By A. Fasim. Kendall College.

Five major immunoglobulin (Ig) classes exist ventolin 100mcg with amex; which are called IgG buy discount ventolin 100 mcg line, IgA, IgM, IgD and IgE, with heavy chains gamma (γ) alpha (α), mu (µ) delta(δ ) , and epsilon(Є) respectively. Four sub classes of IgG have been recognized on the basis of structural and serological differences and are known as IgG1, IgG2, IgG3 and IgG4. IgG subtype characteristics Characteristic IgG1 IgG2 IgG3 IgG4 % of total lgG in 65 25 6 4 serum Complement 4+ 2+ 4+ +/- fixation Half-life in days 22 22 8 22 Placental Yes Yes Yes Yes passage Some Immune Immune specificities Anti-Rh Anti-A Anti-Rh Anti-A Anti-B Anti-B IgM: - Accounts for about 10% of the immunoglobulin pool, with a concentration of about 1. Natural antibodies: are red cell antibodies in the serum of an individual that are not provoked by previous red cell sensitization. But, it is believed that these antibodies must be the result of some kind of outside stimulus and the term naturally occurring gives an inaccurate connotation, so they are called non- red cell or non- red cell immune antibodies. Characteristics - Exhibit optimum in vitro agglutination when the antigen bearing erythrocytes are suspended in physiologic saline (0. Immune antibodies: are antibodies evoked by previous antigenic stimulation either by transfusion or pregnancy, i. Characteristics - Do not exhibit visible agglutination of saline- suspended erythrocytes, and called incomplete antibodies 0 - React optimally at a temperature of 37 C, and are so called warm agglutinins. These antibodies obviously have more serious transfusion implications than the naturally occurring ones. Classification of the blood group was based on his observation of the agglutination reaction between an antigen on erythrocytes and antibodies present in the serum of individuals directed against these antigens. The antibody that reacted with the A antigens was known as anti A, and the antibody that reacted with the B antigen was known as anti B. According to 20 the theory of Bernstein the characters A,B and O are inherited by means of three allelic genes, also called A,B and O. The O gene is considered to be silent (amorphic) since it does not appear to control the development of an antigen on the red cell. This four allelic genes give rise to six phenotypes: A1, A2, B, O, A1B and A2B and because each individual inherits one chromosome from each parent, two genes are inherited for each characteristic and these four allelic gene give rise to ten possible genotypes (table 3. In serological testing, individuals of this type have a weaker B antigen and possess some kind of anti- B in the serum. For example, it can be seen that for the matings A1xB, A2 and A2 B children never occur in the same family as B or O children. However, the finding of, for instance, a group O child in a family where other children are A2 and A2 B would not be possible if they all had the same parents. The antiserum has two be specific: does not cross react, and only reacts with its own corresponding antigen, avid: the ability to agglutinate red cells quickly and strongly, stable: maintains it specificity and avidity till the expiry date. It should also be clear, as turbidity may indicate bacterial contamination and free of precipitate and particles. Agglutination: is the clumping of particles with antigens on their surface, such as erythrocytes by antibody molecules that form bridges between the antigenic determinants. When antigens are situated on the red cell membrane, mixture with their specific antibodies causes clumping or agglutination of the red cells. In hemagglutination the antigen is referred to as agglutinogen and the antibody is referred to as agglutinin. In the first stage- sensitization, antibodies present in the serum become attached to the corresponding antigen on the red cell surface. In the second stage, the physical agglutination or clumping of the sensitized red cells takes place, which is caused by an antibody attaching to antigen on more than one red cell producing a net or lattice that holds the cells together. Agglutination reaction is interpreted as a positive (+) test result and indicates, based on the method used, the presence of specific antigen on erythrocytes or antibody in the serum of an individual. No agglutination reaction produces a negative (-) test indicating the absence of specific antigens on erythrocytes or antibody in the serum of an individual. The maximum span of IgG molecules is 14 nanometer that they could only attach the antigens, coating or sensitizing the red cells and agglutination can not be effected in saline media. On the other hand, IgM molecules are bigger and because of their pentameric arrangement can bridge a wider gap and overcome the repulsive forces, causing cells to agglutinate directly in saline. Temperature: The optimum temperature for an antigen- antibody reaction differs for different antibodies. Most IgG 0 antibodies react best at warm temperature(37 C) while IgM antibodies, cold reacting antibodies react best at room 0 temperature and coldest temperature(4 to 22 C). Ionic strength: lowering the ionic strength of the medium increases the rate of agglutination of antibody with antigen. IgM antibodies, referred to as complete antibodies, are more efficient than IgG or IgA antibodies in exhibiting in vitro agglutination when the antigen - bearing erythrocytes are suspended in physiologic saline. Centrifugation: centrifugation at high speed attempts to over come the problem of distance in sensitized cells by physically forcing the cells together. Trypsin, ficin, bromelin, papain) removes surface sialic acid residue- by which red cells exert surface negative charge, thereby reducing the net negative charge of the cells, thus lowering the zeta potential, and allowing the cells to come together for chemical linking by specific antibody molecules. Colloidal media: certain anti-D sera especially some IgG antibodies of the Rh system would agglutinate Rh positive erythrocytes suspended in colloid (bovine albumin) if the zeta potential is carefully adjusted by the addition of the colloid. Ratio of antibody to antigen: There must be an optimum ratio of antibody to antigen sites for agglutination of red cells to occur.

