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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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The more common inversion injury results in tearing or injury to the lateral ligaments diabete insipidus pioglitazone 30 mg with amex, whereas an eversion injury will injure the medial ligaments of the ankle diabetes mellitus may lead to buy discount pioglitazone 45 mg on line. The injured ligaments may be identified by means of careful palpation for point tenderness around the ankle diabetes diet guidelines after your visit generic pioglitazone 30 mg on-line. The joint should be supported or immobilized at a right angle diabetes uti order pioglitazone 45mg with mastercard, which is the functional position. Use of an air splint produces joint rest, and the extremity can be protected by using crutches. Functional rehabilitation, including edema control, range-ofmotion exercises, strengthening, and restitution of proprioceptive sensation, can prevent long-term disability. Knee Sprains Sprains of the collateral and cruciate ligaments are uncommon in children. These ligaments are so strong that it is more common to injure the growth plates, which are the weakest structures in the knees of children. In adolescence, however, the physes have started to close, and the knee joint is more like that of an adult. Rupture of the anterior cruciate ligament can result from a rotational injury (see Chapter 25). If the injury produces avulsion of the tibial spine, anatomic reduction and fixation is often required. The differential diagnosis includes torn ligament, torn meniscus, and osteochondral fracture. Nontraumatic effusion should be evaluated for inflammatory conditions (eg, juvenile rheumatoid arthritis) or patellar malalignment. After local heat and tenderness have decreased, gentle active exercises may be initiated. Passive stretching exercises are not indicated, because they may stimulate the ossification reaction. If surgery is necessary, it should not be attempted before 9 months to 1 year after injury, because it may restart the process and lead to an even more severe reaction. Vaquero J et al: Intra-articular traumatic disorders of the knee in children and adolescents. Internal Derangements of the Knee Meniscal injuries are uncommon in children younger than age 12 years. Clicking or locking of the knee may occur in young children as a result of a discoid lateral meniscus, a rare congenital anomaly. As the child approaches adolescence, internal damage to the knee from a torsion weight-bearing injury may cause tearing and displacement of a meniscus and result in locking of the knee. Osteochondral fractures secondary to osteochondritis dissecans may also present as internal derangements of the knee in adolescence. Stress films will sometimes demonstrate separation of the distal femoral epiphysis in such cases. Epiphysial injury should be suspected whenever tenderness is present on both sides of the metaphysis of the femur after injury. In contrast to fracture reduction, which may be safely postponed, dislocations must be reduced immediately. It often happens that no anesthetic is necessary for several hours after the injury, because of the protective anesthesia produced by the injury. Following reduction, the joint should be splinted for transportation of the patient. A thorough neurovascular examination should be performed and documented before and after reduction. The dislocated joint should be treated initially by immobilization followed by graduated active exercises through a full range of motion. Back Sprains Sprains of the ligaments and muscles of the back are unusual in children but may occur as a result of violent trauma from automobile accidents or athletic injuries. Back pain in a child may be the only symptom of significant disease and warrants clinical investigation. Inflammation, infection, renal disease, or tumors can cause back pain in children, and sprain should not be accepted as a routine diagnosis. Subluxation of the Radial Head (Nursemaid Elbow) Infants may sustain subluxation of the radial head as a result of being lifted or pulled by the hand. Radiographic findings are normal, but there is point tenderness over the radial head. When the elbow is placed in full supination and slowly moved from full extension to full flexion, a click may be palpated at the level of the radial head. Occasionally, symptoms last for several days, requiring more prolonged immobilization. This should be considered during examination, especially if the problem is recurrent. Contusions Contusion of muscle with hematoma formation produces the familiar "charley horse" injury. Local heat may hasten healing once the acute phase of tenderness and swelling is past. Myositis Ossificans Ossification within muscle occurs when there is sufficient trauma to cause a hematoma that later heals in the manner of a fracture. The injury is usually a contusion and occurs most commonly in the quadriceps of the thigh or the triceps of the arm. When a severe injury with hematoma is recognized, it is important to splint the extremity and avoid activity. If further trauma causes recurrent injury, ossification may reach spectacular proportions and resemble an osteosarcoma. Recurrent Dislocation of the Patella Recurrent dislocation of the patella is more common in loose-jointed individuals, especially adolescent girls. The patella may be reduced by extending the knee and placing