of the organ, in a depression, the foramen cecum, from which a shallow groove, the sulcus terminalis, runs lateralward and forward on either side to the margin of the tongue.

Extrinsic muscles of
the tongue:
1. Genioglossus
2. Hyoglossus
3. Chondroglossus
4. Styloglossus
5. Palatoglossus
N.S. Hypoglossal n. except the Palatoglossus w/c is innervated by the cranial accessory/
vagal component of the pharyngeal plexus.
Intrinsic muscles of the tongue
Sup. Longitudinal muscle 2. Inf. Longitudinal muscle
Transverse muscle 4. Vertical muscle
N.S. Hypoglossal n.

Wednesday, February 18, 2009

Pneumonia

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Pneumonia

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St Segment Elevation Myocardial Infarction

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ELECTROLYTE DISORDERS

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ELECTROLYTE DISORDERS

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Infectious Review

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ARTERIAL BLOOD GAS INTERPRETATION

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Saturday, January 24, 2009

DOH Programs

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PROGRAMS
OF THE
DEPARTMENT OF HEALTH

1. EXPANDED PROGRAM ON IMMUNIZATION (EPI)
2. MATERNAL AND CHILD HEALTH
3. NUTRITION PROGRAM
4. INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS
5. CARI
6. CDD
7. MOTHER & BABY FRIENDLY HOSPITAL INITIATIVE
8. FAMILY PLANNING PROGRAM
9. EARLY CHILDHOOD PROGRAM
10. THE PHILIPPINE NEWBORN SCREENING PROGRAM
11. NATIONAL TUBERCULOSIS CONTROL PROGRAM
12. DENTAL HEALTH PROGRAM
13. RABIES CONTROL PROGRAM
14. NATIONAL HIV AIDS/STD PREVENTION AND CONTROL PROGRAM
15. NONCOMMUNICABLE DISEASES
16. BOTIKA NG BARANGAY

By

CRISOL J. TABAREJO, MD; MSEpi (Public Health)
Medical Specialist II
Department of Health 7 – Center for Health Development

EXPANDED PROGRAM ON IMMUNIZATION (EPI)

RATIONALE
● The Expanded Program on Immunization (EPI) was launched in 1976 and has successfully vaccinated and protected millions of children from vaccine-preventable diseases (TB, diphtheria, pertusis, tetanus, polio, measles, hepa-B) .

● The DOH considered EPI as a priority health program. Previous years of EPI focused on achievement of high immunization coverage. The current thrust is to sustain this high coverage and focus on the control, elimination and eradication of major childhood diseases.

OBJECTIVES:
1. To reduce the morbidity and mortality rates of the seven immunizable diseases by increasing the promotion of the fully immunized child (FIC) in their first year of life;
2. To reduce the incidence of neonatal tetanus by providing pregnant women with Tetanus Toxoid.

COVERAGE AND SCOPE

Immunization shall be an essential health intervention for eligible children and women. This service shall be made available in all health facilities and institutions providing health services for women and children nationwide.

POLICY STATEMENT

Immunization is a basic right of the child and therefore no child shall be deprived of this right. The state regards children as one of the most important assets of the nation and therefore every effort should be exerted to promote their welfare and full development of their potentials for a useful and quality life.

TARGET AGE GROUPS
1. All infants should receive one dose of BCG, three doses of DPT, three doses of OPV, one dose of measles, THREE DOSES OF Hepatitis B vaccine before their first birthday.
2. All women of childbearing age (15-49 years) shall receive five doses of tetanus toxoid for their lifetime protection against tetanus and for prevention of neonatal tetanus among infants.
3. Other age groups that may be determined for supplemental immunization activities.

THE IMMUNIZATION SCHEDULE FOR INFANTS

BCG - 1 dose - Birth or anytime at birth
DPT - 3 doses - 6 weeks old and interval of 4 weeks
OPV - 3 doses - 6 weeks old and interval of 4 weeks
Hepatitis B 3 doses - given at birth and interval of 4 weeks
Measles 1 dose - 9 months
School entrants are given BCG immunization both in private and public school regardless of the presence or absence of BCG scar.
Tetanus toxoid immunization schedule for Women

TT1 - as early as possible during pregnancy
TT2 - at least 4 weeks later
TT3 - at least 6 months later
TT4 - at least one year later
TT5 - at least one year later

CONTRAINDICATIONS TO IMMUNIZATION

1. There are few absolute contraindications to the EPI vaccines. The only absolute contraindications to immunization are:
- DPT vaccine should NOT be given to children over 5 years of age or to children who have suffered a severe reaction to a previous dose of this vaccine
- BCG should NOT be given to children who have signs and symptoms of AIDS or other immune deficiency diseases or those who are immunosuppressed due to malignant disease therapy with immunosuppressive agents or irradiation.
2. Both measles vaccine and OPV can be given to children with HIV/AIDS
3. False contraindications
- children suffering from malnutrition should be immunized
- low grade fever, mild respiratory infections and other minor illnesses should not be considered as contraindications to immunization
- diarrhea should not be considered a contraindication to OPV

MATERNAL AND CHILD HEALTH

Reproductive Health
Today half a million women die each year as a result of pregnancy and childbirth; many times that number suffer ill-health or disability. Prenatal care can help identify women who most likely need skilled care during pregnancy and delivery and help persuade families of the importance of obstetric care, family planning and safe sex.

Protecting and promoting the health of mothers and children are two of the most important mandates of the Department of Health. As a whole, mother and child comprise about 40% of the total population. Three factors affect the health of mothers: the prevalence of endemic diseases among adults, the nutritional status of the mother and the risk of illness and death brought about by pregnancy and delivery. These factors affect strongly the health of children. This includes events shortly before, during or shortly after child birth, the prevalence of immunizable diseases and the occurrence of common childhood illness.

OBJECTIVE

To reduce maternal, perinatal, infant and young child (0-4 years) morbidity and mortality.

ACTIVITIES

1. Pre natal care, natal care and post natal care
● identification/management of high risk pregnant women
● AP visits and TT immunization
● home deliveries/hospital services/cord dressing
● breastfeeding practice and postnatal check-up
2. Under Five Clinic
● monitoring of growth and development
●nutrition education, immunization, micronutrient supplementation
3. Health Manpower Training
● hilot trainings and trainings on MCH
4. Promotion of breastfeeding
● mass media campaign
● training/breastfeeding counseling
● milk code implementation (E.O. 51)
● monitoring and evaluation

Basic Emergency Obstetric Care (BemOC)

The Philippine Government is committed to provide high quality delivery care for pregnant women and newborn babies. This aims to contribute to the reduction of maternal newborn morbidity and mortality and to support the Millennium Development Goal.

The establishment of BemOC aims to avert death and disability among pregnant women. The objectives are:

1. to establish clinical and health promotive guidelines in the provision of basic emergency obstetric care
2. to define standards for management and operations that will guide program managers and implementers in the provision of BemOC
3. to identify training centers to develop and conduct training programs for BemOC and maintain program training standards

MOTHER & BABY FRIENDLY HOSPITAL INITIATIVE PROGRAM
(MBFHI)

The Mother Baby Friendly Hospital Initiative Program was launched in 1991. It is a program transforming hospitals with maternity & newborn services into health facilities which fully protect, promote & support breastfeeding & rooming-in practices.
In early 2005, 95% of targeted hospitals and lying-in clinics were MBFH facilities. However, the biggest challenge is how to support these hospitals so that their breastfeeding practices will be sustained.

OBJECTIVE
All government & private hospitals (w/ maternity and newborn service) and lying-in clinics will be accredited as Mother & Baby Friendly.

NUTRITION PROGRAM

● Nutrition is the combination of processes by which a living organism receives
andutilizes the materials necessary for growth, maintenance of its functions and repair of its components.
● Malnutrition which includes Protein Energy Malnutrition (PEM) and micronutrients deficiency such as Vit. A def., iron def. anemia and iodine def. are still considered major public health problems in the country.

