Manuscript Found In Accra By Paulo Coelho. byPaulo Coelho. Topics Fiction, Inspirational, Novel, Paulo Coelho. Collectionopensource. Manuscript Found In Accra Paulo Coelho. Topics Paulocoelho Identifier ManuscriptFoundInAccraPauloCoelho. Identifier-arkark://. At least I have:) Over the time, I've browsed, found, found & then lost again and read many Manuscript Found in Accra (EPUB | MB).
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of Love is her best work so far (I tend to swim against the current most of time) Feel free to download any number of books but do share how you found em. Here is the collection of the best of Paulo Coelho Novels in (Epub, PDF) format. Ceolho, a writer Manuscript Found in Accra (). Adultery. terney.info Download PDF MANUSCRIPT FOUND IN ACCRA (PB) - EXPORT, PDF Download.
Publication Details Publisher: HarperCollins Publishers Imprint: HarperCollins Publication Date: Paulo Coelho Author Paulo Coelho was born in Brazil and has become one of the most widely read and loved authors in the world. More about Paulo Coelho. Manuscript Found in Accra Embed. Media Manuscript Found in Accra. His best-known poem, in his own lifetime and today, is The Raven In this eerie poem, the haunted, sleepless narrator, who has been reading and mourning the death of his lost Lenore at midnight, is visited by a raven a bird that eats dead flesh, hence a symbol of death who perches above his door and ominously repeats the poems famous refrain, nevermore , source: Woman in the Tower: Stories download for free Woman in the Tower: Stories for the Wounded Child pdf, azw kindle.
The universe seems to be falling apart Join Iona and Koan on a refreshing tour beyond the psyche, to a space uncharted by words.
Far removed from the contemporary travelogue, this is a discovery of innate truth and a liberating examination of society, spirituality and the dazzling void. Check out a radical and genre defining journey to an abundance paradigm, a transcendental reality beyond any illusory facade Tours of the Black Clock read epub download Tours of the Black Clock!
The advent of digital publishing has resulted in an explosion in the number of books being published. The scarcer a commodity the more valuable it is, and indeed vice versa. This approach will save more lives in areas lacking the resources and facilities. The management of acute severe anaemia in these patients requires accurate diagnosis of the aetiology of the anaemia. In addition, acute severe anaemia is also often related to acute chest syndrome.
Management options The modalities of treatment of anaemia in a SCD patient will largely depend on the cause of the anaemia. In correcting acute severe anaemia, packed red cells is the preferred choice of transfusion product and should be given cautiously and in small steps, allowing time for fluid equilibration, in order to avoid hypervolemia.
Whole blood may be used where fractionation of blood is unavailable or in situations, such as acute splenic sequestration, where volume repletion may also be indicated.
Underlying infections should be treated in all situations simultaneously. Anti-malaria prophylaxis is currently not being encouraged in the routine care of SCD patients. There is a knowledge gap as to whether prophylaxis would be beneficial in the routine care given to SCD patients.
Challenges Weak laboratory support in health institutions does not allow clinicians to make complete and confirmatory diagnosis of the causes of acute severe anaemia. Complete blood count can provide some useful information for the clinical care of the patient but does not sufficiently provide the clues for diagnosis. It is important to always determine the reticulocyte count in SCD patients.
This broadly enables clinicians to categorize anaemia into aplastic crisis or as a result of increased haemolysis and or sequestration crisis. Diagnosis of the cause of severe anaemia in SCD is based on history, physical examination and limited laboratory results in most hospital settings in sub-Sahara Africa.
Lack of automated haematology analysers in laboratories to provide prompt complete blood count is a major concern since clinicians do not have enough clinical information to confirm diagnosis. In most laboratories reticulocyte counts are never done or results are unduly delayed and this puts clinicians in treatment dilemmas. Blood safety and availability are major challenges to clinicians. Blood transfusion is key to the management of people with SCD.
Some institutions provide specialized blood-banking services to their SCD patients. Others would have to refer to centres with the blood transfusion facilities. Acute Chest Syndrome ACS Acute chest syndrome is one of the life threatening complications of SCD that is associated with high mortality if not diagnosed promptly and managed with critical care and accuracy.
ACS may be caused by vaso-occlusive damage of lung tissue, infection, or both, and replaces the term pneumonia because the possible causes for the two are not readily distinguishable.
