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Echocardiogram and angiography are used in 23 tated by exercise or running or is associated with syncope diagnosis. Cardiac catheter ization and electrophysiologic studies with invasive monitoring Syncope is the temporary loss of consciousness and tone fol may be necessary in some severe cases. Heart block can be congenital, postsurgical, acquired unusual in children less than 6 years of age. First and second-degree benign in children but must be carefully addressed because it heart block are unlikely to cause syncope. The latter is also associated with congenital breath, nausea, diaphoresis, amnesia, vision changes), and time deafness. Syncope in the absence of pre 7 either occurs in a recumbent position or is associated syncopal symptoms should be approached with a similar level with exercise, chest pain, or palpitations. Personal and family histories of prior episodes diac examination fndings should also be referred for an urgent of fainting are ofen obtained in cases of benign (vasovagal) cardiac evaluation. A menstrual history should be obtained in females to investigate the possibility of pregnancy. Subaortic hypertrophied myocardium quire about access to any potential toxins or medications, causes outfow tract obstruction; the subsequent murmur charac including medications of other family members that might be teristically increases during a Valsalva maneuver and when a accessible. Diuretics, beta-blockers, other cardiac medications, patient rises from a squatting up to a standing position (both and tricyclic anti-depressants are medications that may lead to maneuvers decrease preload). An evaluation is indicated when The physical examination fndings are usually normal in ever a murmur is present in a patient with syncope; a positive children who experience syncope. The examination should in family history should raise the level of suspicion because the in clude a thorough neurologic examination, and the cardiac ex heritance risk is high. A few tonic-clonic contractions are normal 2 obtaining blood pressure (and heart rate) afer resting supine in cases of vasovagal syncope. Loss of consciousness with syncope is and electrolyte levels is usually not helpful, especially in children usually less than 1 minute. Seizures should also be suspected who present for evaluation hours to days afer the episode. Most cases in young people are nonneurogenic and 10 severe occipital headache and unilateral visual changes are caused by medications or hypovolemia. Neurogenic orthostatic hypotension is a signifcant disorder of the autonomic system and more likely to occur in Further evaluation may be indicated because frequent epi older patients or in association with serious medical conditions 11 sodes of syncope are very distressing to a patient, even. A tilt table evaluation may aid in the diagnosis of syncope due to orthostatic intolerance. It is the most common type of Breath-holding spells are the most common mechanism 16 syncope in normal children and adolescents; it occurs most fre of syncope in children younger than 6 years of age. A neurally-mediated dren who are startled or upset hold their breath in expiration, decline in blood pressure (the exact mechanism of which is collapse, and become cyanotic for a brief period. Hemodynamic changes, sweating, pallor, prolonged period of standing, certain stressors like venipunc and subsequent psychological distress regarding the episode are ture, noxious stimuli, fasting, or a crowded location) and pro absent. The absence of a prodromal or presyncopal sensation is accompany hypoglycemia or electrolyte disorders. Supine not consistent with a vasovagal etiology and should prompt position does not provide relief. A history of preceding psychological distress, sensations of Also, vasovagal syncope can occur afer vigorous, usually pro 19 shortness of breath, chest pain, visual changes, and numb longed exertion (such as at the end of a long competitive run) due ness or tingling of the extremities may be reported in children to a warm ambient temperature, venous pooling, and dehydra with syncope due to hyperventilation. Most of these cases have a vasovagal (not cardiac) etiology, but sports participation should be curtailed until a worrisome cardiac etiology has been ruled out. Fever, pain, anemia, and described as rapid or slow, skipping or stopping, and regular or dehydration are common causes of sinus tachycardia. When drugs are responsible for palpitations, the most The goal of the evaluation is to identify the small proportion of 5 common mechanism is a transient increased heart rate, patients who are at risk for serious cardiac disease. Infants may manifest nonspecifc symp Clinical characteristics of hyperthyroidism include goiter, toms of irritability and poor feeding; some cases may progress to 6 accelerated linear growth, failure to gain weight (or weight congestive heart failure prior to identifcation of an abnormal loss), abnormal eyelid retraction, exophthalmos, tremor, and rhythm. Certain medications can be responsible for 48 hours) recommended to attempt to capture an abnormal arrhythmias. Symptoms suggestive of endocrine disorders may rhythm when a patient experiences frequent symptoms. A social history should investigate are more intermittent, an incident or event recorder is preferable; stress levels, cafeine intake, and tobacco use. Although usually benign, a history of syncope, heart associated with an arrhythmia. It can also reveal abnormalities that may cause den death, aggravation by exercise, frequent or prolonged runs, symptoms other than palpitations. Otherwise healthy children experi casionally complain of skipped beats or pauses in their heart rate. They may present with palpita complex, an abnormal P-wave axis, and an unvarying rate that tions, syncope, drowning, or cardiac arrest. It may be asymptomatic in children rates can occur in infants); ventricular conduction can be with normal hearts; children with structural heart disease are 1:1 but some degree of heart block (2:1, 3:1) is more common, so more likely to be symptomatic. It usually occurs in children with congenital heart disease, especially postoperatively, but may Bibliography occur in neonates with normal hearts. The clinical diagnosis of a normal or innocent A family history of sudden death or known hypertrophic 3 murmur should be made only in the presence of a normal history cardiomyopathy is also signifcant and mandates further and physical examination and characteristics consistent with a evaluation. Despite the easy availability of echocardiogra some include an abnormal rhythm, suprasternal thrill, promi phy, the history and physical examination remain the accepted nent apical thrust, digital clubbing, wide or bounding pulses, means of diagnosing normal murmurs. Signs of systemic disease murmur is unclear, it is generally more cost-efective to refer to a. The addition of preductal and postductal pulse oximetry 1 performed in newborn nurseries is recognized as a fairly When the diagnosis of a murmur is unclear, referral to a 4 sensitive means of early identifcation of critical congenital heart pediatric cardiologist is recommended; the severity of the disease. If not recognized in the newborn nursery, serious car clinical picture should determine the urgency of the referral. In older children, exercise or exertion can be assessed by inquiring about level of Rheumatic fever is an immunologically mediated infamma 5 activity and tolerance to extended periods of play or activity tory disorder following infection with group A streptococcus. The A history of fevers, lethargy, and recent dental work suggests modifed Jones criteria are used for diagnosis. A history of fevers in the presence of a new or certain drugs or medications may be risk factors for congenital changing heart murmur should raise the suspicion for both rheu heart disease. Symptoms depend on the size gram because of the autosomal dominant pattern of inheritance. The as a loud, usually holosystolic murmur with a harsh or blow cardiac examination should include assessment of pulses, palpa ing quality and is best heard at the left sternal border; a thrill tion of the precordium, auscultation, and blood pressures in or lift may be palpable with moderate lesions. In neonates both arms (involvement of a subclavian artery [most commonly the murmur may be heard best at the apex. Small defects the lef] in a coarctation would cause a lower blood pressure in may have soft murmurs that become softer over time as the the ipsilateral arm) and a leg. In large defects, the left-to-right shunting in usually 10-20 mmHg higher than upper extremity pressure. Di creases over the first few weeks of life as pulmonary vascular minished femoral pulses or a delay between the radial and femoral resistance falls. Clinical symptoms of congestive heart failure pulses suggest coarctation of the aorta (the simple presence of a develop gradually over this period. Tese murmurs are usually grade 1 to 3, short a hyperdynamic right ventricular impulse and a characteristic systolic murmurs with a slightly grating (rather than vibratory) fxed and widely split second heart sound. They are heard best over the lef upper sternal border and always audible, but large defects may manifest a mid-systolic may or may not transmit to the neck. It can occur in any age group type of defect and the need for monitoring versus repair. Children not diagnosed in infancy can remain asymp with terms such as common innocent murmur, vibratory tomatic (even with severe coarctation) and ofen present with innocent murmur, or classic vibratory murmur.

