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In a highly affected rural area, the groundwater that is used directly as drinking-water had an average concentration of 430 g/L. Analysis of raw groundwater pumped from the lower aquifer for the Hanoi water supply yielded arsenic levels of 240?320 g/L in three of eight treatment plants and 37?82 g/L in another five plants. Aeration and sand filtration that are applied in the treatment plants for the removal of iron lowered the arsenic content to levels of 25?91 g/L, but 50% remained above 50 g/L. The high arsenic concentrations found in tubewells (48% above 50 g/L and 20% above 150 g/L) indicate that several million people consuming untreated groundwater might be at a considerable risk for chronic arsenic poisoning. The maximum concentration was lower than the figures recorded in Taiwan, China, and India, but higher than those reported in Sendai (range, 1?35 g/L), Takatsuki (range, 3?60 g/L) and Kumamoto (range, 5?66 g/L), Japan (Kondo et al. Arsenic concentrations in water from 34 wells in the Niigata Prefecture were measured between 1955 and 1959 as part of a historical cohort study using the Gutzeit method, and ranged from non-detectable to 3000 g/L: six wells had a non-detectable concentration; 17 wells contained < 1000 g/L; and 11 wells contained? All wells with arsenic concentrations > 100 g/L were located within a distance of 500 m from a factory that pro duced arsenic trisulfide (Tsuda et al. Levels of arsenic in hair samples ranged from 40 to 1040 g/kg and levels in drinking-water samples were less than 1 g/L (Saad & Hassanien, 2001). Sulfide minerals such as arsenopyrite and pyrite were present in the Birimian base ment rocks of both areas and these constitute the dominant sources of arsenic. Concen trations were lowest in the shallowest groundwaters, and increased at greater depths. The lateral and vertical variations in dissolved arsenic concentrations were controlled by ambient pH and redox conditions and by the relative influences of sulfide oxidation and sorption (Smedley, 1996). One group consisted of healthy subjects, the second of subjects with suspected arsenic poisoning, and the third of subjects with con firmed arsenic poisoning. The average arsenic concentration in hair was 200 g/kg in the healthy group, 4900 g/kg in the group with suspected poisoning and 5600 g/kg in the group with arsenic poisoning; arsenic concentrations in water samples varied between 30 g/L and 1040 g/L (Pazirandeh et al. In 1991, survey data showed elevated levels of arsenic in the surface water and groundwater in Victoria, particularly around gold mining areas. Concentrations of arsenic in groundwater ranged from < 1 to 300 000 g/L (n = 109) and those in surface water ranged from < 1 to 28 300 g/L (n = 590). In a follow-up study of the same region in the mid-1990s, arsenic concentrations ranged from 1 to 12 g/L in groundwater samples (n = 18), from 1 to 220 g/L in surface water samples (n = 30) and from 1 to 73 g/L in drinking-water samples (n = 170) (Hinwood et al. In an investigation of the relationship between environmental exposure to arsenic from contaminated soil and drinking-water and the incidence of cancer in the Victoria region, median arsenic concentrations in groundwater ranged from 1 to 1077 g/L (total range, 1?300 000 g/L; n = 22 areas) (Hinwood et al. Concentrations of arsenic (As) in drinking-water in other countries Country Population Date Sample (no. The final study population (144 627 from a register-based cohort) consisted of 61 bladder cancer cases and 49 kidney cancer cases diagnosed between 1981 and 1995, as well as an age and sex-balanced random sample of 275 subjects (reference cohort). To evaluate the validity of water sampling, two water samples were taken from each of 36 randomly selected wells at two different times (on average 31 days apart; range, 2 h?88 days). The arsenic concentrations in the original samples and field duplicates were not significantly different. Locally in Finland, drinking-water from privately drilled wells contains high concentrations of arsenic up to 980 g/L (Kurttio et al. In the north-west region of Transylvania, Romania, drinking-water contains arsenic as a result of the geochemical characteristics of the land. The geographical distribution of arsenic in drinking-water in this region, sampled between 1992 and 1995, was hetero geneous, with a mixture of high (mostly in rural areas) and low concentrations in conti guous areas (range, 0?176 g/L arsenic). Estimates indicated that about 36 000 people were exposed to concentrations of arsenic in the drinking-water ranging from 11 to 48 g/L, and about 14 000 inhabitants were exposed to arsenic levels exceeding 50 g/L (Gurzau & Gurzau, 2001). In 1998 in Madrid, Spain, arsenic concentrations of more than 50 g/L, the maximum permissible concentration for drinking-water in Spain, were detected in some drinking water supplies from underground sources. In a second phase, 6 months later, analyses were repeated on those 35 water supplies that were considered to pose a possible risk to public health. Seventy-four per cent of the water supplies studied in the initial phase had an arsenic concentration of less than 10 g/L, 22. Most of the water supplies showing arsenic levels greater than 10 g/L were located in the same geographical area. In the second phase, 26 of the 35 water supplies were in the same range (10?50 g/L arsenic) as in the first survey; nine had changed category, six of which had less than 10 g/L and three had more than 50 g/L. In Madrid, less than 2% of the population drinks water from underground sources (Aragones Sanz et al. In Switzerland, areas with elevated levels of arsenic have been found primarily in the Jura mountains and in the Alps. Weathering and erosion of rocks containing arsenic releases this element into soils, sediments and natural waters. In 312 drinking-water supplies, arsenic concentrations were below 10 g/L (93%), while 21 samples had arsenic concentrations between 10 and 50 g/L (6%). Ore deposits and sediments in the canton of Valais have also been known for some time to contain arsenic. Since then, it has been determined that in this canton approximately 14 000 people live in areas where the drinking-water contains between 12 and 50 g/L (Pfeifer & Zobrist, 2002). Although levels of arsenic in public water supplies are low, there is concern about the 20 000?30 000 private well-water supplies in South-West England, particularly those in old mining areas, which undergo limited or no treatment. From limited available data, three private supplies of those tested in Cornwall had arsenic levels above the 5-?g/L detection limit, and contained 11, 60 and 80 g/L (Farago et al. For virtually all of the rural municipal wells, no chemical or physical water treatment was performed other than periodic chlorination, whereas approximately half of the private wells underwent some form of water treatment. The most commonly used forms of water treatment included water softening with an ion exchange device, filtration and removal of iron. Arsenic was not detected in 25 samples (10 private wells and 15 rural municipal wells) using a method with a detection limit of 1 g/L; 34 samples (13 private wells and 21 rural municipal wells) had levels between 1 and 50 g/L; only two wells (private) had levels greater than 50 g/L (maximum concentration, 117 g/L) (Thompson et al. In an earlier survey of water supplies from 121 communities in Saskatchewan sampled between 1981 and 1985, arsenic levels were below 10 g/L in 88% and below 2 g/L in 42% of the samples taken; the maximum level recorded was 34 g/L (Health Canada, 1992). The concentration of total soluble inorganic arsenic (arsenate plus arsenite) was measured in duplicate water samples from the wells of 94 residents in seven communities in Halifax County, Nova Scotia, where arsenic contamination of well-water was suspected. Levels of arsenic exceeded 50 g/L in 33?93% of wells in each of the commu nities; in 10% of the wells sampled, concentrations were in the range of 500 g/L. Maximum observed concentrations of arsenic ranged from 130 to 48 000 g/L in groundwater from mining areas, from 50 to 2750 in basin-fill deposits, from 170 to 3400 in volcanic areas and from 80 to 15 000 g/L in geothermal areas. About 5% of regulated water systems are estimated to have arsenic concen trations greater than 20 g/L (Welch et al. Using a 25-state database of compliance monitoring from community systems, the Environmental Protection Agency (2001) found that 5. A study in New Hampshire found that drinking-water from private wells contained significantly more arsenic than that from community wells. In addition, this study found that deep wells had higher arsenic concentrations than super ficial wells and that samples voluntarily submitted to the state for analysis had higher concentrations than randomly selected household water samples (Peters et al. This standard was reaffirmed in 1946 and 1962; however, in 1962, the Public Health Service advised that concentrations in water should not exceed 10 g/L when more suitable supplies are or can be made available? (Smith et al. A provisional guideline is established when there is some evidence of a potential health hazard but for which available data on health effects are limited, or when an uncertainty factor greater than 1000 has been used in the derivation of the tolerable daily intake. The Canadian guideline (Health Canada, 2003) is an interim maximum acceptable concentration, again, due to the limited data on health effects. Studies of Cancer in Humans Major epidemiological studies of cancer in relation to arsenic in drinking-water include ecological studies and fewer case?control and cohort studies. For most other known human carcinogens, the major source of causal evidence arises from case?control and cohort studies, with little, if any, evidence from ecological studies. In contrast, for arsenic in drinking-water, ecological studies provide important information on causal inference, because of large exposure contrasts and limited population migration. As a consequence of widespread exposure to local or regional water sources, ecological measures provide a strong indication of individual exposure. Moreover, in the case of arsenic, the ecological estimates of relative risk are often so high that potential con founding with known causal factors cannot explain the results. Historically, several case reports have related cancers of the urinary tract with medi cinal arsenic treatments or arsenic-related diseases such as Bowen disease.

