PHYSIOTHERAPY AND REHABILITATION - During the acute phase, the aim should be

gradual withdrawal over the next few days Antacids should be given simultaneously. (d) Frusemide - 40-80 mg. daily IV. Of special value in patients with LV failure in whom mannitol would be risky. 2. Anticoagulation -Indications - Valvular heart disease particularly MS, recent myocardial infarction, atrial or ventricular thrombus, atrial fibrillation, acute internal carotid artery or basilar artery thrombosis, internal carotid artery dissection, prothrombotic states (e.g. protein C or protein S deficiency), recurrent TIAs or stroke, cerebral venous thrombosis It is best initiated gradually with warfarin. Low dose subcutaneous hearin helpful in prevention. 3. Antiplatelet drugs - have been successfully used in male patients with TIAs, while the response in females has been poor. They may be tried in prosthetic valve replacement or cardiac valvular disease, if anticoagulants cannot be prescribed. Drug combination of Aspirin 12 mg/kg/day and Dipyridamole 2 mg/kg/day or Ticlopidine 25 mg b.d. with food D URGENT NEUROSURGERY - (a) In all cases of subarachnoid or intracerebral hemorrhage (b) Evacuation of cerebellar hematoma, supratentorial hematoma if causing mass effect (c) Supratentorial bleeds in younger patient with superficial cortical hematomas and deteriorating level of consciousness E. PHYSIOTHERAPY AND REHABILITATION - During the acute phase, the aim should beprevention of deformities. The patient's limbs should be maintained in optimal position Passive physiotherapy started after 36 to 48 hours. Joints should be moved through full range of motion. Muscle re education and joint exercises initiated when the first signs of recovery are noted Massage is given as adjuvant to active exercises. It is important to introduce standing as an exercise soon since weight bearing stimulates the maintenance of extensor tone in the lower limbs and on this the ability to walk depends. If the patient can stand unsupported, he is ready for gait training. F. TREATMENT OF APHASIA - Language training, training of left hand in performance of voluntary movement in right handed patients. Secondary prevention 1. GENERAL MEASURES - Stopping smoking, regular exercise. Control of hypertension, diabetes and treatment of hyperlipidemia. 2. ANTICOAGULANTS - Indications have already been mentioned Aspirin has been shown to be of benefit in presenting stroke and vascular death in patients who have had a TIA. Dose 75 mg/day 3 PREVENTIVE NEUROSURGERY – for recurrent subarachnoid and intracerebral bleeding from aneurysms and arterial malformations. 4. CAROTID ENDARTERECTOMY - Indications - (a) Moderate degree of stenosis. (b) TIA, amaurosis fugax, stroke or retinal infarct within 6 months and with good recovery (c) Significantstenosis in patient scheduled for major surgery such as coronary bypass Contraindications - (a) Recent Ml (b) CCF. (c) Uncontrolled hypertension. (d) Age over 80 years. Venous Infarction Thrombosis of cortical veins and/or dural sinuses is less common than central arterial occlusion Causes - Dehydration, pyogenic middle ear or sinus infection, pregnancy and p uerperium, polycythemia, hyperviscosity syndromes, septicemia, ulcerative colitis, severe iron deficiency anaemia, head injury, extracranial malignancy. Clinical features - Onset is sudden commonly with focal epilepsy. Raised intracranial pressure develops rapidly if obstruction of the dural sinuses A focal neurological deficit develops which can be clinically indistinguishable from a stroke due to arterial occlusion. Investigations - An enhanced CT scan may show a clot within the superior sagittal sinus, but this is

cylindrical with hemispherical ends The shells may sometimes contain a medicament They may contain a preservative to prevent growth of fungi. The cont