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Coming almost a century before the frst permanent English settlement at Jamestown in 1607, the colonies of the Iberian countries were not originally intended to be permanent. Eventually, these settlements did in fact become permanent and, with the success in mining gold and silver, their European populations increased in size. But in the course of establishing control, the Spanish had to contend with two well-established New World empires: the Aztec Empire in Mesoamerica and the Inca Empire in Peru. The conquest of the Aztecs established patterns of conquest that were later utilized in the defeat of the Incas. Recruiting native allies and kidnapping local leaders allowed the Spanish to control power from within as they focused their efforts on the strongest group in the area, rather than fghting multiple wars against many groups. In addition, the Spanish inadvertently introduced European diseases like smallpox, which greatly weakened local groups. Pedro Cabral Page | 85Page | 85 Page | 85 Chapter three: InItIal ContaCt and Conquest 2. The majority of the natives killed in the exploration period were slaughtered by the Europeans who possessed superior weapons. The first explorer to reach Brazil and claim it for the throne of Portugal was: a. Recruiting native allies played an important role in the Spanish conquest of the Aztec. The myth of Quetzalcoatl relies on sources that are contemporaneous with the conquest of the Aztec. In 1524, the Council of the Indies was created, which oversaw developments in New Page | 86Page | 86 Page | 86 Chapter three: InItIal ContaCt and Conquest Spain until the close of the colonial period. Each viceroyalty was overseen by a viceroy, who exercised ultimate power over his viceroyalty in a manner reminiscent of a European monarch. The viceroy was also in charge of the Audiencia, a twelve to ffteen judge advisory council and court of law. At the end of each term, the viceroy was subjected to a Residencia, or a judicial review of his term in offce. The provinces were under the control of royal offcials, the corregidores (governors whose territory was known as a corregimiento), the captains general (whose provinces were known as captaincies general), or alcaldes mayores, who held political and judicial power. The frst governors of the provinces were the conquistadores themselves; this system did not last past the frst decade. Most towns had a cabildo or town council, though these units did not represent democracy in the sense of the New England town meetings, as power was lodged in the hands of the royal offcials. Adelantados were commanders of units of conquest or the governors of a frontier or newly-conquered province. Spanish holdings were divided into mining zones when gold and silver was discovered and subsequently became extremely important to the Spanish economy. The rule known as the quinto specifed that one-ffth of all precious metals mined in the colonies was to go to the Spanish Crown. Similar restrictions were placed on trade when there were only two designated ports through which colonial trade could go. Native laborers were provided through the encomienda system (called the mita in Portuguese areas), which was a grant from the King of Spain given to an individual mine or plantation (hacienda) owner for a specifc number of natives to work in any capacity in which they were needed; the encomenderos, or owners, had total control over these workers. Ostensibly, the purpose was to protect the natives from enemy tribes and instruct them in Christian beliefs and practices. The Repartimiento, which granted land and/or Indians to settlers for a specifed period of time, was a similar system. As the Indians were subdued, increasing numbers of sugar plantations emerged along the Atlantic coast. They oversaw production by the slaves and freemen who lived in and around the mill, which was the social center of any area. Probably because the sugar taxes did not generate a large amount of revenue, the Portuguese Crown did not put forth an effort to create a similar highly-centralized system in New Spain until the mid-sixteenth century. Most of the labor on the sugar plantations came from African and Indian slaves, though the latter were especially resistant to control by the Europeans. In fact, many of the captaincies failed in part because of the resistance of the Indians. Because of ongoing rebellions, the Portuguese king in 1549 created a royal governor, or captain general, for Brazil; the powers of the donatarios were consequently limited. During the Iberian Union (1580-1640, a period when Portugal and Spain were ruled by a single dynasty), the Spanish created a Conselho da India (similar to the Spanish Council for the Indies) to regulate the Portuguese colonies. After Portugal regained its independence from Spain in 1640, this structure was maintained. The local provinces were under the control of governors, who were appointed for three-year terms; their military and political power was absolute. Before assuming the position of governor, a candidate had to present his qualifcations to the Senado da Camara, or town council. Judicial affairs were conducted by the Ouvidor and Juiz de Fora, who, like the governors, were appointed to three-year terms. Seven offcials made up the Junta, or council, which decided the policies of the individual captaincy. The Junta consisted of the governor, the judicial offcials, an attorney general, the secretary of the treasury, and two ports offcials. Except for the sugar-holding areas along the northeast coast, most of the remainder of Brazil was sparsely settled through the sixteenth century. By 1600, Africans, who had developed immunity to European diseases over centuries of interaction between the two continents, were replacing indigenous peoples as slaves on the sugar plantations. De las Casas is perhaps the most famous of the reformers, though he came to the New World originally as an adventurer and received an encomienda from the Spanish Crown. By 1514, however, he had had a change of heart and became an advocate for the fair treatment of the natives. In 1542, the Spanish Crown issued the New Laws of the Indies for the Good Treatment and Preservation of the Indians, which limited and eventually ended the encomienda system. Similarly, in Brazil, because the expanding plantation economy demanded a greater and greater supply of cheap labor, slave hunting became a lucrative profession. As was the case in New Spain, one of the voices that spoke out against the exploitation of the natives was that of a Jesuit, Father Joseph de Anchieta, who wrote: the bandeirantes go into the interior and deceive these people [the Indians], inviting them to go to the coast, where they would live in villages as Figure 3. They faced great challenges in ruling over colonies far from the mother country, and the time and distance involved in governance necessitated the establishment of institutions of rule and a colonial bureaucracy. Labor quickly became a defning need in the colonies, and many of the emerging policies and laws focused on the issue of the indigenous peoples. As the sixteenth century progressed, Portugal and Spain, now under one rule, began to offcially address the status of the Indians and to recognize that the abuse of the earliest years must be rectifed if peace were to be attainable in the Iberian colonies. The system that helped provide labor for the Spanish mines and sugar plantations was the: a. Indigo Page | 90Page | 90 Page | 90 Chapter three: InItIal ContaCt and Conquest 3. The biggest challenge that they faced in administering their colonial holdings were those of time and space. Communication between colony and mother country was diffcult, and it took months for messages, orders, and news to travel across the Atlantic. The distance between Europe and the Americas played a very important role in shaping colonial administration along with patterns and methods of imperial control. The ways in which the Iberian powers politically and economically administered their colonial holdings were also a refection of the relationship between mother country and colony. The American holdings were settlement colonies that would be shaped in the image of Spain and Portugal. Spaniards and Portuguese came from the mother country to populate the colonies; they desired to recreate their homeland in their new land, and so sought (sometimes unsuccessfully) to live in a Spanish or Portuguese manner.