Avitaminosis ranks 9 in the leading causes of IMR - 1.3 ( 0.2/1000)

Nutritional Status of the Filipino Child
◙ National Level
0-5 years of age:
● 68% normal weight for age
● 32% underweight, 4% overweight
● 66% normal height
● 34% stunted, 4% tall
● 93% normal weight for height
● 6% wasted, 9% overweight for height

Regional level
Underweight - 33.8
Normal - 65.7
Overweight - 6.5
◙ Assessment
1. History
● dietary history of mother and child
● history of weight and height changes
2. Anthropometric indicators
● deviations from average weight and height
● depletion of fat depots
● decrease in muscle mass
3. Change in psychic reaction
4. Reaction to infection
5. Evidence of specific deficiency

Target Population
Pre-schoolers, pregmant women, lactating women and 15-49 year old women

OBJECTIVES
1. To reduce prevalence of infant and maternal mortality and morbidity;
2. To improve the health and nutritional status of pregnant and lactating mothers and pre-schoolers;
3. To reduce prevalence of low birth weight infants;
4. To generate multi-sectoral support to fight malnutrition at the grassroots level.

VITAMIN A SUPPLEMENTATION

Globally, 3M children suffer clinical Vitamin A deficiency (exhibiting the signs and symptoms of eye damage & xerophthalmia). However, the full magnitude of VAD often remains hidden: an estimated 140-250M children under 5 years are at risk of sub-clinical VAD, mainly in Asia and Africa. Though showing none of the ocular signs or symptoms, these children suffer a dramatically increases risk of death and illness, particularly from measles and diarrhea, as a consequence of VAD. Long known to be a principal cause of childhood blindness (250T-500T children lose sight each year), VAD is now recognized as a major contributing factor in an estimated 1-3M child deaths each year.

Benefits of Vit. A Supplementation

Vit. A is essential for the functioning of the immune system and for the healthy growth and development of children. The simple provision of high-dose Vit. A supplements every 4-6 months not only protects against blindness, but has been repeatedly shown to have a dramatic and multiple impact on the health of young children (aged 6-59 months).
 Overall cause of mortality is reduced by 23%
 Measles mortality is reduced by 50%
 Diarrhea mortality is reduced by 33%
 85% coverage in vitamin A supplementation can result in a 90% reduction in the prevalence of xerophthalmia
 Vit A supplementation has been shown to have a positive impact on child mortality, particularly with measles and diarrhea.
 Vit. A supplementation in measles
 enhances immune response
 reduces the severity of measles
 decreases the incidence/severity of major complications
 results in fewer days in the hospital
 leads to faster recovery and fewer post-measles complications
 In diarrhea, Vitamin A supplementation:
 reduces the frequency of moderate and severe dehydration
 results in fewer signs and symptoms of dehydration
 lowers clinical attendance and the frequency of diarrhea-related hospital admissions

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS
(IMCI)

● Every year some 12 million children die before they reach their fifth birthday, many of them during the 1st year of life. Seven in every 10 (70%) of these children’s death are due to diarrhea, pneumonia, dengue hemorrhagic fever, measles, malaria or malnutrition – and often a combination of these conditions. In addition to this substantial mortality, these conditions are the reason for seeking care at a health facility in at least three out of four sick children.

● IMCI is a strategy to reduce the frequency and severity of illness and disability in children. It combines improved management of childhood illness with aspects of nutrition, VAC supplementation, deworming, immunization and other factors influencing child and maternal deaths.

● A strategy for reducing mortality and morbidity associated with major causes of childhood illness.
● A joint WHO/UNICEF initiative since 1992
● Currently focused on first level health facilities
● Comes as generic guidelines for management which had been adapted to each country

RATIONALE FOR IMCI

● Most sick children present signs related to more than one disease
● This overlap means that a single diagnosis may not be possible
● Treatment may be complemented by the need to combine therapy for several conditions
● Need to move beyond addressing single diseases to addressing the overall health and well-being of the child

OBJECTIVES OF IMCI
● To reduce significantly global mortality and morbidity associated with the major causes of disease in children
● To contribute to healthy growth and development of children

PRINCIPLES OF IMCI
● Assess for “general danger signs”
● Routinely assess for major symptoms
● Use limited number of carefully selected clinical signs
● Address most, if not all the major reasons a sick child id brought to the clinic
● Use a limited number of essential drugs and encourage active participation of caretakers in the treatment
● Counseling of caretakers

COMPONENTS OF IMCI
● Improving case management skills of health workers
- standard guidelines
- training (pre-service and in-service
- follow-up after training
● Improving the health system to deliver IMCI
- essential drug supply and management
- organization of work in health facility
- management and supervision
● Improving family and community practice

TARGET POPULATION
Sick children between the ages of 1 week and 5 years.

CONTROL OF ACUTE RESPIRATORY INFECTIONS
(CARI)

Acute Respiratory Infections (ARI) are myriad of syndrome ranging from simplest, most frequent self-limited common colds to the more complex and often fatal pneumonia. For several years pneumonia has been the leading cause of infant mortality. This could be due to lack of knowledge and skills of mothers/child-minders in the early detection of pneumonia and to the irrational use of antibiotics and cough syrups by some health personnel.

Pneumonia is acutre in that it can kill within 48 hours. However, when detected early enough, it can easily be treated with antibiotics. Factors that contribute to the problem are the following:
2. mother’s failure to recognize the early signs and symptoms of pneumonia thus their inability to act on it
3. indiscriminate use of antibiotics that results to the scarcity of this life saving drug if not its actual inavailability in the field
4. health workers use different methods in detecting pneumonia and its management is not standardized

ACTIVITIES
1. Strengthening of program implementation through amendment to DO 110-E, review proposals for the revisions in the NDFP
2. Provision of CARI Standard Drugs as GOP line item – Cotrimoxazole, Benzyl Penicillin, Chloramphenicol, Nafcillin and Gentamycin
3. Provision of ARI Life Support Equipments - O2 tanks with humidifier, O2 concentrators, nebulaizers, pedia intubation set, pedia ambu bag
4. Support for quality and standardized trainings
5. Strengthening linkages with professional, private, educational and non-governmentr org
6. Institutionalization of ARI standard case management through a revised education package that will be integrated into the medical/nursing/midwifery/pharmacy curricula and will be part of basic undergraduate training
7. Expansion of the role of BHWs in ARI management
8. Strengthening monitoring, supervision and evaluation
9. More aggressive communication strategies

The primary focus of CARI program is mortality reduction through early detection and antibiotic treatment of pneumonia cases among children 0-less than 5 years.

Classification of children with pneumonia
1. Very severe – not able to drink, convulsions, abnormally sleepy or difficult to wake, stridor in calm child or severe undernutrition. They should be referred urgently to the hospital.

2. Severe pneumonia – chest indrawing. The child should be referred urgently to the hospital. However, children with both chest indrawing and recurrent wheezing may have asthma rather than severe pneumonia. These children are managed differently.

3. Not severe – a child with fast breathing and no chest indrawing. Cut offs for fast breathing are:
60X per minute or more for less than 2 months
50X per minute or more for 2 months up to less than 12 months
40X per minute or more for 12months-4 years
Children with pneumonia should be given antibiotics and home care.

4. No pneumonia: cold or cough – no chest indrawing, does not have fast breathing. He should be given homecare. He should not be given antibiotics.

OBJECTIVE
To reduce mortality due to pneumonia among children under 5 years old.

CONTROL OF DIARRHEAL DISEASES

Diarrheal diseases are among the leading causes of childhood morbidity and mortality in developing countries and a major cause of undernutrition. Each under five year old child suffers about 3 diarrheal episodes every year.

OBJECTIVE
To reduce diarrhea morbidity and diarrhea mortality.

