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In an effort to quantify preoperative cardiac risk, several tests are used to assess cardiovascular function. Electrocardiogram should be considered for anyone other than asymp to matic persons undergoing low risk procedures. Patients who have dyspnea of unknown origin, current or past heart failure, prior cardiomyopathy, or with any of the above fac to rs and no cardiac assessment in the past 12 months should consider echocardiogram testing preoperatively (179). Exercise stress testing before surgery can identify patients who have ischemic heart disease not apparent at rest. Likewise, it is recommended for patients with greater clinical risk fac to rs or those undergoing high-risk surgery (179). These patients are at increased risk of developing cardiac complications in the perioperative period. In a study of patients undergoing peripheral vascular surgery, a high-risk group of patients was identified who had ischemic electrocardiographic changes when they exercised to less than 75% of their maximal predicted heart rate. In this group, the incidence of perioperative myocardial infarction was 25% and the overall cardiac mortality rate was 18. Conversely, no perioperative infarctions occurred in patients who were able to exercise to more than 75% of their maximal predicted heart rate and who had no electrocardiographic evidence of ischemia (181). The prognostic value of stress testing was not supported in another prospective study that found that only an abnormal preoperative resting electrocardiography result was an independent risk fac to r (182). The exercise stress test must be selectively applied to a high-risk population because its predictive value depends on the prevalence of the disease. It is not prudent to screen all patients preoperatively; it is preferable to rely on a careful his to ry to identify patients with symp to ms of cardiac disease for whom the test would be most predictive. Exercise stress testing is limited in some patients who cannot exercise because of musculoskeletal disease, pulmonary disease, or severe cardiac disease. Dipyridamole thallium scanning may be used to overcome the limitations of exercise stress testing. This study has a high degree of sensitivity and specificity but a low positive predictive value (179,183). It relies on the ability of dipyridamole to dilate normal coronary arteries but not stenotic vessels. Normally perfused myocardium readily takes up thallium when it is given intravenously. Conversely, hypoperfused myocardium does not show good uptake of thallium when scanned 5 minutes after injection. Reperfusion and uptake of thallium 3 hours after injection identify viable but high-risk myocardium. Several studies show an increasing risk of perioperative myocardial infarction dependent on the extent of reperfusion of thallium, or reversible defect, ranging from 3% to 49% (184,185). This method identifies regional cardiac wall motion abnormalities after dobutamine infusion to identify patients at high risk for cardiac events. Positive and negative predictive values are similar to those of dipyridamole thallium testing for a perioperative event (186,187). Dipyridamole-thallium testing is preferred for patients with known cardiac arrhythmias, and dobutamine is preferred for patients with bronchospastic lung disease and in those with severe cardiac stenosis (188). Coronary angiography should be considered only in patients who have an indication for angiography independent of the planned surgery, such as patients with acute coronary syndromes, unstable angina, angina refrac to ry to medical therapy, or high-risk results on noninvasive testing. Controversy exists regarding the accuracy of these tests to provide prognostic information beyond what is obtained from clinical risk stratification for nonvascular procedures. Diagnostic testing should not lead to unnecessary additional testing or harmful delays in s urge ry. The American College of Cardiology and the American Heart Association present an updated detailed algorithm that incorporates risk-fac to r stratification to guide clinicians to proceed directly to surgery, to delay surgery and obtain preoperative noninvasive testing, or to attempt risk fac to r modification (179). It is rare for patients who are younger than 50 years and who do not have diabetes, hypertension, hypercholesterolemia, or coronary artery disease to suffer a perioperative myocardial infarction. In contrast, patients with coronary artery disease are at increased risk of myocardial infarction in the pos to perative period. Prevention, early recognition, and treatment are important because myocardial infarctions that occur in the pos to perative period have mortality rates of up to 25% and are associated with increased rates of cardiovascular death in the 6 months following surgery (189). Nearly two-thirds of pos to perative myocardial infarctions occur during the first 3 days pos to peratively (189). Although the pathophysiologic fac to rs are complex, the causes of pos to perative myocardial ischemia and infarction are related to decreased myocardial oxygen supply coupled with increased myocardial oxygen requirements. In pos to perative patients, conditions that decrease oxygen supply to the myocardium include tachycardia, increased preload, hypotension, anemia, and hypoxia (190). Conditions that increase myocardial oxygen consumption are tachycardia, increased preload, increased afterload, and increased contractility. Tachycardia and increased preload are the most important causes of ischemia, because both conditions decrease oxygen supply to the myocardium while simultaneously increasing myocardial oxygen demand. Tachycardia decreases the dias to lic time, which, when the coronary arteries are perfused, decreases the volume of oxygen available to the myocardium. Increased preload increases the pressure exerted by the myocardial wall on the arterioles within it, thus decreasing myocardial blood flow. Other fac to rs associated with perioperative myocardial ischemia include physiologic responses to the stress of intubation, intravenous or arterial line placement, emergence from anesthesia, pain, and anxiety. These stresses result in catecholamine stimulation of the cardiovascular system, resulting in increased heart rate, blood pressure, and contractility, which may induce or worsen myocardial ischemia. Loss of intravascular volume because of third spacing of fluids or pos to perative hemorrhage can induce ischemia. Chest pain, which is present in 90% of nonsurgical patients with myocardial infarction, may be present in only 50% of patients with pos to perative infarction because myocardial pain may be masked by coexisting surgical pain and the use of analgesics (175). It is important to maintain a high level of suspicion for pos to perative infarction in patients with coronary artery disease. The presence of arrhythmia, congestive heart failure, hypotension, dyspnea, or elevations of pulmonary artery pressure may indicate infarction and should prompt a thorough cardiac investigation and electrocardiographic moni to ring. Many patients will exhibit P-wave changes that spontaneously resolve and do not represent ischemia or infarction. In a review of over 2,400 patients, the sensitivity of predicting pos to perative cardiac events was 55% to 100%, specificity 37% to 85%, positive predictive value 7% to 57%, and negative predictive value 89% to 100% (192). Pos to perative management of patients with coronary artery disease is based on maximizing delivery of oxygen to the myocardium and decreasing myocardial oxygen utilization. Anemia is detrimental because of loss of oxygen-carrying capacity and resultant tachycardia and should, therefore, be carefully corrected in high-risk patients. Although transfusion criteria are not absolute, all patients with a hemoglobin less than 6 mg/dL, and hemoglobin of 6 to 10 mg/dL with significant cardiac risk fac to rs should be offered blood transfusion (193). Patients with coronary artery disease may benefit from pharmacologic control of hyperadrenergic states that result from increased pos to perative catecholamine production. Beta-blockers decrease heart rate, myocardial contractility, and systemic blood pressure, all of which are increased by adrenergic stimulation. Consider initiating and titrating beta-blockers in patients with coronary artery disease or high cardiac risk (as defined by the presence of more than one clinical risk fac to r) who are undergoing intermediate-risk surgery (155). Therapy should be initiated at least 1 week before surgery to allow for proper titration. The timing and optimal duration of beta-blocker therapy remains an area of uncertainty. Nevertheless, for patients already on beta-blocker therapy, they should continue it perioperatively because abrupt withdrawal results in a rebound hyperadrenergic state. Prophylactic use of other agents such as nitroglycerin and calcium-channel blockers remains controversial, as data did not show a consistent benefit to ward reducing risk of ischemic cardiac events. The pos to perative development of pulmonary edema may be associated with a high mortality rate, especially if it occurs in the setting of cardiac ischemia (198,199). Treatment usually relies on aggressive diuretic therapy, although care must be taken to avoid dehydration, which may result in hypotension during the induction of anesthesia.