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He envi nomic status alone as a measure of human de sioned roads as being clean and free of dust. Thus countries that were His main objective was to use village made goods economically well developed and where people instead of industrial products. All these princi were relatively richer were called advanced na pals are now considered part of sound long-term tions while the rest where poverty was wide development. Gandhiji had designed a sustain spread and were economically backward were able lifestyle for himself when these concepts called developing countries. North America and Europe which had become industrialized at an earlier stage have become A growing realization of the development strat economically more advanced. They not only ex egy that Mahatma Gandhi had suggested many ploited their own natural resources rapidly but decades earlier is now accepted by experts on also used the natural resources of developing development across the world. It has be tries got richer while the poor nations got come obvious that the quality of human life has poorer. The world now begun to realise that their lives were being seri appears to be at a crossroad. It has taken the ously affected by the environmental conse path of short term economic growth and now quences of development based on economic suffers the consequences of environmental deg growth alone. This form of development did not radation at the cost of loss of quality of human add to the quality of life as the environmental life. Society alone could not bring about a better way of life must thus change its unsustainable development for people unless environmental conditions were strategy to a new form where development will improved. This form of sus economic considerations were used, had begun tainable development can only be brought about to suffer from serious environmental problems if each individual practices a sustainable lifestyle due to air and water pollution, waste manage based on caring for the earth. Indira Gandhi said in the Stockholm Con issues between the haves and the have nots? ference in 1972 that poverty was the greatest in society, at the global and national levels. This meant that while the super rich disparity in the lifestyles between the rich and nations had serious environmental problems, the the poor was made worse by these unsustain under-developed in Asia, Africa and South able development strategies. Developing coun Many decades ago, Mahatma Gandhi envi tries were suffering the consequences of a rap sioned a reformed village community based on idly expanding human population with all its Social Issues and the Environment 165 Chapter6. It is based on improving the quality of life for all, Thus increasingly the world began to see the especially the poor and deprived within the car need for a more equitable use of earth resources. It the control over natural resources and the is a process which leads to a better quality of wealth that it produces also begins to create life while reducing the impact on the environ tensions between people that can eventually ment. Its strength is that it acknowledges the lead to both strife within a country and wars interdependence of human needs and environ between nations. How then could a new form of development be brought about that To ensure sustainable development, any activ could solve the growing discontent in the world? Many devel that would not only support the well being and opment projects, such as dams, mines, roads, quality of life of all people living in the world industries and tourism development, have se today but that of future generations as well. Thus current development Large dams, major highways, mining, industry, strategies have come to be considered unsus etc. Forests the newer concept of development has come are essential for maintaining renewable re to be known as Sustainable Development. Their loss impairs future human devel eral documents were created for the United opment. Major heavy industries if not planned care that environment and development were closely fully lead to environmental degradation due to connected and that there was a need to care air and water pollution and generate enormous for the Earth. Toxic and Nuclear wastes Sustainable development is defined as de can become serious economic problems as get velopment that meets the needs of the ting rid of them is extremely costly. Thus the present without compromising the ability economic benefits of a project must be weighed of future generations to meet their own against the possible environmental costs before needs. It includes social development and 166 Environmental Studies for Undergraduate Courses Chapter6. If we see that a development concrete, glass and steel of ultra modern build project or an industry is leading to serious envi ings. Embodied energy Further if new development projects are being planned in and around the place where we live Materials like iron, glass, aluminium, steel, it is our duty to see that this is brought about in cement, marble and burnt bricks, which are accordance with environmental safeguards. We have to see to it that we change ment, fabrication and delivery are all energy development from its present mandate of rapid consuming and add to pollution of earth, air economic growth without a thought for future and water. This energy consumed in the pro ecological integrity, to a more sustainable eco cess is called embodied energy. If new projects of a large size are to be passed Government has made it compulsory to publish Until the 1950s many urban kitchens were based the summary report of the Environmental Im on fuelwood or charcoal. It is essential that all of us as respon ens were isolated from the rest of the house. This changed to electrical many situations there are proponents of the energy and increasingly to natural gas by the project who only look at their own rapid eco 1970s in most parts of urban India. It is for citizens as concerned indi viduals and groups to counter these vested Urban centers in hot climates need energy for interests so that our environment is not de cooling. Life has to be made more liv air-conditioning, which consumes enormous able for all. New buildings in our coun growth of one sector of society while we per try have taken to using large areas covered by mit environmental degradation to destroy the glass. High rise buildings in urban centers Urban centers use enormous quantities of en also depend on energy to operate lifts and an ergy. Traditional housing in India required Social Issues and the Environment 167 Chapter6. With deforestation need to be made energy efficient and re surface runoff increases and the sub soil water duce carbon dioxide emissions, which cause table drops as water has no time to seep slowly heat islands? or pockets of high tempera into the ground once vegetation is cleared. As many areas depend on wells, it has become necessary to go on making deeper and deeper wells. This adds to the cost and further depletes Urban transport depends on energy mainly from underground stores of water. Most urban people use their own years to recharge even if the present rate of individual transport rather than public transport extraction is reduced which seems hardly pos systems for a variety of reasons. As deforestation and desertification spreads due Thus even middle income groups tend to use to extensive changes in land use the once pe their own private vehicles. Water has to be equitably and fairly Each of us as an environmentally conscious in distributed so that household use, agriculture dividual must reduce our use of energy. Imagine the amount of energy wasted by waste water or cause pollution has led to a seri thousands of careless people. Thus save electricity, we would begin to have a more water conservation is linked closely with overall sustainable lifestyle. Traditional systems of collecting water and us ing it optimally have been used in India for many generations. Conserving water in multiple small percolation tanks and jheels? was important in 168 Environmental Studies for Undergraduate Courses Chapter6. Villages all over During the British period many dams were built the country had one or more common talabs? across the country to supply water especially to or tanks from which people collected or used growing urban areas. While this reduced the need over long distances, this was a time consuming to import food material and removed starvation and laborious activity, thus the water could not in the country, the country began to see the be wasted. Many homes had a kitchen garden effects of serious water shortages and problems that was watered by the wastewater. The newer forms of vation of water was done in traditional homes irrigated agriculture such as sugarcane and other through a conscious effort. As excess water evaporates rapidly from the surface of heavily irrigated croplands, it pulls Pani Panchayat Pune District, up subsoil water along with salts to the surface Maharashtra of the soil. Reducing the Mahur village in Pune District of Maharashtra high salinity levels in soil is extremely expensive is situated in a drought prone area. With all these ill effects of the poorly conceived Vilasrao Salunkhe initiated a movement management of water at the national and local known as Pani Panchayat, to conserve wa level there is a need to consider a new water ter in this drought prone area. Conservation of soil and water har plies water to plants near its roots through a vesting through a comprehensive micro system of tubes, thus saving water. Small per watershed management program gradually colation tanks and rainwater harvesting can pro led to a surplus of water.