FAMILY PLANNING PROGRAM

The Philippine Family Planning Program (PFPP) in one of the nationally mandated public health program that support the country’s health and development goals. It systematically provides information and services in all legally permissible and medically acceptable family planning methods needed by women and men of reproductive age in order to plan their families. This program remains an intervention: an important life saving measure based on the conviction that a healthy mother is a key to a healthy child, but at the same time, actively supports and promotes policies that aim at maintaining a proper balance population, resources & the environ. It is a non-coersive program that respects the right of every couple to determine responsibly whether to have children, when and how many, in the light of their own moral & religious beliefs. It rejects abortion as a means of contraception.

TARGET POPULATION
Couples of reproductive age group and unmarried young adults.

OBJECTIVE
To increase and sustain the practice of Family Planning among couples of reproductive age consistent with their status.

LIGTAS BUNTIS CAMPAIGN

The Ligtas Buntis 2005 Campaign is a nationwide response to address the needs of men, women and couples to plan their families which have not been met due to deficiencies in social structures and health care systems as well as problems on availability, accessibility of FP services. LBC caters to both the pregnant and the non-pregnant women. It is set for February –March 2005.

SITUATIONER
Global data:
 600T women 15-49 year old die every year as a result of complications of pregnancy and childbirth
 480-1000 women die for every 100,000 live births in the developing countries
 55T cases of unsafe abortions every year, 95% of them occur in developing countries
 80T women die every year because of unsafe abortion
 22% of all under 5 deaths are maternally related

Local data:
 1998 – NDHS MMR – 172/100,000 LB
1994 UPPI data on cases of abortion – 300,000 – 400,000 annually
2003 NDHS IMR – 29 deaths/1000 LB
 unmet need for FP – Spacing – 7.9% Limiting – 9.4%
 met need (currently using) Spacing – 13.7% Limiting – 35.2%
 % of women who did not discuss FP with a field worker or at a health facility – 80.3%
 total wanted fertility rate = 2.5 vs. Total fertility = 3.5

GENERAL CONCEPT
Ligtas Na Pagbubuntis or safe pregnancy and childbirth and/or
Ligtas Sa Pagbubuntis or safety from risk or unwanted pregnancy

GOAL
Universal access to FP and Maternal Care information and services for men, women and couples of reproductive age.

OBJECTIVE
To directly deliver the needed FP and Maternal Care education and services to the target population (2M women and men of reproductive age).

Priority areas
1. Urban slums
2. Barangays in cities and cities and municipalities established to be among the 25% poorest
3. Communities of indigenous peoples
4. Difficult and hard to reach areas

Target clients
Primary clients
● couples, men and women of reproductive age
● pregnant women
● postpartum mothers
● post abortion mothers
Secondary clients
● adolescents
● men and women with RTIs

POLICY STATEMENTS
 FP as a health intervention – towards the improvement of maternal and child health leading to the reduction of maternal & infant deaths.
 FP prevents high risk pregnancies
 FP reduces maternal deaths
 FP prevents abortion
 FP prevents abortion
 FP responds to the unmet needs & demands of women of reproductive age
 FP as a means to attain sustainable development, healthy and productive families, population growth matching economic growth, with special focus on FP needs of the urban and the rural poor.

PRINCIPLES

1. Responsible parenthood – is the prudent use of human fertility to beget the correct number of children at the appropriate times, taking into consideration the family’s health, financial capacity, psychological preparedness and current social conditions.
2. Birth spacing – the mother’s body needs time to recover from the rigors of pregnancy and childbirth. Pregnancy depletes the resources of the mother’s body to be able to nourish the child in the womb.
3. Informed choice – the government is opposed to FP service that coerces families into accepting a method they do not understand, or promoting only one method or product without making the parents aware of the other options and approaches available. FP program includes both the Natural Family Planning life choice, and the various artificial method of contraception and sterilization. Couples should be fully informed of the disadvantages, risks, side effects and efficacy rates of the methods they are considering. The first major step towards attaining informed choice is by providing fertility awareness.
4. Respect for life – FP emphasizes the moral responsibility to uphold the sanctity of human life. It does not allow abortion.
5. Privacy & confidentiality
6. Multi-agency participation and partnership
7. Integration
8. Institutionalization of the campaign

EARLY CHILDHOOD DEVELOPMENT PROJECT

Early Childhood Care and Development refers not only to what is happening within the child, but also to the care that the child requires in order to thrive. For a child to develop and learn in a healthy and normal way, it is important not only to meet the basic needs for interaction and stimulation, affection, security and learning through exploration and delivery.

TARGET POPULATION

Disadvantaged children 0-6 years who are in need and at risk from the 3 pilot areas identified.

OBJECTIVES
1. Reduction by 30% of the under-five mortality rate from the baseline value (estimated at over 35 per thousand).
2. Improvement in a combine index of child development (motor and cognitive skills) among children under six.
3. Increase to 90% in proportion of children aged 12-18 months fully immunized from the baseline value (estimated at under 85%)
4. Increase to 75% in proportion of total children aged 3-5 in targeted municipalities attending day-care centers (estimated under 60%)
5. Increase completion rate from Grade 1 entrants from the baseline survey (estimated at 50%)

THE PHILIPPINE NEWBORN SCREENING PROGRAM
(R.A. No. 9288 Newborn Screening Act of 2004)

● It is a simple & effective test to find out if your baby has an inborn metabolic disorders that can lead to mental retardation and death.
● It is essential because babies with IEM appears normal & healthy at birth. Babies are not diagnosed until physical defects, developmental delays & irreversible brain damage have set in.

OBJECTIVES

● To establish the incidence of commonly encountered metabolic conditions;
● To make recommendations to appropriate authorities on result of national importance.

MISSION

To gather adequate data to support nationwide implementation of the newborn screening program.

VISION

To make newborn screening available to all Filipinos.

When is newborn screening done?
● 3rd day of life
● if discharged earlier, collect blood specimen before discharge
● repeat screening done within 2 weeks for those tested within 24 hours of life for accurate results

How is it done?
● 3-4 drops of blood is obtained by heelprick & blotted on a filter card
● samples are sent to Newborn Screening Institutes of Health, UP Manila
● results within 3 days (Manila), 2 weeks in the provinces
● if (+), confirmatory testing
● refer to a specialist

6 Metabolic Disorders Tested
1. Congenital hypothyroidism - mental retardation
2. Galactosemia - cataract, death
3. Congenital adrenal hyperplasia - death
4. Homocystinuria - mental retardation
5. Phenylketonuria - mental retardation
6. Glucose-6-phosphate deficiency - kernicterus, hemolytic anemia

Congenital hypothyroidism
● inadequacy or absence of the thyroid hormone essential for the growth of the brain and body
● if not diagnosed: stunted growth, mental retardation

Congenital adrenal hyperplasia
● a genetic disorder of abnormal production of hormones responsible for water balance and sex characteristics
● severe dehydration, salt loss, abnormally high levels of male sex hormones in boys & girls

Galactosemia
● a condition in which babies are unable to process a certain part of sugar called galactose
● accumulation of galactose cause liver & brain damage, cataracts & mental retardation
● treatment: galactose-free diet
● prognosis: reversal of cataracts if treated before 3 months of age

Phenylketonuria
● inherited disorder caused by the absence of an enzyme needed by the body to utilize phenylalanine, a component of protein food
● if undiagnosed: seizures, mental retardation
● treatment:special diet – dietary phenylalanine restriction
● normal development if detected earlier

Homocystinuria
● lack or absence of an enzyme needed to metabolize methionine, another component of protein food
● manifestation: eye & bone abnormalities, blood vessel problems, mental retardation
● treatment: special diet

Glucose-5-phosphate deficiency
● a very common human enzyme defect
● manifestation: anemia, yellow discoloration of the skin
● precipitating factors: severe infection, antibiotics (sulfas), antimalarials
● management: prevention of intake/exposure to certain drugs, foods & chemicals

NATIONAL TUNERCULOSIS CONTROL PROGRAM

Tuberculosis (TB) remains a major health problem in the Philippines. In 1996, TB ranked 5th in the 10 leading cause of death and 5 th in the 10 leading causes of illness. Our country ranks 2nd to Cambodia in terms of new smear-positive TB notification rate, 99.7 per 100,000 population, among the major countries in the WHO Western Pacific Region in 1999. In 1997, the following are the findings of the 2nd National TB Prevalence Survey:
1. Percent of population with TB infection - 63.4% -(54.5%)
2. Annual Risk of TB infection - 2.3% -(2.5%)
3. Prevalence of sputum smear (+) cases - 3.1/1,000 -(6.6)
4. Radiologic finding suggestive of TB - 4.2% -(4.2%)

Annual risk (i.e., probability of a child getting infected with TB within a year) is a more sensitive indicator showed an insignificant decline in 15 years. The survey also shows that TB cases are 3X more common among males than females and most of the cases are in 30-59 years age-group. In 1978 the DOH implemented a national TB control program. Sputum microscopy centers were established in most of the RHUs. Short course chemotherapy (SCC) drugs for TB were procured and distributed by DOH. For the last 5 years, there were about 160,000-280,000 TB cases discovered annually.

