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The most common cause of congenital stridor is laryngo Spasmodic croup is clinically similar to infectious croup 2 9 malacia. If present early in the newborn period or but without evidence of airway infammation. A Laryngomalacia may be evident at birth but most com lack of consensus exists regarding whether a spasmodic croup 3 monly becomes notable at 2 to 4 weeks of age. Symptoms presentation is a distinct entity (with anallergic component) or are characteristically worse when the infant is supine or agitated on the same spectrum as infectious croup, because both have and typically resolve within the frst year. Laryngomalacia is ofen accompanied by tracheomalacia that may cause expira Stridor due to aspiration of a foreign body is generally an 10 tory wheezing and cough as well as stridor. Even if a choking or gagging episode was not observed, rigid Subglottic tracheal stenosis may be congenital or acquired. Posterior-anterior chest x-rays are frequently obtained, may occur at young ages in these children. Aspiration of objects small enough to reach the lower airways is more likely The indication for x-rays will be determined by clinical judg 5 to present with cough and wheezing. Congenital hemangiomas in a subglottic tory distress and a clinical picture suggesting bacterial tracheitis or location are rare but potentially life-threatening. If epiglottitis is suspected, arrangements should be made hemangiomas, particularly on the head and neck, should raise for immediate intubation in an operating room. Rarely, mediastinal lesions, thyroid enlargement, or esophageal foreign bodies may cause stridor by Infectious croup (laryngotracheobronchitis or laryngotra 6 impinging on the larynx. Symptoms are usually worsened by crying Worsening of symptoms at night is typical. High fever may and neck fexion; complete vascular rings may cause swallowing occur. Chest x-rays may suggest the diagnosis; barium 36 Chapter 12 u Stridor 37 esophagrams can be very useful. Other causes include neurologic syndromes (Arnold Chiari malformation) and neck or chest surgery. Papillomas develop primarily in the larynx; occasional spread to other sites in the aerodigestive tract Bibliography occurs in severe cases. Chapters 107, 135, 136 Chest x-rays will not aid in the diagnosis of asthma and should only be considered when the diagnosis is not clear or to rule out Chapter 13 complications of an asthma attack. The classic presentation of acute bronchiolitis begins with nonspecifc cold symptoms and progresses fairly rapidly to profuse rhinorrhea, harsh cough, wheezing, and Wheezing is a high-pitched musical sound caused by obstruc tachypnea. Respiratory distress may occur, especially in younger tion of the lower (intrathoracic) airways. The clinical signifcance of the under enza, rhinovirus, human metapneumovirus, adenovirus, and lying problem can range from mild to severe. Tese pathogens cause more clinically signif and symptoms such as fever, weight loss, night sweats, and dys cant illness in school-aged children than in younger children. Inquire specifcally about any recent choking episodes Cough that progresses over the frst week of illness, fne crackles and about medications (specifcally inquire if the child was ever and wheezes, and nonspecifc x-ray fndings are characteristic. Wheezing with certain viral infections early noted, as should chest wall asymmetry and chest excursion. By defnition, the diagnosis of asthma requires a Most children who wheeze in infancy or early childhood will history of recurrent or chronic symptoms of wheezing or air not wheeze later in childhood. An acute episode of wheezing can be the frst manifestation of asthma, and a positive response to a trial of Diagnosis of foreign bodies can be difcult. Posterior-anterior chest x-rays are frequently manifests itself as a recurrent disorder of airway obstruction obtained, but only 10% to 25% of foreign bodies are radi supported by an appropriate history, physical examination, opaque. Rigid bronchoscopy is increasingly becoming the di and diagnostic testing such as spirometry (if possible). A diag agnostic (and therapeutic) procedure of choice when the H nosis of asthma is supported by: (1) a history of a prolonged and P examination are strongly suggestive. During acute exacerbations, pa 8 symptoms is most likely to occur in children with swallow tients can experience dyspnea and stridor, but the pulmonary ing dysfunction, frequently associated with an underlying neu gas exchange rate is normal. Pulmonary function tests during an episode demonstrate some degree of Primary tracheomalacia and bronchomalacia are character extrathoracic obstruction. Pulmonary function tests and sup 9 ized by wheezing that is located more centrally then periph portive clinical history are adequate to make the diagnosis. The defect is insufcient cartilage to maintain airway patency throughout the breathing Several environmental contaminants including inorganic 13 cycle. Diagnosis is ofen clinically based, sure to birds) has been reported in children, although it is sig but it may be confrmed using bronchoscopy. Abnormal structure of the cilia leads to impaired malformations that compress the airway. Poor feeding and failure to thrive may also diograms may visualize some vascular rings but will miss atretic occur. Other congenital chronic sinusitis and bronchiectasis, they are described as hav malformations that may present with recurrent wheezing or ing Kartagener triad (or syndrome). Suspected 11 since newborn