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The results were somewhat inconsistent in that one study found medi cation to be quite useful, whereas the other found low rates of response and high dropout rates. Fenfluramine has now been taken off the market because of links between its use (mainly in combination with phentermine) and cardiac valvular abnormalities. Lithium may occasionally be used concur rently for the treatment of co-occurring conditions. The opiate antagonist naltrexone has been studied in three randomized trials at dosages used for treating narcotic addiction and prevent ing relapse among alcohol-dependent patients (50?120 mg/day). The results consistently show that the medication is not superior to placebo in reducing bulimic symptoms (699, 704, 707). However, there have been mixed reports concerning the risk of hepatotoxicity with the use of high dosages of naltrexone (705, 706, 718). In a randomized controlled trial, carbamazepine showed efficacy in only one patient, and that patient had a history of bipolar disorder (720). Combinations of psychosocial and medication treatments the relative efficacy of psychotherapy, medication, or both in the treatment of bulimia nervosa has been examined in six studies. In the first study (253), intensive group cognitive psychother apy (45 hours of therapy over 10 weeks) was superior to imipramine alone in reducing binge eating/purging and depressive symptoms. Some advantage was also seen for combination therapy on some variables, such as dietary restraint. These results, however, are difficult to interpret because of the high attrition rate (50% by the 1-month follow-up). The use of sequential medication in this study addressed a limitation of earlier studies in that when one antidepressant fails, a clinician typically tries other agents that often result in better antidepressant efficacy than the first medication alone. In the fifth study (702), no ad vantage was found for the use of fluoxetine over placebo in an inpatient setting, although both groups improved significantly. A recent review concluded that the combination treatment was superior on some variables (711). In general, studies show the importance of achieving abstinence from binge eating and vomit ing regardless of the interventions used in the treatment of bulimia nervosa, and they confirm that longer-term outcome is better when abstinence is achieved after short-term interventions (722). Nutritional rehabilitation and counseling: effect of diet programs on weight and binge eating symptoms Some studies of treatments for binge eating disorder have prioritized weight loss as the primary goal, whereas others have prioritized cessation of binge eating. In some studies using low-calorie diets, either significant weight loss did not occur (727) or weight was partially regained during the first year (290, 728). The pattern of weight regain after initial weight loss is common in all general medical and psycho logical treatments for obesity and not only for obesity associated with binge eating disorder. In one study, the presence of subthreshold or full syndrome binge eating disorder at baseline did not appear to adversely affect weight loss in programs using behavioral weight control, a low calorie diet, and aerobic and strength training (729). Likewise, in a study using telephone and mail-based behavioral weight control for obesity, binge eating status at baseline was not associ ated with outcome (730). Among individuals who do not manifest binge eating prior to treatment, behavioral weight control with a low-calorie diet does not appear to promote the emergence of binge eating (732). Deterioration during the follow-up period has been observed with all three forms of psychotherapy; however, in some cases, maintenance of change at 1-year follow-up has been substantial (271, 272, 731). The addition of exercise appears to augment both binge and weight reduction (731), whereas spouse involvement in treatment does not signifi cantly improve outcome (88). One group reported promising effects on binge eating with a novel virtual reality modification of standard treatment (739, 740). One study failed to find a difference between dieting and nondieting approaches in reducing binge eating and weight. In an expected observation, how ever, even the dieting treatment did not yield significant weight loss in this study, calling into question the integrity of the treatments (742, 743). Self-help programs using self-guided, professionally designed manuals have been effective in reducing the symptoms of binge eating disorder in the short run for some patients and may have long-term benefit (273?277). Fluvoxamine was not su perior to placebo in a controlled study, in part due to a high placebo response (749). A retro spective chart review study of the serotonin-norepinephrine reuptake inhibitor venlafaxine in obese patients with binge eating disorder reported beneficial effects on eating, weight, and mood (750). Where follow-up data were reported, it appears that patients tend to relapse after medication is discontinued (289, 748); however, most medication studies to date do not report follow-up data. For the most part, treatment with antidepressants has not been demonstrated to yield clinically significant weight loss in this population, although one study reported an estimated weight loss of 5. The appetite-suppressant medication sibutramine has also shown promise in the treatment of binge eating disorder. In a randomized controlled trial (284), sibutramine was shown to have significant beneficial effects on binge eating and weight loss, with remission rates of 40% and 27% in the sibutramine and placebo groups, respectively, and a weight decrease of 7. A laboratory feeding study reported that subjects with binge eating disorder treated with sibutramine versus placebo for 4 weeks in a crossover design consumed less in a laboratory binge meal and lost more weight (3. Although the appetite-suppressant medications fenfluramine and dexfenfluramine have also been found to significantly reduce binge frequency (289), their use has been associated with serious adverse events, including a 23-fold increase in the risk of developing primary pulmonary hypertension when used for >3 months (753). Studies have suggested that patients taking the combination of fenfluramine and phentermine may be at greater risk of heart valve deformation and pulmonary hyperten sion; as a result, fenfluramine has been withdrawn from the market (753?756). Most recently, the anticonvulsants topiramate and zonisamide have been studied in patients with binge eating disorder. Two open studies, one a retrospective review of patients with affec tive disorders and co-occurring binge eating disorder (757) and the other an open-label pro spective study (758), as well as one randomized, double-blind, placebo-controlled study (286), found topiramate to be effective for both binge suppression and weight loss. The latter study reported remission in 64% of the topiramate group versus 30% of the placebo group, with weight loss of 5. An open-label study of the anticonvulsant zonisamide (288) suggests that it may have similar effects, both in clinical response and in adverse events. Finally, naltrexone has been associated with a decrease in binge frequency similar to that re ported with antidepressant medications, although the response rate did not differ from that of placebo (699). This observation underscores the fact that high placebo response rates are found in many studies of binge eating disorder, so caution is required in evaluating the claims of ef fective treatments, particularly those using a waiting-list control condition (289, 699, 749). Combined psychosocial and medication treatment strategies In some studies, coadministration of medication with psychotherapy or dietary counseling has been found to be associated with significantly more weight loss than has psychotherapy or di etary counseling alone (290?292). Al though neither adjunctive treatment contributed significantly to weight loss, the 54 subjects who achieved binge remission lost an average of 6. Treatment strategies for night eating syndrome There are few available studies of treatments for night eating syndrome. One open-label study of sertraline at dosages of up to 200 mg/day for night eating syndrome found improvements in both the number of awakenings and the nocturnal ingestions, with full remission in 29% of subjects (302). A subsequent double-blind study of sertraline for night eating syndrome reported that in a group of 24 patients, 75% of those treated with sertraline versus 25% of those who received placebo were considered to have responded to the treatment. A small case series of four patients, two with night eating syndrome and two with the related condition of nocturnal sleep-related eat ing disorder, reported that topiramate treatment was helpful (761). Abbreviated progressive muscle relaxation training may be useful in treating night eating syndrome (301). Finally, other treatments reported to be helpful in sleep-related eating disorder are carbidopa/L-dopa, bro mocriptine, codeine, and clonazepam (762, 763). With respect to interventions, studies are needed on the following: Treatment of Patients With Eating Disorders 87 Copyright 2010, American Psychiatric Association. Studies are required to clarify the benefits versus potential risks of such programs. Targeted prevention through screenings and risk-factor early intervention programs could be beneficial. Studies are needed to better delineate the value of working with children and adolescents regarded to be at greatest risk for developing eating disorders. Improved evidence is needed regarding the choice of treatment setting, selection of specific treatments, and likely length and intensity of treatments to achieve optimal outcomes (immediate and long-term follow-up) based on clearly defined clinical indicators and a more precise delineation of the stages of these disorders. Newer medications affecting hunger, satiety, and energy expenditure as well as commonly associated psychiatric symptoms and conditions need to be developed and tested. Adequate methods for treating osteopenia, osteoporosis, and other long-term medical sequelae of anorexia nervosa are needed. For anorexia nervosa, specific treatments for younger patients, who are likely to be more treatment responsive, may differ from those for older, more chronically ill patients, given that other illness characteristics and treatment responses are likely to vary between these groups. Further more, given the difficulties of recruiting and retaining patients with anorexia nervosa into controlled treatment studies and high dropout rates, large multisite, adequately powered studies are required. For bulimia nervosa, the field requires well-conducted studies that examine transtheo retical? and other treatment approaches, particularly those involving psychodynamically informed therapies, and studies of longer-term results of psychotherapies. Better studies are needed for psychotherapeutically treating the clinically complex patients with multi ple comorbid conditions often seen in practice.