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These infants would get their tracheoesophageal fistulas ligated prior to the definitive esophagoesophagos to my. Fistula ligation would decrease the contamination of the respira to ry tract from the s to mach. The typical repair consists of a posterolateral thoraco to my on side opposite aortic arch. We wait 6-12 weeks to attempt to repair these babies in order to achieve primary esophageal anas to mosis. Bolus feeds are given to the babies in temporal synchrony with oral stimulation, to train them in to associating feeding with feelings of satiety. Bolus feedings also enlarge the s to mach, and potentially distends and elongates the distal esophageal remnant. If unable to achieve primary esophageal continuity and reluctant to do primary esophageal replacement, cervical esophagos to my can be performed. The proximal esophageal pouch brought out on left neck allowing salivary secretions to drain and not be aspirated in to the lungs. An esophagos to my au to matically buys an eventual esophageal replacement with s to mach or colon. A Fogarty balloon catheter is inserted in to fistula and passed in to the esophagus. The most experienced person should intubate these babies since repeated intubations can damage either the tracheal or esophageal repair. When suctioning of salivary secretions is needed, the tip of the catheter should only reach the posterior pharynx proximal to esophageal anastamosis (shallow suctioning). Other maneuvers to decrease the tension on the anas to mosis include mechanical ventilation for 3-5 days, with chin- to -chest position. Notably, there are no data to support that these actually promote anas to motic healing. The drain is left in place until there is fluoroscopic confirmation that the anas to mosis is intact and there is no leak. Alternatively, a small orogastric feeding tube can be passed at the time of the operation, and low volume feedings in to the s to mach. If a leak is seen, feeds are held until another contrast esophagram documents an intact anas to mosis (usually 7 days 388 later). If the baby, shows discoordinated oral mo to r skills, he or she may need evaluation by speech therapy Evaluation for other anomalies should be completed. The wider the gap between the upper and lower esophagus portends higher leak rates. Leaks are documented during esophagrams scheduled at a pre-determined time after repair. In contrast, anas to motic disruptions are symp to matic and present with pneumothorax and/or hydrothorax. The leak from the anas to mosis is large enough that the thoracic drain cannot handle the salivary secretions and swallowed air. It requires surgery to make certain that the area is adequately drained, and the lung is able to inflate fully. An attempt a re-doing the repair is usually not done, since the tissues are often friable and contaminated. Any leaks associated with esophageal anas to mosis increases the likelihood of a stricture. Esophageal strictures are sually seen 2-6 weeks post-operatively and present with inability to handle secretions, apnea/bradycardia episodes (from oropharyngeal aspirations). The causes of strictures are multifac to rial and may include anas to motic tension, local vascular insufficiency, and tissue fragility leading to leak. Baloon dilation is the current standard of care and may be required several times. Surgeons attempt to put intervening tissue or graft(Surgisys) between the tracheal repair and the esophageal anas to mosis to prevent this complication. Tracheomalacia is one of the differential diagnoses in children with apenea and bradycardia episodes after definitive surgery. A rigid bronchoscopy in a spontaneously breathing child is required to make the diagnosis of tracheomalacia; the posterior trachea coapts with the anterior trachea during expiration. If tracheomalacia is severe, an aor to pexy (aorta is pexed to the underside of the sternum) may be necessary. It is hypothesized that the distal esophageal dissection added to the cephalad pull on the distal esophagus straightens out the gastroesophageal junction, leading to increased reflux in this population. If reflux leads to recurrent aspiration pneumonias, significant apnea, emesis leading to failure to thrive, repeated episodes of anas to motic stricture, a fundoplictaion may be necessary. It is thought that this may be due to the natural disappearance of the right umbilical vein during the course of fetal development. Associated anomalies are rare except for intestinal atresia (10-15%) of cases Risk fac to rs include maternal use of to bacco, salicylates, pseudoephedrine, or phenylpropanolamines during the first trimester. Management in the Delivery Room In the delivery room, an airway if infant in respira to ry distress. The intestines should be handled gently making sure that the mesentery is straight. The bowel is placed on to p of abdomen without tension to avoid impediment to venous drainage and to avoid inducing bowel edema and injury. The baby should be have his legs placed in a plastic bag (bowel bag) or if this is not 391 available, the bowel should be carefully wrapped in warm saline-soaked gauze. The decision whether the abdominal wall is closed or a silo is placed depends upon the physiologic ramifications of having the intestines inside. Post-operative Management: Primary Abdominal Closure: the baby is extubated as soon as possible. The baby requires sedation and pain medication about 15 minutes before the reduction. Apply gentle pressure on the intestines, pushing the intestines about 2-3 cm during each reduction. Keep the silo vertical by securing the bag with another umbilical tape to the to p of the bed. Unlike gastroschisis, the defect is contained within umbilical cord, unless ruptured. If the sac is not ruptured, carefully wrap herniated viscera in warm saline-soaked Kerlix. If a ruptured omphalocele is present, the initial management is similar to gastroschisis. A sepsis work-up should be considered, especially in ruptured omphalocele patients. Administration of intravenous antibiotics such as ampicillin and gentamycin should be considered. This should include a cardiac echocardiogram, renal ultrasound, and chromosomal studies. Operative Considerations If the defect is small (3cm or less), primary closure can be achieved easily. The baby with giant omphalocoele is often able to breathe without support and eat without any problems.

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Thiazolidinediones increase insulin sensitivity in muscle resulting in lower circulating glucose concentrations. Thiazolidinediones, rosiglitazone (Avandia) and pioglitazone (Ac to s), decrease fasting plasma glucose by 30 to 60 mg/dL and decrease HbA1c level by 1% to 1. Rosiglitazone and pioglitazone may be used for monotherapy or in combination with metformin or a sulfonylurea or insulin. Thiazolidinediones are no more effective than metformin, and they should be used only in patients who have contraindications to metformin. Adverse effects of thiazolidinedione therapy include weight gain and peripheral edema. Expansion of the extracellular fluid space can occur, and anemia is occa sionally seen. Diet, weight loss, and exercise remain the most important initial steps in the management of type 2 diabetes. Pharmacologic therapy is manda to ry for patients who are unable to achieve glycemic control with lifestyle modifications or who have significant symp to ms. Lean patientswith type 2 diabetes usually have insulin deficiency as the predominant feature, and a sulfonylurea is recommended in this subgroup. If control remains suboptimal, metformin or an alpha-glucosidase inhibi to r may be added. First-line therapy with metformin is also reasonable, especially if glucose levels are only mildly elevated, because risk of hypoglycemia in these patients is increased with sulfonylurea therapy. Metformin should be considered the first-line agent because of the weight loss and lack of hypoglycemia. If control is suboptimal with metformin, the addition of a thiazolidinedione may be beneficial. If adequate control cannot be achieved with two drugs, the addition of a third oral agent should be considered. Alternatively, insulin could be added or substituted entirely (a patient who is 20 percent above ideal body weight and has a fasting blood glucose of 180 mg/dL should be started on a to tal dose of 21 units per day). Pharmacotherapy of Type 2 Diabetes Agent Starting Maximum Comments dose dose Sulfonylure as 5 mg daily 20 mg twice May cause Glipizide daily hypoglycemia, (Glucotrol) 2. Glyburide daily 10 mg twice Maximum dose (DiaBeta, daily should be used Micronase only in combi) 1 mg daily nation with in Glimepirid 8 mg daily sulin therapy e (Amaryl) Biguanide Do not use if Metformin 500 mg 850 mg serum (Glucopha daily three times creatinine is ge) daily greater than 1. Treatment of type 1 diabetes mellitus Goals of intensive diabetes treatment Premeal Postpran Bedtime Hemoglobin blood glu dial (ie, glucose A1c (HbA1c) cose level mealtime) level level glucose level 90 to 130 120 to 180 110 to 150 Less than mg/dL mg/dL mg/dL 6. Looser control may be appropriate in young children; elderly patients with active cardiac, cognitive, or visual disorders; and patients who (1) have hypoglycemic unawareness or recurrent severe hypoglycemia, (2) abuse alcohol or drugs, (3) have poor social support, or (4) have diabetes resulting from combined exocrine and endocrine pancreatic failure. Looser control is also indicated in patients in whom a hypoglycemic event might put them or others in danger (eg, bus drivers). Over time, patients who have type 1 diabetes without intercurrent illness typically need 0. Initiating Insulin Therapy in a Patient with Newly Diagnosed Type 1 Diabetes the to tal daily insulin dosage is 0. Two-thirds of the to tal daily insulin dose may be given 20 to 30 minutes before breakfast and one-third of the dose may be given 20 to 30 minutes before the evening meal. Pharmacokinetic properties of types of insulin Dura Type of Peak tion Dosing insulin Onset effect of interval ac tion Mealtime Insulin Lispro 30 (Humalog) 5-15 min-1. In patients with type 2 diabetes in whom oral agents have failed, the starting dose of N insulin is 0. The to tal insulin dose required in obese patients with type 2 diabetes aver ages 1. Lispro insulin is superior to regular insulin in controlling postprandial glucose spikes when given in addition to a background insulin. Other advantages of lispro insulin are that it can be injected anytime from 15 minutes before to shortly after the meal, and it carries less risk of hypoglycemia and weight gain. Glargine insulin is a human insulin that is slowly released, resulting in a relatively constant concentration over 24 hours with no pronounced peak. When patients are switched to glargine from twice-daily N insulin, it is suggested that 10% to 20% less glargine be given than the previous daily to tal dose of N insulin. Because of its consistency and prolonged action, glargine is a superior background insulin. Near-normoglycemia usually requires two to four daily injections or use of the insulin pump. However, some active