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A child who sucks vigorously is more likely to threshold necessary to produce an effect on the teeth, but even prolonged sucking has little impact on the underlying form of the jaws. On close analysis most other habits have such a short duration that dental effects, much less skeletal effects, are unlikely. Much attention has been paid at various times to the tongue and tongue habits as possible etiologic factors in malocclusion. The possible deleterious effects of "tongue thrust swallowing" (Figure 5-34), de fined as placement of the tongue tip forward between the incisors during swallowing, received particular emphasis in the 1950s and 1960s. Note that the tongue is lowered and the cheeks contract during sucking, the the result is 4 mm of separation of the incisors, because of the pressure balance against the upper teeth is altered, and the upper geometry of the jaw. A delay in the normal swallow transition can be expected when a child has a sucking habit. When there is an anterior open bite and/or upper in cisor protrusion, as often occurs from sucking habits, it is more difficult to seal off the front of the mouth during swallowing to prevent food or liquids from escaping. Bringing the lips together and placing the tongue between the separated anterior teeth is a successful maneuver to close off the front of the mouth and form an anterior seal. In other words, a tongue thrust swallow is a useful physio logic adaptation if you have an open bite, which is why an individual with an open bite also has a tongue thrust swal low. After swallow," with the tongue tip between the incisors protruding a sucking habit stops, the anterior open bite tends to close forward to put in contact with the elevated lower lip. Laboratory studies indicate that individuals who place Until the open bite disappears, an anterior seal by the the tongue tip forward when they swallow usually do not tongue tip remains necessary. Swallowing is not a learned behavior, but is physiologic maturation; and in individuals of any age with integrated and controlled physiologically at subconscious displaced incisors, in whom it is an adaptation to the space levels, so whatever the pattern of swallow, it cannot be con between the teeth. It is true, however, that terior open bite (nearly always) conditions a child or adult individuals with an anterior open bite malocclusion place to place the tongue between the anterior teeth. A tongue the tongue between the anterior teeth when they swallow thrust swallow therefore should be considered the result of while those who have a normal incisor relationship usually displaced incisors, not the cause. It follows, of course, that do not, and it is tempting to blame the open bite on this correcting the tooth position should cause a change in pattern of tongue activity. It is neither nec Maturation of oral activities, including swallowing, essary nor desirable to try to teach the patient to swallow has been discussed in some detail in Chapter 2. From equi ity until about age 6 and is never achieved in 10% to 15 librium theory, light but sustained pressure by the tongue of a typical population. Tongue thrust swallowing in older against the teeth would be expected to have significant ef patients superficially resembles the infantile swallow (de fects. Tongue thrust swallowing simply has too short a du scribed in Chapter 3), and sometimes children or adults ration to have an impact on tooth position. Pressure by the who place the tongue between the anterior teeth are spo tongue against the teeth during a typical swallow lasts for ken of as having a retained infantile swallow. Only brain damaged children retain a about 800 times per day while awake but has only a few truly infantile swallow in which the posterior part of the swallows per hour while asleep. One thousand seconds of pressure, Since coordinated movements of the posterior tongue of course, totals only a few minutes, not nearly enough to and elevation of the mandible tend to develop before pro affect the equilibrium. During very light, could affect tooth position, vertically or hori the transition from an infantile to a mature swallow, a child zontally. Tongue tip protrusion during swallowing is some can be expected to pass through a stage in which the swal times associated with a forward tongue posture. Since it is per fectly possible to breathe through the nose with the lips separated, simply by creating an oral seal posteriorly with the soft palate, the facial appearance is not diagnostic of the respiratory mode. Note that the prevalence of anterior open bite at any age is only a small frac tion of the prevalence of tongue thrust swallowing and is also less seems entirely reasonable that an altered respiratory pat than the prevalence of thumbsucking. This in turn could alter the equilibrium of pres sures on the jaws and teeth and affect both jaw growth and tooth position. In order to breathe through the mouth, it is normal, so that the pattern of resting pressures is different, necessary to lower the mandible and tongue, and extend there is likely to be an effect on the teeth, whereas if the (tip back) the head. If these postural changes were main postural position is normal, the tongue thrust swallow has tained, face height would increase, and posterior teeth no clinical significance. Thus there is no reason to believe that a tongue the association has been noted for many years: the de thrust swallow always implies an altered rest position and scriptive term adenoid facies has appeared in the English will lead to malocclusion. The odds are approximately 10 literature for at least a century, probably longer (Figure to 1 that this is not the case for any given child. Unfortunately, the relationship between mouth who has an open bite, tongue posture may be a factor, but breathing, altered posture, and the development of mal the swallow itself is not. Respiratory needs are the pri shifting to oral respiration might appear at first glance. At rest, mini position of the tongue and mandible, also produces a vari mum airflow is 20 to 25 L/min, but heavy mental concen ety of malocclusions. It seems clear that altered posture is tration or even normal conversation lead to increased air the mechanism by which growth changes were produced. The increased work for nasal respiration is physiologically acceptable up to a point, and indeed respiration is most efficient with modest resistance present in the system. If the nose is partially obstructed, the work associated with nasal breathing increases, and at a cer tain level of resistance to nasal airflow, the individual switches to partial mouth breathing. This crossover point varies among individuals, but is usually reached at resis tance levels of about 3. Chronic respiratory obstruction can be produced by prolonged inflammation of the nasal mucosa associated with allergies or chronic infection. When the obstruction is relieved, head noids normally are large in children, and partial obstruction posture returns to its original position. Individuals who have had chronic nasal obstruction may continue to breathe partially through the mouth even after the obstruction has been relieved. If respiration had an effect on the jaws and teeth, it should do so by causing a change in posture that secondar ily altered long-duration pressures from the soft tissues. Experiments with human subjects have shown that a change in posture does accompany nasal obstruction. The jaws move apart, as much by elevation of the maxilla because the head tips back, as by depression of the mandible. This physiologic response occurs to the same extent, several months of total nasal obstruction during growth. Note the however, in individuals who already have some nasal ob mandibular prognathism, the most common response in this struction, which indicates that it may not totally result from series of experiments. To carry out the experiments, it in children, many children who appear to be mouth was necessary to gradually obstruct their noses, giving the breathers may not be. The cy There are only a few well-documented cases of facial cles alternate between the two nostrils: when one is clear, growth in children with long-term total nasal obstruction, the other is usually somewhat obstructed. For this reason, but it appears that under these circumstances the growth clinical tests to determine whether the patient can breathe pattern is altered in the way one would predict (Figure 5-39). One partially obstructed nostril portant clinical question is whether partial nasal obstruc should not be interpreted as a problem with normal nasal tion, of the type that occurs occasionally for a short time in breathing. This allows the percentage of it is difficult to know what the pattern of respiration really nasal or oral respiration (nasal/oral ratio) to be calculated, is at any given time in humans. Observers tend to equate for the length of time the subject can tolerate being con lip separation at rest with mouth breathing (see Figure tinuously monitored. It is perfectly possi centage of oral respiration, maintained for a certain per ble for an individual to breathe through the nose while the centage of the time, should be the definition of significant lips are apart. To do this, it is only necessary to seal off the mouth breathing, but despite years of effort such a defini mouth by placing the tongue against the palate. The best current experimental data for the relationship between malocclusion and mouth breathing are derived from studies of the nasal/oral ratio in normal versus long 46 face children. It is useful to represent the data as in Figure 5-40, which shows that both normal and long face children are likely to be predominantly nasal breathers under laboratory conditions. A minority of the long-face children had less than 40% nasal breathing, while none of the normal children had such low nasal percentages. When adult long-face patients are examined, the findings are similar: the number with evidence of nasal obstruction is increased in comparison to a normal population, but the majority are not mouth breathers in the sense of predomi nantly oral respiration. It seems reasonable to presume that children who re quire adenoidectomy and/or tonsillectomy for medical purposes, or those diagnosed as having chronic nasal al lergies, would have some degree of nasal obstruction (although it must be kept in mind that this has not been documented).