slight pressure on the patella while gentle traction is exerted on the leg. In subluxation of the patella, the symptoms may be more subtle, and the patient will complain that the knee "gives out" or "jumps out of place. Surgery is reserved for individuals with reparable osteochondral injuries, loose bodies, and recurrent dislocation following appropriate nonoperative therapy. The farther the fracture is from the growing end of the bone, the longer the time required for remodeling. The fracture can be considered healed when no tenderness or local heat is present and when adequate bony callus is seen on radiograph. Fracture of the Clavicle Clavicular fractures are very common injuries in infants and children. The healing callus will be apparent when the fracture has consolidated, but this unsightly lump will generally resolve over a period of months to a year. Epiphysial Separations In children, epiphysial separations and fractures are more common than ligamentous injuries. This finding is based on the fact that the ligaments of the joints are generally stronger than the associated growth plates. In instances in which dislocation is suspected, a radiograph should be taken to rule out epiphysial fracture. Radiographs of the opposite extremity, especially for injuries around the elbow, may be valuable for comparison. Reduction of a fractured epiphysis should be done under anesthesia to align the growth plate with the least amount of force. Fractures across the growth plate may produce bony bridges that will cause premature cessation of growth or angular deformities of the extremity. Epiphysial fractures around the shoulder, wrist, and fingers can usually be treated by closed reduction, but fractures of the epiphyses around the elbow often require open reduction. In the lower extremity, accurate reduction of the epiphysial plate is necessary to prevent joint deformity if a joint surface is involved.
If weight loss persists diabetes mellitus canine purchase pioglitazone 15 mg online, careful monitoring of vital signs diabetes test during pregnancy what week purchase pioglitazone 45mg on line, including supine heart rate diabetic diet oatmeal pioglitazone 15 mg otc, is important in determining whether an increased level of care is needed blood sugar 106 buy discount pioglitazone 45mg on line. Concomitantly, the patient should be referred to a psychotherapist, and if indicated, assessed by a psychiatrist. LeGrange D et al: Manualized family-based treatment for anorexia nervosa: A case series. An episode of binge eating is characterized by both of the following: (1) eating, in a discrete period of time (eg, within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months. Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. If laxatives are used, then a metabolic acidosis develops with hypokalemia and hypochloremia. Asking whether patients have binged, feel out of control while eating, or whether they cannot stop eating can clarify the diagnosis. Parents may report that significant amounts of food are missing or disappearing more quickly than normal. If the physician is suspicious, direct questioning about all the ways to purge should follow. Indicating first that the behavior is not unusual can make questioning less threatening and more likely to elicit a truthful response. For example, the clinician might say, "Some teenagers who try to lose weight make themselves vomit after eating. Short-Term Complications Complications in normal-weight bulimic patients are related to the mechanisms of purging, and many of these complications are listed under Symptoms and Signs, earlier. If the bulimic patient is significantly malnourished, complications may be the same as those encountered in the anorexic patient. Other complications of bulimia include esophageal rupture, acute or chronic esophagitis, and rarely, Barrett syndrome. Chronic vomiting can lead to metabolic alkalosis, and laxative abuse may cause metabolic acidosis. Diet pill use can cause insomnia, hypertension, tachycardia, palpitations, seizures, and sudden death. Treating constipation can be difficult psychologically, because the practitioner may need to prescribe agents similar to the drugs of abuse used during the eating disorder. This can be due to gastroesophageal reflux, as the lower esophageal sphincter is compromised due to repetitive vomiting. Frequent vomiting may result in esophagitis or gastritis, as the mucosa is irritated from increased acid exposure. Early satiety, involuntary vomiting, and complaints of food "coming up" on its own are frequent. Patients may report diarrhea or constipation, especially if laxatives have been used. Erosion of dental enamel results from increased oral acid exposure during vomiting. Although the patient may be able to vomit some of the food, much is actually digested and absorbed. On physical examination, bulimic patients may be dehydrated and have orthostatic hypotension. Sialadenitis, tooth enamel loss, dental caries, and abdominal tenderness are the most common findings. Abrasion of the proximal interphalangeal joints may occur secondary to scraping the fingers against teeth while inducing vomiting. Mortality the mortality rate in bulimic patients is similar to that in anorexic patients. Typically extracellular K+ is spared at the expense of intracellular K+, so a patient may become hypokalemic several days after the serum K+ concentration appears to be corrected. Usually cessation of purging is sufficient