The classical definition of the condition is usually difficult to establish since it relies on radiological findings. However, all clinicians responsible for the care of SCD patients should have a high index of suspicion for the diagnosis of ACS in patients with chest pain and respiratory distress, otherwise appropriate treatment may be delayed, resulting in high mortality.
Often patients develop ACS in the context of pain episodes being managed with increased hydration and parenteral opioid analgesics.
Management Options The treatment options include antibiotics, adequate pain control, hydration, careful monitoring for the need for and provision of supplementary oxygen, and blood transfusion. ACS is a painful episode and therefore adequate analgesics should be provided with caution to avoid respiratory distress especially in instances where opioids have to be used.
Broad-spectrum antibiotics, plus macrolides, are used in order to cover the possibility of bacterial infection, and especially mycoplasma and chlamydia, which are sometimes associated with ACS. The choice of antibiotics is critical and it is based on the issues raised in treatment of infections.
Red cell transfusion is indicated based on degree of hypoxia, respiratory distress, and anaemia. Again clinical trials involving hydroxyurea has shown that the medicine can be used to ameliorate the episodes of ACS in adults and children. However radiological support in health institutions is not a crucial requirement to make a definitive diagnosis of ACS. The absence of this facility requires clinicians to apply their clinical judgement to treat ACS without radiological confirmation.
The distinction between pneumonia and pulmonary infarction in SCD is clinically immaterial since the management of ACS is designed to address both possibilities. Stroke The diagnosis and management of stroke remains one of the biggest challenges facing clinicians in developing countries.
Although stroke is a clinical diagnosis, brain imaging studies are necessary to distinguish infarctive from haemorrhagic stroke in order to apply correct intervention. Clinicians in developing counties should have a high level of suspicion of stroke in their SCD patients with sudden onset of neurological changes and offer them the best support.
Often musculo-skeletal manifestations like limping or change in gait is attributed to vaso-occlusive episode in the SCD patient because it is the most frequent presentation.
However a carefully history and examination may indicate the occurrence of stroke. Management and Challenges Management of acute stroke includes vital signs monitoring and support, exchange red cell transfusion, and neurosurgical intervention in severe haemorrhagic stroke. Once stroke is diagnosed, the long-term management to prevent recurrence is a major challenge in developing countries. This is because the patient requires chronic transfusion therapy i.
Identification of the child with SCD at increased risk of stroke using Trans-Cranial Doppler TCD ultrasonography, followed by preventive chronic transfusion therapy, as practiced in developed countries, 34 is non-existent in most developing countries. The offer of chronic blood transfusion is a major challenge in most African settings.
Safe and reliable supply of blood is critical in the effective management of this complication in SCD patients. Hip Necrosis The most common long-term orthopaedic complication seen in SCD in developing countries is aseptic necrosis of the head of the femur. The best options are physical therapy in milder cases or palliative surgical interventions, and ultimately hip replacement for advanced cases. There are currently no preventive measures in place to prevent avascular necrosis of the femoral head; however the use of crutches is encouraged to the delay the need for replacement and also use of hydroxyurea has been associated with the reduction in incidence and progression.
The overall benefit of the hydroxyurea however favours its used to address most of the complication of SCD. Patient and parental education is paramount in using the drug. Summary and Current Therapeutic Options The current management strategies for SCD could be considered under the public health principles of early diagnosis, primary prevention and prompt management of acute episodes and complications.
The successes of early detection and prevention programmes in some North African countries should be emulated. There are clear evidence in favour for the use of pneumococci vaccines in reducing morbidities and mortalities associated with SCD patients. Hydroxyurea, a cytotoxic has been found to improve the clinical course of the disease.
The incidence and severity of most of the complications of the disease are remarkably reduced under hydroxyurea therapy. Chronic blood transfusion is now indicated for SCD patients with higher than usual risk of stroke. However the risk of iron overload should be considered in all patients on the regimen.
Prompt diagnosis, identification of causal factors and management of the complications are key to the survival of the SCD patient. In developing countries diagnostic support required to compliment the clinical information is usually lacking and therefore clinicians are faced with challenges during the management of the disease. SCD is the most common genetic disorder in sub-Saharan Africa and organized specialized clinics would promote and facilitate the care of patients suffering from the disease.
Furthermore, health information materials should be made available for health workers and patients. Lastly, as technology advances the need to fund more research into interventions such as transplantation should be encouraged.