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The pathophysiology is thought to involve abnormal sensitivity of digital arteries/arterioles to vasoconstrictive infuences cheap diltiazem online master card symptoms uterine prolapse. Between 3-7 dyas purchase diltiazem uk medicine cat herbs, neutrophils start disintegrating with early phagocytosis caused by macrophages buy diltiazem 180 mg amex medications 2. Presence of macrophages would have been a better answer but in the given question, presence of neutrophils is the best option. Subendocardial infarcts being limited to only the inner one-third or at most one half of the ventricular wall do not cause ventricular aneurysms. Aneurysm of the ventricular wall most commonly results from a large transmural anteroseptal infarct. After twenty-four hours of the attack light microscopy shows coagulative necrosis of myofbrils with loss of nuclei and striations along with an interstitial infltrate of neutrophils. This may create confusion during the evaluation of myocardial injury in a hypothyroid patient presenting with chest pain. Troponin I is considered superior, marker for the diagnosis of myocardial infarction in hypothyroid patient. When atherosclerosis involves intestinal arteries, the bowel suffers from diminished blood supply. Intestinal hypoperfusion, which can be very painful, is especially pronounced after meals when more blood is needed for the digestion and absorption of nutrients. Chronic mesenteric ischemia is most often caused by atherosclerotic narrowing of the celiac trunk, superior mesenteric artery and inferior mesenteric artery. This triad of symptoms characterizes the disease: • Epigastric or peri-umbilical abdominal pain occurs 30-60 minutes after food intake. Atherosclerotic arteries are not able to dilate in response to increased blood fow requirements during the digestion and absorption of food. Patients report severe pain; but the phy- sician examination will usually appear benign. Mesenteric duplex ultrasonography is a non- invasive alternative in assessing intestinal blood fow. A similar pathogenesis accounts for acute mesenteric ischemia associated with mural thrombus. The anterior wall of the heart is the most frequent site of rupture, leading to fatal cardiac tamponade. Internal rupture of the interventricular septum or of a papillary muscle may also be seen. Arrhythmias are the most important early complication of acute myocardial infarction. Pump failure, ventricular aneurysms and mural thrombosis are other complications that may develop as a result of permanent damage to the heart after infarction. The exacerbation with swal- lowing indicates that the posterior pericardium may be involved, and the radiation into the neck suggests involvement of the inferior pericardium, which is adjacent to phrenic nerve afferents supplying the diaphragm. A fbrinous or serofbrinous early onset pericarditis develops in about 10-20% of patients between days 2 and 4 following a transmural myocardial infarction. The infammation affects the adjacent visceral and parietal pericardium; in other words, the infammation is usually local- ized to the region of the pericardium overlying the necrotic myocardial segment. The pain of myocardial ischemia is not usually sharp or pleuritic in nature, but rather is constant, substernal, and “crushing. Dressler’s syn- drome typically begins one week to a few months after a myocardial infarction. Typical features include fever, pleuritis, leukocytosis, pericardial friction rub, and chest radiograph evidence of new peri- cardial or pleural effusions. Dressler’s syndrome is thought to be an autoimmune polyserositis provoked by antigens exposed or created by infarction of the cardiac muscle. These include rupture of the ventricular wall leading to hemopericardium and cardiac tamponade (as this patient had), rupture of the interventricular septum, and rupture of the papillary muscle. Fibrinous and serofbrinous pericarditis may follow acute myocardial infarction (Dressler’s syndrome) and can be seen in uremia, chest radiation, rheumatic fever, systemic lupus erythematosus and following chest trauma (including chest surgery) or chest radiation. Occasional dark mottling Beginning of coagulative necrosis, edema and hemorrhage 12-24 hr. Dark mottling Ongoing coagulative necrosis, marginal contraction band necrosis, beginning of neutrophilic infltration 393393 Review of Pathology Time Gross Light Microscopy Reversible injury 1-3 days Mottling with yellow tan infarct center. Coagulation necrosis, interstitial neutrophilic infltrate 3-7 days Hyperemic borders, central yellow Beginning of disintegration with dying neutrophils, early phagocytosis by tan softening macrophages 7-10 days Maximum yellow tan and soft Early formation of fbrovascular granulation tissue at margins depressed red-tan margin 10-14 days Red gray depressed infarct borders Well established granulation tissue and collagen deposition 2-8 weeks Gray-white scar progressive from Collagen deposition, ↓ Cellularity border towards infarct core > 2 months Scarring complete Dense collagenous scar Have a close at the table given above, the answer is undoubtedly is macrophage. However, under certain circumstances, when blood fow is restored to cells that have been ischemic but have not died, injury is para- doxically exacerbated and proceeds at an accelerated pace. The following mechanisms have been proposed for the reperfusion injury: • New damage may be initiated during reoxygenation by increased generation of reactive oxygen and nitrogen species from parenchymal and endothelial cells and from infltrating leukocytes. Some IgM antibodies have a pro- pensity to deposit in ischemic tissues, for unknown reasons, and when blood fow is resumed, complement proteins bind to the deposited antibodies, are activated, and cause more cell injury and infammation. High dietary intake of cholesterol and saturated fats (present in egg yolks, animal fats, and butter, for example) raises plasma cholesterol levels. Conversely, diets low in cholesterol and/or with higher ratios of polyunsaturated fats lower plasma cholesterol levels. Prolonged (years) smoking of one pack of cigarettes or more daily increases the death rate from ischemic heart disease by 200%. When locally synthesized within atherosclerotic intima, it can also regulate local endothelial adhesion and thrombotic states. Most importantly, it strongly and independently predicts the risk of myocardial infarction, stroke, peripheral arterial disease, and sudden cardiac death, even among apparently healthy individuals 56. Other important points The characteristic features seen in the kidney are called benign nephrosclerosis include: • Hyaline arterioslcerosis • Normal or small kidney size with leather grain appearanceQ. Hyperplastic arteriosclerosisQ: Proliferation of the internal smooth muscle cells seen in the interlobular arteries giving onion skin like appearanceQ Renal involvement is called malignant nephrosclerosis having the features like a. Kidneys have a typical “fea bitten “appearanceQ (due to petechial hemorrhage on cortical surface) b. Necrotizing glomerulonephritis: Necrotizing arteriolitis may involve the glomeruli also. But after discussion with many senior faculty members, the answer of consensus is option ‘a’ i. Electron microscopy reveals increase in number of myoflaments comprising myofbrils, mitochondrial changes and multiple intercalated disks. Fatty streaks begin as multiple yellow spots approximately 1 mm in diameter which join to form streaks approximately 1 cm long. They may contain a few lymphocytes, but foam cells are the predominant constituents. The fatty streaks are not signifcantly raised, so, they do not disturb normal blood fow. They can be seen in the aortas of children less than 1 year old and are present in the aortas of all children over 10. Whereas some fatty streaks maybe precursors of atheromatous plaques not all fatty streaks progress to these more advanced atherosclerotic plaques.