Some of the constraints that affect the NTP program implementation includes: inadequate budget for drugs, poor quality of diagnostic test, irregular program supervision and monitoring, different approaches in diagnosis and treatment of TB patients by the doctors and poor treatment compliance.

The main strategy of the NTP is the Directly Observed Treatment Short Course (DOTS). This was introduced in the late 1980’s in other countries. This strategy dramatically improved the cure rate of the TB patients to more than 85% in areas where it has been implemented.

VISION: A country where TB is no longer a public health concern.

MISSION: Ensure that TB diagnostic, treatment and information services are available and accessible to the communities in collaboration with the LGUs and other partner.

GOAL: Morbidity and mortality from TB are reduced in half in ten years (by the year 2010)

TARGETS OF THE NTP
1. Cure at least 85 % of the sputum smear (+) TB patients discovered.
2. Detect at least 70% of the estimated new sputum smear (+) TB cases.

Notes on BCG Immunization
It is generally accepted that in children, BCG vaccination provides a certain degree of protection against serious forms of TB, such as miliary TB and tuberculous meningitis. The present recommendation by WHO in countries with high TB prevalence is that BCG should be given routinely to all infants at birth under the EPI.

NTP POLICIES AND PROCEDURES

A. CASE FINDING

this is the basic step in TB control which is the identification and diagnosis of TB cases among individuals with suspected signs and symptoms of TB
the principal diagnostic method adapted by the new NTP is the direct sputum-smear exam because of the following reasons:
1. it provides definitive diagnosis of active TB
2. the procedure is simple
3. it is economical
4. a microscopy center could be organized even in remote areas.
OBJECTIVE
Early identification and diagnosis of TB cases.
POLICIES
1. Direct sputum-smear exam shall be the primary diagnostic tool in NTP case finding
2. Passive case finding shall be implemented in all health stations
3. Only adequately trained Med Tech or NTP microscopist shall perform sputum-smear exam
SPECIMEN – shall be collected within two days
First specimen is also referred to as spot specimen – it is collected at the time of the consultation.
Second specimen or early morning sputum
Third specimen is also referred to as spot specimen – collected at the time the TB symptomatics comes to a health facility to submit the second specimen.
Smear positive result – at least 2 sputum smear results are positive
Doubtful result – when only 1 positive out of 3 specimens examined
Smear negative result – when all the 3 sputum smear results are negative

B. CASE HOLDING

the procedure that ensures that patients complete treatment. The strategy developed to ensure treatment compliance is the Directly Observed Treatment (DOT). It is one of the component of DOTS in order to achieve sufficient cure rate and prevent drug resistance. DOT works by assigning a responsible person to observe or watch the patient take the correct medications daily during the whole course of treatment.

OBJECTIVE
The general objective of chemotherapy is to treat TB cases effectively and completely, especially pulmonary sputum smear positive cases.

DENTAL HEALTH PROGRAM

Dental disease is so widespread that it affects a great number of our people. The Dental Health Program is one of the basic health services of the Department of Health, with its primary objective focused on promotive, curative and restorative dental health care of the population. It also addresses the various problems on dental health. The two most important dental diseases are dental caries and periodontal diseases.

TARGET POPULATION
All individuals 2 years and above specifically: pre-schoolers (2-5 years old), school age group (6-14 years), pre-natals and other adults.

OBJECTIVE
To improve the oral status of the population particularly pregnant mothers, children and other adults through reduction of dental caries prevalence and reduction of periodontal disease prevalence.

RABIES CONTROL PROGRAM

Rabies remains a public health problem in the Philippines. Approximately 300-600 Filipinos die of rabies every year. Our country ranked 3rd worldwide in rabies incidence in 2000. Dog remains the principal reservoir of rabies in the country. Thus, the most cost effective measure against rabies is through vaccination of dogs; education of dog owners and the public on responsible pet ownership should include restrictions of dogs within homes or properties. Stakeholders should push for the creation of local ordinances on dog control measures, dog vaccination and the practice of responsible pet ownership.

RABIES IN MAN
A highly fatal disease caused by a virus from the saliva of an infected animal and is characterized by hydrophobia, muscle spasm and paralysis. The rabies virus is transmitted to man through the bite by an infected animal, usually the dog, or through contamination with virus-laden saliva on breaks in the skin and the eyes, lips and the mouth.

WHEN BITTEN BY A DOG
- wash the wound immediately with soap and water
- consult a physician immediately or call the nearest Animal Bite Treatment Center.

RESPONSIBLE PET OWNERSHIP MEANS
- vaccinating pet dogs against rabies at 3 months of age and every year thereafter
- providing clean, comfortable and proper shelter
- providing enough exercise
- providing enough care and nutrition
- keeping them within our backyard, where they are free from contact with infected dogs. Keeping them on leash when we take them for daily exercise
- bringing the pet for regular health consultation with the veterinarian

COVERAGE
To ensure uniformity in the management of animal bite patients, government doctors at all levels as well as private practitioners in the country are hereby advised to follow the guideline.

PROGRAM POLICIES

There are 3 categories of exposure to rabid animal or to animal suspected to be rabid. Each of the three categories has a corresponding management of potential rabies exposure.

Category I
Feeding/touching an animal, licking of intact skin
Management:
a. Wash exposed skin immediately with soap and water
b. No vaccine or RIG needed
Category II
Nibbling of uncovered skin, minor scratches/abrasions without bleeding, licks on broken skin
Management:
1. Start vaccine immediately
Complete vaccination until day 90 if animal is rabid, killed, died or unavailable for 14-day observation or examination; if animal under observation died within 14 days and was FAT-positive or no FAT testing was done or had signs of rabies
2. Complete vaccination regimen until day 30 if the animal is alive and remains healthy after 14-day observation period; if animal under observation died within 14 days, was FAT-negative and without signs of rabies

Category III
Single or multiple transdermal bites or scratches, contamination of mucous membrane with saliva, exposure to a rabies patient through bites, and etc., handling of infected carcass or ingestion of raw infected meat, all category II exposures on head and neck area.