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A presumptive diagnosis of reactive airway disease is made, and he is discharged to home on oral albuterol and prednisone. She returns 2 days later with increased coughing and tachypnea with an oxygen saturation of 94% in room air. A presumptive diagnosis of pneumonia is made and she is admitted to a general hospital for further evaluation and management of pneumonia and asthma exacerbation. She returns to the office 3 days later with increasing coughing and hypoxia (oxygen saturation 92%). Based on her clinical presentation of hypoxia and repetitive coughing; a working diagnosis of pertussis is made. Household contacts are subsequently interviewed, and erythromycin prophylaxis is started in all contacts. After 7 days, she improves and is discharged to home to complete her course of erythromycin. Bordetella pertussis is a gram negative coccobacilli that is the cause of an acute respiratory illness initially characterized by protracted coughing. With respect to the differential diagnosis, protracted coughing can also be caused by Mycoplasma, parainfluenza or influenza viruses, enteroviruses, respiratory syncytial virus, or adenoviruses. Pertussis is extremely contagious, with attack rates as high as 100% in susceptible individuals exposed to aerosol droplets at close range. Although a person may be fully immunized, either actively or passively, the rate of subclinical infection is as high as 50%. Neither natural disease nor vaccination provides complete or lifelong immunity against reinfection or disease (1). Protection against typical disease begins to wane 3-5 years after vaccination and is unmeasurable after 12 years. In addition, pertussis incites histamine sensitivity, insulin secretion and leukocyte dysfunction. There are 3 post-incubation stages: 1) catarrhal, 2) paroxysmal, and 3) convalescent. After an incubation period from 3 to 12 days, the catarrhal stage is marked by: congestion, rhinorrhea, low-grade fever, sneezing, and lacrimation. As symptoms wane, the paroxysmal coughing stage begins which can be characterized by one or more of the following: 1) Intermittent, irritative hacking paroxysmal coughing, 2) Choking, gasping, eyes watering and bulging, 3) Occasional coughing up of mucous plugs, 4) Post-tussive exhaustion, 5) Coughing in long spasms with the face turning red, or sometimes blue. Conjunctival hemorrhages and petechiae on the upper body are common due to all the coughing, Pertussis should be suspected in a patient who complains of incessant coughing for 2 weeks, especially if nothing else shows up on the physical exam. Chlamydia trachomatis presents with purulent conjunctivitis, tachypnea, rales or wheezes. Leukocytosis (normal small cells, rather than the large atypical lymphocytes seen with viral infections) due to absolute lymphocytosis occurs in the late catarrhal and paroxysmal stages. Neutrophilia would suggest a different diagnosis or secondary bacterial infection. The chest radiograph shows perihilar infiltrates or edema and variable degrees of atelectasis. However, a false negative can occur in those who have received amoxicillin or erythromycin. A flexible swab kept in the posterior nasopharynx until the patient coughs, is one way to obtain the specimen. Those under 2 months of age have the highest reported rates of pertussis-associated hospitalization (82%), pneumonia (25%), seizures (4%), encephalopathy (1%), and death (1%). The principal complications of pertussis are: apnea, secondary infections (such as otitis media and pneumonia), and physical sequelae of forceful coughing. Coughing transiently increases the intrathoracic and intra-abdominal pressure resulting in conjunctival hemorrhages, petechiae on the upper body, epistaxis, hemorrhage in the central nervous system and retina, pneumothorax and subcutaneous emphysema, and umbilical and inguinal hernias. Page 192 Reversible bronchiectasis or pseudobronchiectasis occurs commonly after pertussis. The bronchi may appear cylindrically dilated on bronchography, but usually resolved in about 4 months. Patients with significant respiratory infections should be hospitalized if they are less than 3 months of age, (other causes of pneumonia presenting during the first weeks of life include C. Other indications for hospitalizations include: severe coughing paroxysms, cyanosis, poor social support, or an infection in a high risk patient (prematurity, cardiac disease, chronic pulmonary disease, neuromuscular disorder, etc. Admission orders should include: Cardiorespiratory monitoring, continuous pulse oximetry, apnea monitor. Detailed cough records (cyanosis, tachycardia, bradycardia, presence of coughed up mucus plug; post-tussive exhaustion and/or unresponsiveness). Prn oxygen, stimulation, or suctioning (note: suctioning of nose, oropharynx, or trachea always precipitates coughing, occasionally causes bronchospasm or apnea, and should be done prn only). Medication order should include: erythromycin (estolate form preferred) 40-50 mg/kg/day div qid (max 2 g/day 24 hr) x 14 days. Nursing orders should include: Respiratory isolation for at least 5 days after start of erythromycin. Restricting visitation of coughing family members who might be spreading pertussis to others in the hospital (until they have taken erythromycin for 5 days). Management orders of household close contacts should include: Erythromycin, 40-50 mg/kg/day divided qid (max 2 g/day 24 hr) for 14 days to all household and close contacts, i. Hospital discharge criteria should include clinical improvement plus: no intervention required during coughing, adequate nutrition, absence of complications, and the parents are prepared for further home care. The vaccine currently used in the primary immunization series is a safer acellular vaccine composed of a suspension of inactivated B. It resulted in more frequent pain, swelling, erythema, and systemic reactions, such as fever, fretfulness, crying, drowsiness, and vomiting. Febrile seizures, albeit rare, occurred within 48 hr and were brief, generalized, self-limited, and occurred more commonly in those with a history of seizures. Collapse or shock-like state (hypotonic-hyporesponsive episode) was rare, uniquely associated with pertussis vaccine, and has no permanent neurologic sequelae. Very rarely, pertussis vaccine was associated with acute neurologic illness in children who were previously normal. Severe adverse events, such as death, encephalopathy, onset of a seizure disorder, developmental delay, or learning or behavioral problems, have occurred in individuals temporally associated with pertussis immunization or alleged to be causally associated. The concept of herd immunity is that if 99% of the population is immune, then the infection can never find enough susceptible hosts to sustain itself and the few susceptible individuals within the population are unlikely to be exposed to the infection. However, herd immunity does not apply to pertussis since pertussis immunity declines substantially with age. Although teens and adults with pertussis will manifest with only mild to moderate respiratory symptoms, they represent a large population of susceptible individuals who can sustain an epidemic, and thus expose unimmunized infants and children, who may have more severe infections and complications. Upon admission to the ward you repeat the physical exam and also note retinal hemorrhages, which are confirmed by an ophthalmologist who just happens to be around. The parents have returned to the neighbor island for the weekend to fulfill important obligations and have already made arrangements to return on Monday. Given the presence of retinal hemorrhages, do you make a referral to Child Protective Services. Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures. Pertussis Vaccination: Use of acellular pertussis vaccines among infants and young children. Efficacy and immunogenicity of acellular pertussis vaccine by manufacturer and patient age. Choices a and e are the closest to being correct, but technically, these answers are incorrect. Suctioning of nose, oropharynx, or trachea always precipitates coughing, occasionally causes bronchospasm or apnea, and should be done prn only. Increased intrathoracic and intra-abdominal pressure during coughing can result in conjunctival hemorrhages, petechiae on the upper body, epistaxis, hemorrhage in the central nervous system and retina, pneumothorax and subcutaneous emphysema, and umbilical and inguinal hernias. A child protective services report is not necessarily indicated since pertussis could cause this.