adolescents do best on a 60:40 ratio, whereas more sedentary adults might need a 40:60 ratio. Hypothyroidism Hypothyroidism is second only to diabetes mellitus as the most common endocrine disorder, and its prevalence may be as high as 18 cases per 1,000 persons in the general population. The disorder becomes increasingly common with advancing age, affecting about 2 to 3 percent of older women. Hypothyroidism also occurs after treatment of hyperthyroidism by either surgical removal or radioiodine ablation. Less common causes of hypothyroidism include congenital dyshormonogenesis, external radiotherapy, infiltrative diseases, such as amyloidosis, and peripheral resistance to thyroid hormone action. Symp to ms and signsof hypothyroidism include fatigue, weight gain, muscle weakness and cramps, fluid retention, constipation, and neuropathy (eg, carpal tunnel syndrome). Severe hypothyroidism may be associated with carotenemia, loss of the lateral aspect of the eyebrows, sleep apnea, hypoventilation, bradycardia, pericardial effusion, anemia, hyponatremia, hyperprolactinemia, hypercholesterolemia, hypothermia, and coma. When symp to ms are nonspecific, a follow-up assessment of the free thyroxine (T4) level can help distinguish between primary and secondary hypothyroidism. Most otherwise healthy adult patients with hypothyroidism require thyroid hormone replacement in a dosage of 1. In young patients without risk fac to rs for cardiovascu lar disease, thyroid hormone replacement can start close to the target goal. In most healthy young adults, replacement is initiated using levothyroxine in a dosage of 0. Levothyroxine (Synthroid) should be initiated in a low dosage in older patients and those at risk for cardio vascular compromise; the usual starting dosage is 0. In patients with pituitary insufficiency, measurements of free T4 and T3 levels can be performed to determine whether patients remain euthyroid. In patients at higher risk for osteoporosis or fractures, the deleterious effects of excessive thyroid hormone can be avoided by withholding replacement until the free T4 and T3levels drop below normal. Thyroiditis Thyroiditis refers to a group of inflamma to ry diseases affecting the thyroid gland. Chronic lymphocytic thyroiditis is the most common inflamma to ry condition of the thyroid gland and the most common cause of goiter. Up to 95 percent of cases of chronic lymphocytic thyroiditis occur in women, usually between 30 and 50 years of age. The definitive indica to r of chronic lymphocytic thyroiditis is the presence of thyroid-specific au to antibodies in the serum. Because thyroiditis is usually asymp to matic, many patients do not require treatment. Lifetime replacement of levothyroxine is indicated in hypothyroid patients, at a starting dosage of 25 to 50:g per day, with gradual titration to an average daily dosage of 75 to 150:g. Subacute lymphocytic thyroiditis occurs most often in the postpartum period but may also occur sporadically. Antimicrosomal antibodies are present in 50 to 80 percent of patients, while antithyroid peroxidase antibodies are present in nearly all patients. Subacute lymphocytic thyroiditis starts with an initial hyperthyroid phase, followed by subsequent hypothyroidism and, finally, a return to the euthyroid state. In the postpartum patient, thyro to xicosis usually develops in the first three months following delivery and lasts for one or two months. Patients usually present with tachycardia, palpitations, heat in to lerance, nervousness and weight loss. If the hypothyroid phase lasts longer than six months, permanent hypothyroidism is likely. Subacute granuloma to us thyroiditis is the most common cause of a painful thyroid gland. It is most likely caused by a viral infection and is generally preceded by an upper respira to ry tract infection.

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A2541 12:00-1:00: authors will be present for discussion with assigned facilita to rs P1494 Persistent Hyperventilation Following High Altitude Facilita to r: D. Johnson, Chermside, P798 Correlation of Ventila to ry Limitation and Exercise Capacity Australia, p. A2550 P1495 Ventila to ry Chemoreflexes in Individuals of Himalayan Ancestry Residing at Sea Level/E. A2543 Parameters During Cardiopulmonary Exercise Testing in Obese Patients with Dyspnea/L. P800 Breathing Index During Cardiopulmonary Exercise Testing in Stampfli, Winnipeg, Canada, p. A2544 Patients with Dyspnea and Its Relation to Spirometric Indices and Breathing Reserve/L. A2552 P1497 Chronic E-Cigarette Exposure Increases Oxidative Metabolism P801 Forced Vital Capacity and Gas Exchange Parameters During in Murine Skeletal Muscle/S. A2554 P1499 Acute Effects of Electronic Cigarette Use on Lung Functions in Healthy and Asthmatic Individuals/M. A2547 P803 Impact of Age on the Outcome of Cardiopulmonary Exercise Testing in the Evaluation of Dyspnea/T. A2555 Hyperresponsiveness and Pulmonary Inflammation Induced by Acute Exposure to Ozone/R. A2556 P1501 Increased Airway Narrowing Capacity of Bronchial Segments from Preterm Lambs in an Ovine Model of Chorioamnionitis/A. Noble, Crawley, Failure: Dynamic Hyperinflation or Impaired Inspira to ry Muscle Australia, p. Neder, Por to Alegre, Brazil, P1502 A Modified Algorithm for Chronic Mountain Sickness p. A2557 Screening Through Noninvasive Hemoglobin Assessment: A Cross-Sectional Study in Puno Region, Peru/R. A7594 Op to electronic Plethysmography to Isolate Respira to ry Motion During Exercise/A. A2559 the information contained in this program is up to date as of March 9, 2017. A2560 P821 Usefulness of Measuring Oxygen Pressure in Mask-Inspired Gas to Evaluate Alveolar-Arterial O2 Difference While P810 An Improved Model and Method for Calculation of Breathing 100% Oxygen/C. Shindoh, Sendai, Japan, P823 Order in the Chaos: Can Variability Analysis of Respira to ry p. A2564 Area H, Hall B-C (Middle Building, Lower Level) Viewing: Posters will be on display for entire session. A2566 P842 Use of Non-Invasive Mechanical Ventilation to Prevent Hypoxia P816 Pitfalls in Using Paired Stimulations of the Femoral Nerve to During Bronchoscopy in Patients with Sleep Apnea or at High Quantify Quadriceps Force/G. A2576 P817 Evaluation of Function and Regional Lung Ventilation of P843 Res to ration of Sleep Quality Using a Novel Biomimetic Morbidly Obese Women Through the Electrical Impedance Pro to col for the Resolution of Obstructive Sleep Apnea/ Tomography/S. A2578 the information contained in this program is up to date as of March 9, 2017. A2580 Discussion: 11:15-12:00: authors will be present for individual discussion Facilita to rs: K. A2592 P860 A Case of Positive Pressure Ventilation in Bullous Lung P849 Comparison of Objective Adherence and Effectiveness Disease/D. Teo, Metro Manila, Philippines, P850 Characterizing Site and Severity of Upper Airway Collapse to p. A2594 Guide Patient Selection for Oral Appliance Therapy for Obstructive Sleep Apnea/M. P862 Crazy Little Thing Called Love(s Park): An Unusual Case of Taran to Montemurro, A. A2595 P851 Evaluation of Au to mated Oxygen Flowrate Titration (FreeO2)in P863 Lacrimal Duct Air Regurgitation in a Patient on Continuous a Model of Induced Cyclic Desaturations in Healthy Subjects Positive Airway Pressure Therapy/M. Sankaran, Norwich, P852 Developing a Novel Minimally Invasive Surgical Approach to United Kingdom, p. A2597 the Base of Tongue for Implantation to Treat Obstructive Sleep Facilita to rs: E. A2600 P854 Oxy to cin Decreases the Durations of Hypopneas in Patients with Obstructive Sleep Apnea/V. A2602 P870 Supranormal Expira to ry Airflow After P856 Upright Posture Mitigates Hypoxemia in Peruvian Bilateral-Lung-Transplantation: Two Cases with Two Different Highlanders/L. A2590 the information contained in this program is up to date as of March 9, 2017. P883 Comparison Between Radiological and Clinical Neck Discussion: 11:15-12:00: authors will be present for individual discussion Circumference Measurements/A. A2616 P872 the Effects of Anthropometric Parameters on Screening P885 Gender Differences in Polysomnographic Findings in Egyptian Obstructive Sleep Apnea Using Breathing Sounds During Patients with Obstructive Sleep Apnea Syndrome/H. A2605 P886 Evaluation of a Contact Free Moni to ring Technology for Measurement of Obstructive Sleep Apnea/Z. Kimoff, P887 Poor Inter-Rater Reliability in Interpretation of Overnight Montreal, Canada, p. A2607 P889 High Resolution Pulse Oximetry as an Outcome Predic to r in P876 Accuracy of Non-Dipping Blood Pressure in Predicting Stroke/A. Genta-Pereira, P890 Impact of Skeletal Muscle in Patients with Obstructive Sleep D. P891 Is Overnight Fluid Shift Clinically Detectable in Obstructive Lorenzi-Filho, E. P878 Investigating the Effects of Pharyngeal Tissue Content on Redolfi, Paris, France, p. A2611 P880 Pulse Transit Time in Pregnant Women with and Without Obstructive Sleep Apnea/B. A2612 the information contained in this program is up to date as of March 9, 2017. Assemblies on Thoracic Oncology; Behavioral Science and Health Services Research; Clinical Problems 11:45 a. Grand Ballroom North (Ballroom Level) Outcomes research and quality improvements in lung cancer use a range of data sources including clinical trials, administrative and insurance-linked registries. At the 2017 forum information, requirements that demand much of routinely collected clinical data. Perez-Stable, who was named to this position in clinicians, registry data are not clinically relevant, despite the high levels of 2015, has been called "a highly respected leader with rich experience in expenditure and effort required for their collection. Target Audience Practicing internists and subspecialists in Pulmonary, Critical Care, and Sleep Pre-registration is required. This symposium is intended to assist clinicians with established global health careers. The end of the session will provide Q&A time to allow participants to interact directly with faculty. The session will also Catholic University (Level M1) elucidate how understanding alveolar cells and intracellular communication forms the lung and informs the processes altered in disease. Each speaker will review recent studies, discuss current gaps and highlight implications to clinical practice and future research. The session will be this session will review the current state of knowledge in critical care. The audience will participate though interactive questions that are tallied electronically. Additional discussion by 2:15 Introduction presenters and master panelists will enhance the educational experience. Papers presented will be recent publications, selected by the edi to rs, to At the conclusion of this session, the participant will be able to : be of significant importance to the field of critical care medicine. Room 207 A-B (South Building, Level 2) Learners will have the opportunity to observe master clinicians approach Chairing: J. Collaboration with a master radiologist reviewing the films and a master pathologist reviewing pathology slides will demonstrate the Speakers And Talks To Be Announced the information contained in this program is up to date as of March 9, 2017.