screening for cystic fbrosis has been imple diagnosis, availability, radiation risk, and need for sedation mented for all U. Although the screening is 95% sensitive, should all factor into the selection of a diagnostic test. An echocardiogram will quickly Cyanosis refers to a bluish discoloration of the skin or mucous help to establish most diagnoses. It occurs secondary to signifcant Pulmonary hypertension may cause peripheral cyanosis if 6 arterial oxygen desaturation. A minimum of 5 g/dL of desatu the patient has a patent foramen ovale allowing right-to-lef rated hemoglobin must be present in order for cyanosis to be shunting. Pulmonary hypertension has a number of hematologic etiologies, or be a result of decreased oxygen in the causes. For infants, the birth history and age ferrous [Fe12]) state; it is normally present at a level of less than of onset of cyanosis are important. Any globinemia can be due to the presence of abnormal Hgb (the physical stigmata that may be suggestive of a genetic syndrome most common inherited variant is Hgb M) or a defciency of. Certain drugs or toxins (oxidizing agents in gressive illness, including growth parameters, clubbing, vascular drugs or anesthesia, nitrates in well water, and even nitrite skin markings, and stigmata of neuromuscular disease. Also inquire about be responsible for the disorder, especially in young infants who potential exposure to any medications, drugs, or potential toxins have low levels of methemoglobin reductase activity and in (including food poisoning). Mild forms of value early in the assessment of a cyanotic patient is recom congenital methemoglobinemia may appear later in infancy or mended. It is most common in young infants who have vaso that is a measurement of O2 dissolved in plasma). Systemic arterial saturation is normal; pulse etry values will be low but rarely below 85%; O2 saturation val oximetry is normal. A methemoglobin level must be genic medication use), and feeding difculties (especially easy obtained to confrm the diagnosis. They are usually triggered by injury, oximetry performed afer 24 hours of age has emerged as a very anger, or frustration.

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Use of nonconjugated polysaccharide vaccine is indicated for persons at least 2 years of age, and is administered as a single intramuscular injection. Persons at high risk for invasive pneumococcal disease (asplenia, sickling hemoglobinopathy, congenital and acquired immunodeficiency, immunosuppression, spinal fluid leak, chronic cardiac, pulmonary, hepatic, or renal disease) should receive a second dose of unconjugated pneumococcal polysaccharide vaccine, administered between 3 years and 5 years following the initial dose. The primary series is administered by intramuscular injection at 2 months, 4 months, and 6 months of age, and a fourth (booster) dose is administered between the ages of 12 months and 15 months. The number of conjugated pneumococcal vaccine doses required to immunize older children not receiving vaccine in infancy is reduced due to the brisker antibody response seen when older children receive conjugated pneumococcal vaccine. If the first dose of vaccine is not administered until the child is between 12 months and 23 months of age, then only 2 doses are required to complete the regimen. Page 26 the most common adverse reactions following conjugated Streptococcus pneumoniae immunization are fever and local reactions at the injection site. Occasionally, fever may be high and local reactions severe, especially with subsequent doses of vaccine. Measles (Me) vaccine is an attenuated live virus vaccine that causes subclinical infection following administration, provoking a host immune response that protects against subsequent infection following exposure to wild-type virus. The first measles vaccine developed was a killed virus vaccine, which was associated with the potential development of an infection called "atypical measles" when vaccinated individuals were subsequently infected with wild-type virus. The current monovalent attenuated live virus vaccine (Attenuvax) contains the Moraten ("more attenuated") strain of measles virus, which effectively confers immunity while reducing the incidence of adverse events following vaccination (9). Approximately 95% of vaccine recipients respond to a single dose of vaccine; however, due to an increase in wild-type measles observed in vaccine recipients during the 1980s, current recommendations require a second dose of vaccine, generally administered between the ages of 4 years and 6 years prior to school entry (9). Encephalitis has been suggested as an extremely rare complication of measles immunization, but definitive proof is lacking. No valid scientific evidence supports measles vaccine as causal causation for autism despite sensational claims to the contrary. Occasionally, transient arthralgia/arthritis and peripheral neuritis may occur from rubella vaccine (9). Varicella (V) vaccine is an attenuated live virus vaccine that causes subclinical infection following administration, provoking a host immune response that protects against subsequent infection following exposure to wild-type virus. Varicella vaccine exists as monovalent vaccine (Varivax), which is administered as a single subcutaneous injection for children 12 months through 12 years of age, and as a two dose regimen separated by an interval of at least 4 weeks for children 13 years old and older. A single dose of varicella vaccine is associated with a 97% seroconversion rate in children <13 years old and a 94% seroconversion rate in older persons. A second dose of vaccine in associated with 99% seroconversion in adolescents and adults. Young children should routinely receive varicella vaccine as a component of universal childhood immunization, and older children and adolescent who have not had chickenpox should be identified and immunized (10,11). The most common adverse reactions to varicella immunization are fever and local reactions at the injection site. Occasionally, recipients may have a localized (at the injection site) or more generalized varicella-like rash due to vaccine strain virus. A minority of vaccine recipients may have a mild case of chickenpox ("breakthrough chickenpox") due to wild-type virus following exposure to naturally occurring disease. The first dose of vaccine produces protective antibody response within two weeks following administration. A second dose is administered to provide long term, durable protection against disease. The pediatric formulation of hepatitis A vaccine is indicated for use in the age group 2 years through 18 years. The initial dose is administered by intramuscular injection, followed by a second dose administered between 6 months and 12 months following the first. Routine childhood immunization with hepatitis A vaccine is recommended for those regions and states where the incidence of hepatitis A infection is at least twice the national average, occurring at a frequency of at least 20 cases per 100,000 population annually. Eleven states surpass this threshold: Alaska, Arizona, California, Idaho, Nevada, New Mexico, Oklahoma, Oregon, South Dakota, Utah, and Washington. Childhood immunization with hepatitis A vaccine should be considered for those regions and states where the incidence of hepatitis A infection exceeds the national average and occurs at a frequency of between 10 and 20 cases per 100,000 population annually. Six states meet this criterion: Arkansas, Colorado, Missouri, Montana, Texas, and Wyoming. Hepatitis A immunization is also recommended for community control of recent outbreaks of infection, for travelers to hepatitis A endemic areas, for persons who have chronic liver disease, for homosexual and bisexual men, for injectors of illicit drugs, and for individuals with clotting factor disorders. The most common adverse reaction to hepatitis A immunization is a local reaction at the injection site. Influenza vaccine is a vaccine that exists as an inactivated whole virus vaccine (not currently available in the United States) or as a split virus vaccine (subvirion vaccine; purified surface antigen vaccine) that contain the hemagglutinins of the predominately circulating strains of influenza virus. The vaccine is formulated and administered annually to compensate for antigenic shifts that occur in virus isolates in order to enhance strain-specific immunity during the current respiratory virus season. Those who should receive annual immunization include health care workers and others who may be significant vectors for contagion, healthy persons 50 years old or older, persons with underlying diseases (pulmonary, cardiac, metabolic, renal, and hemoglobinopathies), individuals receiving immunosuppression or chronic aspirin therapy, and pregnant women (beyond the first gestational trimester). Children between the ages of 6 months and 23 months should be immunized annually due to increased morbidity of influenza infection in this age group (13). Children younger than 9 years old receiving influenza vaccine for the first time should receive two doses of split virus vaccine administered in the age appropriate volume separated by at least a one month interval in order to enhance immunologic response and protection against infection. In 2003, a live attenuated, cold-adapted trivalent viral influenza vaccine (FluMist) prepared by viral reassortment was approved for use in the United States. The vaccine exists as a spray for intranasal instillation, and contains the same three strains of influenza virus that are present in the current parenteral vaccine formulation. Children 5 to 8 years old not previously immunized receive two doses of intranasal vaccine administered 60 days apart. Children 5 to 8 years old previously immunized with the intranasal vaccine, and all persons 9 to 49 years of age receive a single vaccine dose annually. The most common adverse reactions to influenza immunization are fever and local reactions at the injection site. Guillain-Barre syndrome is a rare complication of influenza vaccination, apparently limited to adults. In the special circumstance of a susceptible person requiring immediate protection against disease, either prior to or following exposure to infection, transient immunity may be conferred by passive immunization, where preformed protective antibodies are administered. The advantages of passive immunization is the potential to provide immediate protection to the host. The major disadvantage of passive immunity is the subsequent decay of passively acquired antibody by metabolism and elimination, ultimately rendering the host potentially susceptible to infection once passively acquired antibody titers fall to subprotective concentrations. Active immunization utilizes a live or killed antigen to stimulate the immune system to form an active immune response, while passive immunization is merely the injecting or infusing human or animal-derived antibodies into the body. In fact, this is why the administration of attenuated live virus vaccines (measles, mumps, rubella, varicella) is