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The hypertrophic matrix within these centres then proliferating chondrocytes in early osteogenesis express degrades, and the recruited osteoblasts replace the degraded and secrete angiogenic inhibitors (Moses et al. This with osteoblast differentiation) homozygous null mice, no autocrine/paracrine system will further encourage inwards blood vessel ingrowth into the cartilage occurs, not even penetration of the vascular endothelium (Peterson et al. Whereas, during postnatal bone growth, canal plates, iii) loss of metaphyseal blood vessels and, iv) a formation for blood vessels develops in unison with vessel reduction in trabecular bone formation (Haigh et al. The bone vasculature and promoting vascularisation during endochondral bone comprises of an arteriole, which divides into a complex formation (Coultas et al. The sinusoids in the bone marrow detected and this expression is linked to the bone formation are characterized by a highly permeable thin wall process (Carano and Filvaroff, 2003; Zelzer et al. Therefore, the marrow, monocyte chemoattraction, neuronal protection development of these vessel networks is integral to the as well as bone formation (Ferrara et al. These reactive oxygen and nitrogen species (Carano and two cell types can therefore communicate via a gap Filvaroff, 2003; Kanczler et al. These stress/strain and oxygen the intercellular signalling pathways of endothelial sensitive pathways may play a role in the response of cells have also been implicated in the functions of the endothelial cells at a fracture site and hence be at the osteoclastic lineage. It has been Angiogenesis and bone fracture repair hypothesised that the endothelium may direct osteoclast precursor to specific areas of bone to help tightly control Bone has the unique capacity to regenerate without the the resorptive process (Parfitt, 2000). Therefore, alterations development of a fibrous scar, which is symptomatic of in the micro-vascular supply network will ultimately affect soft tissue healing of wounds. This is achieved through the tightly regulated resorption sequence resulting in the complex interdependent stages of the healing process, decreases in bone formation, regeneration and repair as which mimics the tightly regulated development of the well as altered osteointegration of orthopaedic and dental skeleton. Hence, if fibrous scars were to develop in bone implants (Glowacki, 1998; Burkhardt et al. This disruption of the circulation leads In addition, bone endothelial cells secrete high levels of to the activation of thrombotic factors in a coagulation hormone B-type Natriuretic peptide (Bordenave et al. Differences factors such as cytokines and growth factors that recruit have also been noted in the sulphation patterns of heparan osteoprogenitor and mesenchymal cells to the fracture site. At the edge of the bone fractures, the transiently bone marrow endothelial cells (Imai et al. The callus size is reduced and the normal predominantly before the onset of osteogenesis in bone vascular supply is restored. Thus, we are now beginning to understand the leading to the remodelling of the fracture callus during intimate relationship between the vasculature and bone, endochondral ossification (Saijo et al. In the homeostasis, offering the possibility of novel new bone remodelling sequence Niida et al. Unfortunately, fundamental factor in the lack of bone healing in non-union these techniques face serious limitations due the possible fractures. With this in mind researchers have shown that risk of infection and rejection, limited stock supplies and angiogenic factors released from biomimetic scaffolds can cost (Oreffo and Triffitt, 1999; Bauer and Muschler, 2000). Prolonged polyorthoesters, polycaprolactones, polycarbonates, and concomitant hypoxic regions and lack of nutrients will polyfumerates which are free of potential contamination, ultimately lead to significant cell death (Potier et al. However, one of the major problems with these to the scaffold/defect there was a significant increase in types of scaffolds is the lack of osteoconductivity compared bone formation within the boundaries of the defect and a to the current gold standard of allograft. In 2005, demonstrated orthotopic bone formation in a rabbit cranial Levenberg et al. Although this has been successful in animal models scaffolds requires an internal interconnecting of therapeutic angiogenesis (Takeshiti et al. As these scaffolds are biodegradable, bioactive 200 m from the blood supply source (Sutherland et al. Figure 2 demonstrates the significant effect healing and regeneration (Geiger et al. Therefore, the ability to deliver a combined delivery 2) factors from a biodegradable scaffold seeded with system of growth factors at different rate kinetics locally human bone marrow stromal cells on the regeneration of from biodegradable scaffolds could enhance the reparative bone in a critical sized mouse femur defect. Hence, the mechanism of critical sized bone defects; thus, mimicking combined effect of human bone marrow stromal or the in vivo bone repair conditions. Conversely, formation and maturation of a significant number of blood transplantation of endothelial cells can enhance bone vessels. The addition of seeded We would like to thank the members of the Bone & Joint human bone marrow cells or progenitor cells onto these Research Group for many helpful discussions in preparing dual release scaffolds will produce some of the key this manuscript, and to Professor Kevin Shakesheff, components to enhance the repair of delayed or non-union Professor Steve Howdle (University of Nottingham) and delayed fractures. Professor Julian Chaudhuri (University of Bath) for In conclusion, the ability to deliver, over time, a extensive collaborations. J Biomed Angiogenesis plays a critical role in the systematic growth Mater Res 55: 141-150. Understanding the paracrine angiogenesis in the metaphysis of osteopetrotic (toothless, relationship between bone cells and endothelial cells and tl) rats. Increasing our understanding will ultimately help in Alagiakrishnan K, Juby A, Hanley D, Tymchak W, devising new approaches in vascularised engineered tissue Sclater A (2003) Role of vascular factors in osteoporosis. Optimising drug delivery to angiogenic and J Gerontol A Biol Sci Med Sci 58: 362-366. Slow release at the time of calcification in the growth plate studied in growth factor/scaffold formulations, gene therapy and stem vitro: arrest of type X collagen synthesis and net loss of cells are all currently being used to enhance bone fracture collagen when calcification is initiated. The addition of stem cell based (1999) Growth factor regulation of fracture repair. J Bone therapies to these scaffold designs will, ultimately, provide Miner Res 14: 1805-1815. Tamaki K, Tanzawa K, Thorpe P, Itohara S, Werb Z, Cheung C (2005) the future of bone healing. Clin Hanahan D (2000) Matrix metalloproteinase-9 triggers the Podiatr Med Surg 22: 631-641. D, Gennari C (1993) Bone endothelial cells as estrogen Collin-Osdoby P, Rothe L, Anderson F, Nelson M, targets. Collin-Osdoby P, Rothe L, Bekker S, Anderson F, Burkhardt R, Kettner G, Bohm W, Schmidmeier M, Huang Y, Osdoby P (2002) Basic fibroblast growth factor Schlag R, Frisch B, Mallmann B, Eisenmenger W, Gilg T stimulates osteoclast recruitment, development, and bone (1987) Changes in trabecular bone, hematopoiesis and pit resorption in association with angiogenesis in vivo on bone marrow vessels in aplastic anemia, primary the chick chorioallantoic membrane and activates isolated osteoporosis, and old age: a comparative avian osteoclast resorption in vitro. Nippon Domaschke H, Gelinsky M, Burmeister B, Fleig R, Seikeigeka Gakkai Zasshi 66: 548-559. A, Yamano Y, Kato Y, Koike T (1998) Local application Glowacki J (1998) Angiogenesis in fracture repair. Clin of basic fibroblast growth factor minipellet induces the Orthop Relat Res 355S: S82-S89. Johnell O (1997) the socioeconomic burden of Logeart-Avramoglou D, Anagnostou F, Bizios R, Petite fractures: today and in the 21st century. Acceleration of fracture healing in nonhuman primates by Meury T, Verrier S, Alini M (2006) Human endothelial fibroblast growth factor-2. J Biomed Mater Res A growth factor induces differentiation in cultured 69: 728-737. J Clin Invest 110: 751 Sustained release of vascular endothelial growth factor 759. Oudina K, Logeart-Avramoglou D, Petite H (2007) Nakamura K, Kawaguchi H, Aoyama I, Hanada K, Hypoxia affects mesenchymal stromal cell osteogenic Hiyama Y, Awa T, Tamura M, Kurokawa T (1997) differentiation and angiogenic factor expression. Avramoglou D, Petite H (2007) Prolonged hypoxia Nakamura T, Hanada K, Tamura M, Shibanushi T, Nigi concomitant with serum deprivation induces massive H, Tagawa M, Fukumoto S, Matsumoto T (1995) human mesenchymal stem cell death. Connect Tissue Res 20: 283 essential for osteoblast differentiation and bone 288. Sojo K, Sawaki Y, Hattori H, Mizutani H, Ueda M Clin Orthop Relat Res 355S: S294-S300. J Biomed Mater Res A 74: endothelial cells by oscillatory shear stress stimulates an 533-544. Osteoprotegerin: A Novel Secreted Protein Involved in the Tammela T, Enholm B, Alitalo K, Paavonen K (2005) Regulation of Bone Density. Am J Physiol osteoprogenitor bone formation using encapsulated bone Cell Physiol 282: C775-C785.