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For these organisms, alternate diagnostic approaches must be used, such as immunologic methods, cell culture, and molecu lar diagnostics (see the following). Viruses and some other microorganisms are obligate intracellular pathogens and, as such, cannot be cultivated using the techniques described previously. For instance, respira to ry syncytial viruses cause fusion of cells to produce multinucleated giant cells, termed syncytia. Some viruses produce proteins that are expressed on the membrane of infected cells. These viral proteins bind erythrocytes, which can be detected by testing for hemadsorption or hemagglutination. It is not always possible to isolate a microorganism in culture or visualize it microscopically. In such cases, immunoassays are often used to detect the presence of a particular agent. In general, immunoassays involve one of two main principles: testing for the presence of specific microbial antigens or testing for specific microbial-antigen antibodies. These assays may involve the detection of a microbial antigen directly from a clinical specimen or the detection of a specific antigen once an organism is cultured in vitro. If the antigen is present in the specimen, a bright yellow-green fiuorescence will be seen under a fiuorescent microscope. While microscopy, culture, and phenotypic character ization remain the mainstay for microbial identification in most labora to ries, advances in molecular techniques have resulted in improved speed, sensitivity, and specificity for identification of some infectious microorganisms. Despite improving the ability to make some diagnoses, most molecular techniques are used more as research to ols rather than as a standard-of-care test. Applications of molecular methods for infectious disease testing include the identification of microorganisms or the detection of fac to rs used to moni to r dis ease or predict outcome. Such fac to rs include antimicrobial resistance genes, virulence fac to rs, and quantitation of microorganisms. Nucleic acid probe technology is based on the selection of unique genomic sequences for a particular group of etiologic agents or specific genes with subsequent cloning, synthesis, and utilization. Hybridization is detected by labeling the probe with radioiso to pes, enzymes, antigens, or chemiluminescent compounds 42 I. While molecular tests may be very sensitive tests for detecting microorganisms even at very low levels, one must consider that false positives from contamination (specimen or environmental) or false negatives from a failure of the detection process are possible. Furthermore, molecular tests only detect known, previously identified gene sequences. Recent and novel mutations in microorganisms may not be readily detected by common commercial molecular assays, as those have to be first modified to have the ability to detect the novel genetic-altered microorganism. Finally, from a financial perspective, molecular diagnostics are often more costly than traditional culture based identification methods. Microbiology labora to ries have to take cost analyses in to consideration when deciding whether to implement molecular test methods. However, such methodologies are useful in situations in which culture-based tech niques are unable to recover the organism in vitro, or for instances when current labora to ry methods may have low sensitivities and specificities or are simply to o time-consuming with long turnaround times for test results. The microbiology labora to ry plays an essential role in the diagnosis, prognosis, and ultimately the treatment of patients with infectious diseases. Therefore, the detection and identification along with determi nation of antibiotic susceptibility require multiple tests or combinations of tests for confirmation of the infectious etiology of a disease. Defined previously with the most common etiologies within three main categories: infection, malignancy, or collagen vascular disease. Usually a fever occurring in a patient who has been hospi talized for at least 24 hours without a defined source prior to admission or 3 days of evaluation. A recurrent or persistent fever in a patient with neutrope nia (absolute neutrophil count less than 500 cells/mm3 or 0. The more common etiologies include nosocomial etiologies (as mentioned previously) as well as opportunistic bacterial infections (see the following), aspergillosis, candidiasis. Tuberculosis (Mycobacterium tuberculosis; pulmonary and extrapulmo nary disease; see Chapter 14) 2. Sinusitis (most commonly with chronic infections or hospitalized patients with nasogastric tubes) 4. Dental abscess (usually oral bacterial fiora and may or may not be associ ated with a recent dental procedure) 5. Prostatitis (especially with a recent prostate procedure and is characterized by chronic pelvic pain) 9. Q fever (Coxiella burnetii; associated with exposure to farm animals [cat tle, sheep, or goats] and is characterized by fiu-like symp to ms with fevers, pneumonia, and hepatitis) 15. Brucellosis (Brucella spp; associated with exposure to animals [goats, sheep, bison, or swine] and is characterized by intermittent fevers, gastroin testinal symp to ms [e. Lep to spirosis (Lep to spira interrogans; usually associated with rodents or colonized dogs [the organism resides in the renal tubules and is shed in the urine] during recreational activities and is characterized by malaise, headaches, myalgias, abdominal pain, and conjunctival erythema) 17. Psittacosis (Chlamydophila psittaci; usually associated with birds, espe cially parrots, and is characterized by fevers, chills, malaise, myalgias, and nonproductive cough) 18. Malaria (Plasmodium spp; transmitted by the Anopheles mosqui to and usu ally characterized by periodic fevers, chills, and rigors) 19. Leishmaniasis (a group of obligate intracellular parasites that are transmit ted by sand fiies [genera Phlebo to mus and Lutzomyia]; commonly associ ated with cutaneous lesions [e. Babesiosis (Babesia spp; an intraerythrocyte parasitic infection transmitted by the bite of an Ixodes tick and characterized by fevers, chills, night sweats, fatigue, weakness, and anemia) 21. Enteric fever (Salmonella enterica, serovar Typhi; associated with travel and characterized by fevers, headaches, myalgias, malaise, and gastrointes tinal pain) 22. Toxoplasmosis (Toxoplasma gondii; most commonly a reactivation infec tion in immunocompromised patients) 23. Rat-bite fever (Strep to bacillus moniliformis; patients have an exposure to rats and the disorder is characterized by fevers, headaches, chills, polyar thralgias, and a maculopapular rash on the hands and/or feet) 24. Cat scratch disease (Bar to nella henselae; a disorder characterized by fevers and localized adenopathy with an exposure to cats) 25. Whipple disease (Tropheryma whippelii; a disorder characterized by fevers, arthralgia, abdominal pain, chronic diarrhea, weight loss, and generalized lymphadenopathy) 26. Cryp to coccus neoformans (commonly associated with chronic corticoste roid use or immunocompromised patients and usually presents as fevers with meningitis or pulmonary pneumonia) 29. Aspergillosis (Aspergillus spp; opportunistic pathogens that can be associ ated with fevers and pulmonary cavities or endocarditis) 30. Candidiasis (Candida spp; opportunistic pathogens that can be associ ated with fevers and catheter infections, endocarditis, or hepa to splenic candidiasis) B. Pancreatic carcinoma (most commonly not associated with biliary or pan creatic duct obstruction) 7. The fever usually resolves within 2 to 5 days of discontinuation of the medication. Antibiotics (penicillin, cephalosporin, sulfonamide, tetracycline, and rifampin) b. Defined as a fever with two peaks within 24 hours; conditions to consider include endocarditis, malaria, military Mycobacterium tuberculosis, adult Still disease, and leishmaniasis. Consider Mycobacterium tuberculosis, polyarteritis nodosa, brucellosis, or salmonellosis. Physicians must be meticulous and systematic when obtaining information for the following key elements: 1. While most patients exhibit atypical manifesta tion, it is important to establish in chronological fashion the onset of symp to ms and events that may be related to the fever. This area should focus on any recent or chronic medical illness or infection; any prior diagnosis of malignancy; any prior surgery or complication related to surgery; and any implanted prosthetic device, prosthetic valve, pacemaker or implantable defibrilla to r, cosmetic implanted surgical device, indwelling venous catheter, or implanted vascu lar graft. A complete list of prescription, over-the-counter, and herbal medications should be documented. Medication allergies may suggest a drug fever while environmen tal allergies may suggest an a to pic condition.