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If the Apgar score remains low afer 5 minutes, eforts at resuscitation must be continued. Resuscitation can also be stopped if there are no signs of life (no heart beat) afer 10 minutes. Infants that start breathing as soon as mask and bag ventilation is provided can be observed with their mothers. Teir temperature, pulse and respiratory rate, colour and activity should be recorded and their blood glucose concentration checked. If the infant has signs of respiratory difculty, or is centrally cyanosed in room air afer resuscitation, it is essential to provide oxygen while the infant is being moved to the nursery. Preventing meconium aspiration 1-20 Does the meconium-stained infant need special care? All infants that have meconium-stained amniotic fuid (liquor) need special care to reduce the risk of severe meconium aspiration afer delivery. Whenever possible all these at-risk infants should be identifed before delivery, especially infants with thick meconium in the amniotic fuid. Only afer delivery, when the infant inhales air, does meconium enter the small airways and alveoli. Meconium contains enzymes from the fetal pancreas that can cause severe lung damage and even death if inhaled into the alveoli afer delivery. The same process should be followed if a meconium stained infant is delivered by casarean section. Some infants develop apnoea and bradycardia as a result of the suctioning and, therefore, may need mask ventilation for a few minutes afer delivery. The mouth can be wiped with a towel and meconium can be removed from the skin during routine drying. If a meconium-covered infant needs resuscitation, it is beter to intubate the infant immediately to clear the airways. The pharynx can also be suctioned under direct vision using a laryngoscope, before ventilation is started. Infants with lightly meconium-stained amniotic fuid who appear well afer delivery can be kept with their mothers. Routine stomach washouts in all preterm infants or infants born by caesarean section are not needed. Meconium-stained infants do not need to be washed or bathed immediately afer delivery. Neonatal encephalopathy 1-25 What is the danger of hypoxia before or afer delivery? The kidneys may be damaged, resulting in haematuria, proteinuria and decreased urine output for the frst few days afer delivery. The lungs may be damaged resulting in respiratory distress with pulmonary artery spasm (persistent pulmonary hypertension). With severe, prolonged hypoxia, cardiac output eventually falls and as a result the brain and myocardium may also sufer ischaemic damage. Diferent types of brain damage can occur depending on the gestational age of the fetus and the severity of the hypoxia: 1. This is common especially where monitoring and care of the fetus during labour is poor. In preterm infants, hypoxia before delivery may damage small blood vessels around the ventricles of the brain causing an intraventricular haemorrhage. Hypoxia may also cause blindness, deafness or learning and behaviour problems at school. Either depressed level of consciousness with poor feeding, or staring with increased irritability. Neonatal encephalopathy presents with abnormal neurological signs soon afer birth. This is common with mild encephalopathy when the infant appears normal by 7 days of age. This is ofen seen when the signs of neonatal encephalopathy have not disappeared by 7 days of life. Resuscitation is started and at 5 minutes the infant has a heart rate of 120 beats per minute and is breathing well. The Apgar score at 1 minute is 4: heart rate=1, respiration=1, colour=1, tone=1, response=0. The diagnosis of failure to breathe well is supported by the low Apgar score at 1 minute. Both the intravenous drugs and the anaesthetic gases cross the placenta and may sedate the fetus. Because there is no history of fetal distress to indicate that this infant had been hypoxic before delivery. The rapid response to resuscitation also suggests that there was not fetal hypoxia. Tere is also no good reason why the fetus should be hypoxic as the mother has had an elective caesarean section and was not in labour. Case study 2 Afer fetal distress has been diagnosed, an infant is delivered by a difcult vacuum extraction. The difcult delivery by vacuum extractionprobably resulted in failure to breathe well and a low Apgar score, while inhaled meconium may have blocked the airway. This will usually prevent severe meconium aspiration as the airway is cleared of meconium before the infant starts to breathe. Should this infant be given a bath and stomach washout in the labour ward afer it starts to breathe spontaneously? A bath should not be done until the infant has been stable for a number of hours in the nursery. As there was thick meconium, the infant should be given a stomach washout with normal saline or 2% sodium bicarbonate in the nursery followed by a breastfeed. This infant may develop meconium aspiration syndrome as meconium was probably inhaled into the lungs afer birth. Chest compressions were also given, and the heart rate remained slow afer ventilation was started. Despite further eforts at resuscitation, the Apgar score at 5, 10, 15 and 20 minutes remained 2. Abruptio placentae (placental separation before delivery) is a common cause of severe hypoxia and fetal distress. Why is it possible to successfully resuscitate some infants that appear dead at birth? Case study 4 Afer a normal labour and delivery at term, an infant cries well at birth. The infant is centrally cyanosed, has a heart rate of 50 beats per minute and starts to gasp at 5 minutes. The infant became more and more hypoxic while atempts were made to intubate the trachea. Tere was no indication for giving naloxone in this infant as the mother had not received any analgesia. An urgent telephone call to the referral hospital could have provided the correct advice needed. Some infants with poor breathing at birth will eventually start gasping spontaneously even if the correct resuscitation is not given. Clinics and hospitals should not deliver infants if they are not able to provide good resuscitation. Only if the heart rate remained below 60 per minute afer 60 seconds of efective ventilation. Clear airway if needed Assess breathing Poor breathing Bag and maskventilation or intubate andventilate Assess heartrate Heartrate less than 60 Chest massage Assess heartrate Heartrateremains less than 60 Adrenaline Figure 1-1: The important steps in basic newborn resuscitation. A score of 1 is given if the heart rate is less than 100, while a score of 0 is given if no heart beat can be detected. If infants are being ventilated, stop the ventilation for a few seconds to assess any spontaneous respiration. When lying face up, the arms and feet are moved actively in the air or are held in a fexed position against the body. The best way to learn how to perform an Apgar score accurately is to score infants with an experienced colleague.