to correct K+ concentration and is the recommended intervention for K+ above 3. Total body K+ can be assumed to be normal when serum K+ corrects and remains normal 2 days after supplements are stopped. The renin-angiotensin-aldosterone axis and the antidiuretic hormone level may be elevated to compensate. These systems do not shut down automatically when laxatives are stopped, and fluid retention of up to 10 kg/wk may result. This puts patients at risk for congestive heart failure and can scare them as their weight increases B. Parents and patients should be advised of this possible complication of initial therapy to help maintain their confidence in the care plan. Another reason to hospitalize bulimic patients is failure of outpatient management. The binge-purge cycle is addictive and can be difficult for patients to interrupt on their own. Hospitalization can offer a forced break from the cycle, allowing patients to normalize their eating, interrupt the addictive behavior, and regain the ability to recognize satiety signals. Cognitive-behavioral therapy is crucial to help bulimic patients understand their disease and to offer suggestions for decreasing bingeing and purging. Nutrition therapy offers patients ways to regulate eating patterns so that they can avoid the need to binge. Medical monitoring should be done to check electrolytes periodically, depending on the purging method used. Fluoxetine has been studied most extensively; a dose of 60 mg/d is most efficacious in teenagers. Treatment for gastroesophageal reflux and gastritis should be used when appropriate. The pain and swelling of enlarged parotid glands can be helped by sucking on tart candy and by the application of heat. Bacaltchuk J et al: Antidepressant versus placebo for the treatment of bulimia nervosa: A systematic review. Panagiotopoulos C et al: Electrocardiographic findings in adolescents with eating disorders. An episode of binge eating is characterized by both of the following: (1) eating, in a discrete period of time (eg, within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances. The binge-eating episodes are associated with three (or more) of the following: (1) eating much more rapidly than normal (2) eating until feeling uncomfortably full (3) eating large amounts of food when not feeling physically hungry (4) eating alone because of being embarrassed by how much one is eating (5) feeling disgusted with oneself, depressed, or very guilty after overeating C. The binge eating is not associated with regular use of inappropriate compensatory behaviors (eg, purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa. Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision. Specific questionnaires are available for evaluating patients suspected of binge-eating disorder. Laboratory Findings the clinician should assess causes and complications of obesity, and laboratory evaluation should include thyroid function tests and measurement of cholesterol and triglyceride levels. Symptoms and Signs Binge-eating disorder most often occurs in overweight or obese individuals. Patients with bingeeating disorder have an increased incidence of depression Treatment A combination of cognitive-behavioral therapy and antidepressant medication has been helpful in treating bingeeating disorder in adults. The eating disorder not otherwise specified category is for disorders of eating that do not meet the criteria for any specific eating disorder. For females, all of the criteria for anorexia nervosa are met except that the individual has regular menses.
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Extensive experience with and evaluation of high-risk families have shown that the provision of home visitor services to families at risk can prevent abuse and neglect of children blood sugar too high generic pioglitazone 15mg without a prescription. These services can be provided by public health nurses or trained paraprofessionals diabetes test how to prepare pioglitazone 30mg with mastercard, although more data are available describing public health nurse intervention metabolic brain disease journal generic pioglitazone 15 mg. The availability of these services could make it as easy for a family to pick up the telephone and ask for help before they abuse a child as it is for a neighbor or physician to report an episode of abuse after it has occurred diabetes type 2 ppt discount 45 mg pioglitazone with amex. Parent education and anticipatory guidance are also helpful, with attention to handling situations that stress parents (eg, colic, crying behavior, and toilet training), age-appropriate discipline, and general developmental issues. Prevention of abusive injuries perpetrated by nonparent caregivers (eg, babysitters, nannies, and unrelated adults in the home) may be addressed by education and counseling of mothers about safe child care arrangements and advocating for affordable day care for all families. Promising new data suggest the efficacy of hospital-based programs that teach parents about the dangers of shaking an infant and how to respond to a crying infant. Most efforts in this area involve teaching children to protect themselves and their "private parts" from harm or interference. McCann J et al: Healing of hymenal injuries in prepubertal and adolescent girls: A descriptive study. Department of Health and Human Services: Administration for Children, Youth, and Families. In this chapter, special attention is given to the pediatric