Gangrene(From Wikipedia, the free encyclopedia) Gangrene is a serious and potentially life-threatening condition that arises when a considerable

mass of body tissue dies (necrosis).[1][2] This may occur after an injury or infection, or in people suffering from any chronic health problem affecting blood circulation.[2] The primary cause of gangrene is reduced blood supply to the affected tissues, which results in cell death.[3] Diabetes and long-term smoking increase the risk of suffering from gangrene.[2][3] There are different types of gangrene with different symptoms, such as dry gangrene, wet gangrene, gas gangrene, internal gangrene and necrotising fasciitis.[1][2] Treatment options include debridement (or, in severe cases, amputation) of the affected body parts, antibiotics, vascular surgery, maggot therapy or hyperbaric oxygen therapy.[4] Causes Gangrene is caused by infection or ischemia, such as by the bacteria Clostridium perfringens[5] or by thrombosis (a blocked blood vessel). It is usually the result of critically insufficient blood supply (e.g., peripheral vascular disease) and is often associated with diabetes and long-term smoking. This condition is most common in the lower extremities. The best treatment for gangrene is revascularization (i.e., restoration of blood flow) of the affected organ, which can reverse some of the effects of necrosis and allow healing. Other treatments include debridement and surgical amputation. The method of treatment is, in general, determined depending on location of affected tissue and extent of tissue loss. Gangrene may appear as one effect of foot binding. Types Dry Dry gangrene begins at the distal part of the limb due to ischemia, and often occurs in the toes and feet of elderly patients due to arteriosclerosis. Dry gangrene is mainly due to arterial occlusion. There is limited putrefaction and bacteria fail to survive. Dry gangrene spreads slowly until it reaches the point where the blood supply is adequate to keep tissue viable. The affected part is dry, shrunken and dark reddish-black, resembling mummified flesh. The dark coloration is due to liberation of hemoglobin from hemolyzed red blood cells, which is acted upon by hydrogen sulfide (H2S) produced by the bacteria, resulting in formation of black iron sulfide that remains in the tissues.[6] The line of separation usually brings about complete separation, with eventual falling off of the gangrenous tissue if it is not removed surgically, also called autoamputation. Dry gangrene is actually a form of coagulative necrosis. If the blood flow is interrupted for a reason other than severe bacterial infection, the result is a case of dry gangrene. People with impaired peripheral blood flow, such as diabetics, are at greater risk of developing dry gangrene. The early signs of dry gangrene are a dull ache and sensation of coldness in the affected area along with pallor of the flesh. If caught early, the process can sometimes be reversed by vascular surgery. However, if necrosis sets in, the affected tissue must be removed just as with wet gangrene. Wet Wet gangrene occurs in naturally moist tissue and organs such as the mouth, bowel, lungs, cervix, and vulva. Bedsores occurring on body parts such as the sacrum, buttocks, and heels although not

necessarily moist areas are also categorized as wet gangrene infections. It is characterized by numerous bacteria and has a poor prognosis (compared to dry gangrene) due to septicemia. In wet gangrene, the tissue is infected by saprogenic microorganisms (Clostridium perfringens or Bacillus fusiformis, for example), which cause tissue to swell and emit a fetid smell. Wet gangrene usually develops rapidly due to blockage of venous (mainly) and/or arterial blood flow. The affected part is saturated with stagnant blood, which promotes the rapid growth of bacteria. The toxic products formed by bacteria are absorbed, causing systemic manifestation of septicemia and finally death. The affected part is edematous, soft, putrid, rotten and dark. The darkness in wet gangrene occurs due to the same mechanism as in dry gangrene. Wet gangrene is coagulative necrosis progressing to liquefactive necrosis. Gas Main article: Gas gangrene Gas gangrene is a bacterial infection that produces gas within tissues. It is a deadly form of gangrene usually caused by Clostridium perfringens bacteria. Infection spreads rapidly as the gases produced by bacteria expand and infiltrate healthy tissue in the vicinity. Because of its ability to quickly spread to surrounding tissues, gas gangrene should be treated as a medical emergency. Gas gangrene is caused by a bacterial exotoxin-producing clostridial species, which are mostly found in soil and other anaerobes (e.g., Bacteroides and anaerobic streptococci). These environmental bacteria may enter the muscle through a wound and subsequently proliferate in necrotic tissue and secrete powerful toxins. These toxins destroy nearby tissue, generating gas at the same time. A gas composition of 5.9% hydrogen, 3.4% carbon dioxide, 74.5% nitrogen, and 16.1% oxygen was reported in one clinical case.[7] Gas gangrene can cause necrosis, gas production, and sepsis. Progression to toxemia and shock is often very rapid. Other