deferred for persons who have recently received blood products (including immunoglobulin preparations), since passively acquired antibody may prevent the vaccine-induced subclinical infection and the active immune response from developing. Killed virus, toxoid, conjugated polysaccharide, recombinant subunit, and bacterial antigen vaccines are not as adversely affected by the presence of passively acquired antibodies, and thus may be administered without consideration of blood products (including immunoglobulin preparations) recently received by the potential vaccine recipient. These agents are labeled "hyperimmune" because effective concentrations of neutralizing antibody have been specifically ascertained. Passive immunization products that protect against virulent toxins associated with infection are often called "antitoxin", and are administered to mitigate the significant systemic toxicity associated with infection. Botulism antitoxin (trivalent against botulism toxins A, B, and E) and diphtheria antitoxin are derived from horse serum (15). Attenuated live virus vaccines (measles, mumps, rubella, varicella) should not be administered to persons who have impairment in immunity (congenital or acquired immunodeficiency, receiving immunosuppressive therapy, have malignancy or have undergone bone marrow or organ transplant) or are pregnant, due to the potential risk for the expected subclinical infection following immunization to become clinical, and potentially severe, posing risk to the vulnerable host or unborn child. Moreover, attenuated live virus vaccines should be administered simultaneously (during the same office visit), or individually separated by an interval of at least 4 weeks to prevent immunological interference with the second vaccine. Note specifically that attenuated live virus vaccines can be given simultaneously or at least 4 weeks apart, but at no time between these two time points. Additional doses of attenuated live virus vaccines in excess of those recommended for childhood immunization may be administered without increased risk of adverse reactions (16). Noninfectious vaccines (killed virus, recombinant subunit, toxoid, conjugated polysaccharide, bacterial antigen) may be administered to persons who have impairment in immunity without increased risk, since these vaccines are incapable of causing infection. Immunologically impaired hosts may have suboptimal response to these vaccines, and may not be protected against subsequent development of disease following exposure. Noninfectious vaccines may be administered simultaneously or separated at any interval without appreciable risk of impaired immunologic response (16). Additional doses of these vaccines in excess of those recommended for childhood immunization are generally well tolerated, although the risk for enhanced systemic and local reactions may increase. Whole cell pertussis vaccine, diphtheria vaccine, and pneumococcal polysaccharide vaccine may be particularly prone to provoke exaggerated reactions with excessive doses of vaccine. Page 28 Vaccines are the single most cost-effective interventions performed to improve and maintain the health of citizens of the United States, and have been cited as one of the most significant advancements in medical practice occurring during the 20th century (17).

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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. Jack Scott assistance toll-free (Canada) at: President-Elect 1-800-267-6354; outside Canada: Dr. Notice of change of address should be received and December/January combined) by the Canadian Dental Association. Copyright 1982 by before the 10th of the month to become effective the following month. Peter Greenhough, Journal of the Canadian Dental Association, c/o Keith Communications Inc. Advanced new brushhead clinically proven more effective 1 than the leading brushhead. New Smart Technology uses onboard computer to provide positive feedback for your patients. New Oral-B Triumph has so many innovative technologies, it will inspire your patients to become more passionate about their oral health. For more product information, call your authorized dental dealer or call us directly at 1 800 268-5217 or visit oralbprofessional. Participants were asked to rate potential fac tors contributing to the commercialism of dentistry. As we move its legitimate roles away from being a health care profession to While I was window shopping there one as a business and providers of esthetic services, we will be pres Sunday, a particular shopfront caught my atten a profession. Some notable recommendations included: I found it interesting, given the overtly com creating realistic expectations for patients about mercial nature of the dental lounge, that its what outcomes good dental care can provide; immediate neighbour was an equivalent shop reinforcing the message that oral health is an selling beauty and hair care products and ser important component of overall health; vices. Customers could very efficiently take care mounting a significant campaign to promote of their esthetic requirements by visiting these comprehensive oral health care; getting more 2 establishments. Its unique formula protects against plaque for 12 hours, even after eating and drinking. The clinical ef cacy of a new tooth whitening dentifrice formulation: A six-month study in adults. While this may be somewhat of a self-serving goal, the pro fession has a vested interest in the financial the Evolution success of all of its members. Dentistry has fought