cylindrical with hemispherical ends The shells may sometimes contain a medicament They may contain a preservative to prevent growth of fungi. The contents of soft capsules usually consist of liquids or solids dissolved or dispersed in suitable excipients to give a paste-like consistency but may also consist of powders or granules As soft gelatin shells contain appreciable amounts of water, migration of capsule contents, particularly of 'water-soluble ingredients, may occur Modified-release Capsules: Modified-release (Sustained-release) Capsules are hard or soft capsuls in which the contents or the shell, or both, contain auxiliary substances or are prepared by a special process designed to modify the rate at which the active ingredients are released Enteric Capsules: Enteric Capsules are hard or soft capsules prepared in such a manner that the shell resists the action of the gastric fluid but is attacked by the intestinal fluid to release the contents STANDARDSContent of active ingredients: Determine the amount of active ingredient(s) by the method desctibed in the Assay and calculate the amount of active ingredient(s) in each capsule. The result lies within the range for the content of active ingredient(s)stated in the monograph. This range is based on the requirement that 20 capsules, or such other number as may be indicated in the monograph, are used in the Assay. Where 20 capsules cannot be obtained, a smaller number, which must not be less than 5, may be used, but to allow for sampling errors the tolerances are widened in accordance with Table 1. The requirements of Table 1 apply when the stated limits are between 90 and 110%. For limits other than 90 to 110%, proportionately smaller or larger allowances should be made. Uniformity of weight: This test is not applicable to capsules that are required to comply with the test for Uniformity of content for all active ingredients. Weigh an intact capsule. Open the capsule without losing any part of the shell and remove the contents as completely as possible. To remove the contents of a soft capsule the shell may be washed with ether or other suitable solvent and the shell allowed to stand until the odour of the solvent is no longer detectable. Weigh the shell. The weight of the contents is the difference between the weighings Repeat the procedure with a further 19 capsules Determine the average weight. Not more than two of the individual weights deviate from the average weight by more than the percentage deviation shown in Table 2 and none deviates by more than twice that percentage TABLE 2Average weight of capsule Percentage deviation contentsLess than 300 mg 10300 mg or more 7.5 Uniformity of content: This test is applicable to capsules that contain' less than 10mg or less than 10% w/w of active ingredient. For capsules containing more than one active ingredient carry out the test for each active ingredient that corresponds to the afore-mentioned conditions. The test should be carried out only after the content of active ingredient(s) in a pooled sample of the capsules has been shown to be within accepted limits of the stated content NOTE - The test is not applicable for capsules containing multivitamins and trace elements. Determine the content of active ingredient in each of =10 capsules taken at random using the method given in the monograph or by any other suitable analytical method of equivalent accuracy and precision. The capsules comply with the test if not more

calcium phosphates, calculated as Ca3(P04)2 Identification: Complies with the tests described under Dibasic Calcium Phosphate. Acid-insoluble substanc

more than 100.5 per cent of calcium phosphates, calculated as Ca3(P04)2 Identification: Complies with the tests described under Dibasic Calcium Phosphate. Acid-insoluble substances. Not more than 0.3%, determined by the method described under Dibasic Calcium Phosphate. Water-soluble substances: Digest 2.0 g with 100ml of water for 30 minutes on a water-bath, cool, addsufficienl water to restore the original volume, stir well and filter. Evaporate 50 ml of the filtrate to dryness and dry the residue at 105° to constant weight (0.5%) Arsenic Dissolve 2.0 g in a mixture of 15 ml of brominated hydrochloric acid, add 45 ml of water and remove the excess of bromine with a few drops of stannous chloride solution AsT, the resulting solution complies with the limit test for arsenic, Appendix 3.9 (5 ppm) Heavy metals: Not more than 40 ppm, determined by Method A, Appendix 3.12, on 25 ml of the solution prepared in the following manner. Warm 1.0 g with 4 ml of dilute hydrochloric acid, add sufficient water to produce 50 ml and filter Iron: Dissolve 0.2 g in a mixture of 5 ml of water and 0.5 ml of iron free hydrochloric acid with the addition of 1 g of citric acid. Dilute the solution to 40 ml with water, the solution complies with the limit test for iron, Appendix 3.13 (200 ppm).Carbonate. Suspend 1 g in 10 ml of water and add 2 ml of hydrochloric acid, no effervescence is produced Chloride: Dissolve 0.5 g in 25 ml of water by the addition of 1 ml of nitric acid the solution compiles with the limit test for chlorides. Appendix 3.10 (500 ppm) Sulphate: Dissolve 100 mg in water with the aid of 3 ml of IM hydrochloric acid and dilute to 60 ml with water 15 rnl of the resulting solution complies with the limit test for sulphates, Appendix 3.15 (0.6%) Proteinous impurities; Heat 0.5 g gently in a dry test-tube, no change in colour is observed and no unpleasant odour is emitted. Loss on ignition" Not more than 8.0%, determined on 1 g by igniting at 800° for 30 minutes, Appendix 8.7 Water Not more than 2.5% w/w, determined on I g. Appendix 3.24 Assay. Weigh accurately about 1 g and dissolve in 10 ml of hydrochloric acid by heating on a water-bath, add 50 ml of water, cool and dilute to 250.0 ml with water. To 250 ml of the resulting solution add 30.0 mf of 0.05M disodium edetate, 10.0 ml of ammonia buffer pH 10.9 and 100 ml of water and titrate the excess of disodium edetate with 0.05M zinc chloride using mordant black 11 solution as indicator. Each ml of 0.5M disodium edetate is equivalent to 0.00517 g of Ca3(PO4)2 CAPSULESCapsules are solid dosage forms in which the drug or a mixture of drugs is enclosed in Hard Gelatin Capsule Shells, in soft, soluble shells of gelatin, or in hard or soft shells of any other suitable material, of various shapes and capacities. They usually contain a single dose of active ingredient(s) and are intended for oral administration. The consistency of soft shells may be adjusted by the addition of substances such as Glycerin and Sorbitol Excipients such as opaque tillers, anti -microbal preservatives, sweetening agents, flavouring agents and one or more colouring agents permitted under the Drugs and Cosmetic Rules. 1945 may be added Capsules may bear surface markings.The contents of capsules may be of solid, liquid or paste-like consistency. They consist of the medicament(s) with or without excipients such as vehicles, solvents, diluents, lubricants.