Necrotizing fasciitis affects the deeper layers of the skin. Noma is a gangrene of the face. Fournier gangrene usually affects the male genitals and groin.

Treatment Treatment is usually surgical debridement, with amputation necessary in many cases. Antibiotics alone are not effective because they do not penetrate infected muscles sufficiently.[citation needed] Another treatment is hyperbaric oxygen therapy. This treatment is used to treat gas gangrene. This form of treatment uses increased pressure and increased oxygen content. The outcome of this treatment is to allow blood to carry more oxygen, which helps stop the growth of anaerobic bacteria. History As early as 1028, when antibiotics had not yet been discovered, fly maggots were commonly[citation needed] used to treat chronic wounds or ulcers to prevent or arrest necrotic spread, as some species of maggots consume only dead flesh, leaving nearby living tissue unaffected. This practice largely died out after the introduction of antibiotics, acetonitrile[citation needed] and enzyme to the range of treatments for wounds. In recent times, however, maggot therapy has regained some credibility and is sometimes employed with great efficacy in cases of chronic tissue necrosis.

Etymology The etymology of gangrene derives from the Latin word gangraena and from the Greek gangraina(), which means "putrefaction of tissues". It has no etymological connection with the word green, despite the affected areas turning black and/or green and/or yellowish brown. It is coincidence that, in Lowland Scots the words "gang green" (go green) can be said to be an eggcorn for gangrene, as it describes the symptoms of the affliction.

Sherpa people From Wikipedia, the free encyclopedia Tibetans, Jirels This article contains Tibetan script. Without proper rendering support, you may see question marks, boxes, or other symbols instead of Tibetan characters. Sherpa (Tibetan: "eastern people", from shar "east" + pa "people") are an ethnic group from the most mountainous region of Nepal, high in the Himalayas.[1] Most Sherpa people live in Nepal's eastern regions; however, some live farther west in the Rolwaling valley and in the Helambu region north of Kathmandu. Pangboche is the Sherpas' oldest village in Nepal. The Sherpa language belongs to the south branch of the Tibeto-Burman languages. This language is however separate and not intelligible for Lhasa Tibetan speakers.[2] Nepal estimated there were 150,000 Sherpas in 2001.[3] The number of Sherpas immigrating to the West has also significantly increased in recent years, especially to the United States. With a population of about 2500 Sherpas, New York City has the largest Sherpa Community in the U.S.A. The 2001 Nepal Census recorded 154,622 Sherpas in that country, of which 92.83% were Buddhists, 6.26% were Hindus, 0.63% were Christians and 0.20% were Bn. History According to oral Buddhist traditions, the initial Tibetan migration, was a search for beyul (Shangri-La). The Sherpa were nomadic Tibetans and then primarily settled in the Solukhumbu District (khumbu) district and then gradually moved further westward. Salt trade occurred along these routes. In oral history, four groups migrated at different times giving rise to four main Sherpa clans, Minyagpa, Thimmi, Sertawa and Chawa. There are over 20 clans today which are sub-groups of the four. About 1840 Sherpa ancestors migrated from Kham. Mahayana Buddhism religious conflict may have contributed to the migration. Sherpa migrants traveled through and Tsang, before crossing the Himalaya.[4]