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Sul? Intra-articular corticosteroids may be helpful if one or fasalazine also causes hemolysis in patients with two joints are the chief source of difficulty. Patients with aspirin sensitivity should not be given more than four times a year. Patients taking sulfasalazine should have complete blood counts monitored every 2-4 weeks for the B. It is generally well tolerated and often produces a toid arthritis and is administered as a single oral daily dose benefcial effect in 2-6 weeks. The most frequent side effects are diarrhea, rash, of methotrexate orally once weekly. Some patients ated methotrexate but has not responded in 1 month, the experience dramatic unexplained weight loss. The most frequent Thus, it is contraindicated in premenopausal women or in side effects are gastric irritation and stomatitis. Antimalarials-Hydroxychloroquine sulfate is the anti? rarely pancytopenia, due to bone marrow suppression is malarial agent most often used against rheumatoid arthri? another important potential problem. Monotherapy with hydroxychloroquine should be oping pancytopenia is much higher in patients with reserved for patients with mild disease because only a small elevation of the serum creatinine (greater than 2 mgldL percentage will respond and in some of those cases only [176. Methotrexate is contraindicated in a of hydroxychloroquine is its comparatively low toxicity, patient with any form of chronic hepatitis. Heavy alcohol especially at a dosage of 200-400 mg/day orally (not to use increases the hepatotoxicity, so patients should be exceed 5 mg/kg/day). The prevalence of the most impor? advised to drink alcohol in extreme moderation, if at all. Liver function tests should be ofpatients (dosed properly) during the first 10years ofuse, monitored at least every 12 weeks, along with a complete but rising to 20% after 20 years of treatment. The dose of methotrexate should be reduced logic examinations every 12 months are required. Other if aminotransferase levels are elevated, and the drug should reactions include neuropathies and myopathies of both be discontinued if abnormalities persist despite dosage skeletal and cardiac muscle, which usually improve when reduction. Tofacitinib-Tofacitinib, an inhibitor of Janus kinase 3, taken orally 24 hours after the dose of methotrexate). While it appears to be superior subacute interstitial pneumonitis that can be life-threaten? to methotrexate as initial monotherapy for rheumatoid ing but which usually responds to cessation of the drug arthritis, it has greater toxicity. Because methotrexate is either as monotherapy or in combination with methotrex? teratogenic, women of childbearing age as well as men ate. It is administered orally in a dose of 5 mg or 10 mg must use effective contraception while taking the medica? twice daily. Methotrexate is associated with an increased risk of latent tuberculosis prior to receiving the drug. Amoxicillin can decrease renal frequently added to the treatment of patients who have not clearance of methotrexate, leading to toxicity. Probenecid responded adequately to methotrexate and are increasingly also increases methotrexate drug levels and toxicity and used as initial therapy in combination with methotrexate should be avoided. Sulfasalazine-This drug is a second-line agent for umab, golimumab, and certolizumab pegol. Course & Prognosis Each drug produces substantial improvement in more than 60% of patients. Minor After months or years, deformities may occur; the most irritation at injection sites is the most common side effect common are ulnar deviation of the fngers, boutonniere of etanercept and adalimumab. The bacterial infections and a striking increase in granuloma? excess mortality associated with rheumatoid arthritis is tous infections, particularly reactivation of tuberculosis. When to Refer resemble multiple sclerosis have been reported rarely in Early referral to a rheumatologist is essential for appropri? patients taking etanercept, but the true magnitude of this ate diagnosis and the timely introduction of effective risk-likely quite small-has not been determined with therapy. Most adults are in their 20s or 30s; onset nal antibody that depletes B cells, can be used in combina? after age 60 is rare. An evanescent salmon-colored nonpruritic involved in the pathogenesis of rheumatoid arthritis. It is rash, chiefy on the chest and abdomen, is a characteristic used most often in combination with methotrexate for feature. The rash can easily be missed since it often appears patients whose disease has been refractory to treatment only with the fever spike. Joint symptoms are mild or absent in the beginning, but a destructive arthritis, especially of the wrists, may develop months later. It is imperative to ascertain that the condition has not been induced by a drug (see Drug? Induced Lupus below). Leukopenia (< 4000/mcL), or are secondary to the trapping of antigen-antibody com? c. Lymphopenia (< 1500/mcL), or plexes in capillaries of visceral structures or to autoanti? d. Antibodies to antiphospholipid antibodies based on (1) lgG from a mild episodic disorder to a rapidly fulminant, life? or lgM anticardiolipin antibodies, (2) lupus anticoagulant, or threatening illness. The role; most cases develop after menarche and before meno? 1982 revised criteria for the classification of systemic lupus erythe? pause. Updating the American College of Rheumatology revised cri? white women but in 1: 250 black women. Clinical Findings silent but occasionally can produce acute or chronic val? vular regurgitation-most commonly mitral regurgitation. Most patients have skin lesions at some time; presence of aneurysms in medium-sized blood vessels. Several forms of glomerulonephritis may occur, includ? Joint symptoms, with or without active synovitis, occur ing mesangial, focal proliferative, diffuse proliferative, and in over 90% ofpatients and are often the earliest manifesta? membranous (see Chapter 22). The arthritis can lead to reversible swan-neck defor? have interstitial nephritis. With appropriate therapy, the mities, but erosive changes are almost never noted on survival rate even for patients with serious chronic kidney radiographs. Laboratory Findings bodies) represent degeneration of nerve fibers due to occlusion of retinal blood vessels. Restrictive lung disease can antibody tests based on immunofuorescence assays using develop. Atypical verru? rheumatoid arthritis, autoimmune thyroid disease, sclero? cous endocarditis of Libman-Sacks is usually clinically derma, and Sjogren syndrome. Frequency (%) of laboratory abnormalities of their use-must be tailored to match disease severity. Patients should be cautioned against sun exposure and Anemia 60% should apply a protective lotion to the skin while out of doors. Skin lesions often respond to the local administra? Leukopenia 45% tion of corticosteroids. Antiphospholipid antibodies Antimalarials (hydroxychloroquine) may be helpfl in treating lupus rashes or joint symptoms and appear to Biologic false-positive testfor syphilis 25% reduce the incidence of severe disease fares. The dose of Lupus anticoagulant 7% hydroxchloroquine is 200 or 400 mg/dayorally and should Anti-cardiolipin antibody 25% not exceed 5 mg/kg/day; annual monitoring for retinal Direct Coombs-positive 30% changes is recommended. Drug-induced neuropathy and myopathy may be erroneously ascribed to the underlying Proteinuria 30% disease. Hematuria 30% Corticosteroids are required for the control of certain Hypocomplementemia 60% complications. Forty to 60 mg of oral prednisone is often needed initially; Systemic lupus erythematosus: a review of clinicolaboratory fea? however, the lowest dose of corticosteroid that controls the tures and immunologic matches in 150 patients with emphasis on demographic subsets. Central nervous system lupus may require higher doses of corticosteroids than are usually given; however, corticosteroid psychosis may mimic l? Cyclophosphamide, which improves renal survival only 60% and 30% of patients, respectively. Depressed but not patient survival, has been used for many years as the serum complement-a fm ding suggestive of disease activity? standard treatment for both phases of lupus nephritis. The first causes the biologic false-positive (500 mg intravenously every 2 weeks for 6 doses followed tests for syhilis; the second is the lupus anticoagulant, by maintenance with azathioprine). Mycophenolate mofetil which despite its name is a risk factor for venous and arterial appears to be an equally effective alternative treatment to thrombosis and for miscarriage.