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Although the candidate presents a technically acceptable patient presentation, he/she cannot justify the rationale for the specific treatment provided. Wikipedia Board Certification in the process by which a physician, dentist, Prosthodontics pharmacist, or podiatrist, demonstrates through either written, practical, and/or Heather J. Removable Prosthodontic Procedures Mandibular Kennedy Class I removable partial denture Altered occlusal plane due to missing teeth. All Units may be implant supported but there must be a of the teeth in my lower minimum of 6 natural teeth restored jaw and half of the teeth in Candidate should seriously consider replacement of all my upper jaw are now foundation restorations and should be prepared to justify chipped and my upper foundation material selected incisors are cracked. The scope of the Commission on Dental Accreditation encompasses dental, advanced dental and allied dental education programs. Commission on Dental Accreditation Revised: January 30, 2001 Prosthodontics Standards -5 Accreditation Status Definitions Programs That Are Fully Operational: Approval (without reporting requirements): An accreditation classification granted to an educational program indicating that the program achieves or exceeds the basic requirements for accreditation. Circumstances under which an extension for good cause would be granted include, but are not limited to: sudden changes in institutional commitment; natural disaster which affects affiliated agreements between institutions; faculty support; or facilities; changes in institutional accreditation; interruption of an educational program due to unforeseen circumstances that take faculty, administrators or students away from the program Programs That Are Not Fully Operational: A program which has not enrolled and graduated at least one class of students/residents and does not have students/residents enrolled in each year of the program is defined by the Commission as not fully operational. Initial Accreditation is the accreditation classification granted to any dental, advanced dental or allied dental education program which is not yet fully operational. This accreditation classification provides evidence to educational institutions, licensing bodies, government or other granting agencies that, at the time of initial evaluation(s), the developing education program has the potential for meeting the standards set forth in the requirements for an accredited educational program for the specific occupational area. Prosthodontics Standards -6 Preface Maintaining and improving the quality of advanced education in the nationally recognized specialty areas of dentistry is a primary aim of the Commission on Dental Accreditation. The Commission is recognized by the public, the profession, and the United States Department of Education as the specialized accrediting agency in dentistry. Accreditation of advanced specialty education programs is a voluntary effort of all parties involved. The process of accreditation assures students/residents, specialty boards and the public that accredited training programs are in compliance with published standards. Accreditation is extended to institutions offering acceptable programs in the following recognized specialty areas of dental practice: dental public health, endodontics, oral and maxillofacial pathology, oral and maxillofacial radiology, oral and maxillofacial surgery, orthodontics and dentofacial orthopedics, pediatric dentistry, periodontics and prosthodontics. Program accreditation will be withdrawn when the training program no longer conforms to the standards as specified in this document, when all first-year positions remain vacant for a period of two years or when a program fails to respond to requests for program information. Advanced education in a recognized specialty area of dentistry may be offered on either a certificate-only or certificate and degree-granting basis. Accreditation actions by the Commission on Dental Accreditation are based upon information gained through written submissions by program directors and evaluations made on site by assigned consultants. The Commission has established review committees in each of the recognized specialties to review site visit and progress reports and make recommendations to the Commission. Review committees are composed of representatives selected by the specialties and their certifying boards. The Commission is also responsible for adjudication of appeals of adverse decisions and has established policies and procedures for appeal. A copy of policies and procedures may be obtained form the Director, Commission on Dental Accreditation, 211 East Chicago Avenue, Chicago, Illinois 60611. This document constitutes the standards by which the Commission on Dental Accreditation and its consultants will evaluate advanced programs in each specialty for accreditation purposes. The Commission on Dental Accreditation establishes general standards which are common to all dental specialties, institution and programs regardless of specialty. Each specialty develops specialty-specific standards for education programs in its specialty. The general and specialty-specific standards, subsequent to approval by the Commission on Dental Accreditation, set forth the standards for the education content, instructional activities, patient care responsibilities, supervision and facilities that should be provided by programs in the particular specialty. Specialty-specific standards are identified by the use of multiple numerical listings. The Commission views change as part of a healthy educational process and encourages programs to make them as part of their normal operating procedures. If the Commission determines that an intentional breech of integrity has occurred, the Commission will immediately notify the chief executive officer of the institution of its intent to withdraw the accreditation of the program(s) at its next scheduled meeting. When a change is planned, Commission staff should be consulted to determine reporting requirements. Depending upon the timing and nature of the change, appropriate investigative procedures including a site visit may be warranted. Such notification will provide an opportunity for the program to seek consultation from Commission staff regarding the potential effect of the proposed change on the accreditation status and the procedures to be followed. A request for an increase in enrollment with all supporting documentation must be submitted in writing to the Commission one (1) month prior to a regularly scheduled semiannual Review Committee meeting. The Commission will not retroactively approve enrollment increases without a special focused site visit. Special circumstances may be considered on a case-by-case basis, including, but not limited to, temporary enrollment increases due to: Student/Resident extending program length due to illness, incomplete projects/clinical assignments, or concurrent enrollment in another program; Unexpected loss of an enrollee and need to maintain balance of manpower needs; Urgent manpower needs demanded by U. Student(s)/Resident(s) who have already been formally accepted or enrolled in the program will be allowed to continue. Prosthodontics Standards -10 Definitions of Terms Used in Prosthodontics Accreditation Standards the terms used in this document. The definitions of these words used in the Standards are as follows: Must or Shall: Indicates an imperative need and/or duty; an essential or indispensable item; mandatory. Intent: Intent statements are presented to provide clarification to the advanced specialty education programs in prosthodontics in the application of and in connection with compliance with the Accreditation Standards for Advanced Specialty Education Programs in Prosthodontics. The statements of intent set forth some of the reasons and purposes for the particular Standards. Examples of evidence to demonstrate compliance include: Desirable condition, practice or documentation indicating the freedom or liberty to follow a suggested alternative. Levels of Knowledge: In-depth: A thorough knowledge of concepts and theories for the purpose of critical analysis and the synthesis of more complete understanding. Familiarity: A simplified knowledge for the purpose of orientation and recognition of general principles. It is that level of skill acquired through advanced training or the level of skill attained when a particular activity is accomplished with repeated quality and a more efficient utilization of time. Competent: the level of skill displaying special ability or knowledge derived from training and experience. Exposed: the level of skill attained by observation of or participation in a particular activity. Prosthodontics Standards -11 Other Terms: Institution (or organizational unit of an institution): a dental, medical or public health school, patient care facility, or other entity that engages in advanced specialty education. Sponsoring institution: primary responsibility for advanced specialty education programs.