By the 1800s, Khumbu Sherpa people maintained autonomy within the newly formed Nepali state. In the 1960's, among growing tensions between China and India, Nepali government influence on the Sherpa people grew. In 1976, Khumbu became a national park and tourism became a major economic force.[4] According to Oppitz (1968), Sherpas migrated from the Kham region in eastern Tibet to Nepal within the last 300400 years.[5] On the other hand, Gautam (1994) concluded that Sherpa migrated from Tibet approximately 600 years ago, through the Nangpala pass. It is presumed that the group of people from Kham region, east of Tibet, was called as " Shyar Khamba" (People who came from eastern Kham), and the place where they settled was called " Syar Khumbu". As the time passed the " Shyar Khamba", inhabitants of shyar Khumbu, were called as Sherpa.[6] A recent Nepal Ethnographic Museum (2001) study postulated that Sherpas were not migrants who crossed the border of Tibet to Nepal. This is because the modern political entity of Nepal was not in existence then. Only after the unification by P.N. Shah in 1768, then the Himalayan region of present day Nepal became an integral part of the kingdom of Nepal. Prior to this, there was no separate political identity of Nepal and Tibet. Sherpas, like some other indigenous Kirat Nepalese tribes, would move from one place to another place of the Himalayan region as Alpine pastoralists and traders, since ancient times.[7] Mountaineering Sherpa mountain guide at Khumbu Ice Fall Sherpas are highly regarded as elite mountaineers and experts in their local terrain. They were immeasurably valuable to early explorers of the Himalayan region, serving as guides at the extreme altitudes of the peaks and passes in the region, particularly for expeditions to climb Mt. Everest (Nepali: Sagarmatha, Tibetan: Chomolungma). Today, the term is often used casuallyand incorrectlyby foreigners to refer to almost any guide or porter hired for mountaineering expeditions in the Himalayas. Sherpas are renowned in the international climbing and mountaineering community for their hardiness, expertise, and experience at high altitudes. It has been speculated that a portion of the Sherpas' climbing ability is the result of a genetic adaptation to living in high altitudes. Some of these adaptations include unique hemoglobin-binding enzymes, doubled nitric oxide production, hearts that can utilize glucose, and lungs with an increased efficiency in low oxygen conditions.[8] Religion Thame Gompa is one of numerous temples used by Sherpas Sherpas belong to the Nyingmapa, the "Red Hat Sect" of Tibetan Buddhism. Allegedly the oldest Buddhist sect in Tibet, founded by Padmasambhava during the 8th century, it emphasizes mysticism and local deities shared by the pre-Buddhist Bon religion, which has shamanic elements. Sherpa are the group that particularly believe in hidden treasures and valleys. Traditionally, Nyingmapa practice was advanced orally among a loose network of lay practitioners. Monasteries with celibate monks and nuns, along with the practice of reincarnated spiritual leaders are later adaptations.

In addition to Buddha and the great Buddhist divinities, the Sherpa also believe in numerous deities and demons who inhabit every mountain, cave, and forest. These have to be respected or appeased through ancient practices that have been woven into the fabric of Buddhist ritual life. Many of the great Himalayan mountains are respected as sacred. The Sherpas call Mount Everest Chomolungma and respect it as the "Mother of the World." Mount Makalu is respected as the deity Shankar (Shiva). Each clan recognizes certain mountain peaks and their protective deities. Today, the day-to-day Sherpas religious affairs are presided by lamas (Buddhist spiritual leaders) and other religious practitioners living in the villages. The village lama who presides over ceremonies and rituals can be monastic or a married householder. In addition, shamanic (lhawa) and soothsayers (mindung) deal with the supernatural and the spirit world. Lama identify witches (pem), act as the mouthpiece of deities and spirits, and diagnose spiritual illnesses. An important aspect of Sherpa religion is the monastery or gompa. There are some two dozen of these institutions scattered through the Solukhumbu region. They are communities of lamas or monks (sometimes of nuns) who take a vow of celibacy and lead a life in isolation searching for truth and religious enlightenment. They are respected by and supported by the community at large. Their contact with the outside world is focused on monastery practices and annual festivals to which the public is invited, as well as the reading of sacred texts at funerals. Men wear long-sleeved robes called chhuba, which fall to slightly below the knee. Chhuba is tied at the waist with a cloth sash called kara, creating a pouch-like space called tolung which can be used for storing and carrying small items. Traditionally, chhuba were made from thick home-spun wool, or a variant called lokpa made from sheepskin. Chhuba are worn over raatuk, a blouse (traditionally made out of bure, white raw silk), trousers called kanam, and an outer jacket called tetung. Women traditionally wore long-sleeved floor-length dresses of thick wool called tongkok. A sleeveless variation called engi is worn over a raatuk (blouse) in warmer conditions. These are worn with colourful striped aprons; metil aprons are worn on the front, and gewe on the back, and are held together by an embossed silver buckle called kyetig.[9] Sherpa clothing resembles Tibetan clothing. Increasingly, home-spun wool and silk is being replaced by factory-made material. Many Sherpa people also now wear ready-made western clothing. Traditional housing Traditional Sherpa architecture, but with a steel roof. When a son marries and has children, the community may help to construct a new house, as the extended family becomes too large for a single home. The neighbors often contribute food, drinks and labor to help the family. Houses are typically spaced to allow fields in between. A spiritual ceremony may be conducted at every building stage as the house must have space for deities, humans and animals. Once constructed, the house is often handed down heirloom among families and not sold. The house style depends on the lay of the land: old river terraces, former lake beds or mountain slopes.