Centrifuge, if necessary, to remove any insoluble material. Using this solution as solution (1), carry out the test described under

Betamethasone Dissolution. Comply with the dissolution test Centrifuge, if necessary, to remove any insoluble material. Using this solution as solution (1), carry out the test described under for tablets and capsules, Appendix 7.3. using as medium 900 ml of water and 1 ml of 0.05% w/v solution of testosterone RS (internal standard) in methanol and placing one tablet in the vessel for each test and rotating the paddle at 50 rpm for 45 minutes. Withdraw a suitable volume of the sample and filter. Carry out the method for high performance liquid chromatography, Appendix 4.3, using the filtrate as solution (1) For solution (2) dilute a mixture of 1 ml of each of a 0.05% w/v solution of betamethasone RS in methanol and 1 ml of a 0.05% w/v solution of testosterone RS in methanol to 900 mt with water. The chromatographic procedure may be carried out using (a) a column (30 cm x 3.9 mm) packed with stationary phase LCI. (b) a mixture of 60 volumes of methanol and 40 volumes of water as the mobile phase with a flow rate of 2 ml per minute and (c) a detection wavelength of about 254 run D: Not less than 75% of the stated amount of C22H29FO5. Uniformity of content.1 Comply with the requirements stated under Tablets using the following method of analysis. Carry out the method for high performance liquid chromatography, Appendix 4.3, protected from light, using the following solutions in methanol (50%). For solution (1) finely crush one tablet, add 20 ml of a 0.002% w/v solution of hydrocortisone (internal standard) in methanol (50%), shake for 10 minutes and filter through a glass-fibre filter paper (Whatman GF/C is suitable) Solulion (2) contains 0.0025% w/v of betamethasone RS and 0.002% w/v of hydrocortisone. The chromatographic procedure may be carried out using (a) a stainless steel column (20 cm x 5 mm) packed with stationary phase LCI (Spherisorb ODS 1 is suitable), (b) a mixture of 53 volumes of water and 47 volumes of methanol as the mobile phase with a flow rate of 1.4 ml per minute and (c) a detection wavelength of about 238 nm. Calculate the content of C22H29FO5 in each tablet from the declared content of C22H29FO5 in betamethasone RS. Other requirements : Comply with the requirements of tests stated under Tablets Assay: Carry out the method for high performance liquid chromatography. Appendix 4.3, protected from light, usingthe following solutions in methanol (50%). For solution (1) weigh and powder 20 tablets Weigh accurately a quantity of the powder equivalent to 2.5 mg of Betamethasone, add 20 ml of methanol (50%), shake for 10 minutes and filter through a glass-fibre filter paper (Whatman GF/C is suitable). Solution (2) contains 0.0125% w/v of betamethasone RS and 0.01096 w/v of hydrocortisone RS (internal standard) Prepare solution (3) in The