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This variation is impacted largely by the mechanism of transmission, the number of parasitized individuals in the area, the adequacy of public health measures to handle human and animal waste, and the ability of public health measures to provide clean drinking water for inhabitants of the area (27, 28). The prevalence of many gastrointestinal parasitic infections is therefore great in resource poor countries that have a high burden of disease and inadequate public health facilities to handle waste and provide clean drinking water (28). The mechanism of transmission is important for predicting which types of parasites are likely to be encountered. For example, one expects to encounter patients infected with Enterobius vermicularis in both resource-rich and resource-poor countries given that the eggs are infectious soon after passage and child- to -child transmission is possible either directly or through fomites. In contrast, one is far less likely to encounter hookworm infections in locales where shoes are common than in areas where the citizens are often barefooted. The number of parasitized individuals in the community affects the likelihood of infection or reinfection due to the increased number of opportunities for infection. For example, a child with pica in an area of low endemicity is less likely to acquire an infection by a geohelminth, such as Trichuris or Ascaris, than a similar child in an area where parasites are highly endemic because they are more likely to encounter parasite eggs in the dirt. Additionally, the areas that have large numbers of infected individuals are often resource poor and unable to appropriately handle human waste, so contam ination of the environment and subsequent infections become the norm. Resource-rich countries that adequately handle human waste significantly diminish the likelihood that parasitic cysts and eggs that originate from a human source will contaminate the environment, the food supply, or the drinking water. Therefore, it is imperative that in addition to wastewater treatment being employed, modern drinking water treatment be em ployed. Failures in the system responsible for clean drinking water, which we often take for granted, demonstrate how important these systems are in public health. When the fac to rs described above are considered, the list of gastrointestinal patho gens that one may expect to find in a citizen of the United States or another resource-rich country is very different from those encountered in an infected individual from a resource-poor region of the world where parasites are highly endemic. Trends in immigration may bring patients from countries where parasites are endemic who present with otherwise-rare or -infrequent pathogens. Additionally, travel is easier than ever, and adventurous excursions can place individuals at risk for infections that are uncommon in their home locale. Medical Education and Consultation Related to Human Parasitic Infections the expansion of medical knowledge in the past decade is incredible. The medical profession has responded through increased specialization and subspecialization. In the past, a surgeon might specialize as an orthopedic surgeon, whereas now, it is common to find practices with individuals who specialize in only knee or hip disease. Therefore, it is unreasonable to expect individuals who are not subspecialty trained in January 2018 Volume 31 Issue 1 e00025-17 cmr. A clinical parasi to logist or clinical microbiologist with expertise in parasi to logy is perfectly positioned to help educate physicians and provide guidance in test selection. These labora to rians, whenever possible, should participate in educating the next generation of physicians, not just to teach them at that point in their career but also to inform them that highly trained labora to rians remain available to assist them as needed throughout their professional careers. Additionally, this group should participate, whenever possible, in medical technology training programs. This training should go beyond the basic training of specimen processing, testing, and results reporting and should include preparing the technologist for his/her role as an integral member of the health care delivery team. A clinical microbiologist should work with the medical staff to formulate the test requisition forms, which are largely becoming solely electronic. They should work to aid clinicians in finding and using the most appropriate test for the clinical scenario encountered (see below). They should play an active role in moni to ring test utilization and use instances of inappropriate utilization as opportunities for education. Importance of a Complete Patient His to ry (Physician and Diagnostic Labora to ry) the importance of location in determining the type of parasite that the patient may have acquired has been noted above and should be disclosed as part of taking a thorough his to ry. It remains remarkable after many years of practice and attendance in infectious diseases/microbiology teaching conferences how often the clues to the definitive diagnosis were present in the clinical his to ry or, unfortunately, should have been present had a thorough clinical his to ry been taken. The clinical his to ry is designed to discover epidemiologic risk fac to rs that are important for guiding testing. In addition to general aspects of a his to ry assessment, specific questions concerning past medical his to ry, countries of previous residence, travel, outdoor activities, family, food, and drinking water should be addressed. It is very common to find evidence of multiple gastrointestinal parasites in the s to ols of children who have been adopted from a resource-poor country where parasites are highly endemic in to a low-prevalence, resource-rich coun try (31). If the his to ry did not include the location of prior citizenship, then an ova and parasite examination (O&P) of the s to ol may not have been performed, as the individual may have been asymp to matic. Note that, technically, parasite eggs rather than ova are examined; however, the abbreviation O&P remains conventionally accepted. Although there are no accepted general guidelines in these cases, routine parasi to logy exami nations (ova and parasites) may be an appropriate option. Travel his to ry similarly discloses potential risks to the traveler (Cyclospora, Mexico), as does questioning about specific outdoor activities (Cryp to sporidium, swimming in late summer, contact with calves). A his to ry of backpacking and drinking stream water is classically associated with giardiasis, for example. Family his to ry and past medical his to ry are important to disclose inherited genetic diseases or other conditions that may put patients at increased risk for certain parasitic diseases. For example, individuals with common variable immunodeficiency are at increased risk for Giardia lamblia (G. Food and drink his to ries are among the most important, since many parasitic infections are acquired through ingestion. For example, the discovery that a patient is a bear hunter would make one consider January 2018 Volume 31 Issue 1 e00025-17 cmr. Clinical Microbiology Reviews trichinellosis, when in the absence of a classical presentation it might otherwise not be considered (33). It should be recognized that not all labora to ries offer the same types of services. Physician ofice-based labora to ries may offer no parasi to logy but should have clear guidelines regarding the best test to perform for each clinical scenario and the materials for appropriate specimen collection and shipping. Small hospital labora to ries may offer limited parasi to logy, the degree of which should be determined by test volume and technologist competency. It is important to critically assess competency for very low-volume tests, as it is dificult to remain proficient if testing is not commonly performed. In instances of low-volume testing, it may be better for the patient if the test is referred to a reference labora to ry where expertise is maintained. The performance of a full ova and parasite examination should be based on skill and competency. Many of the newer multiplex molecular diagnostic assays for gastrointes tinal pathogens include some parasite pathogens, such as Giardia lamblia (G. These are moderately or highly complex tests and represent options for expanded testing in small labora to ries that may lack parasi to logy expertise. Large hospital labora to ries and reference labora to ries should offer full parasi to logy services. These include enzyme immunoassays, full ova and parasite examination, modified acid-fast staining for Cryp to sporidium, Cyclospora, and Cys to isospora, modified trichrome staining for microsporidian species, and the ability to identify adult helminths that may be passed in the s to ol. These labora to ries will often also offer advanced molecular diagnostics for parasites. Thorough competency assessments are necessary, and participation in challenging parasite proficiency testing should be ongoing. The test menu should include the options available for each clinical scenario that are most commonly encountered. These options are many, and it is likely that a busy clinician may not always review these options thoroughly, which might lead to inappropriate test orders. If the wrong selection is discovered and the correct test is eventually performed, then the diagnosis is delayed and there is waste in performing the initial incorrect test.

Syndromes

  • Uncontrollable eye movement (nystagmus)
  • Damage to the artery in the groin, which may need urgent surgery
  • General discomfort or sick feeling
  • Smoking (smokers are more likely to have such hearing loss than nonsmokers)
  • Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil) and naproxen (Aleve), acetaminophen (Tylenol), or prescription painkillers to relieve cramping and pain.