There are a stone single story, one and a half story (on a slope), and the two story house, with ample room for animals. Many well-to-do families will have an annex shrine room for sacred statues, scriptures and ritual objects. The roof is sloping and is made from local natural materials, or imported metal. There's space in the roof to allow for fire smoke to escape. There may be an internal or external outhouse for making compost.[10] Sherpas One of the most well known Sherpas is Tenzing Norgay. In 1953, he and Sir Edmund Hillary became the first people known to have reached the summit of Mount Everest.[11][12][13] Norgay's son Jamling Tenzing Norgay also climbed Everest in honor of his father with the famous Ed Viesturs and Araceli Segarra during the disastrous year of 1996. Two Sherpas, Pemba Dorjie and Lhakpa Gelu, recently competed to see who could climb Everest from base camp the fastest. On 23 May 2003, Dorjie summited in 12 hours and 46 minutes. Three days later, Gelu beat his record by two hours, summiting in 10 hours 46 minutes. On 21 May 2004, Dorjie again improved the record by more than two hours with a total time of 8 hours and 10 minutes.[14] On 11 May 2011, Apa Sherpa successfully reached the summit of Everest for the twenty-first time, breaking his own record for the most successful ascents.[15] He first climbed Mount Everest in 1989 at the age of 29.[16] Perhaps the most famous Nepalese female mountaineer is Pasang Lhamu Sherpa, the first Nepali female climber to reach the summit of Everest, but who died during the descent. Another woman Sherpa who is well known is the two-time Everest summiteer Pemba Doma Sherpa, who died after falling from Lhotse on 22 May 2007.[17] Lakpa Tsheri Sherpa is one half of a Nepali duo that was voted "People's Choice Adventurers of the Year 2012". In April 2011, Lakpa Tsheri and Sano Babu Sunuwar made the 'Ultimate Descent': a three-month journey in which they climbed Chhomolangma (Nepali: Sagarmatha, English: Everest), then paraglided down the mountain and proceeded to kayak through Nepal and India until they reached the Indian Ocean.[18] On May 19th 2012, 16-year-old Nima Chhamzi Sherpa became the youngest woman to climb Everest . Frostbite From Wikipedia, the free encyclopedia Frostbite (congelatio in medical terminology) is the medical condition where localized damage is caused to skin and other tissues due to extreme cold. Frostbite is most likely to happen in body parts farthest from the heart and those with large exposed areas. The initial stages of frostbite are sometimes called "frost nip".

Classification

There are several classifications for tissue damage caused by extreme cold including:

Frostnip is a superficial cooling of tissues without cellular destruction.[1] Chilblains are superficial ulcers of the skin that occur when a predisposed individual is repeatedly exposed to cold Frostbite involves tissue destruction.