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It is rare for the internal Staged surgery buy 60 mg diltiazem fast delivery symptoms 3 days dpo, using a progressively tightened opening to be obvious at initial abscess drainage generic 60mg diltiazem overnight delivery medicine upset stomach, suture (known as a Seton) passed through the and it should not be sought as there is a risk of fistula best 60mg diltiazem medications with codeine, which cuts slowly through the involved sphincter damage. A reasonably successful operation is to excise the A pilonidal sinus is a midline pit commonly con- internal and external openings of the track without taining hair, occurring in the natal cleft, most com- laying the whole length of it open. Presentation may be as an incision can be closed by suture and the internal acute abscess but most patients complain of chronic closed by an advancement flap of mucosa. The cancer arises in the anal skin and is there- If necessary, the track can be demonstrated by the fore a squamous carcinoma. It spreads to the inguinal injection of a radio-opaque contrast material, a lymph nodes, not the intra-abdominal nodes. Investigation Management Biopsy of any suspicious anal lesion is essential, A pilonidal abscess requires incision and drain- particularly in immunosuppressed patients. Management Chronic pilonidal sinus is treated traditionally Anal carcinoma is sensitive to radiotherapy and chem- by wide excision of the sinus and any secondary otherapy. Ninety per cent of patients do not require tracts, leaving the wound open to heal by secondary surgery. Since some patients have extensive branching sinuses, this can lead to prolonged recovery with a large, uncomfortable, slow-healing wound. Less extensive day case procedures to excise the Mucosal prolapse is associated with straining pits and curette any abscess have become popular during defaecation. Investigation This removes a probable cause and gives a greater The prolapse should be visible or appear with chance of primary healing. Anal warts are diagnosed on clinical grounds and treated in the same way as warts anywhere Management else in the body. If they are sexually transmitted, Mucosal prolapse can be treated by banding or by contacts must be traced and treated in the usual stapling (stapled prolapsectomy). In children the condition is self-limiting, pro- vided the parents can be persuaded to be patient. This may involve plication of the pro- ulcers and abscesses with characteristic purplish lapsed rectal muscle (Delorme’s procedure) or peri- skin discoloration. Investigation Abdominal rectopexy (-pexy means fixing) Diagnosis is made histologically by biopsy. The attaches the rectum to the pre-sacral fascia The rest of the gut should be assessed by radiological recurrence rate is less than 5 per cent. Crohn’s disease is chronic and relapses of its ease have perianal manifestations – fissures, fistulae, anal manifestations are common. Chilton Diseases of the urinary tract encompass some of the and the posterior superior iliac spine, lateral to the most common benign and malignant conditions erector spinae muscle mass. A thor- severity can range from an occasional dull ache to a ough history and examination followed by a logical severe persistent pain. Pain may radiate round the approach to diagnostic imaging and other investi- loin into the groin; in men it may even be felt in the gations will usually reveal the underlying pathology. The pain is not characteristically The causes of renal and ureteric pain are summa- colicky in the same way as pain arising from small rized in Table 20. The most important conditions bowel obstruction for, although the pain waxes and are upper tract infection, stone disease, upper tract wanes, it is rarely described as griping and rarely obstruction, and renal malignancy. Clinical diagnostic indicators Renal pain is felt in the flank, and when asked to Urine analysis localize it the patient will place his or her hands over Urine dipstick testing may reveal the presence of an area spanning the lower border of the twelfth rib blood, or there may be evidence of leucocytes and nitrites, which taken together are strongly indica- tive of urinary tract infection. Urine microscopy and culture will provide a more Renal trauma accurate measure of haematuria and the presence Renal calculus of infection. If there is any suspicion of tuberculo- Renal cell cancer sis, three early-morning urine specimens should be submitted for culture using Lowenstein–Jensen Infection (pyelonephritis) medium if there is any suspicion of tuberculosis. Passage of ureteric calculus, clot or sloughed renal papilla Blood tests Pelviureteric junction obstruction A standard full blood count should be performed and the serum urea and electrolytes measured to Urothelial malignancy check renal function. This may reveal the presence of renal Kidney tract calculi, although differentiating urinary tract Trauma calcification from other abdominal and pelvic cal- Infection cification can be difficult. This test delineates the Calculus pelvi-calyceal systems, the ureters and the bladder. Approximately 85 per cent