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The agglutination reaction is also used to estimate the titre of antibacterial agglutinins in the serum of patients with unknown diseases. A potentially serious problem with agglutination tests is prozone reaction: if too much antibody is present, the lattice will not form and agglu tination will be inhibited. A prozone reaction gives the impression that anti body is absent; this error, however, can be avoided by testing serial dilutions of the serum. There is a commonly used agglutination test that uses Staphylococcus aureus, which contains a protein, Protein A, on its surface. IgG antibody-coated staphylococci produce visible agglutination in the presence of a speci c antigen. The test is mainly used to identify organisms cultured from clinical specimens or to detect bac terial antigens in body uids of infected patients (cerebrospinal uid in the case of meningitis). Fluorescent antibody tests In immuno uorescence tests, the immunoreagent (antigen or antibody) is attached to a uorescent dye, such as uorescein or rhodamine, and the reac tion between the antigen and the antibody is detected by uorescence microscopy. In the direct antigen-detection test, uorescein-conjugated anti bodies are used to reveal the presence of a speci c antigen. The test is a valu able aid in the rapid identi cation of Chlamydia trachomatis, C. Fluorescein-labelled antihuman immunoglobulin is then placed on the prepa ration, which is washed and examined by uorescence microscopy. Serological tests for syphilis the serological tests for the diagnosis of syphilis include non-treponemal and treponemal tests. These tests are practical, inexpensive, and reproducible, although they are not absolutely speci c. They may con rm the diagnosis of early or late symptomatic syphilis or provide diagnostic evidence of latent syphilis. This test is superior to the treponemal tests as a follow-up investigation after treatment. The treponemal tests use Treponema pallidum antigens to detect speci c anti bodies that have developed in serum in response to syphilis infection. The procedures are used to verify the speci city of positive reactions in non treponemal tests. Although false-positive reactions can some times be observed in the serum of healthy persons, they are often associated with a speci c disease or following vaccination. Acute false-positive reactions often have low titres (1:8 or less) and are mainly seen in persons with viral or bacterial infections (atypical pneumonia, psittacosis, infectious mononu cleosis and infectious hepatitis), during pregnancy or after recent vaccination. Prolonged false-positive reactions usually have high titres that are caused by autoantibodies (rheumatoid factors) in patients with lepromatous leprosy, tuberculosis, immune disorders. After the bottle of buffered saline has been opened, it should be stored in the refrigerator. Place the glass stopper in the bottle and shake the bottle up and down approximately 30 times in 10 seconds. If cerebrospinal uid is to be tested, dilute the antigen emulsion a further 1:2 with an equal volume of 10% saline solution. Shake the bottle gently for 10 seconds and allow to stand for a minimum of 5 minutes and a maximum of 2 hours before using. Spread the serum with a circular motion of the pipette tip so that it covers the entire inner surface of the paraf n or ceramic well. Use only clean plates that allow the serum to cover evenly the entire surface within the paraf n or ceramic well. Take a syringe with an 18-gauge needle and, holding it vertically, carefully add 1 drop of antigen (1/60ml) to the serum. Place the plates on the mechanical rotator under a humidity cover and rotate for 4 minutes. If a mechanical rotator is not available rotate the card by hand with a steady circular motion for 4 minutes. Examine the plate immediately after rotation using a microscope with a 10 ocular and a 10 objective. Read the reactions as follows: Medium and large clumps R Reactive Small clumps W Weakly reactive No clumping or very slight roughness N Non-reactive Serum that produces weakly reactive or rough non-reactive results should be retested with the semi-quantitative test as prozone reactions are occasionally encountered. Report the results in terms of the highest serum dilution that produces a reactive (not weakly reactive) result in accordance with the following examples: Dilution Report Undiluted serum 1:2 1:4 1:8 1:16 1:32 W N N N N N Weakly reactive, undiluted R W N N N N Reactive, undiluted R R W N N N Reactive, 1:2 dilution R R R W N N Reactive, 1:4 dilution W W R R W N Reactive, 1:8 dilution N (rough) W R R R N Reactive, 1:16 dilution W: weakly reactive; R: reactive; N: non-reactive. If reactive results are obtained up to dilution 1:32, prepare further twofold serial dilutions in 0. As only a small amount of sample is required, plasma or serum from capillary blood can also be used. Unopened antigen reagent has a shelf-life of one year; storage in a refrigerator is recommended. Once opened, the antigen reagent maintains its reactivity for 3 months when stored in the refrigerator in its plastic dispenser. Some commercial kits require a mechanical rotator for mixing the reagents, whereas others can be rotated manually. Reconstitute the control serum by adding the recommended volume of dis tilled water. Use the disposable dropper to add 50ml of unheated serum or plasma to the corresponding well. Gently shake the antigen suspension and add one free-falling drop to each well using the antigen delivery needle provided. Place the card on the mechanical rotator under a humidity cover and rotate for 8 minutes. A brief rotation and tilting of the card by hand can help to differentiate weakly reactive from non-reactive samples. Spread the diluted samples over the entire area of the test well starting with the highest dilution. Gently shake the antigen add 1 free-falling drop to each well using the antigen delivery needle provided. If a mechanical rotator is not available rotate the card by hand with a steady circular motion for 2 minutes, then place it in a moist chamber containing wet tissue or lter-paper for 6 minutes. The highest dilution to contain macroscopic agglutination is the titre of the sample. Inactivated patient serum is incubated with a sorbent consisting of Reiter treponemes for absorption of nonspeci c treponemal group antibodies. After rinsing, a conjugate of antihuman antibodies with a uorescent stain (uorescein isothiocyanate) is added to the treponemes. The conjugate will bind to the antibodies that have bound to the treponemes and can be visu alized by uorescence microscopy. Reactivity can be observed three weeks after infection and is permanent in untreated patients.