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Patients with mucosal-associated lymphoid tumors of the stomach may be appropriately treated with combina? B. Laboratory Findings tion antibiotics directed against H pylori and with acid the peripheral blood is usually normal even with extensive blockade but require frequent endoscopic monitoring. Those with localized disease may low-risk patients (zero risk factors) to less than 50% for receive short-course immunochemotherapy (such as three high-risk patients (four or more risk factors). Patients with diffse large B-cell lym? stem cell transplantation offers a 50% chance oflong-term phoma who relapse after initial chemotherapy can still be lymphoma-free survival. When to Refer Mantle cell lymphoma is not effectively treated with All patients with lymphoma should be referred to a hema? standard immunochemotherapy regimens. Admission is necessary only for specific complications of Ibrutinib is active in relapsed or refractory patients with lymphoma or its treatment and for the treatment of all mantle cell lymphoma. Mantle cell lymphoma: evolving management produce better results than whole-brain radiotherapy and strategies. Current therapeutic strategies and new treat? Patients with high-grade lymphomas (Burkitt or lym? ment paradigms for follicular lymphoma. Autologous stem cell transplantation is often incorporated in frst-line ther? apy. General Considerations progression of the disease to a more aggressive form of lymphoma. Hodgkin lymphoma is characterized bylymph nodebiopsy the International Prognostic Index is widely used to showing Reed-Sternberg cells in an appropriate reactive categorize patients with aggressive lymphoma into risk cellular background. Factors that confer adverse prognosis are age over lymphocytes of germinal center origin. Pulmo? nary toxicity can unfortunately occur following either There is a bimodal age distribution, with one peak in the chemotherapy (bleomycin) or radiation and should be 20s and a second over age 50 years. Most patients seek treated aggressively in these patients, since it can lead to medical attention because of a painless mass, commonly in permanent fibrosis and death. Others may seek medical attention because of Classic Hodgkin lymphoma relapsing after initial treat? constitutional symptoms such as fever, weight loss, or ment may be treatable with high-dose chemotherapy and drenchingnight sweats, or because ofgeneralized pruritus. This An unusual symptom of Hodgkin lymphoma is pain in an offers a 35-50% chance ofcure when disease is still chemo? involved lymph node following alcohol ingestion. Hodgkin lymphoma should be distinguished pathologically from All patients should be treated with curative intent. Progno? other malignant lymphomas and may occasionally be con? sis in advanced stage Hodgkin lymphoma is infuenced by fsed with reactive lymph nodes seen in infectious mono? seven features: stage, age, gender, hemoglobin, albumin, nucleosis, cat-scratch disease, or drug reactions (eg, white blood count, and lymphocyte count. Disease staging is further categorized as lymphocyte predominant) is highly curable with radio? "? When to Admit dative radiotherapy, they are usually associated with increased toxicity and lack a definitive overall survival Patients should be admitted for complications of the dis? advantage. Risk assessment in the management of newly diag? bination of short-course chemotherapy with involved? nosed classical Hodgkin lymphoma. Light chain components may be depos? ited in tissues as amyloid, resulting in kidney failure with albuminuria and a vast array of systemic symptoms. Myeloma patients are prone to recurrent infections for a number ofreasons, including neutropenia, the underproduc. Bone pain, often in the spine, ribs, or proximal tion of normal immunoglobulins and the immunosuppres? long bones. Monoclonal paraprotein by serum or urine protein prone to infections with encapsulated organisms such as electrophoresis or immunofixation. The most common presenting complaints are those related to anemia, bone pain, kidney disease, and infection. General Considerations ent as a pathologic fracture, especially of the femoral neck Multiple myeloma is a malignancy of hematopoietic stem or vertebrae. Patients may also come to medical attention cells terminally differentiated as plasma cells characterized because of spinal cord compression from a plasmacytoma by infltration of the bone marrow, bone destruction, and or the hyperviscosity syndrome (mucosal bleeding, vertigo, paraprotein formation. The diagnosis is established when nausea, visual disturbances, alterations in mental status, monoclonal plasma cells (either kappa or lambda light hypoxia). Many patients are diagnosed because of labora? chain restricted) in the bone marrow (any percentage) or as tory findings of hypercalcemia, proteinuria, elevated sedi? a tumor (plasmacytoma), or both, are associated with end? mentation rate, or abnormalities on serum protein organ damage (such as bone disease [lytic lesions, osteope? electrophoresis obtained for symptoms or in routine nia], anemia [hemoglobin less than 10 g/dL {100 g/L}], screening studies. L}], or kidney injury [creatinine greater than 2 mg/ Examination may reveal pallor, bone tenderness, and dL {176. Sixty percent or more clonal plasma cells in the bone related to neuropathy or spinal cord compression. Fever marrow or a serum free kappa to lambda ratio of greater occurs mainly with infection. Laboratory Findings plasma cells in the bone marrow, a serum paraprotein level of 3 g/dL (30 g/L) or higher, or both, without plasma cell? Anemia is nearly universal. The absence of rouleaux formation, however, mas) that may cause spinal cord compression or other sof? excludes neither multiple myeloma nor the presence of a tissue problems. The neutrophil and platelet counts are excessive osteoclast activation mediated largely by the usually normal at presentation. Approximately 15% of patients will have no demonstrable the paraproteins (monoclonal immunoglobulins) paraprotein in the serum because their myeloma cells pro? secreted by the malignant plasma cells may cause problems duce onlylight chains and not intact immunoglobulin, and in their own right. Very high paraprotein levels (either IgG the light chains pass rapidly through the glomerulus into or IgA) may cause hyperviscosity, although this is more the urine. Overall, the paraprotein is of bone pain or other symptoms and complications related IgG (60%), IgA (20%), or light chain only (15%) in multiple to the disease. The initial treatment generally involves at a myeloma, with the remainder being rare cases ofIgD, IgM, minimum an immunomodulatory agent, such as thalido? or biclonal gammopathy. In sporadic cases, no paraprotein mide or lenalidomide, or a proteasome inhibitor, such as is present ("nonsecretory myeloma"); these patients have bortezomib, in combination with moderate or high-dose particularly aggressive disease. The major side effects oflenalidomide are the bone marrow will be infltrated by variable num? neutropenia and thrombocytopenia, venous thromboem? bers of monoclonal plasma cells. Bortezomib has the morphologically abnormal often demonstrating multi? advantages of producing rapid responses and of being nucleation and vacuolization. The major side effect marked skewing of the normal kappa-to-lambda light of bortezomib is neuropathy (both peripheral and auto? chain ratio, which will indicate their clonality. Many nomic), which is largely ameliorated when given subcuta? benign processes can result in bone marrow plasmacytosis, neously rather than intravenously. A common regimen for but the presence of atypical plasma cells, light chain restric? initial treatment is lenalidomide, bortezomib, and dexa? tion, and effacement of normal bone marrow elements methasone. Imaging Carflzomib, a second-generation proteasome inhibitor, produces responses in patients for whom bortezomib treat? Bone radiographs are important in establishing the diagno? ment fails and does not cause neuropathy. Lytic lesions are most commonly seen in some inhibitor, ixazomib, is available for relapsed disease. The radionuclide bone scan is not useful in detecting bone After initial therapy, many patients under age 80 years lesions in myeloma, since there is usually no osteoblastic are consolidated with autologous hematopoietic stem cell component. In the evaluation of patients with known or transplantation following high-dose melphalan. Differential Diagnosis posttransplant maintenance therapy but at the expense of an elevated rate of second malignancies. Vertebral collapse with its attendant pain defined as bone marrow monoclonal plasma cells less than and mechanical disturbance can be treated with vertebro? 10% in the setting of a paraprotein (serum M-protein less plasty or kyphoplasty. Hypercalcemia and hyperuricemia than 3 g/dL [30 g/L]) and the absence of end-organ dam? should be treated aggressively and immobilization and age. The bisphosphonates (pamidronate gresses to overt malignant disease in a median of one 90 mg or zoledronic acid 4 mg intravenously monthly) decade. Multiple myeloma, smolder? and are an important adjunct in this subset of patients. However, long-term bisphosphonates, linemia (which is commonly seen in cirrhosis). Myeloma patients with oliguric or anuric renal failure at Patients with smoldering myeloma treated with lenalido? diagnosis should be treated aggressively with chemo? mide (an immunomodulatory agent) and dexamethasone therapy and considered for plasma exchange (to reduce take longer to progress to symptomatic myeloma and live the paraprotein burden), as return of renal function can longer than when simply observed. An update on the use oflenalidomide for the the outlook for patients with myeloma has been steadily treatment of multiple myeloma. The International Staging System for myeloma relies on two factors: beta 2-microglobulin and albumin. Infiltration of bone marrow by plasmacytic is established when beta-2-microglobulin is greater than lymphocytes. General Considerations at chromosome l4q32 (such as the finding of t[4;14] or t[l4;16]) or multiple copies of the lq2l-23 locus.