of patients with renal or ureteric colic will Clinical diagnostic indicators have microscopic haematuria. Painless haematuria Haematuria is defined on urine microscopy as the strongly suggests the presence of a tumour some- presence of more than three red blood cells per where in the urinary tract. Clinically, haema- turia may turn the urine pink or deep red with Urinalysis clots of blood or be invisible. Painful haematuria implies an inflammatory Imaging or infective process such as urinary tract infection A renal ultrasound scan will show the anatomy of or the passage of a calculus, although malignancies the kidney. Endoscopy Voiding phase symptoms Cystoscopy, usually flexible, is used to evaluate the Slow stream bladder and urethra. Hesitancy: difficulty initiating micturition It is important to evaluate completely both the Intermittency: a urinary stream which stops upper and lower urinary tract of any patient pre- and starts senting with haematuria. In the one-stop haematu- Straining: use of muscular effort from the ria clinic all investigations can be completed in one abdominal wall to initiate or maintain flow visit. Urinary symptoms are perceived very The functional activity of the bladder has two phases, differently. The normal bladder spends seen as normal by some individuals but unacceptable most of the time in the storage phase. The impact of urinary symptoms on quality compliant organ and can accommodate increasing of life has been quantified by a number of validated volumes of urine without large increases in intravesi- instruments including the International Prostatic cal pressure. The patient is asked to record derangement of either the storage or voiding phase. This yields a wealth Clinical diagnostic indicators of information about bladder function, including Storage phase symptoms maximum functional capacity, and the relationship Urgency: a sudden compelling desire to void of nocturia to fluid intake. Increased daytime frequency: the complaint Urinalysis by the patient who considers that he or she A urine dipstick test or urine culture is vital to voids too often during the day. Intravesical pressure Serum creatinine and electrolytes should be meas- is a composite of detrusor pressure and the intra- ured to exclude the presence of upper urinary tract abdominal pressure measured by means of a moni- deterioration secondary to lower tract dysfunction. During the filling phase, warm saline is instilled Uroflowmetry into the bladder at a constant rate. The bladder, the detrusor pressure should change very patient is asked to void into a funnel-shaped recep- little as the bladder fills until the maximal capac- tacle which is linked to a measurement device. The patient is asked to report the (Qmax) above 15 mL/second – in young men much first sensation of filling and then when discomfort higher. Once maximal bladder capacity has been Uroflowmetry does not diagnose outflow reached, the patient is asked to void and pressure obstruction. However, it is an ana- sound scan estimates the post-void residual urine tomical as opposed to a functional diagnosis, so volume, which should normally be less than 50 mL. Cystoscopy Antenatal and infantile hydronephrosis consti- Cystoscopy may be valuable in patients in whom tute an important and extensive topic and will not storage symptoms predominate in order to rule out be discussed further in this text. It is mandatory in those with tive hydronephrosis in adults are summarized in concurrent haematuria. Urodynamic studies Investigation Urodynamics is the study of detrusor pressure dur- ing bladder filling (cystometrogram) and voiding Clinical diagnostic indicators phases. It is an invasive test requiring placement The main and often only symptom is renal pain but of a small urethral filling catheter and pressure this can occur with many other conditions.

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It is tempting when or at the interface between the pleural effusion at its presented with a confusing image to turn up the gain in maximum depth and the underlying compressed lung the hope that the image will become clearer; however buy diltiazem with a mastercard treatment quincke edema, (Figure 8 buy diltiazem toronto medicine xl3. Lateral resolution should also be con- overuse will add to the noise of the image discount diltiazem uk symptoms ulcer stomach. If the lateral resolution is poor, two separate learning pleural ultrasound are advised to avoid the structures may appear as one image on the screen. The use of the gain and auto gain controls, and attempt lateral resolution is best at the narrowest part of the to optimize the image by systematically adjusting the ultrasound beam. With increasing skill of most interest will focus the narrowest part of the and experience, the operator will learn to adjust the beam on this area, hence improving lateral resolution machine settings to display the best image, providing (Figure 8. This eters should be moved together to stay in alignment contrasts with gain, which will amplify the whole of the (Figures 8. Undue aligned, a band of bright white or dark echoes may increases in gain