history and physical examination, normal developmental stages, office telephone management, and community pediatrics. This relationship develops over time, with increasing numbers of visits, and is facilitated by the continuity of clinicians and other staff members. This clinical relationship is based on trust that develops as a result of several experiences in the context of the office visit. Perhaps the greatest factor facilitating the relationship is for patients or parents to experience advice as valid and effective. Important skills include choosing vocabulary that communicates understanding and competence, demonstrating commitment of time and attention to the concern, and showing respect for areas that the patient or parent does not wish to address (assuming there are no concerns relating to physical or sexual abuse or neglect). Parents and patients expect that their concerns will be managed confidentially and that the clinician understands and sympathizes with those concerns. Parents and patients may provide a specific and detailed history, or a vague history that necessitates more focused probing. Parents may or may not be able to distinguish whether symptoms are caused by organic illness or a psycho- logical concern. It is often helpful to ask what problems the parents specifically wish to address in order to determine what really prompted the office visit. Some visits are occasioned by problems at school, such as low grades or troublesome peer relationships. Understanding the family and its hopes for and concerns about the child can help in the process of distinguishing organic illness from emotional or behavioral conditions, thus minimizing unnecessary testing and intervention. Direct histories not only provide firsthand information but also give the child a degree of control over a potentially threatening situation and may reveal important information about the family. Many offices provide questionnaires for parents to complete before the clinician sees the child. Data from questionnaires can make an outpatient visit more productive, allowing the physician to address problems in detail while more quickly reviewing areas that are not of concern. Questionnaires may be more productive than face-to-face interviews in revealing sensitive parts of the history. However, failure to review and assimilate this information prior to the interview may cause a parent or patient to feel that the time and effort have been wasted. Elements of the history that will be useful over time should be readily accessible in the medical record. Demographic data; a problem list; information about chronic medications, allergies, and previous hospitalizations; and the names of other physicians providing care for the patient are commonly included. Documentation of immunizations, including all data required by the National Childhood Vaccine Injury Act, should be kept on a second page. B Mother Father Sibs S. Use of a summary sheet such as this at the front of the record facilitates reorienting the caregiver and his or her partners to the patient. Some practices keep track of health supervision visits on this sheet to tell the physician whether the child is likely to have received the appropriate preventive services. A second page documenting immunizations should record data required by the National Childhood Vaccine Injury Act. When an allergy with potential for anaphylaxis is identified, the patient should wear a medical alert bracelet and obtain an epinephrine kit, if appropriate. Items 8 and 9, and a focused review of systems, are dealt with at each acute or chronic care visit. The entire list should be reviewed and augmented with relevant updates at each health supervision visit. A gentle, friendly manner and a quiet voice help establish a setting that yields a nonthreatening physical examination. The examiner should take into consideration the need for a quiet child, the extent of trust established, and the possibility of an emotional response (crying! Painful or unpleasant procedures (eg, otoscopic examinations) should be deferred until the end of the examination. Whether or not the physician can establish rapport with the child, the process should proceed efficiently and systematically. Triggering allergen, nature of the reaction, treatment needed, and date allergy diagnosed. Maternal health during pregnancy, medications, street drugs used, complications of pregnancy; duration and ease of labor; form of delivery; analgesics and anesthetics used; need for monitoring; and labor complications. Results of newborn screening, vision and hearing screening, any health screen, or screening laboratory tests. A concise chronologic summary of the problems necessitating a visit, including the duration, progression, exacerbating factors, ameliorating interventions, and associations. Eating patterns, likes and dislikes, use of vitamins, and relative amounts of carbohydrates, fat, and protein in the diet. Information about the illnesses of relatives, preferably in the form of a family tree. Because young children may fear the examination and become fussy, simple inspection is important. Examinations of adolescents should be chaperoned whenever a pelvic examination or a stressful or painful procedure is performed. Although a thorough physical examination is important at every age, at some ages the examination tends to focus on specific issues and concerns. At any age, an astute clinician can detect signs of important clinical conditions in an asymptomatic child. In infancy, for example, physical examination can reveal the presence of craniosynostosis, congenital heart disease, or developmental dysplasia of the hip. Similarly, examination of a toddler may reveal pallor (possible iron-deficiency anemia) or strabismus. The routine examination of an adolescent may reveal scoliosis or acanthosis nigricans (a finding associated with insulin resistance). In areas where evidence-based information is lacking, expert opinion has been used as the basis for these plans.