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Risk administration ofintravenous zidovudine prior to cesarean factors for transmission include blood transfsion, injec? delivery and during labor in women whose viral load near tion drug use, employment in patient care or clinical labo? delivery is greater than or equal to 1000 copies/mL or ratory work, exposure to a sex partner or household unknown. Ledi? of each can be reliably made by appropriate laboratory pasvir/sofosbuvir (Harvoni) has been shown to be safe in tests. All women should be tested for syphilis and C tracho? animal studies, but there are no human studies on safety or matis as part of their routine prenatal care. Early antenatal care: does it make a difference to outcomes of pregnancy associated with syphilis? Most infected neonates are born to women with no history, symptoms, or Complications involving the gastrointestinal tract, liver, and signs of infection. Nausea and vomiting Women who have had primary herpes infection late in in the frst trimester affect the majority of pregnant women pregnancy are at high risk for shedding virus at delivery. Nausea and vomiting in the last half of orally three times daily, to decrease the likelihood of active pregnancy, however, are never normal; a thorough evalua? lesions at the time oflabor and delivery. Some of these condi? Women with a history of recurrent genital herpes have tions are incidental to pregnancy (eg, appendicitis), while a lower neonatal attack rate than women infected during others are related to the gravid state and tend to resolve with the pregnancy, but they should still be monitored with delivery (eg, acute fatty liver of pregnancy). Likewise, interpretation of laboratory studies include routine cultures in individuals with a history of must take into account the pregnancy-associated changes in herpes without active disease. Cesar? For conditions in which surgery is clinically indicated, ean delivery is indicated at the time of labor if there are operative intervention should never bewithheld based soley prodromal symptoms or active genital lesions. The use of acyclovir in surgery is avoided during pregnancy, women who undergo pregnancy is acceptable, and prophylaxis starting at 36 weeks surgical procedures for an urgent or emergent indication gestation has been shown to decrease the number of cesar? during pregnancy do not appear to be at increased risk for ean sections performed for active disease. Varying degrees of fu-like symptoms are also classic symptoms of nausea, vomiting, and right upper typical. Eventually, symptoms progress to those of fulmi? quadrant pain, usually after meals, and is confirmed with nant hepatic failure: jaundice, encephalopathy, dissemi? right upper quadrant ultrasound. On examination, sis without cholecystitis is usually managed conservatively, the patient shows signs of hepatic failure. Cholecystitis results Laboratory fndings include marked elevation of alka? from obstruction of the cystic duct and often is accompa? line phosphatase but only moderate elevations of alanine nied by bacterial infection. Hypocholesterolemia and hypofibrinogenemia are treatment with cholecystectomy will help prevent compli? typical, and hypoglycemia can be extreme. Renal function should be assessed as well, trimesters of pregnancy and should not be withheld based since hepatorenal syndrome commonly causes acute kid? on the stage of pregnancy if clinically indicated. The white blood cell count is elevated, and the copy is preferred in the first half of pregnancy but becomes platelet count is depressed. Obstruction of the common bile duct, which can lead to Liver aminotransferases for fulminant hepatitis are higher cholangitis, is an indication for surgical removal of gall? (greater than 1000 units/mL) than those for acute fatty stones and establishment of biliary drainage. There does, however, appear to be a slightly higher rate of post-procedure pancreatitis in pregnant. Continued evidence for safety of endoscopic retro? grade cholangiopancreatography during pregnancy. Acute fatty liver ofpregnancy: clinical outcomes 25132918] and expected duration of recovery. With improved recognition incomplete clearance of bile acids in genetically susceptible and immediate delivery, the maternal mortality rate in women. The disorder is usually generalized but tends to have a predilection for the palms seen after the 35th week of gestation and is more common and soles. Presentation is typically in the third trimester, in primigravidas and those with twins. The incidence is and women with multi-fetal pregnancies are at increased about 1: 10,000 deliveries. The finding of an elevated serum bile acid level, ide? the etiology of acute fatty liver of pregnancy is likely ally performed in the fasting state, confirms the diagnosis. Although rare, the bilirubin level may be sufficiently elevated to result in clinical jaundice. Clinical Findings after delivery but can recur in subsequent pregnancies or Pathologic findings are unique to the disorder, with fatty with exposure to combination oral contraceptives. Clinical onset is gradual, with Ursodeoxycholic acid (8-10 mg/kg/day) is the treatment nausea and vomiting being the most common presenting of choice and results in decreased pruritus in most women. Furthermore, nausea, vomiting, and mild nonreassuring fetal status, meconium-stained amniotic leukocytosis occur in normal pregnancy, so with or without fuid, and stillbirth, have consistently been reported in these fndings, any complaint of right-sided pain should women with cholestasis of pregnancy. Imaging can help confrm the diagnosis if perinatal outcomes appears to correlate with disease sever? clinical fndings are equivocal. Abdominal sonography is a ity as measured by the degree of bile acid elevation, and reasonable initial imaging choice, but nonvisualization ofthe women with fasting bile acids greater than 40 mcmol! Because of the sensitive than ultrasound, and with proper shielding, the risks associated with cholestasis of pregnancy, many clini? radiation exposure to the fetus is minimized. Evidence-based recommendations regarding such man? Unfortunately, the diagnosis of appendicitis is not made agement practices, however, are not currently available. With early diagnosis and appendectomy, the pregnancy with adverse pregnancy outcomes: a prospective prognosis is good for mother and baby. Diagnosis & Evaluation trauma, and traumatic taps are the most common causes of bloody effsions. Synovial fuid glucose and protein levels add Joint infammation manifests as warmth, swelling, and little information and should not be ordered. Both the number of light microscopy identifes and distinguishes monosodium affected joints and the specific sites of involvement affect urate (gout, negatively birefringent) and calcium pyro? phosphate (pseudogout, positive birefringent) crystals. Some diseases? gout, for example-are characteristically monarticular, Gram stain has specificity but limited sensitivity (50%) for whereas other diseases, such as rheumatoid arthritis, are septic arthritis. Only two diseases frequently cause gonococci, tubercle bacilli, or fngi are ordered as appropriate. Interpretation-Synovial fuid analysis is diagnostic in joint: osteoarthritis and psoriatic arthritis. Most large joints are easily aspirated, and contraindications to arthrocentesis are few. The aspirating needle should never be passed through an overlying cellulitis or psoriatic plaque because of the risk of introducing infection. A degenerative disorder with minimal articular long-term anticoagulation therapy with warfarin, joints can inflammation. Radiographicfindings: narrowed joint space, osteo? phytes, increased density of subchondral bone, A. Recreational running does not increase the incidence of osteoarthritis, but participa? Representative tion in competitive contact sports does. Jobs requiring Characteristic Status Disease frequent bending and carrying increase the risk of knee Inflammation Present Rheumatoid arthritis, osteoarthritis (see Chapter 41). Initially, there is articular stiff? osteoarthritis) ness, seldom lasting more than 15 minutes; this develops First metatarsal Gout, osteoarthritis later into pain on motion of the affected joint and is made phalangeal worse by activity or weight bearing and relieved by rest. There is no ankylosis, but limitation of Osteoarthritis, the most common form of joint disease, is motion of the affected joint or joints is common. Joint effusion and other radiographic features of osteoarthritis in weight-bearing articular signs of infammation are mild. Sex is also a risk factor; osteoarthritis develops in women more frequently than in men. Laboratory Findings this arthropathy is characterized by degeneration of cartilage and by hypertrophy of bone at the articular mar? Osteoarthritis does not cause elevation of the erythrocyte gins. Prevention Radiographs may reveal narrowing of the joint space; Weight reduction reduces the risk of developing symptom? osteophyte formation and lipping of marginal bone; and atic knee osteoarthritis. Bone cysts may also be of greater than 1 em with shoe modifcation may prevent present. Differential Diagnosis occurrence and progression of osteoarthritis, in addition to being important for bone health. Because articular infammation is minimal and systemic manifestations are absent, degenerative joint disease should seldom be confused with other arthritides. Furthermore, thejoint enlargement is bony-hard and osteoarthritis of the frst carpometacarpal joint. Patients with cool in osteoarthritis but spongy and warm in rheumatoid mild to moderate osteoarthritis of the knee or hip should arthritis. Skeletal symptoms due to degenerative changes in participate in a regular exercise program (eg, a supervised joints-especially in the spine-may cause coexistent meta? walking program, hydrotherapy classes) and, if overweight, static neoplasia, osteoporosis, multiple myeloma, or other should lose weight.