may produce artifactual echoes in appear in the middle of the image (see Chapter 2 for the fluid. If artifact is present alter the angulation of scanning the chest to minimize artifact and the probe, followed by scanning in both the optimise the image obtained: horizontal and vertical plane in one position to observe the effect on the image. Alter the depth so that the diaphragm is Similarly ask the patient to take some deep the deepest image on the screen, usually breaths and observe the movement with 12–15 cm. If the image is still sub-optimal, change the position of the patient and scan again. If there is difficulty identifying artifact, or image acquisition in this scenario). Identify any possible artifacts on the image, have a formal departmental scan by an i. For the novice there are several limitations commonly When both air and fluid are present in the pleural encountered in ultrasound of the chest. This can produce confusing images Patient factors include body habitus, chest wall deform- for the novice (see Figure 5. Obesity is an increas- x-ray has been examined prior to the ultrasound exam- ingly common barrier to obtaining good images of ination, and the air fluid levels identified, this can be the pleural space. Excessive adipose tissue covering correlated with the ultrasound images obtained, aiding the chest wall can make visualization of deeper struc- in interpretation. A hydropneumothorax will produce ture difficult due to increased absorption of the sound a different image appearance, again one that can be waves. This can usually be overcome by using a lower- difficult to interpret for the beginner (see Figure 5. Subtle abnormalities of the chest wall and parietal subcutaneous tissues, will cause obscuration of deeper pleura may be obscured. The presence of this situation attempting to angle the probe between subcutaneous emphysema may indicate the presence of the patient’s ribs can usually overcome this difficulty. Atelectatic lung has a to cooperate with the examination, by lying/sitting in characteristic sonographic appearance, and should be the necessary position, changing position as required, easily differentiated from pleural pathology. Atelectatic lung is echogenic, and has Pathological factors sharp borders defined by visceral pleura (Figure 8. Problems in interpretation related to the underlying pathology include the presence of air in the pleural space, subcutaneous emphysema, atelectatic lung, locu- lated fluid, and solid masses. The presence of air in the pleural space may be encountered in the patient with a malignant pleural effusion and “trapped lung,” fol- lowing any pleural procedure where air is introduced into the pleural space, or in the presence of a broncho- pleural fistula. In this rare situation color Doppler can be Other sonographic signs of malignant pleural disease, used to distinguish between the two. A solid tumor such as pleural thickening, are usually present with (both primary and metastatic) will have a color pleural metastases and should be looked for to aid in Doppler signal as it has vascularity. Loculated pleural effusions can be easily missed on pleural ultrasound, especially if located in an anterior position. It is therefore important to scan the entirety of the hemithorax to ensure loculated pockets of fluid are not missed. These ●● Echogenic fluid represents pus or two pathologies may also have similar sonographic hemothorax. Common errors during ultrasound- guided pleural procedures Two of the most common errors made by the clini- cian inexperienced in bedside pleural ultrasound are a failure to adequately scan the entire chest and a failure to appreciate when it is unsafe to proceed with an invasive pleural procedure. One of the attractive features of bedside pleural ultrasound is the ability to quickly identify a pleural effusion to enable safe aspiration. The temptation is to simply place the transducer on the chest wall, confirm that fluid is present, and mark a spot for aspiration. This approach can lead to a failure to appreciate the extent of the effusion, and overlook important pathological features such as septations. Bedside pleural ultrasound has been shown to improve the safety of pleural procedures. This involves using the sonographic appearance to decide when it ●● The distance from the chest wall to the effusion is safe to proceed with thoracentesis/chest drain inser- is greater than the length of the needle to be used tion. Visualization of the heart immedi- ately below the effusion should prompt reevaluation of the safety of proceeding with pleural intervention. Philadelphia: Elsevier Mosby, 2004: Gold Coast: Australian Institute of Ultrasound, 2010. Lowering the frequency of the probe when scanning a patient with a large body habitus. This is a mistake often made by novice users; instead of improving image quality it will increase the noise of the image, thus making things less clear. A benchmark have allowed for the development of portable ultra- that providers and institutions should strive for is a sound units that can provide real-time, point-of-care pneumothorax rate of ~1. This low rate can even be