Management:
1. Complete vaccination regimen until day 90 if the animal is rabid, killed, died or unavailable for 14-day observation/ treatment; if animal under observation died within 14 days and was FAT-positive or no FAT testing was done or had signs of rabies
2. Complete vaccination regimen until day 30 if the animal is alive and remains healthy after 14-day observation period; if animal under observation died within 14 days and was FAT-negative and without any signs of rabies.
IMMUNIZATION
1. Active immunization
a. Vaccine is administered to induce antibody and T-cell production in order to neutralize the rabies virus in the body. It induces an active immune response (in 7-10 days after vaccination) and may persis for 1 year or more
b. The type of anti-rabies vaccine available in the Philippines are: Purified Verocell Rabies Vaccine (PVRBV), Purified Duck Embryo Cell Vaccine (PCECV)
c. All vaccines are considered to be highly immunogenic and safe. For active immunization, any of the three vaccines may be administered IM or intedermally.
2. Passive immunization
a. Rabies Immunoglobulin (RIG) is given in combination with anti-rabies vaccine to provide immediate protection to patients with Category III exposure. RIG has a half-life of approximately 21 days.
b. Only rabies vaccines and RIG that have been evaluated and recognized by WHO and approved by BFAD should be used. National Health authorities should evaluate any new vaccine or RIG prior to use. There 2 types of RIG:
● Human Rabies Immunoglobulin (HRIG) – 20 IU/kg
● Equine Rabies Immunoglobulin (ERIG) – 40 IU/kg
c. RIG should be given as a single dose for all Category III exposures
d. RIG should be infiltrated around and into the wound as much as anatomically feasible, even if the lesion has begun to heal. Any remaining RIG should be administered IM at the site distant from the site of vaccine injection.
e. The RIG should not exceed the calculated dose as it may reduce the efficacy of the vaccine.
f. RIG should be administered at the same time as the first dose of vaccine.
g. A skin test must be performed prior to ERIG administration.

C. Treatment
1. Post-exposure treatment
a. Local wound treatment
1. wounds should be immediately and vigorously washed and flushed with soap and water preferably for 10 minutes
2. apply alcohol, tincture of iodine or any antiseptic
3. if possible suturing of the wounds should be avoided, however, if suturing is necessary, anti-rabies IG shouldbe infiltrated around and into the wound
4. do not apply ointment, cream or occlusive dressing to the bite site
5. anti-tetanus imminization and anti-microbial may be given if indicated
b. 2-site intradermal schedule (2-2-2-0-1-1)
● 1 dose for intradermal adm is equivalent to 0.1ml for PVRV and 0.2 ml for PDEV/PCECV
● 1 dose should be given at 2 sites on days 0,3 and 7 and at one site on days 30 and 90
● injections should be given at the deltoid area of each upper arm in adults, or in infants, at the anterolateral aspect of the thigh
● the schedule should be strictly followed as it may cause treatment failure
● a 1 ml. Insulin syringe with gauge 25 needle should be used for intradermal inj
● vaccine should be stored within 4-8 degrees centigrade after reconstitution and should be used within 8 hours
2. Pre-exposure prophylaxis

NATIONAL HIV AIDS/STD PREVENTION AND CONTROL PROGRAM

GLOBAL HIV – AIDS SITUATION (as of December 2002)

 Total no. of HIV-AIDS cases worldwide = 42 M
Sub-Saharan Africa = 29.4 M
South & Southeast Asia = 6.1 M
Latin America = 1.5 M
East Asia & Pacific = 1.2 M
Eastern Europe & Central Asia = 1.2 M
North America = 980 T
Western Europe = 570 T
North Africa & Middle East = 550 T
Caribbean = 440 T
Australia & New Zealand = 15 T

 HIV-AIDS Picture in the Philippines (Jan 1884-August 2003)
Total of 1,921 HIV Ab seropositive cases
Most are in the 20-39 age group
30% are Overseas Filipino Workers (OFW)
62% are males
Most common mode of transmission is heterosexual (86%)
At the time of report, 1,302 (68%) were asymptomatic & 619 (32%) were AIDS cases
Of the reported AIDS cases, 255 (42%) were already dead due to AIDS-related complications
 Cebu
56 cases by sexual transmission, OCW, 19-39 y.o.
TARGET POPULATION
High risk group: commercial sex workers, persons practicing unsafe sex, individuals who inject drugs not following hygienic methods, blood transfusion recipients, children of infected parent (transplacental), sexually abused children, paramedical/health personnel.

OBJECTIVES
1. To reduce the transmission of HIV and STDs
2. To curtail development of STD complications
3. To mitigate the impact of HIV infection, AIDS and STDs on the individual, family, community and society

 Any person can get STD/AIDS at any age
 Transmitted thru:
 unprotected penetrative sex with HIV infected partner
 infected blood and blood products
 infected mothers to child
 4 body fluids known to transmit HIV – blood, semen, vaginal/cervical fluids, breastmilk
 Factors that can help HIV Transmission
 presence of STDs
 intoxication w/ alcohol & drugs
 multiple sex partner
 Symptoms could be
 neurology
 ophthalmic
 pulmonary
 gastrointestinal
 dermatologic
 No vaccine discovered to give immunity to HIV
 No treatment yet for AIDS

HOW TO PREVENT STD/HIV

A Abstinence
B Be faithful
C Careful sex (condom)
D Don’t use drugs
E Education

 Infection history
 Exposure
 Window period (seroconversion 6 weeks to 6 months)
 Asymptomatic stage (5-10 years)
 AIDS (6 months – 2 years)
 DEATH

NATIONAL LEPROSY CONTROL PROGRAM
(NLCP)

The NLCP is integrated in the basic health services of the RHUs and BHS. Because of the failure to control leprosy through Dapsone treatment and confinement in sanitaria, the home-based Multiple Drug Therapy (MDT) was introduced as an innovative strategy in pilot provinces (Ilocos Norte and Cebu). The success of the project led to its nationwide implementation in 1988. In 1991, the Philippines together with other member nations of WHO adopted the goal for the global elimination of leprosy as a public health problem by the year 2000 by bringing down the prevalence rate to less than 1 case /10,000 population.

TARGET POPULATION
The 10% of total population with skin problems, the actual number of Hansen’s Disease cases and their contacts.

OBJECTIVE
To eliminate leprosy as a public health problem

KEY STRATEGIES
1. Case finding
2. Treatment of leprosy
3. Advocacy
4. Manpower development

NATIONAL DENGUE PREVENTION & CONTOL PROGRAM

Dengue fever is one of the mosquito-borne diseases that is fast becoming a public health problem. It is currently the most important vector-borne viral diseases affecting all ages but most commonly the 0-9 year age group. The disease which is commonly found in the urban areas, has now spread to the developing rural areas and even to some remote barangays. Lack of effective mosquito control & increasing urbanization may have contributed to the increase transmission.

TARGET POPULATION
General population, with priority to 0-15 year group

OBJECTIVE
To prevent and control the transmission of dengue virus from its mosquito vector to man by 90% by the end of the 15-year period

KEY STRATEGIES
1. Case management
2. Health education/Training/Surveillance
3. Rapid response mosquito control during epidemic
4. Integrated vector control
5. Research & project development

MALARIA CONTROL PROGRAM

Malaria is still of the ten leading causes of morbidity in the country despite the reduction of mortality rate. The endemic areas are usually rural, hilly or mountainous, hard to reach. The high risk groups are the upland subsistence farmer, forest related workers, indigenopus cultural groups, settlers in frontier areas, migrant agricultural workers and soldiers assigned in endemic areas. Transmission is perennial and generally higher during the rainy season than in the dry season.

OBJECTIVE
To reduce malaria morbidity by 10% by the end of 5 years.

KEY STRATEGIES
1. Improve the knowledge, attitude and skills of health workers in endemic areas on malaria control
2. Strengthening the surveillance system in highly endemic areas
3. Intensification of IEC campaign especially on vector control and drug abuse through the conduct of community assemblies and meetings
4. Optimal utilization of available resources
5. Establishment of a regular monitoring scheme, an effective evaluation system and application of innovative measures

ENVIRONMENTAL SANITATION PROGRAM

Environmental Sanitation is a component program of Communicable Disease Control which is mainly for the prevention and control of diseases by eliminating and controlling environmental factors which may form links in disease transmission. Of the several fields of environmental sanitation, we focus mainly on the three major areas namely: Sanitary Waste Disposal, Water Supply Sanitation and Food Sanitation.

TARGET POPULATION

The general public

OBJECTIVES
To provide all households with safe water, to increase provision of sanitary toilets to household beneficiaries and to enhance capability building of Sanitarias, Food Operators and Food Handlers.