BETAMETHASONE TABLETSUsual strengths. 0.5 mg; 1.0 mg. Storage: Store in well-closed, light-resistant containers STANDARDSE

w/v and 0.010% w/v respectively of the substance being examined. Solution (4) contains 0.10% w/v each of the substance being examined and prednisone RS. After removal the plate, allow it to dry in air until the odour of solvents is no longer detectable and examine under ultra-violet light (254 nm) Any secondary spot in the chromatogram obtained with solution (1) is not more intense than the spot in the chromatogram obtained with solution (2) and not more than one such spot is more intense than the spot in the chromatogram obtained with solution (3) The test is not valid unless the chromatogram obtained with solution (4) shows two clearly separated principal spots. Sulphated ash: Not more than 0.1 %, Appendix 3.22 Loss on drying: Not more than 0.5%, determined on 1 g by drying at a pressure not exceeding 0.7 kPa for 3 hours, Appendix 8.6 Assay: Weigh accurately about 0.1 g and dissolve in sufficient aldehyde free ethanol to produce 200.0 ml. Dilute 5.0 ml of this solution with aldehyde free ethanol to 250.0 ml (test solution). Carry out the assay of steroids, Appendix 3.50, using belamethasone RS for preparing the standard solution BETAMETHASONE TABLETSUsual strengths. 0.5 mg; 1.0 mg. Storage: Store in well-closed, light-resistant containers STANDARDSEetamethasone Tablets contain not less than 90.0 per cent and not more Than 110.0 per cent of the stated amount of betamethasone, C22H29FO5. Identification. A : Powder a few tablets and extract with chloroform. Evaporate the extract to dryness. The residue complies with tests A, C and D described under Betamethasone.B'. The residue obtained in test A complies with the test for identification of steroids. Appendix 3.6, using solvent I and mcbile phase A At a fourth point apply to the plate 2ul of a mixture of equal volumes of solution (I) and a 0.25% w/v solution of dexamethasone RS in a mixture of 9 volumes of chloroform and 1 volume of methanol. The chromatogram obtained with this solution shows two closely running spots.Related substances :Transfer a quantity of the powdered tablets equivalent to .about 2 mg of Betamethasone to a glass-stoppered 50-m1 centrifuge tube. Pipette 20 ml of ethanol (95%) into the tube, shake for 2 minutes and allow to stand for 20 minutes with occasional shaking. Centrifuge the mixture for 5 minutes Pipette 10 ml of the clear supernatant liquid into a glass-stoppered tube and evaporate the ethanol on a water-bath with the aid of a current of air to about 0.5 ml, then evaporate wilhout heat to dryness. Pipette 1 ml of a mixture of 9 volumes of chloroform and 1 volume of methanol, insert the stopper and mix.

solution of homatropine hydrobromide RS (internal standard) in methanol (solution A), extract with two quantities, each of 5 mL of chloroform and disc

006% w/v solution of homatropine hydrobromide RS (internal standard) in methanol (solution A), extract with two quantities, each of 5 mL of chloroform and discard the chloroform extracts Add 1 ml of 5M ammonia. Extract with two quantities, each of 5 ml, of chloroform, shake the combined extracts with 1 g of anhydrous sodium sulphate, filter and evaporate the filtrate to dryness. Dissolve the residue in 0.5 ml of a mixture of 20 volumes of diehloromethane 4 volumes of N,O-bis(trimethylsilyl)acetamide and 1 volume of trimethylchlorosilane, mix and allow to stand for 30 minutes. For solution (2) add 1 ml of solution A and 1 ml of 5M ammonia to 5 ml of a 0.012% w/v solution of atropine sulphate RS. Extract with two quantities, each of 5 ml, of chloroform and complete the procedure described under solution (1) beginning at the words "shake the combined extracts with 1 g of anhydrous sodium sulphate,". Prepare solution (3) in the same manner as solution (2) but omitting the addition of solutionA.The chromatographic procedure described under Assay in Atropine Sulphate Eye Ointment may be used. Calculate the content Of (C17H23NO3)2.H2SO4,H2O from the declared content of (C17H23NO3)2.H2SO4,H2O in atropine sulphate RS. Other requirements: Comply with the requirements of rests stated under Tablets. Assay. Weigh and powder 20 tablets. Carry out the method for gas chromatography, Appendix 4.2. For solution (1) shake a quantity of the powdered tablets equivalent to 5 mg of Atropine Sulphate with 10 ml of 0.1 M hydrochloric acid, add 1 ml of a 0.5% w/v solution of homatropine hydrobromide RS (internal standard) in methanol (solution A) extract with two quantities, each of 10 ml, of chloroform and discard the chloroform extracts Add 1 ml of Slvl ammonia. Extract with two quantities, each of 10 ml. of chloroform