  • Unusual movements
  • Alcoholism
  • Puffy eyes or face

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It can be an isolated occurrence or associated with other genetic and developmental abnormalities. The groups can be subdivided in to muscles of mastication (nervous supply: trigeminal nerve) and muscles of expression (nervous supply: facial nerve). Infranuclear lesions produce a lower mo to r neuron paralysis with both upper and lower facial muscles there is typically unilateral weakness. After piercing through the buccina to rs, it enters the oral cavity opposite the 2nd upper molar to oth Submandibular Gland Mixed serous and mucous salivary gland. Dental health can be affected by a variety of problems, not least a poor diet, smoking and alcohol. Complications of dental disease include submandibular abscesses, deep neck space abscesses and are part of the differential diagnosis of acute to nsillitis and peri to nsillar abscesses. Inferiorly by the floor of mouth and mylohyoid Superiorly by the hard palate Figure 52: Oral cavity (reproduced with permission from O to laryngology Hous to n, The anterior triangle is bounded superiorly by the mandible, laterally by the sternocleidomas to id muscle and medially by the midline. The posterior triangle is bounded anteromedially by the sternocleidomas to id, inferiorly by the clavicle and posteriorly by trapezius muscle Fascial Layers of the Neck Superficial layer this layer forms a thin sheet of fascia that encircles the platysma muscle. Deep Layer consists of 3 separate layers: Investing layer (external) (Figure 54) It splits to invest the trapezius, sternomas to id and parotid, and its deeper layer invests the great vessels to form the carotid sheath. Pretracheal layer (visceral) (Figure 55) covers the salivary glands, muscles, thyroid gland and other structures located in front of the trachea Prevertebral layer (internal) (Figure 56) covers the prevertebral muscles. Oral Stage (voluntary) Oral prepara to ry Food bolus is formed and held in the anterior part of the oropharyngeal cavity. The oral cavity is closed posteriorly by the soft palate and to ngue to prevent leakage in to the pharynx Oral Propulsive the dorsum of the to ngue gradually propels the food bolus to the back of the oral cavity 2. The pharyngeal constric to r muscles contracts from to p to the bot to m, squeezing the bolus inferiorly 3. Oesophageal Stage the food bolus enters the upper oesophageal sphincter, which includes the cricopharyngeus muscle. This muscle relaxes at the arrival of the food bolus Peristalsis propels the food bolus at a rate of 4cm/s to wards the lower oesophageal sphincter which also relaxes Gravity aids peristalsis in the upright position Figure 57: Swallowing Physiology Taking His to ry of a Neck Lump Opening How old are youfi Past Medical and Surgical His to ry to include: Have you had any previous investigations for this neck lump Have you received any treatments for this lump Medication and Allergies Do you take any regular medicationsfi Social His to ry Ask about smoking & quantify Ask about drinking alcohol and quantify Red Flag Symp to ms for urgent referrals (with or without a neck lump) Unexplained neck lump that has changed over a period of 3 6 weeks Hoarse voice > 3weeks New onset dysphagia Unexplained persistent swelling in the salivary glands Otalgia > 4 weeks and normal o to scopy Unexplained persistent sore or painful throat Non healing ulcers White or red lesion in the mouth or oropharynx Causes of Neck Lump Commonest aetiology of lymphadenopathy relative to age Child / young adult: inflamma to ry > congenital > neoplastic Adult: inflamma to ry > neoplastic > congenital Older adult: neoplastic > inflamma to ry Branchial Cysts Description these present as upper neck masses in young adults, often in the third decade of life. Causes of dysphagia Extraluminal (external pressure on the pharynx and oesophagus) Neck mass. Other bacterial examples include Haemophilus influenza, Strep to coccus pneumonia and Staphylococci the latter being more associated with dehydration and previous antibiotic use. If symp to matic, particularly if risk of aspiration and recurrent pneumonia endoscopic stapling is the first line. Division of the cricopharyngeus is important in resolving the pathological abnormality causing the pouch. It is associated with laryngopharyngeal reflux (30%), cricopharngeal spasm and oesophagitis. Suspicious features on ultrasound include solid hypoechogenic nodules with microcalcifications, irregular margins, taller than wider, and lymphadenopathy. This can diagnose papillary carcinoma but cannot distinguish follicular adenoma (benign) from follicular carcinoma therefore the entire nodule must be assessed (by performing a diagnostic hemithyroidec to my). Removal of the only thyroid tissue in thyroglossal cysts renders patient hypothyroid. Multinodular goitre Epidemiology Commonest cause of goitre in the western world Cause Unknown aetiology. Pathologically can be hyperactive or atrophic Symp to ms Neck lump which can be asymp to matic Cosmetic deformity If very large pressure symp to ms. May be one dominant nodule Dullness on percussion of manubrium in retrosternal goitre Complications Mass effect/compression, cosmetic appearance Nodule haemorrhage. Non-operative Watch and wait Anti-thyroid drugs +/ beta-blockers if hyperthyroid (usually under the care of the endocrinologist) Operative If mass effect or suspicion of cancer. It is more common in women and risk fac to rs include radiation exposure and family his to ry. The order of prevalence is papillary, follicular, medullary, anaplastic thyroid cancer, as well lymphoma of the thyroid gland. Patient should undergo surgical resection of the nodule (lobec to my) to distinguish between a follicular adenoma and carcinoma (as cy to logy insufficient to assess perivascular or pericapsular invasion). It is the 3rd most common thyroid cancer and it represents 5% of all thyroid cancers. Radioiodine cannot be used as there is no iodine uptake (since the cancer is of neuroendocrine cells and not follicular cells). Treatment is chemotherapy +/ radiotherapy as per lymphoma regimens guided by oncology team. The submandibular and sublingual glands account for about 20% of salivary gland tumors and the incidence of malignancy is higher. Pain is a late symp to m Increasing size of the tumour can affect speech and swallowing. Advanced cancer resection of primary lesions, neck dissection and post-operative radiotherapy. Sometimes reconstruction with flaps is needed with larger to ngue resections Chemotherapy (for. Carcinoma of the Oropharynx Tumours of the to ngue base (posterior third of the to ngue) and the to nsils (or to nsillar fossae if the to nsils have been previously removed). Treatment Surgery +/ radiotherapy or chemotherapy Chemoradiotherapy Carcinoma of the Hypopharynx Hypopharyngeal cancers are named for their location. Patients are typically men aged 55-70 years old with a his to ry of to bacco use and/or alcohol use. Advanced cancers surgery + radiotherapy +/ neoadjuvant chemotherapy Many hypopharyngeal cancers are incurable at presentation and best supportive care may be the most appropriate option for management Carcinoma of the Larynx the larynx is subdivided in to 3 components. Left glottic squamous cell carcinoma encroaching on the anterior commissure (reproduced with permission from O to laryngology Hous to n, Symp to ms the commonest symp to ms are hoarseness, throat clearing, chronic cough, globus pharygeus and dysphagia. Pro to n pump inhibi to rs are widely prescribed although there is little high quality or statistically significant evidence to support their use. Patient selection for surgical intervention is crucial and obese patients tend to be poor candidates for surgery. However none have a good evidence base for effectiveness and surgical intervention, particularly nasal surgery should be undertaken with caution and careful preoperative counselling. The common infectious causes include supraglotitis and deep neck space infections.

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Secondary osteoporosis develops secondary to many conditions such as corticosteroid administration, hyperthyroidism, and hypogonadism. Defective mineraliza tion results in an increase in the thickness of the osteoid seams. In contrast, vitamin C deficiency (scurvy), which results from failure of osteoid forma tion, is characterized by thin osteoid seams. Osteopetrosis (marble bone) is a bone modeling abnormality related to hypofunction of the osteoclasts. Osteoporosis results from a reduction in the mass of bone, which still has the normal ratio of mineral to matrix. Reactive bone formation occurs in bone or soft tissue in response to such conditions as tumors, infections, or trauma. Because of the high bone turnover, the serum alkaline phosphatase level is markedly increased, and amounts of collagen breakdown products, such as hydroxyproline and hydroxylysine, are increased in the serum and the urine. Most commonly the organism is Staphylococcus aureus (but remember patients with sickle cell anemia are prone to develop Salmonella osteomyelitis). Cat bites are associated with Pasteurella mul to cida; human bites are associated with anaerobes; foot puncture wound with pseudomonas; and hip replacement with S. Typical granuloma to us infec tions produce caseous necrosis of the bone and bone marrow leading to destruction and collapse of vertebral bodies. Clinically patients with osteomyelitis develop an acute illness with malaise, fever, chills, and severe, throbbing pain over the affected portion of bone. The peripheral blood reveals increased numbers of neutrophils (neu trophilia), and blood cultures are usually positive. X-rays may reveal a lytic focus of bone destruction surrounded by a peripheral zone of sclerosis. The new osteoblastic periosteal bone is called the involucrum; the trapped necrotic bone is the sequestrum. The abscess may drain through the bone (the hole formed in the bone being called the cloaca) forming a draining sinus. The most common site of infection varies with age: kids at metaphysis and adults at epiphysis and subchondral. Organisms may be introduced in to the bone by direct penetration or hema to genous spread. Recall that nutrient arteries to long bones divide to supply the metaphyses and dia physes. In the metaphyses, the arteries become arterioles and finally form capillary loops adjacent to epiphyseal plates. This ana to mic feature allows bacteria to settle in the region of the metaphysis and makes it the site ini tially involved in hema to genous osteomyelitis. Destruction of the intervertebral disks and adja cent vertebral bodies is characteristic of tuberculosis. This destruction causes the bone to collapse, and these compression fractures may result in angular kyphosis or scoliosis. Caseous material may extend from the verte brae in to paravertebral muscles and along the psoas muscle sheath to form a psoas abscess in the inguinal regions. Tuberculous osteomyelitis occurs most often in the long bones and spine and via hema to genous spread from a primary site elsewhere. Medullary infarcts produce geographic necrosis of the cancellous bone and marrow only; the cortical bone is not involved. Subchondral 538 Pathology infarcts are characterized by a wedge-shaped pale area of necrosis that has the subchondral bone as the base and the center of the epiphysis as the apex. For example, avascular necrosis of the femoral head will be seen grossly as a wedge-shaped yellow infarct. Clinical features include the sudden onset of severe pain and difficulty in walking. Avascular necrosis of the femoral head in children is called Legg-Calve-Perthes disease. Compare this to Osgood Schlatter disease, which results from avascular necrosis of the anterior tib ial tuberosity where the patellar tendon inserts. Individuals will develop intermittent swelling and pain below the knee at the tibial tuberosity. In contrast to the abnormal yellow area of avascular necrosis, irregular white deposits in joints may suggest pseudogout (chondrocalcinosis), while bone that is grossly black in color is suggestive of alkap to nuria (ochronosis). This disorder is caused by the excess accumulation of homogentisic acid, which results from a deficiency of homogentisic oxidase. Osteosarcomas usually arise in the metaphyses of long bones of the extremities, although they may involve any bone. They are composed of malignant anaplas tic cells, which are malignant osteoblasts that secrete osteoid. There may be marked variation his to logically depending on the amount of type I collagen, osteoid, and spicules of woven bone produced. Osteosarcomas produce a char acteristic sunburst x-ray pattern due to calcified perpendicular striae of reactive periosteum adjacent to the tumor. Two-thirds of cases are associated with mutations of the retinoblas to ma (Rb) gene. Patients with retinoblas to ma are at an increased risk for developing osteogenic sarcoma. Osteosarcomas metastasize hema to genously and usually spread to the lungs Musculoskeletal System Answers 539 early in the course of the disease. With surgery, radiation, and chemotherapy the 5-year survival rate is now about 60%. In contrast to the his to logic appearance of osteogenic sarcoma, aneurys mal bone cysts are composed of multiple blood filled spaces that are not lined by endothelial cells. Finally, osteopetrosis is characterized clinically by thick bone trabeculae with osteoclasts that lack a normal ruffled border. Osteochondromas (exos to ses) usually occur at the cortex of the metaphysis near the growth plates of long tubular bones. They are thought to occur as a result of the displacement of the lateral portion of the growth plate. In con trast, chondromas usually occur at the diaphysis and may be found either within the medullary cavity (enchondromas) or on the surface of the bone, while chondroblas to mas usually occur at epiphyses of the distal femur and proximal tibia or humerus. X-rays typically reveal a radiolucent area (the tumor itself) surrounded by thickened (reactive) bone. His to logic sections reveal 540 Pathology an oval mass, the central nidus of which consists of interconnected trabec ulae of woven bone containing numerous osteoblasts and uncalcified osteoid. A his to logic picture that is identical to the central nidus of an osteoid osteoma is seen with the osteoblas to ma.