Limited Thoracotomy Equipments : Basic Thoracotomy set General Anaesthesia machine cheap 100 mcg ventolin amex, Tracheal intubation set organised well in operation room with other basic facilities eg buy ventolin 100 mcg without prescription. Good negative suction source, satisfactory illumination, patient warming gadgets etc. Situation 2 Human resources : Well trained pediatric surgeon, Respiratory pediatrician & Anaesthesiologist mandatory ,Assistent Surgeon, Resident doctors & specialised nursing staff round the clock, Anaesthesia technician. Inguinal hernia is suspected in any child with a swelling in the inguinoscrotal region. Introduction: Inguinal hernia repair is one of the most common pediatric operations performed. All pediatric inguinal hernias require operative treatment to prevent the development of complications, such as inguinal hernia incarceration or strangulation. Case definition: Inguinal hernia is a type of ventral hernia that occurs when an intra-abdominal structures, such as bowel or omentum, protrude through the open processus vaginalis through the inguinal canal. Premature infants are at increased risk for inguinal hernia, with incidence rates of 2% in females and 7-30% in males. Premature infants are at an increased risk for inguinal hernia, with the incidence ranging from 7- 30%. Moreover, the associated risk of incarceration is more than 60% in this population. If a child has developed a unilateral hernia, there is a potential risk of developing a hernia on the opposite side-this risk is higher in premature babies and infant girls. These families need to be counseled about signs and symptoms of these recurrences. Gets larger when child cries, may disappear completely when the child is quietly lying down. Even in the absence of the mass at examination, a strong history is adequate for diagnosis. General tests towards anaesthesia fitness may be required ( haemoglobin, urine analysis). Referral Criteria: A strong clinical history and physical findings of inguinal hernia are indications for referral for surgery. The parents typically provide the history of a visible swelling or bulge, commonly intermittent, in the inguinoscrotal region in boys and inguinolabial region in girls. The bulge commonly occurs after crying or straining and often resolves during the night while the baby is sleeping. Patients with an incarcerated hernia generally present with a tender firm mass in the inguinal canal or scrotum. The mass may only be noticeable after coughing or performing a Valsalva maneuver and it should be reduced easily. Occasionally, the examining physician may feel the loops of intestine within the hernia sac. In girls, feeling the ovary in the hernia sac is not unusual; it is not infrequently confused with a lymph node in the groin region. In boys, palpation of both testicles is important to rule out an undescended or retractile testicle. Hernia and hydrocele: Transillumination has been advocated as a means of distinguishing between the presence of a sac filled with fluid in the scrotum (hydrocele) and the presence of bowel in the scrotal sac. However, in cases of inguinal hernia incarceration, transillumination may not be beneficial because any viscera that are distended and fluid-filled in the scrotum of a young infant may also transilluminate. It is indicated when presentation and examination suggest a diagnosis other than hernia or hydrocele. Laparoscopy: Diagnostic laparoscopy may rarely be required for determining the presence of an inguinal hernia. It is used only in the following: a) assessment of contralateral hernia when one is being operated upon, and b) recurrent hernia after previous surgery. Inguinal hernias do not spontaneously heal and must be surgically repaired because of the ever-present risk of incarceration. Repair is usually planned as an elective procedure as soon as possible after diagnosis. If successful, the operation is performed after 24-48 hours to allow local oedema to settle down. If reduction is unsuccessful, or if there is clinical evidence of inflammation (as evidenced by pain, redness, edema of skin on hernia) emergency exploration and hernia repair is necessary. Hydroceles without hernia in neonates: This is the only exception in which surgical treatment may be delayed. Repair of hydroceles in neonates without the presence of hernia is typically delayed for 12 months because the connection with the peritoneal cavity (via the processus vaginalis) may be very small and may have already closed or be in the process of closing.

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