Such lumping together of the different types and extent of disabilities not only ignored bodily physical differences but it also ignored the changes within domains and forms of sociality diabetes testing kit reviews buy generic pioglitazone 45 mg on line, an issue discussed below diabetes mellitus eye exam purchase pioglitazone 15 mg without prescription. Some get entangled with the practices and politics of the areas in which they operate (Finnstrom 2005:112; Ingstad 1995) diabetes insipidus genetic testing discount pioglitazone 30mg visa. Others set their objectives according to funding sources and their own agendas (Chibwana and Mohan 2001) diabetes mellitus foundation pioglitazone 30 mg overnight delivery. Elsewhere, intervention programs have been put in place to fulfill political interests (Bruun 1995; Silla 1998; Van den Bergh 1995). In Northern Uganda, some agencies were interested in specific conditions and targeted particular groups like former rebels as well as government soldiers, leaving out those with other disabilities. Some were interested in offering specific services like credit facilities, literacy courses, and counseling, while others focused on particular groups: women, children, the formerly abducted, and so on. Many concentrated on people in particular locations like markets, military barracks, displacement camps, and slums. This range of projects by the various intervention agencies was not accidental; it represented sociopolitical steps toward predefined agendas and targeted different people, in different places, and at different times. These agencies neglected to examine the impact of their activities on the target populations, focusing instead on the (pre)defined "guidelines," "methods," and ultimate "indicators" of achieving their objectives. The construction of disability as a war phenomenon led to the exclusion of those whose disabilities were due to causes that were different from those targeted by most skills-training programs. Particularly in the rural areas, few had gone through the formal institutional processes. Polio survivors and the visually impaired were categorized as "disabled disabled," and as such, were not targeted for skills training. In Northern Uganda, the focus on "reliable" data, for instance, envisioned people with war-related disabilities, mainly those Muyinda Skilling, Disability, and Technology S127 who had a history of being in contact with formal institutions that could issue documents about their conditions. Most of those injured during the war went through hospitals and rehabilitation centers and had "valid" documents needed for the "evidence-base of their interventions. The emphasis on valid documents also left out many women; the few that were reached often received training in inappropriate skills. This is because most of them did not participate in combat activities like men did. Also, apart from the land mine survivors, most women had disabilities due to causes other than the war and therefore lacked the valid documents and did not "qualify" for skills training. Most disabled women were not connected to formal institutions since they spent most of their time at home, while men were mobile and had contacts with formal disability organizations and other sociopolitical and economic groups. The need for accurate data is often based on the prejudiced assumption that all problems people have in Ugandan postconflict settings are due to the war. Yet, it is evident that many of the cited problems in postconflict settings are also due to other factors found even in areas where there is no war (Finnstrom 2005). Although there is need for accurate data to plan for proper resettlement and skills training, in war-affected areas like Northern Uganda, sound social, health, and demographic data are often missing; use of personal accounts, demands, and dynamics of communities to address real-life situations is sometimes inevitable. Unfortunately, international, national, and local organizations rarely acknowledge the challenges to aid provision in order to develop meaningful approaches to understanding and addressing them. As one study points out (Ghobarah, Huth, and Russet 2004), if this acknowledgement does not occur, it may hinder the capacity of programmatic responses to deliver appropriate skills consistent with realities on the ground. Skilling and Unstable Domains of Sociality Before the war, the Acholi people traditionally lived in familybased households surrounded by homes of patrilateral relatives who supported their disabled kin (Girling 1960). Relatives assisted their disabled members by offering direction for the visually impaired, carrying or pushing wheelchairs for those with mobility problems, providing shelter and protection against any dangers, and more (Atkinson 1999). They depended on their relatives to gather raw materials and to sell their products. Kin-based sociality is the means through which