NONCOMMUNICABLE DISEASES

1. OCCUPATIONAL HEALTH PROGRAM
2. NATIONAL ASTHMA EDUCATION, PREVENTION & CONTROL PROGRAM
3. NATIONAL CARDIOVASCULAR DISEASE PREVENTION & CONTROL PROGRAM
4. PHILIPPINE CANCER CONTROL PROGRAM
5. VISUAL HEALTH PROGRAM/PREVENTION OF BLINDNESS PROGRAM
6. SMOKING CESSATION PROGRAM
7. HEALTH PROMOTION FOR OLDER PERSONS
8. COMMUNITY BASED REHABILITATION PROGRAM
9. NATIONAL OSTEOPOSROSI EDUCATION AND PREVENTION PROGRAM
10. NATIONAL MENTAL HEALTH PROGRAM

There is an increasing trend in premature mortality, morbidity and disability due to noncommunicable diseases (NCDs) worldwide especially in most countries in the WHO Western Pacific Region. These include cardiovascular diseases ( mainly hypertension, coronary artery disease and strokes), diabetes, cancers and chronic obstructive pulmonary disease or COPD (including bronchial asthma).

To prevent and control NCDs, it is important to understand how these diseases develop, particularly their causes and associated risk factors. Some risk factors can be changed, while others cannot. Primary prevention can, therefore, be directed to the prevention and modification of these factors.

EPIDEMIOLOGY OF NCDs:

The Global Picture
 CVD and diabetes are major causes of premature deaths, morbidity and disability in most countries.
 CVD – Approx 10M of the total 15M CVD deaths each year occur in developing countries. There are 7M deaths each year from coronary heart disease and 4.5M from stroke.
 Stroke – In the US, it is the 3rd leading cause of death after diseases of the heart and cancer, about 600T. Stroke is a leading cause of serious, long-term disability and accounts for more than half of all patients hospitalized for neurological disease that strikes quickly.
 Diabetes – the prevalence of diabetes in adults aged 20 years and over was estimated to be 4.0% in 1995, and expected to rise to 5.5% by 2025. 75% will live in the developing countries. Complications asso with diabetes impose a heavy burden on health care systems and on quality of life. It is a major cause of blindness, renal failure and lower limb amputations.
 COPD – in 2000 WHO estimated 2.74M deaths worldwide from COPD. It was ranked 12th as a burden of disease in 1990; by 2020 it is projected to rank 5th. In the US it is the 4th leading cause of death. Cigarette smoking is the primary cause of COPD. WHO estimates 1.1B smokers worldwide, increasing to 1.6B by 2025. In low and middle income countries, rates are increasing at an alarming rate.

The Philippine Situation

Cardiovascular Diseases (diseases of the heart and the blood vessels)
 remains as the 1st and 2nd leading caused of mortality. This was mainly due to hypertension
 heart diseases were the 7th cause of morbidity
 prevalence is 21%
 hypertension was highest in Regions 3, NCR, 8, 5 and the Cordilleras
 prevalence of risk factors of CVDs: elevated serum cholesterol, cigarette smoking

Cancer
as of 1998, cancer was the 4th leading cause of mortality with a rate of 43.9/100,000 population
among the 10 leading sites of cancer for both sexes in 1998 are: lung, breast, liver and cervix.
for females, the leading site of cancer are: breast and cervix; for males are lung and liver

Diabetes Mellitus
 the eight leading cause of death as of 1998. Prior to 1994, DM was not even included among the 10 leading causes of mortality
 as of 1992, the prevalence of diabetes among 20-65 years was 4.1%. Urban areas had higher prevalence compared to rural areas. Metro Manila prevalence was the highest
 1999, data showed that 3.9% of adults have FBS level > 125 mg/dl. It was highest in Region III, IV and NCR.

COPD and Bronchial Asthma
 COPD and allied conditions were the 7th leading cause of death as of 1998.
 there is no available data on asthma and COPD

Accidents
 the 5th leading cause of death in 1998
 a major portion of deaths due to accidents may be attributed to alcohol intoxication

Public Health Significance of NCDs

Factors that influence the increasing trend of NCDs:

 increasing life expectancy – more older persons, therefore more are experiencing chronic diseases
 increasing urbanization – rapid migration from rural to urban areas has resulted in overpopulation in urban areas and poverty, problems of environmental pollution, proliferation of conveniences as fast food chains, transportation and the like, which in turn have resulted in poor nutrition and sedentary life.
 with globalization, there is increasing industrialization, growing mobility of capital and labor and increased trade in many products including foodstuff and tobacco products.
All these factors have a profound impact of lifestyles of people – dists have changed, levels of physical activity have reduced and access to alcohol & tobacco has increased. Health care cost of treatment and rehabilitation is also increasing. Although a national insurance system is currently being established in the country through Philhealth, it is not adequate. There is, therefore a need
to direct public health efforts toward prevention rather than cure.

Causes and Risk Factors of Major NCDs
A. Disease of the Heart a& Blood Vessel (Cardiovascular Diseases)
1. Hypertension
Description
 a sustained elevation in mean arterial pressure
 a disorder with many causes, a variety of symptoms, and a range of responses to therapy
 a major risk factor for the development of other CVDs like coronary heart disease and stroke

Etiology
 Primary hypertension – essential or idiopathic hypertension
 Secondary hypertension – result of some other primary diseases
 Exact cause is unknown, it is attributed to atherosclerosis

Risk Factor
 no single cause for primary hypertension but several risk factors have been implicated in its development
 risk factors include family history, advancing age, race & high salt intake
 other lifestyle interact with these factors and contribute to the development of hypertension

Key areas for Prevention of Hypertension
 proper nutrition
 weight reduction by proper nutrition & exercise
 smoking cessation
 those with the risk factors, regular check-ups for possible hypertension and modification of risk factors

2. Coronary Heart Disease
Description
 CAD is caused by impaired coronary blood flow. It also known as Ischemic Heart Disease
 Narrowing or clogged arteries affects oxygen supply to the heart muscles causing chest pain
 CAD can use MI, arrhythmias, heart failure and sudden death

Etiology
 Most common cause is atherosclerosis
 Atherosclerosis usually occurs due to high level of cholesterol
 DM accelerates atherosclerosis resulting to CAD, MI and stroke

Risk Factors
 Modifiable factors as elevated blood lipids and cholesterol, hypertension, smoking, DM, obesity, inactivity and stress. Some risk factors are nonmodifiable as gender, family history and age.

Some Interesting Facts About Risk Factors of CAD
 hypertension & smoking double the chances of developing CAD if you have high cholesterol
 a person who has all three risk factors is 8X more likely to develop heart disease than someone who has none
 obesity and being overweight increase the chance of developing high blood cholesterol and high blood pressure
 physical inactivity increases the risk of heart attack
 diabetes is an independent risk factor for CAD. Diabetes even without other risk factors may lead to heart disease because it accelerates the development of atherosclerosis.