Stages At or below 0 C (32 F), blood vessels close to the skin start to constrict, and blood is shunted away from the extremities via the action of glomus bodies. The same response may also be a result of exposure to high winds. This constriction helps to preserve core body temperature. In extreme cold, or when the body is exposed to cold for long periods, this protective strategy can reduce blood flow in some areas of the body to dangerously low levels. This lack of blood leads to the eventual freezing and death of skin tissue in the affected areas. There are four degrees of frostbite. Each of these degrees has varying degrees of pain.[2] First degree This is called frostnip and this only affects the surface skin, which is frozen. On the onset, there is itching and pain, and then the skin develops white, red, and yellow patches and becomes numb. The area affected by frostnip usually does not become permanently damaged as only the skin's top layers are affected. Long-term insensitivity to both heat and cold can sometimes happen after suffering from frostnip. Second degree If freezing continues, the skin may freeze and harden, but the deep tissues are not affected and remain soft and normal. Second-degree injury usually blisters 12 days after becoming frozen. The blisters may become hard and blackened, but usually appear worse than they are. Most of the injuries heal in one month, but the area may become permanently insensitive to both heat and cold. Third and fourth degrees If the area freezes further, deep frostbite occurs. The muscles, tendons, blood vessels, and nerves all freeze. The skin is hard, feels waxy, and use of the area is lost temporarily, and in severe cases, permanently. The deep frostbite results in areas of purplish blisters which turn black and which are generally blood-filled. Nerve damage in the area can result in a loss of feeling. This extreme frostbite may result in fingers and toes being amputated if the area becomes infected with gangrene. If the frostbite has gone on untreated, they may fall off. The extent of the damage done to the area by the freezing process of the frostbite may take several months to assess, and this often delays surgery to remove the dead tissue.[3] Risk factors

Risk factors for frostbite include using beta-blockers and having conditions such as diabetes and peripheral neuropathy. Causes Factors that contribute to frostbite include extreme cold, inadequate clothing, wet clothes, wind chill, and poor blood circulation. Poor circulation can be caused by tight clothing or boots, cramped positions, fatigue, certain medications, smoking, alcohol use, or diseases that affect the blood vessels, such as diabetes.[4] Exposure to liquid nitrogen and other cryogenic liquids can cause frostbite as well as prolonged contact with the chemical butane (see deodorant burn). Treatment Do not make affected area (skin) touch any cold or hot objects. Keep affected area warm. Treatment of frostbite centers on rewarming (and possibly thawing) of the affected tissue. The decision to thaw is based on proximity to a stable, warm environment. If rewarmed tissue ends up refreezing, more damage to tissue will be done. Excessive movement of frostbitten tissue can cause ice crystals that have formed in the tissue to do further damage. Splinting and/or wrapping frostbitten extremities are therefore recommended to prevent such movement. For this reason, rubbing, massaging, shaking, or otherwise applying physical force to frostbitten tissues in an attempt to rewarm them can be harmful.[5] Caution should be taken not to rapidly warm up the affected area until further refreezing is prevented. Warming can be achieved in one of two ways: Passive rewarming[6] involves using body heat or ambient room temperature to aid the person's body in rewarming itself. This includes wrapping in blankets or moving to a warmer environment.[7] Active rewarming[6] is the direct addition of heat to a person, usually in addition to the treatments included in passive rewarming. Active rewarming requires more equipment and therefore may be difficult to perform in the prehospital environment.[5] When performed, active rewarming seeks to warm the injured tissue as quickly as possible without burning them. This is desirable as the faster tissue is thawed, the less tissue damage occurs.[5] Active rewarming is usually achieved by immersing the injured tissue in a water-bath that is held between 40-42C (104-108F). Warming of peripheral tissues can increase blood flow from these areas back to the bodies' core. This may produce a decrease in the bodies' core temperature and increase the risk of cardiac dysrhythmias.[8] Surgery Debridement and/or amputation of necrotic tissue is usually delayed. This has led to the adage "Frozen in January, amputate in July"[9] with exceptions only being made for signs of infections or gas gangrene.[10] Prognosis

A number of long term sequelae can occur after frost bite. These include: transient or permanent changes in sensation, paresthesia, increased sweating, cancers, and bone destruction/arthritis in the area affected.[11] s a sensation of tingling, burning, pricking, or numbness of a person's skin with no apparent long-term physical effect. It is more generally known as the feeling of "pins and needles" or of a limb "falling asleep". The manifestation of paresthesia may be transient or chronic.