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This meta-analysis would ideally be from multiple specimens, 153 and an absent score in juvenile specimens was treated more as uncertainty, rather than as 154 definitive evidence of absence. It is off 163 white and fairly firm, particularly proximally, close to its muscle junction. Other muscles 164 overlie and are attached to the patellar tendon superficially, but are not ideally positioned, or 165 sufficiently strongly connected, to contribute as much force along their line of action, as is 166 the triceps femoris. The patellar tendon sits within the patellar groove on the distal femur, 167 bordered by the lateral (larger) and medial (smaller) femoral condyles. At a position 168 approximately one-third along its length, whilst it is still within the patellar groove, the 169 tendon partially splits to form superficial and deep portions (Fig. The superficial 170 portion bridges the femorotibial joint and inserts on to the lateral and cranial cnemial crests of 171 the tibiotarsus, whilst the deep portion blends with a grossly fatty structure within the patellar 172 sulcus of the femur, and is also attached to the cartilaginous femorotibial menisci (Fig. This lack of any discernible 179 mineralisation/ossification was confirmed microscopically, by the absence of calcium salts 180 using von Kossa staining in birds of this age (data not shown). His to logy 185 confirmed the presence of an abrupt junction between the patellar tendon and the triceps 186 femoris muscles proximally. In all ages, the collagen fibres here have a dense and 187 predominantly transverse orientation, which become more longitudinally oriented as they 188 penetrate in to the tendon distally (Fig. Surprisingly, the body of the patella tendon is 189 overwhelmingly comprised of adipocytes, with collagen fibre bundles running throughout in 190 mixed orientations resulting in a meshwork-like appearance. In some sections, a blood vessel 191 is seen in the proximal deep region of the tendon, within the adipocyte-rich tissue (Fig. Cells in the collagen fibre bundles are typically slender and fusiform with elongate 195 nuclei, resembling tenocytes (Fig. Blood vessels are visible 198 in the synovial sub-intima and deeper fascia, particularly laterally (apparently away from the 199 point of tendon contact with bone). The synovial layer is continuous over 203 the tendon split but does not interdigitate with it. A further difference between 206 the age groups is the appearance of an apparent third tissue type, in addition to the adipose 207 and collagenous tissues already described. In the five week old emu patellar tendons, this 208 tissue is basophilic with H&E staining and highly vacuolated or vesicular (Fig. This 209 material is most abundant in the deep, proximal region of the tendon and also close to the 210 tendon split laterally. There are lesser amounts along the deep surface distally, and around the 211 dense collagen bundles running along the proximal (triceps) and superficial muscle-tendon 212 junctions. The substance is also present in minimal amounts within the body of the tendon, 213 especially in the deepest third, where it seems to follow collagen bundles as they travel 214 through the adipose tissue. The cells associated with this material have plump and sometimes 215 finely stippled nuclei, in contrast to the compressed nuclei of adipocytes or the elongate 216 nuclei of tenocytes. This material has taken up more H&E stain and is less 221 vesicular and more homogenous than in the five week old emus. Certain collagen fibres near 222 to this material also appear slightly more basophilic (Fig. In addition, 225 there are some areas where rounded cells sit within chondrocyte-like lacunae, giving the 226 tissue a chondroid (cartilage-like) appearance. Rounded, 231 chondroid cells occupy lacunae within the basophilic tissue, and also within nearby collagen 232 fibre bundles (Fig. In both the five week and 18 month old patellar tendons, 233 SafraninO/fast green stains the vesicular and chondroid tissue intensely red, differentiating it 234 from nearby collagen fibre bundles (Fig. Similar to the emu, the patellar tendon of the ostrich includes regions of cartilage-like 239 tissue, especially between and deep to the ossified sesamoids. It also contains areas with 240 apparently discrete strata of adipose tissue, unlike the diffuse and abundant incorporation of 241 fat within the emu patellar tendons. There are small areas of calcified cartilage at some edges of the bones, but 245 no articular cartilage lining the deep surface as in the guineafowl. The guineafowl patella has 246 an outer compact bone cortex with some longitudinal secondary osteons, inner trabecular 247 structure with mostly fatty marrow, and a thick articular cartilage pad lining its deep surface. Although a patella may have originated earlier than in the 253 common ances to r of Hesperornithiformes and Neornithes (see below), the fossil record of 254 many ornithurine taxa argues strongly against this possibility. Hou (1997) speculated that a 255 sliver of bone in a Confuciusornis specimen was a patella, but its disarticulated position 256 renders its identification uncertain, and the absence of a patella in dozens of other PeerJ PrePrints | dx. Where present in these taxa, the patella is a small flake-like 261 bone enclosed in the patellar tendon, situated in the patellar groove of the femur (Fig. We 262 also observed the double patella in ostriches evident in over 12 specimens from diverse 263 collections and well documented in the literature (Haugh to n 1864; Macalister 1864; 264 Thompson 1890; de Vriese 1909; Deeming 1999; Gangl et al. In contrast, we did not 265 find evidence of patellae in other palaeognath specimens (emus, rheas, cassowaries, moa, and 266 elephant birds). No matter how the relationships within Palaeognathae are organised (based on the 271 most detailed recent analyses), our phylogenetic optimizations always show a small flake of 272 bone as plesiomorphic for Neornithes (ancestral for the Hesperornithiformes + Neornithes 273 clade); a condition shared by the common ances to r of Neognathae. However, patterns of 274 patellar evolution within Palaeognathae itself can vary considerably depending on tree 275 to pology. Unlike the typical tendon of most tetrapod vertebrates, in 280 which the microana to my consists predominantly of dense, parallel collagenous bundles 281 (Khan et al. Additionally, in older emus there are 283 patchy regions of cartilage-like tissue that are most prominent near the proximal muscle 284 tendon junction, which corresponds to the location of the patellar sesamoid in most other 285 birds, including the proximal patella in ostriches. Terminology varies, but characteristically the 291 tendon cells become rounded and chondroid in appearance and produce a stainable, 292 sometimes granuloma to us matrix (Jarvinen et al. This type of tendon 293 change is usually reported in the context of tendon pathology, particularly in cases where the 294 duration of symp to ms is longstanding (Hashimo to et al. Chondroid cells can also be 295 seen at tendon/ligament junctions with bone (Vigorita 1999). Accumulation of adipocytes in a tendon, variably called 298 tendolipoma to sis, lipoid degeneration, or fatty infiltration, is well documented (Hashimo to et 299 al. The adipocytes occupy spaces 300 between the collagen fibres and may amass to such a point that they weaken and disrupt the 301 fibres (Jozsa et al. However, it seems unlikely that the 302 appearance of the patellar tendon in these emus is due to an underlying pathology. Tendinopathies also predispose the 305 tendon to rupture (Sharma & Maffulli 2005), and there are no reports of patellar tendon 306 rupture in emus. Rather than tendinopathy, this emu patellar tendon composition is more 307 likely indication of a limited ability for tendon remodelling (in this case physiologically 308 rather than pathologically) (Khan et al. It may also reflect the strange evolutionary 309 his to ry of emus (and other ratites) which seemingly involves loss of the patella, possibly 310 during the convergent evolution of flightlessness. The 314 presence of a cartilage-like tissue in the adult emus is consistent with fibrocartilage formation 315 observed in tendons subject to bending or compression (Vogel & Peters 2005). This 316 hypothesis is supported by the apparent ageing-related differentiation of this tissue. In the 317 youngest emus, corresponding regions exhibit basophilic vesicular material and rounded cells 318 with plump nuclei; Safranin O-positive staining supports the presence of high proteoglycan 319 content in this tissue. The evidence suggests that the basophilic vesicular material may be the 320 extra-fibrillar matrix of the tendon which contains proteoglycan and has a vacuolated 321 appearance when newly formed (Maffulli et al. The vesicular appearance might also 322 result if this tissue derives from metaplastic adipocytes. Nearby collagen bundles are also more basophilic-staining and contain 326 chondrocyte-like cells, suggesting they are either transforming or being replaced by this 327 tissue. In the oldest emus, this tissue is highly reminiscent of cartilage and Safranin O 328 staining indicates it has high proteoglycan content. Regardless, this tissue is far from ossified, 329 and the absence of a documented patellar ossification in the literature on emu morphology at 330 least circumstantially supports the inference that this absence represents the general condition 331 for emus. A commonly presumed function of sesamoids is protective; 334 reinforcing the tendon from high compressive forces as it bends around bone. Fat pads near 335 joints are hypothesised to have a similar function in cushioning tendon and stress dissipation 336 (Benjamin et al.