Key Areas for Prevention of CAD
 promote regular physical activity and exercise
 encourage proper nutrition
 maintain body weight and prevent obesity
 smoking cessation
 early diagnosis, prompt treatment and control of diabetes and hypertension

3. Cerebrovascular Disease or Stroke
Description
 stroke is a loss or alteration of bodily function that results from insufficient blood supply to some parts of the brain.
 Stroke is one of the leading causes of disability

Etiology
 there 3 types of stroke: thrombotic stroke, embolic stroke, hemorrhagic stroke
 almost all are caused by occlusion of cerebral vessels
 the most fatal type of stroke is due to intracranial hemorrhage, thsat is, rupture of intracerebral blood vessels
 like coronary artery disease, the common cause of stroke is also atherosclerosis

Risk Factors of Stroke
 increasing age – more than doubles for each decade of lifeafter the age 55
 gender – more women than men die of stroke though equal in prevalence/incidence
 heredity and race
 hypertension
 cigarette smoking
 diabetes mellitus
 heart disease
 high RBC count
 season and climate
 socioeconomic factors
 excessive alcohol intake
 drug abuse
Key Areas for Prevention of Stroke
 treatment and control of hypertension
 smoking cessation and promoting a smoke-free environment
 prevent thrombus formation in RHD and arrhythmias with appropriate medications
 limit alcohol consumption for women
 avoid IV drug abuse and cocaine
 prevent all other risk factors of atherosclerosis

B. Cancer
 not all tumors are cancerous
 different types of cancer behaves differently
 multiple causes and risk factors

Causes of Cancer
 heredity – breast cancer
 carcinogens – chemical, radiation, viruses
 chemicals – polycyclic hydrocarbons, aflatoxin, etc.
 benzopyrene – in broiled food and smoked fish, repeatedly reused cooking oil in frying
 nitrosamines – preservative in tocino, longganisa, bacon, hotdog
 radiation
 viruses

Key Ares for prevention of cancer
 promote lifestyle change – smoking cessation, nutrition
 increase intake of dietary fiber
 eat less fat and fatty foods
 limit consumption of smoked, charcoal-broiled, salt-cured and salt-pickled foods
 avoid moldy foods
 promote smoke-free environment, early detection and treatment

C. Diabetes mellitus
Description
 it is genetically and heterogeneous group of metabolic disorders characterized by glucose intolerance, with hyperglycemia at time of diagnosis

Etiology
 genetic predisposition (diabetogenic genes)+ environment/lifestyle (obesity, nutrition, lack of exercise)

Types of diabetes
 Type I – IDDM absolute lack of insulin due to damaged pancreas, prone to develop ketosis and dependent on insulin injections. Genetic, environment, or due to viruses and chemical toxins
 Type II – NIDDM – more common characterized by fasting hyperglycemia despite availability of insulin. Possible causes include impaired insulin secretion, peripheral insulin resistance and increased hepatic glucose production
 80 % occurs in overweight and older individuals

RiskFactors of Type 2 DM
 Family history of diabetes
 Overweight (BMI 23kg/m2) and obesity (BMI 30 kg/m2)
 Sedentary lifestyle
 Hypertension
 HDL cholesterol  35 mg/dl sand triglyceride level > 250mg/dl
 History of gestational diabetes mellitus
 Previously identified to have impaired glucose tolerance (IGT)

Comlications)
 Acute complications include diabetic ketoacidosis, hyperosmolar hyperglycemic nonketotic coma and hypoglycemia especially in Type I diabetetics
 Chronic complications cause most of the disability associated with the disease. These include chronic renal disease, blindness, coronary artery disease and stroke, neuropathies and foot ulcers

Facts on DM
 After 15 years of diabetes, 30% of IDDMs and 20% of NIDDMs develop significant kidney disease
 In 20 years, 50% will have peripheral vascular disease
 There is no relationship between severity or duration of DM with severity of coronary artery disease; a severe Cad may develop even in so called “mild” diabetes
 Infection is the frequent cause of death in the Philippines

Key areas of prevention and control of Diabetes
 Maintain body weight and prevent obesity
 Encourage proper nutrition
 Promote regular physical activity and exercise
 Advise smoking cessation

D. Chronic Obstructive Pulmonary Disease
 COPD is a major cause of chronic morbidity and mortality throughout the world
 Currently the 4th leading cause of death in the world

Epidemiology of COPD
 In 2000, WHO estimated 2.74M deaths worldwide from COPD
 COPD ranked as the 12th leading cause of burden in developing countries
 In the Philippines, COPD is the 7th leading cause of mortality
 No available data on prevalence yet

Description
 COPD is a disease state characterized by airflow limitation that is not fully reversible, which is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases
 The lungs undergo permanent structural change, which leads to varying degrees of hypoxemia and hypercapnea

Etiology and Risk Factors
 Usually due to chronic bronchitis and emphysema, both of which are due to cigarette smoking
 Cigarette smoking is the primary cause of COPD

Diagnosis
 Cough, sputum production, dyspnea and/or history of exposure to risk factorsfor the disease. Diagnosed by spirometry.
 Chronic cough and sputum production often prcede the development of airflow limitation by many years

Complications
 Respiratory failure
 Cardiovascular

E. Bronchial Asthma

Definition
 A chronic disease. It is an inflammatory disorder of the airways in which many cells and cellular elements play a role
 Increase in airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing, particularly at night or in early morning
Epidemiology
 One of the most common chronic diseases worldwide
 Prevalence is increasing in many countries particularly in children
 Locally it is 9% among rural and urban Filipino adults in Bulacan
 ISAAC study in 1996, prevalence is 16.4% among 6-7 years, 17.6% among 13-14 age group
 Is a major cause of school/work absence

Causes and Risk Factors
 Both genetic and environmental
 Genetic predisposition, atopy or allergy, airway hyperresponsiveness, gender, race/ethnicity
 Environmental: indoor allergens, outdoor allergens, occupation sensitizers, tobacco smoke, air pollution, respiratory infections, socioeconomic factors, parasitic infections, family size, diet & drugs, obesity

Asthma Triggers
 Triggers are risk factors for exacerbations, they do not cause asthma
 Examples are: irritant gases and smoke, dustmite, respiratory infections, inhaled allergens, weather changes, cold air, exercise, certain foods, additives and drugs.

Key Areas for Primary Prevention and Exacerbation of Asthma
 Recognize triggers that exacerbate asthma
 Avoid these triggers if possible, particularly smoking
 Promote exclusive breastfeeding as long as possible; early introduction to cow’s milk may predispose baby to allergies and possible asthma

NATIONAL HEALTH INSURANCE PROGRAM

► instituted in 1995 by virtue of Republic Act 7875 popularly known as the National Health Insurance Act of 1995.
► NHIP aims to effectively provide accessible, affordable, acceptable and adequate health care services to all Filipinos
► mandates the Philippine Health Insurance Corporation (Philhealth), a government-owned and controlled corporation, to administer and manage a sustainable program that will not only ensure better benefits at an affordable cost but also extend quality and relevant health care services to a broader membership base that will lead to universal coverage.

The NHIP replaced the old Medicare program to:
■ Accelerate universal coverage
■ Enhance and expand the benefits to include more outpatient services
■ Consilidate the Medicare program previously administered separately by the SSS, GSIS and OWWA
■ Ensure a sustainable National Health Insurance Program for all

Who are covered by the NHIP?
 employed sector
 individually paying members
 non-paying members – retirees and pensioners, permanent and partial disability pensioners; survivorship pensioners of the SSS
 indigent members under the Medicare Para Sa Masa

Coverage that extends to the family
 legitimate spouse who is not a Philhealth member
 children (legitimate, illegitimate, legally adopted and stepchildren) below 21 years old, unmarried and unemployed
 child-dependents, 21 years old or above but are suffering from any illness or disease, congenital or acquired are automatically covered
 parents – 60 years old and above, not qualified as Philhealth Non-paying Members, and wholly dependent on the member for support

Philhealth Benefits
 room and board
 professional fee
 laboratory & other medical examination services
 drugs & medicines
 Operatin Room
 Outpatient: chemotherapy, radiation therapy, hemodialysis, cataract extraction and minor surgical procedures performed in an operating room complex of an accredited facility

Entitlement to Benefits
 members must have paid at least three (3) monthly premium contributions prior to the month of confinement. Individually paying members are required to have one quarter payment immediately before the quarter of ailment
 confinement in a Philhealth accredited hospital for at least 24 hours, or availment of an outpatient procedure as long as this is done in an operating room complex of an accredited facility
 provided that the 45-day room and board allowance for the applicable year has not been exhausted

Hospital Category
Primary – hospitals which are capable of performing routine laboratory and minor surgical procedures only
Secondary – hospitals which has the capacity to perform general surgery like most district hospitals
Tertiary – big medical centers which have sophisticated equipment with major specialty services