the conditions of disabled persons are understood and accepted and legitimate social positions are (re)created and acted upon. As the region transitioned from emergency and postemergency scenarios into resettlement processes, there were rapid socioeconomic changes. Both the international and local organizations that had provided the backbone of much of disability support began pulling out. The few service providers that remained were either scaling down or reorienting their activities, a situation that was made more complex by uncertain kinship support. This was still the case, even when, over time, women assumed many responsibilities that were previously identified with men. On top of being the main producers of food and caretakers of their families, women were also active in income-generating activities. This was especially important given that most disabled women in Northern Uganda were single mothers (Muyinda 2013). Like Akello, most were rejected by their spouses and other family members; this hampered family support for them and their skilling process. So the brothers and other male relatives of a man would not provide assistance to such a woman for fear of accusations of sexual trespass. Thus, the rejected disabled women would face challenges regarding housing, cultivation, and other activities associated with moving back to villages because relatives would not openly help them when their husbands had abandoned them. Without family and institutional support, the disabled women would have to be multiskilled so that they could handle their various needs. Further, the effect of the changes within the domain of sociality was evident in the skilling of former fighters. The disabled government soldiers were trained in various skills and were given a package for resettlement to start a new civilian life after retiring from the army. For the former rebel fighters, the government set up reception centers specifically for their rehabilitation. The former fighters received technical skills training in carpentry, shoemaking and repairs, electronic repairs, financial management, and use of assistive (mobility) devices and were given farm instruments and seeds. With such skills, the former fighters considered their abilities in performing their roles to be superior and expected to be treated with high regard and respect by their communities. As one former rebel fighter amputee related to me: "As a professional [soldier] I feel I can do so many things and can work with anyone. This was partly because much of the skills training in military rehabilitation institutions and reception centers for the former rebels emphasized technical skills-mainly tailoring, carpentry, agriculture, and metal works-and so little attention was placed on social and behavioral life skills. The material training neglected the reintegration skills the former fighters needed to help them fit into the civilian communities. The military skilling institutions were faced with bureaucratic and hierarchical challenges. There was confusion as to whose decisions to follow-those of the army officers or the technical skills trainers. When they tried to settle back in their villages, most of the former fighters were rejected since they continued to live a military-like life in civilian settings. The former fighters continued to communicate by giving orders; they expected to be given free food, services, and other necessities of life as in the military; and some of them were violent. With such behavior, many of the disabled former fighters were not perceived as "real" disabled people; they were seen more as people who had caused deaths and instability in the area, rather than as persons with disabilities needing sympathy. Their war-related identities overshadowed their physical impairments and functional limitations. The former fighters needed to unlearn some of the militaristic practices and approaches to life and at the same time adopt civilian approaches. The few former fighters who had been accepted in society had translated their military and other skills learned in the rehabilitation centers into locally applicable services to their communities. Some of them started adult learning sessions in the community, bicycle repair, carpentry-skills applicable to meet local needs and integration into the "new" domains of sociality. New Socialities In Uganda, people affected by recent war-related impairments may engage in a number of unpredictable attempts to adapt to their new situations and integrate these novel experiences into their lives as individuals and members of collective groups. The impaired person can stop or alter ways of doing particular things due to changes in the body; someone may no longer be able to stand for long, move across long distances, use one or both hands, or be able to read or write due to loss of sight. These experiences are defined by intersections of disability, lack, loss, and/or underutilization of resources, both material and nonmaterial. There were four such platforms in Gulu that developed, based on geographical proximity and different activities. One of the groups (two men, one woman) established a mobile phone charging project. Most of the rural areas in Northern Uganda had no electricity, yet many people used mobile phones. Another "shared knowledge group" of two men started an electronic repair shop, and another two women living nearby started a hair salon.
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