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Chlorpromazine should not generally be used in infants under 1 year except for narcotic withdrawal in neonates. In children and growing adolescents ciprofloxacin is only recommended where the benefits outweigh the risk of arthropathy. Liquid is not suitable for administration down a nasogastric tube as it may block the tube. Doses should be used for 7 days in conjunction with amoxicillin or metronidazole plus omeprazole. Orally, < 12 years initially 125microgram/kg twice a day (max 500microgram/kg, or 15mg twice daily) 12 18 years Initially 10mg twice a day (max 30mg twice daily) Increase doses at 5 day intervals until satisfac to ry response or maximum achieved. Clonazepam can be infused undiluted, in to large vessels (preferably a central line). If this occurs control may be re-established by increasing the dose or interrupting therapy for 2 to 3 weeks. Orally, initially, 25microgram at night for 1-2 weeks then increase to 50microgram at night. If required dose can be further increased by 25microgram every 2 weeks, side effects permitting. Administration: Reconstitution (using the appropriate displacement values) so the resulting concentration is 60mg of co-amoxiclav in 1ml. Where severe allergy symp to ms have occurred previously or the extent of the allergy is unknown an alternative antibiotic should be given. Notes: a) Codeine phosphate should be avoided in children with renal impairment and used with caution in patients with hepatic impairment. Orally, initially, Under 1 year 1g (fi sachet)/day (max 9g/daily in 2-4 doses) 1 6 years 2g (fi sachet)/day (max 18g/daily in 2-4 doses) 6 12 years 4g (1 sachet)/day (max 24g/daily in 2-4 doses) 12 18 years 4-8g (1-2 sachet)/day (max 36g/daily in 2-4 doses) Notes: a) All other drugs should be administered at least 1 hour before or 6 hours after colestyramine to reduce possible interference with absorption, especially digoxin and warfarin. Notes: a) Colistin has excellent antipseudomonal activity and is probably the first line choice for nebulised use. For peripheral injection, the manufacturers recommend a 25-fold dilution, in glucose 5% or sodium chloride 0. Dilution to less than 1 in 10 is not possible as the propylene glycol precipitates out. Notes: a) Sulphonamides displace bilirubin from protein binding sites, and so, because of the risk of kernicterus, co-trimoxazole is contraindicated in neonates and also the last month of pregnancy. Counsel patient/parent to report all rashes, sore throats, fevers and other manifestations of agranulocy to sis. Administration: Cyclophosphamide is a cy to to xic drug therefore it must be reconstituted by the oncology pharmacy department. Notes: Premedication: Cold Cap should be in place 15-20 minutes before starting cyclophosphamide. A second dose of Granisetron 40 microgram/kg (up to a max of 3mg) can be given in a 24 hour period. Administration: Dissolve contents of vial with 60ml of water for injection and give as a bolus injection. Notes: a) Dantrolene has been associated with symp to matic hepatitis (fatal and non-fatal). Liver function tests should be performed before starting treatment and at regular intervals during treatment. Notes: a) Dapsone Syndrome may occur after 3 to 6 weeks therapy; symp to ms include rash, fever and eosinophilia discontinue therapy immediately. Patients who receive < 7ml/kg/month of packed red blood cells may require 10mg/kg Aim to maintain ferritin level. Patients who receive > 14 ml/kg/month of packed red blood cells may require 30mg/kg Aim to decrease ferritin level. Patients who are at increased risk of complications, have pre-existing renal conditions, have co-morbid conditions, or are receiving medicinal products that depress renal function should be moni to red weekly during the first month after initiation or modification of therapy. Reduce rate after a few hours to ensure maximum dose 80mg/kg in 24 hours is not exceeded. Administration: Dissolve contents of vial in 5ml water for injection to give 500mg in 5ml (10% solution). Hearing and vision should be moni to red regularly; effects can be reversed on cessation of therapy. The dose may be repeated every 12 hours as required or 600mcg/kg single dose (maximum of 12mg). Notes: a) Patients should be moni to red at least weekly for side effects whilst dose is being established. Orally, initially, 4 weeks 1 year 50microgram/kg twice a day 1 4 years 500microgram twice a day 5 12 years 1-1. The above doses are used on an as required basis in post operative skeletal muscle spasm. The above doses may initially be used for the control of tension and irritability of cerebral spasticity, however larger doses may be required. Notes: a) Diclofenac is contraindicated in patients with a his to ry of hypersensitivity (including asthma, angioedema, urticaria or rhinitis) to aspirin or any other non-steroidal anti-inflamma to ry drug or with a coagulation defect. Give 25% of maintenance dose after haemodialysis or au to mated peri to neal dialysis session. Notes: a) Reduced loading dose required if cardiac glycosides have been administered in the preceding two weeks. Maximum dose 40mcg/kg/min (neonates 20mcg/kg/min) Administration: Dilute further with sodium chloride 0. Concentrations as high as 5mg in 1ml have been used in fluid restricted patients although these concentrations must be infused via a central line. Notes: a) Domperidone liquid is often used in children less than 1 month, however extrapyramidal side effects may occur in these young children. Low doses may be infused peripherally if no other choice, however, use a dilute solution, not more than 3. Administration: Nebulised: Do not mix with other drugs or solutions in the nebuliser. Wait for at least 1 hour after a dose is given before physiotherapy to see most benefit. If anticholinesterase treatment is excessive, edrophonium will either have no effect or symp to ms will intensify. Notes: a) Have atropine sulphate drawn up in a syringe before test, as edrophonium may cause profound bradycardia. Once an ampoule is open, draw up the next three doses required in syringes and these may be kept at room temperature for up to 24 hours. Weekly dose of Epoetin Beta(units) x 2 = Fortnightly dose of 240 Darbepoetin (micrograms) f) Darbepoetin Alfa SureClick is a pre-filled disposable injection device it can be ordered on request from pharmacy. The manufacturers recommend changing the infusion every 12 hours due to instability, however in practice the loss in potency following 12 hours is not clinically significant as the dose is titrated to the response. After adequate control achieved initiate oral therapy with digoxin or alternative, see tachycardia guidelines. Decrease infusion rate by 50% one hour after first oral dose and s to p infusion one hour after second oral dose, as long as patient is stable. In fluid restricted patients dilute to 20mg in 1ml and administer via a central line. The condition is difficult to diagnose in children under 6 years of age and is more likely to occur in renal failure. Orally, initially 2 microgram daily, increasing every six months to 5 micrograms, then to 10 micrograms, then to 20micrograms daily. Notes: After 12 to 18 months of treatment give proges to gen for 7 days of each 28 day cycle. Notes: a) A full blood count is recommended before and 4-6 weeks after starting treatment. Symp to ms of angina, tachycardia, ventricular arrhythmias and hypertensive episodes associated with headaches and tremor may occur. Notes: a) Flecainide has a negative inotropic effect and can itself precipitate serious arrhythmias.

References:

  • http://www.phschool.com/atschool/florida/pdfbooks/sci_Marieb/pdf/Marieb_ch08.pdf
  • https://www.dshs.wa.gov/sites/default/files/BHSIA/FMHS/DSHSTelehealthGuidebook.pdf
  • https://www.nasponline.org/Documents/Resources%20and%20Publications/Handouts/Families%20and%20Educators/Early_Childhood_Disabilities_and_Special_Education.pdf
  • https://www.ucsfbenioffchildrens.org/pdf/manuals/43_BacterialInfections.pdf

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