assessment for a variety of diseases as well as guide achieved in patients in the intensive care unit requiring diagnostic and therapeutic procedures. The use of mechanical ventilation where the “self-trained” pulmo- ultrasound to guide pleural procedures requires a basic nary physician directs the house staff where to insert the understanding of the physics and principles of ultra- needle. This chapter will review the logical imaging, as well as the patient’s history and use of ultrasound to guide pleural procedures. Many inpatients receive computed Even in the hands of trained pulmonologists, sup- tomographic imaging at some point during their stay, posedly experts of these procedures and the thoracic and if available, this type of imaging can be quite helpful physical exam, the use of ultrasound is associated in identifying size and location of pleural fluid, as well with a significant reduction in near misses (i. Ambulatory out- Given the strength of the literature regarding ultra- patients can be placed in a variety of positions to help sound and pleural disease, the current recommenda- facilitate procedures, whereas the ability to position a tions from the British Thoracic Society recommend critically ill patient on a ventilator with multiple forms the use of ultrasound to guide pleural interventions, of life support (dialysis, ventricular assist devices, etc. Because of this procedural variability It should be noted that most studies utilizing ultra- physicians must maintain a certain comfort level in sound for thoracentesis do not use real-time guidance performing ultrasound-guided pleural procedures in for needle insertion, but rather insert the needle multiple positions and situations. Willie Sutton, the famous bank robber, performed with delay in needle insertion (having radiol- was once asked why he robs banks. He replied, “Because ogy use ultrasound to mark the spot, followed by needle that’s where the money is. The height of the bed/exam table should be begin with identification of the diaphragm, including adjusted so that the physician can perform the proce- the presence of dynamic changes (change of shape with dure in an ergonomically comfortable position (see respiratory movement).

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The scheme was first started in February discount diltiazem american express medications you cannot crush, 1952 in the industrial towns of Not more than 5 hours work at a stretch followed by Delhi and Kanpur and now it covers most of the industrial rest for at least half an hour buy diltiazem with a mastercard medicine in ancient egypt. No child to work for more than four and the following: a half hours a day and not at night from 10 pm to 6 • Nonpower using factories employing 20 or more am (Section 71) cheap diltiazem on line symptoms kidney failure dogs. At present the Certain accidents to be notified by the manager of the employees drawing wages up to Rs. An employee who is covered specified in the third schedule of the Act, the manager at the beginning of a contribution period shall continue shall send notice therefore to the prescribed authorities. An industrial worker is • Minister for Labor-Chairman exposed to ‘employment injury’ which includes • Secretary, ministry of labor-Vice Chairman accidents and diseases related to his occupation. During • 5 representatives of Central Government 95 illness or employment injury, a worker faces fear of • One representative each from the States and one economic, physical or even social ruin. Social insurance representatives of Union Territories • 5 representatives of employees and 5 of employers, • Maternity-benefits 2 of medical profession and 3 Members of • Disablement benefit Parliament. The medical benefit also includes • Director General of Health Services; ambulance services, domiciliary treatment facility and • Deputy Director General of Health Services; provisions of drugs, dressings and some appliances. A dispensary with full time medical assisted by 4 Principal Officers: (1) Medical Commis- officer and paramedical staff serves an area having sioner, (2) Financial Adviser and Chief Accounts Officer, 1000 or more ‘employees family units’; but part (3) Insurance Commissioner, (4) Actuary. Indirect system or Panel system: In this system Regional and Local Medical Benefit Councils. It empanelled private medical practitioners called delegates them powers to administer the scheme in the ‘Insurance Medical Practitioner’ provide care to the States. It also appoints Inspectors to inspect factories workers and their dependent family members. The scheme is primarily funded by contribution raised from insured employees and their employers as Extended sickness benefit (cash): For some specified a small but specified percentage of wages payable to long-term diseases like paralytic disorders, tuberculosis, such employees. The covered employees contribute leprosy, coronary artery disease, psychosis, chronic 1. Employers earning less than fifty rupees a day absence from work on medical advice are entitled for as daily wage are exempted from payment of their share the cash benefit for longer period