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If the ablation zone remains same or increase in size, recurrence should be suspected. Following ablation, the treatment zone is normally larger than original lesion but it should reduce in size over time. Any nodular or 148 central enhancement in the ablation zone is also suggestive of recurrence. Benign metastasizing leiomyoma is an unusual variant with tumour in lungs, peritoneum nodules & lymph nodes. Perineal injury grading: 1 -involves skin only 2 -Perineal muscle 3 -Involving less than 50% of external sphinctera 3b -> 50% 3 -Internal sphincter. In carcinoma of vulva, N Ipsilateral femoral or inguinal lymph nodes & all pelvic nodes. On Doppler, moles have prominent associated vessels with low resistance & high peak systolic velocity. Answers: (a) Not correct (b) Correct (c) Correct (d) Correct (e) Not correct Explanation: Antenatal ultrasound shows multiple non-communicating cysts of variable size. Nephrectomy is required if it fails to involute or if there is uncontrolled hypertension. Multicystic dysplastic kidney is the second most common cause of neonatal abdominal mass (first is hydronephrosis). Answers: (a) Not correct (b) Correct (c) Not correct (d) Not correct (e) Correct Explanation: Medullary sponge kidney is a common sporadic condition affecting young to middle aged adults. There is dysplastic cystic dilatation of papillary and medullary collecting ducts. Meckel Gruber syndrome is an autosomal recessive syndrome comprising of multicystic dysplastic kidneys, occipital encephalocele and polydactyly. Answers: (a) Not correct (b) Correct (c) Correct (d) Correct (e) Not correct Explanation: Cortex is not involved in renal papillary necrosis. Answers: (a) Correct (b) Correct (c) Correct (d) Correct (e) Correct 154 Explanation: Ureterocoele is a congenital dilatation of distal most portion of ureter. Answers: (a) Not correct (b) Not correct (c) Not correct (d) Correct (e) Not correct Explanation: Prune belly syndrome is a sporadic nonhereditary condition, exclusively affecting males. It is characterized by triad of absent anterior abdominal wall muscles, non-obstructed megaureters and cryptorchidism (due to bladder distension). In 20% cases death occurs in first month of life and another 30% within 2 yrs of life. Answers: (a) Not correct (b) Correct (c) Correct (d) Not correct (e) Not correct Explanation: In paediatric patients intratesticular flow can be difficult to demonstrate on colour Doppler. Which of the following are correct regarding screening tests for breast cancer in the general population. Answers: (a) Correct (b) Not correct (c) Not correct (d) Correct (e) Not correct Explanation: Two views of each breast are taken as baseline, but single view is taken as follow up. Answers: (a) Not correct (b) Correct (c) Not correct (d) Not correct (e) Correct Explanation: Medullary carcinoma presents as well defined mass which may show lobulated margins or halo sign. Colloid carcinoma is seen in older age group (over 60 yrs) and has a good prognosis as tumour is slow growing. Which of the following are correct regarding calcification detected on mammography. Answers: (a) Correct (b) Not correct (c) Correct (d) Correct (e) Correct Explanation: Milk of calcium appears amorphous and ill-defined on cranial caudal view. On medial-lateral oblique view it is typically sharply defined, semilunar or crescent shaped and upwardly concave. Answers: (a) Not correct (b) Correct (c) Not correct (d) Correct (e) Correct 157 Explanation: Fibroadenomas are multiple in 10% 20% of cases but are found bilaterally in only 4 % of cases. They are well circumscribed masses with homogenous internal echoes but variable posterior acoustic pattern. Answers: (a) Correct (b) Not correct (c) Correct (d) Not correct (e) Correct Explanation: Sclerosing adenosis is only mildly associated (2. It is frequently detected only on mammography, though may present as a palpable mass. Regarding ultrasonography in the first trimester of pregnancy, which of the following are correct. The biparietal diameter becomes the most accurate towards end of the first trimester. A coexistent intrauterine and ectopic pregnancy (heterotopic pregnancy) is extremely rare (1 in 30000 pregnancy). Its accuracy declines after 28 weeks after which it is combined with second measurement like femur length. Answers: 159 (a) Correct (b) Not correct (c) Correct (d) Not correct (e) Correct Explanation: In leiomyomas (fibroids) cystic degeneration is rare, seen only in 4 % cases. Calcification is seen associated with red degeneration, and is typically scattered and amorphous marking the site of hyaline degeneration. Mucous retention within endocervical glands is known as nabothian cyst and can be seen in any wall of cervix. Answers: (a) Not correct (b) Not correct (c) Not correct (d) Correct (e) Correct Explanation: Hematocolpos refers to vagina distended with blood and hematometra refers to uterine cavity distended with blood. Approximately 25% of neonates have a fluid collection within the endometrial cavity, thus a normal finding. Answers: (a) Not correct (b) Not correct (c) Correct (d) Not correct (e) Not correct Explanations: the cysts are typically subcapsular in polycystic ovaries with central stroma showing increased echogenicity. The ovaries are bilaterally enlarged (more than 3 14 cm) in 70% cases and of normal size in 30% cases. There is increase in ratio of luteinising hormone to follicular stimulating hormone resulting in immature follicles. The following are correct regarding transabdominal ultrasound in early pregnancy: (a) Yolk sac is only visible from 7 weeks onwards. Answers: (a) Not correct (b) Not correct (c) Correct (d) Correct (e) Not correct Explanation: Yolk sac is visible from 6 weeks onwards and gestational sac from 5 weeks onwards. Which of the following are correct regarding xanthogranulomatous pyelonephritis: (a) Is more commonly diffuse than segmental. Answers: (a) Correct (b) Correct (c) Not correct (d) Not correct (e) Not correct Explanation: Pyuria is associated in 95 % cases of xanthogranulomatous pyelonephritis. There is global enlargement of kidney with centrally obstructing calculi seen in 75% of the cases. Which of the following are correct regarding pheochromocytoma: (a) Is associated with gastric haemorrhage. Answers: (a) Correct (b) Correct 162 (c) Not correct (d) Not correct (e) Correct Explanation: the pheochromocytoma follows 10% rule. It is bilateral in 10% cases, 10% cases are extra adrenal, 10% are malignant, 10% are in children, 10% are familial, 10% are not associated with hypertension and 10% show calcification. Which of the following are correct regarding schistosomiasis: (a) Calcification is the most important single imaging feature. Answers: (a) Correct (b) Not correct (c) Correct (d) Not correct (e) Not correct Explanation: Schistosomiasis is commonly associated with ureteric calculi, dilatation of lower ureter in early stage and reduced bladder capacity in advanced stages. Answers: (a) Correct (b) Not correct (c) Not correct (d) Not correct (e) Correct Explanation: Renal angiomas cannot be distinguished from renal cell carcinoma on imaging. Concerning developmental abnormalities of the kidneys which of the following are correct: 163 (a) Accessory renal arteries normally enter the upper and mid poles.


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