Case Type Classification
Catastrophic cases refer to:
 illness or injuries such as but not limited to cancer cases with metastasis and/or requiring chemotherapy or radiotherapy, meningitis, encephalitis, cerebro-vascular dse, coma of any cause, shock of any cause, cardiac arrest, massive hemorrhage, renal failurte except acute and congenital renal failre, glomerular dse requiring hemodialysis, neonatal infectious dse, etc.
 surgical procedures done in one sitting with a total RVU of 201 and above

Intensive Cases refer to:
 all confinements requiring services in the ICU
 other similar serious illnesses or injuries such as but not limited to localized cancer, HIV, immune def dse, MI, chronic rdeumatic dses, congenital malformations of the respiratory & circulatory system, pulmonary heart dses, of pulmonary circulation, acute renal failurte, congenital malformations of the digestive system except cleft lip and palate, burns and corrosions confined to the eyes and internal organs, severe injuries to major organs except to the CNS, etc.
surgical procedures done in one sitting with RVU of 81-200
Ordinary cases refer to illnesses or injuries other than those included in the above enumeration

Services that Philhealth does not compensate at the moment
outpatient psychotherapy and counseling for mental disorders
home and rehabilitation services
non-prescription drugs and devices
drug and alcohol abuse or dependency treatment
cosmetic surgery
optometric services
normal obstetrical delivery other than the first
primary consultation

THE HEALTH SECTOR REFORM

seeks to cure the problem of inappropriate service delivery system, inadequate regulatory mechanism and poor financing by addressing certain areas of reform

through the reform agenda, the health sector expects to gain significant breakthroughs in health care delivery system through greater and more effective coverage of national and local public health programs and increased access to health services.

AREAS OF REFORM

 HEALTH SECTOR REFORMS: HOSPITAL SYSTEMS
 fiscal autonomy through authorization to collect, retain and allocate revenues from socialized user fees
 upgrading of critical capacities including diagnostic equipment, laboratory and medical staff
 reduction of dependence on direct public subsidies to free resources for other priorities
 establishment of appropriate institutional management to facilitate conversion to public corporations

 HEALTH SECTOR REFORMS: PUBLIC HEALTH PROGRAMS
 upgrading management infrastructure
 ensuring long-term funding for programs to eliminate infectious diseases
 investment in new programs to address emerging health problems
 increase for spending for health promotion and disease prevention
 investment in critical capabilities to provide technical leadership over local health systems

 HEALTH SECTOR REFORMS: LOCAL HEALTH SYSTEMS
 allocation of resources for upgrading local health systems
 use of block grants to leverage for the establishment of local hea;th networks
 promotion of cost-sharing among local government units and local health networks
 provision of incentives for private sector participation in local health networks
 HEALTH SECTOR REFORMS: REGULATORY AGENCIES
 strengthening the capacity for standard development, regulation and licensing to improve quality, effectiveness and efficiency
 reduction of cost of health services and products including pharmaceuticals

 HEALTH SECTOR REFORMS: FINANCING OF HEALTH SERVICES
 increase of benefits to make the National Health Insurance Program (NHIP) more attractive
 improvement of benefits to aggressively enlist members for NHIP especially from the poor sectors
 development of administrative infrastructure to handle increased workload

FOURmula ONE for Health: Implementation Framework for Health Reforms

GOALS:
- better health outcomes
- more responsive health system
- equitable health financing

FOUR THRUSTS:
- financing (more, better and sustained)
- regulation (assured quality and affordability)
- service delivery (ensured access and availability)
- governance (improved performance)

Republic Act No. 8172
An Act Promoting Salt Iodization Nationwide
(Asin Law)

Purposes:
1. contribute to the elimination of micronutrient malnutrition in the country, particularly iodine deficiency disorders, through the cost-effective preventive measure of salt iodization.
2. require all producers/manufacturers of food-grade salt to iodize the salt they produce, manufacture, import, trade or distribute
3. require the DOH to undertake the salt iodization program and its BFAD, to set and enforce standards for food-grade iodized salt and to monitor compliance thereof by the food-grade salt manufacturers
4. require the LGUs, through their health officers and nutritionist-dietitians, or in the absence through their sanitary inspectors, to check and monitor the quality of the food-grade iodized salt and to monitor the quality of food-grade salt being sold in their markets in order to ascertain that such salt is properly iodized
5. require the DTI to regulate and monitor trading of iodized salt
6. direct the DOST, in collaboration with the Technology and Livelihood Resource Center to initiate, promote and cause the transfer of technology for salt iodization
7. authorize the National Nutrition council, the policy-making and coordinating body on nutrition, to serve as the advisory board on salt iodization
8. provide mechanism and incentives for the local salt industry in the production, marketing and distribution of iodized salt
9. ensure the sustainability of the salt iodization program

WATER SUPPLY SANITATION

Water Supply Sources:

A. Surface Water – derived from rivers, lakes, seas, oceans. They are almost always contaminated by surface run-off, and require high costs of treatment when used as drinking-water source.

B. Ground Water – this is part of atmospheric water or rain that percolate through the ground and recharges the aquifers or water-bearing formations. It can be obtained from wells and springs.

C. Rain or Atmospheric Water – rainwater

Levels of Water Supply

Level I – POINT SOURCE - this refers to a protected well, developed spring, or rain water cistern with an outlet but without a distribution system. Normally serves around 15-25 households

Level II – COMMUNAL FAUCET SYSTEM OR STANDPOST - this refers to a system composed of a source, a reservoir, a piped distribution network, and a communal faucet located not more than 25 meters from the farthest house.

Level III - WATERWORKS SYSTEM – is a system with a source, transmission pipes, a reservoir, and a piped distribution network for household taps.

METHODS OF EXCRETA COLLECTION, TREATMENT AND DISPOSAL

Types of sanitation facility based on level of services:

1. LEVEL l – PIT LATRINES

a. Sanitary pit privy – it is made up of a pit, squatting plate, superstructure and exhaust pipe.
b. Antipolo type – built on the same principle as the sanitary pit, except for its location. It is situated in an elevated area and can be considered an indoor facility.
c. VIP – a sophisticated type of latrine called the ventilated improved pit (VIP). It has 2 distinct features: it is designed to be safe for the user and has a superstructure that is slightly away from the pit and a tall, vertical vent pipe with a fly screen that is fitted outside of the latrine superstructure.

2. LEVEL II – POUR-FLUSH TOILET
There are two basic types of pour-flush toilets:
a. the pour-flush with pit
b. the pour-flush with septic tank

3. LEVEL III – FLUSH TOILETS

Types of sanitation facilities based on design:

1. Level I – pit latrines
a. Vent
b. Fly screen

2. Level II – Pour-flush toilets
a. Location of pits
b. Pit volume
c. Pit shape
d. Pit lining
e. Pit cover
f. Pour-flush pan
g. Trap
h. Plinth
i. Pipe
j. Superstucture
k. Septic tank design
l. Construction and operation of septic tanks

3. Level III – Flush toilets

The location of any toilet or sewage disposal system should not be within the 25 m radius from the water supply sources as prescribed in the Sanitation Code.

SENTRONG SIGLA

Sentrong Sigla promotes the idea that, as Centers of Vitality, individuals, families and communities live in an environment where they are able to produce and provide for health. As an approach, it empowers the individuals to adopt healthy lifestyles, improve health-seeking behavior, promote well being for all, demand quality services and ultimately become self-reliant. SS also enables health providers to actually provide quality health services. This is done with the DOH as the provider of technical and financial packages for health care, the LGUs as the direct implementers for health programs and prime developers of health systems, and involving all sectors of society for the institutionalization of health systems and good health practices towards the attainment of improved life.

Botica ng Barangay (BnB)

BnB is a drug outlet where affordable yet good quality primary, non-prescription generic drugs(except amoxicillin and cotrimoxazole) are sold in areas with poor or no access to medicines. This is done through partnership with LGUs, community organizations, non-government organizations in the community through the Health Plus Program, the DOH-endorsed pharmaceutical division network Outlets are owned by the community.

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