of two years. The state government as per the payable in cash as extended sickness benefit is equal to provision of the act bears one-eight share of about 70 percent of the daily wages. The Benefit to employee: Various benefits under the act that duration of benefit for miscarriage is 6 weeks. The rate the insured employees and their dependants are entitled of payment of the benefit is equal to wage. The payment is made according to labor enactments such as Workmen’s Compensation the plan prescribed. Worker Absenteeism Other benefits: Absenteeism is a major factor affecting work productivity • Free supply of physical aids and appliances such as and is closely related to a worker’s health as well as his crutches, wheelchairs, spectacles and other such personal, domestic and social life. The causes of • Rijiv Ghandhi Shramik Kalyan Yojana: Under this absenteeism are: scheme the insured person who are rendered • Sociocultural causes related to domestic and social unemployed involuntarily due to retrenchment / factors such as joint family system, harvesting season, closure of factory is entitled for unemployment fairs and festivals, quarrels, etc. Rehabilitation benefit: Workers entitled to receive an It should be apparent from the above that the first artificial limb are awarded a rehabilitation allowance, for two causes are not directly related to disease or each day of their admission at the artificial limb center, occupational hazard at all, while the third cause has only for provision or replacement of an artificial limb. It is thus implicit, and several other Acts that have been framed to ensure amply borne out by facts, that only a small proportion worker’s rights, safety, health and welfare. The Government of India will bear the Some New Initiatives employer’s share of provident Fund contribution on 14 wages upto Rs. Delhi: National certify skills of youth population in the country to Book Trust 17, 1984. Directorate General • Courses are available for persons having completed of Employment and Training. Ministry of • Persons with skills acquired through years of work Labour and Employment. Employees’ State Insurance but without any formal certificate can get their skills Corporation. Its major the earth fuels (coal and oil), synthesis and use of source is automobile exhaust. It is produced Well-known environmental tradegies, like the cases by combustion of sulfur bearing fossil fuels and coal. Sulfur dioxide is readily and a wide range of other natural resources was being absorbed by soil, plants and water surfaces. Municipal workers entering large sewers have died of hydrogen sulfide Air Pollution poisoning. Air pollutants are the materials that exist in the air in such concentrations as to cause unwanted effects. We are concerned here mainly with the facturing nitric acid, sulfuric acid and nylon intermediates. The chief culprit is These are substances that are gaseous at normal tempe- automobile exhaust. Substances with boiling point below during petroleum combustion yield ozone in the 200°C are also included in this category. This is sozone levels in atmosphere have not decreased in spite because of the low particulate content and minimal of substained efforts. Particulate Pollutants Transportation These comprise both solid and liquid particles varying Example is fuel combustion in vehicular engines. The particulate pollutants may be Industrial Processes described as follows: Cement and steel industries are particularly polluting. Dust Solid W aste Disposal It consists of solid particles, usually 1 to 100 microns in Burning of solid waste also causes air pollution. Effects of Air Pollution Fum es These will be described separately in relation to man, These are particles below one micron, generally formed 1 animals, plants, materials and the atmosphere. The harmful effects of air pollution are most noticeable on the respiratory system. Mist These are liquid particles below 10 microns produced Gaseous Pollutants by condensation of vapor. An example is conversion Carbon monoxide is well known to cause death through of sulfur trioxide from gas to liquid (mist) form at 22°C. It may be mentioned that the affinity of carbon monoxide to hemo- Spray globin is 240 times stronger than that of oxygen. Sulfur These are liquid particles produced from parent liquid dioxide is a very serious pollutant. At lower levels, it causes by mechanical disintegration processes, such as atomi- bronchiolar smooth muscle spasm. The effect of sulfur dioxide is much greater in the presence of an inert aerosol, such as sodium chloride. It may be mentioned that though undesirable compounds to produce sulfuric acid droplets incomplete combustion produces gaseous hydrocarbons which, when inhaled, cause lung damage. Sulfur dioxide and oxides of sulfur and nitrogen also, only the solid can also cause respiratory allergy. It can cause pulmonary edema and hemorrhage Particulate contaminants comprise about 22 metallic at very low concentrations. Among oxides of nitrogen, elements, the most common of which are calcium, nitric oxide is non-irritant while nitrogen dioxide is a sodium, iron, aluminum and silicon.