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The axillo-femoral and femoral-to-femoral grafts are extra-anatomic bypasses because the abdominal cavity is not entered and the aorta is not cross-clamped; the operative risk is less than with aorto-bifemoral bypass, but the grafts are less durable. Mortal? ity is low (2-3%), but morbidity is higher and includes a 5-10% rate of myocardial infarction. Thesuperficial femoral artery is theperipheral artery most commonly occluded by atherosclerosis. Prognosis quently occurs where the superfcial femoral artery passes Patients with isolated aortoiliac disease may have a further through the abductor magnus tendon in the distal thigh reduction in walking distance without intervention, but (Hunter canal). The common femoral artery and the pop? symptoms rarely progress to rest pain or threatened limb liteal artery areless commonly diseasedbutlesions in these loss. Life expectancy is limited by their attendant cardiac vessels are debilitating, resulting in short-distance disease with a mortality rate of 25-40% at 5 years. Symptoms and Signs tom relief for patients with short stenoses are also good with 20% symptom return at 3 years. Recurrence rates fol? Symptoms of intermittent claudication caused bylesions of lowing endovascular treatment of extensive disease are thecommon femoral artery, superficial femoral artery, and 30-50%. Paclitaxel? canal when the patient has good collateral vessels from the eluting stents or paclitaxel-coated balloons offer modest profunda femoris will cause claudication at approximately improvement over bare metal stents and noncoated bal? 2-4 blocks. However, the success of local drug delivery in funda femoris or the popliteal artery, much shorter dis? peripheral arteries is not as robust as that in the coronary tances may trigger symptoms. The 1-year patency rate is 50% for balloon angio? claudication, dependent rubor of the foot with blanching plasty, 70% for drug-coated balloons, and 80% for stents. Chronic low blood fow states is much harder, however, to treat restenosis in stents than will also cause atrophic changes in the lower leg and fo ot vessels that have undergone angioplasty. Ongoing investi? with loss of hair, thinning of the skin and subcutaneous gation will determine which therapy is best. Thromboendarterectomy-Removal of the atheroscle? mon femoral pulsation is normal, but the popliteal and rotic plaque is limited to the lesions of the common femo? pedal pulses are reduced. Since the vessels may be larly long bypasses with vein harvest, have a risk of wound calcified in diabetes mellitus, chronic kidney disease, and infection that is higher than in other areas of the body. In such patients, the Wound infection or seroma can occur in as many as toe brachial index is usually reliable with a value less than 10-15% of cases. Complica? with cuffs placed at the high thigh, mid-thigh, calf, and tion rates ofendovascular surgery are 1-5%, making these ankle will delineate the levels of obstruction with reduced therapies attractive despite their lower durability. However, when claudication significantly limits daily activity and undermines quality oflife as well as over. Conservative Care with repeated ultrasound surveillance so that any recurrent As with aortoiliac disease, risk factor reduction, medical narrowing can be treated promptly to prevent complete optimization, and exercise treatment are the cornerstone of occlusion. Revascularization is reserved for patients who femoral artery, superficial femoral artery, and popliteal remain signifcantly disabled after failure of this conserva? artery is 65-70% at 3 years, whereas the patency of angio? tive regimen. Surgical Intervention ing associated coronary lesions, 5-year mortality among patients with lower extremity disease can be as high as 1. Bypass surgery-Intervention is indicated ifclaudication 50%, particularly with involvement of the infrapopliteal is progressive, incapacitating, or interferes signifcantly with vessels. However, with aggressive risk factor modifcation, essential daily activities or employment. When to Refer the superfcial femoral artery is a femoral-popliteal bypass with autogenous saphenous vein. Endovascular surgery-Endovascular techniques are often used for lesions of the superficial femoral artery. Results for primary bypass versus primary dent rubor may be prominent with pallor on elevation. The angioplasty/stent for intermittent claudication due to superfi? skin of the fo ot is generally cool, atrophic, and hairless. Imaging Digital subtraction angiography is the gold standard method to delineate the anatomy ofthe tibial-popliteal seg. However, if ulcerations appear and there is no significant healing Occlusive processes of the tibial arteries of the lower leg within 2-3 weeks and studies indicate poor blood flow, and pedal arteries in the foot occur primarily in patients revascularization will be required. There often is extensive calcification of the infrequent rest pain without ulceration is not an indication artery wall. The first manifesta? with monophasic waveforms requires revascularization to tion of ischemia is frequently an ulcer or gangrene rather prevent threatened tissue loss. Symptoms and Signs been shown to be an effective mechanism to treat rest pain and heal gangrene or ischemic ulcerations of the foot. Unless there are associated lesions in the aortoiliac or Because the foot often has relative sparing of vascular dis? femoral/superficial femoral artery segments, claudication ease, these byasses have had adequate patency rates (70% may not occur. Fortunately, in nearly all series, limb salvage be supplied from collateral vessels from the popliteal rates are much higher than patency rates. Drug-coated balloons have not been successfl cation, and rest pain or ulceration may be the first sign of in the tibial vessels. The presence of rest pain or ated with the best success when used in short lesions. Amputation emic rest pain is confined to the dorsum of the foot and is relieved with dependency; the pain does not occur with Patients with rest pain and tissue loss are at high risk for standing or sitting. It is severe and burning in character, amputation, particularly if revascularization cannot be and because it is only present when recumbent, it may done. If the pain is relieved by simply dangling the foot over Many patients who have below-the-knee or above-the? the edge of the bed, which increases blood fow to the fo ot, knee amputations due to vascular insufficiency never then the pain is due to vascular insufficiency. Leg night attain independent ambulatory status and often need cramps (not related to ischemia) occur often in patients assisted-living facilities. Complications circulation, and the remainder to the upper extremities and mesenteric and renal circulation. Atrial fbrillation is the most the complications of intervention are similar to those common cause of cardiac thrombus formation; other causes listed for superfcial femoral artery disease with evidence are valvular disease or thrombus formation on the ventricular that the overall cardiovascular risk ofintervention increases surface of a large anterior myocardial infarct. The patients with critical limb isch? Emboli from arterial sources such as arterial ulcerations emia require aggressive risk factor modifcation. Wound or calcified excrescences are usually small and go to the infection rates after bypass are higher if there is an open distal arterial tree (toes). If the stenosis has developed over time, collateral blood ves? Patients with tibial atherosclerosis have extensive athero? sels will develop, and the resulting occlusion may only sclerotic burden and a high prevalence of diabetes. Symptoms and Signs Patients with diabetes and foot ulcers should be referred the sudden onset ofextremity pain, with loss or reduction in for a formal vascular evaluation. This often will necessary but the severity of the disease will be quantified, be accompanied by neurologic dysfnction, such as numb? which has implications for future symptom development. With popliteal occlusion, Any patient with a diabetic foot infection should be treated symptoms may only affect the foot. Signs of severe arterial spectrum antibiotics should be given to cover gram-positive, ischemia include pallor, coolness of the extremity, and mot? gram-negative, and anaerobic organisms. Impaired neurologic fnction progressing to anesthesia a multidisciplinary limb preservation center staffed with accompanied with paralysis suggests a poor prognosis. There will belittle or no fowfound with Doppler examina? tion of the distal vessels. A systematic review of the effectiveness of abrupt cutoff of contrast with embolic occlusion. Blood revascularization of the ulcerated foot in patients with diabe? workmay show myoglobin and metabolic acidosis. Evidence of neurologic injury, including loss of light touch sensation, indicates that collateral fow is inadequate to maintain limb viability and? Heparin As soon as the diagnosis is made, unfractionated heparin should be administered (5000-10,000 units) intravenously. This helps pre? occlude proximal arteries in the lower extremities are almost vent clot propagation and may also help relieve associated always from the heart. Anticoagulation may improve symptoms, but go to the lower extremities, 20% to the cerebrovascular revascularization will still be required. One-third ofalischemic strokes may be due cations such as bleeding diathesis, gastrointestinal to arterial emboli.


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