temperature regulation sense perception mechanical protection water balance The two types of skin The skin can be divided into two classes:

temperature regulation sense perception mechanical protection water balance The two types of skin The skin can be divided into two classes: (i) the thin skin, and (2) the thick skin.The thick skin is found in the sole and palm of the hand; all other skin are thin skin. Characteristics, by which the thick skin differs from the thin skin are: the thick skin is - (i) more thick than the thin variety, the layer called stratum corneum (horny layer) being particularly thick,(ii) the thick skin contains no hair and no sebaceous gland in persons accustomed to walk barefooted, the skin of the sole may be as thick as 1 cm or so, whereas the skin on the upper eyelid may be as thin as 0. 5 mm only. Appendages of the skin The epidermis of the skin develops from the ectoderm of the fetus. This ectoderm, while developing into the skin ectoderm, may develop into nails, hairs, sebaceous glands and sweat glands. These structures are collectively called the 'appendages' of the skin. Microscopic anatomy of the skin From a physiological point of view, the term skin should include three layers, viz (i) epidermis, (ii) dermis, and (iii) the subcutaneous tissue. Some physiologists, indeed, have used the term skin in this way.* Classical histologists, however, include only the epidermis and the dermis in the skin (the subcutaneous tissue is thus excluded). In this book, the term skin will be used in the sense a classical histologist uses, because, as this author believes, this is the most popular usage. The skin, therefore, consists of two layers: (i) tha epidermis and (ii) the dermis. *Hellier, F. F : <>, in Bell, G. H., Emslie - Smith D, and Patterson, C. R. Text Book of Physiology. ELM. 10th Ed. Churchil, 1980 chap. 17 The epidermis (fig. 8.5.1) consists of 5 layers which are: stratum corneum stratum lucidum. stratum granulosum. stratum spinosum (or prickle cell layer) stratum geriminatirvum (the deepest layer of epi dermis) Fig. 8.5. 1. Microscopic features of skin The cells of the stratum germinativum (= the layer which generates, i. e. generates new cells) continuosly produce new cells (by mitotic division); these cells move continuously towards the surface side and on the way receive a special material, called , ultimately when the superficial most surface is reached, the cells become dead and highly keratinized and constitute the stratum corneum: Stratum germinativum cells are columnar and stand on the basement membrane. The basement membrane stands between the epidermis and the dermis. Stratum spinosum (prickle cell layer) is several (3 to S) cells thick, the individual cells have a prickly (thorny) appearance (and hence the name). The prickled appearance is due to the fact that cytoplasmic processes come out from the individual cells to meet their fellow cytoplasmic strands of the adjacent( cells. Stratum granulosum is about 3 cell layers thick and lies superficial to the prickle cell layer. Although the mechanism of synthesis of keratin is rather complicated, it may be (rather crudely) stated that the cells of the stratum granulosum (=the granular layer) are very important for keratin synthesis. The precursors of keratin take the shape of granules which are present within the cells of the stratum granulosum from which the name has been derived. Stratum lucidum, when present, is found in between the str. granulosum and sir. comeum (Fig. 8. 5.1). it is, when stained by hematoxylin and eosin, rather a clear (lucidum = clear) layer. Str. lucidum is found only in thick skin. When the granules of the str. granulosum are converted into eleidin, the cells become rather clear and form str. lucidum. Eleidin is precursor of keratin. Stratum corneum (comeus =