a long and successful battle against outside business interests becoming involved in the profession. Managed care, while the hallmark of practice models in many areas of the United States, has had no suc cessful foothold in Canada. Avoiding these situations has not been a process that begins with an initial involvement happy accident but can be traced back to our in organized dentistry and continues as your pro the profession organizations supporting their members while fessional interests and experience grow. The debt load that our fledging dentists and dignity that earned him the endearing are harnessed with is real, but the knowledge and respect of his colleagues and friends. During this 5-year interval as a tradi However, I look forward to the challenges. While I have always maintained that a healthy dental practice must also be a healthy business, the 2 are not mutually exclusive. The financial pressures on our newly graduated dentists present special challenges. Wayne Halstrom: In Perfect Harmony entists must wear several hats in the of dental services with one of the largest course of their day-to-day lives: health non-profit health carriers in Canada, and was Dcare professional, employer, counsellor, ultimately named chair of the board in 1990 community leader and business owner, to and president in 1993. Dental indicative of how the modern dental practi Association, he rose up the ranks of organized tioner must be able to adapt and adjust to the dentistry, being elected to its first Board of demands of the current practice environment. He is he pursued personal business interests, equally at ease in a white lab coat or a straw becoming a managing partner in several real boater hat and red-striped jacket. Halstrom graduated from the He believes that this first-hand experience University of Alberta in 1960, returning to the in the business world was invaluable to the west coast to set up a private practice in North progression of his career. Halstrom speaks confidently on the subject, drawing on his experience from both sides of this issue. Halstrom was initially drawn to the dental profession by a lifelong fascination with performing tasks that demanded digital dexterity. As a lifelong snorer of legendary proportion, his nocturnal rumblings eventually began affecting Dr. Halstrom was exhibiting the signs and symptoms of its conclusion in order to maintain our professional obstructive sleep apnea, and after a series of single-car independence. We need to put aside invasive, reversible technology and came up with the any regional differences and focus on making sure that we Halstrom Hinge precision attachment. The device is now being used by patients all direction to make the most of our collective efforts while over the world. Halstrom cites his singing career as particularly mem Canadian dentistry, he notes the encroachment by the orable.

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Consider and rate 2 components: (a) Search methods described in enough detail to permit replication. Consider and rate 2 components: (a) Were the criteria specified clearly enough to permit replication. Consider criteria related to study population, intervention, outcomes, and study design. Were the primary studies evaluated for quality, and were quality assessments done appropriately. Consider and rate 2 components: (a) Did 2 or more independent raters abstract data. Consider and rate 2 components: (a) Was there a check for heterogeneity statistically or graphically. Consider whether any of the following methods were employed: Funnel plots, test statistics, or search of trials registry for unpublished studies. Marinopoulos S, Dorman T, Ratanawongsa Improving the quality of reports of meta N, et al. Effectiveness of Continuing analyses of randomised controlled trials: the Medical Education. Peer Reviewers the Duke Evidence-based Practice Center is grateful to the following peer reviewers who read and commented on a draft version of this report: Thanos Athanasiou, M. Patients receiving warfarin therapy were older concomitant Maze procedure during mitral valve repair is (p [ 0. The linear procedure combined with mitral valve repair between ized rates of thromboembolic event and death without 1997 and 2012 were evaluated. In published se discontinuing of anticoagulation, which may improve ries of mitral valve surgery, about 40% to 60% of patients quality of life. In this regard, the risk of thromboembolism without Accepted for publication Feb 10, 2015. We also sought vascular Surgery, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea; e-mail: jwlee@amc. Patients with patients with sinus rhythm underwent the same moni concomitant valve surgery in aortic and pulmonary toring once a year. Holter monitoring was usually done at valves, aorta surgery, and coronary artery bypass grafting 6 to 12 months after surgery. This study was approved by our Institutional Review Board, which waived the Data Analysis requirement for informed patients consent based on the Categoric variables were expressed as frequencies and retrospective nature of the study. The details of this method have been described in baseline characteristics between the patient groups were a previous study [7]. The two-dimensional echocardiographic classi cation Postoperative Management and Follow-Up of preoperative mitral valve regurgitation was as follows: We started anticoagulation therapy 2 days after surgery when the patient was hemodynamically stable. The atrial lead was placed on the right atrium routinely at the end of surgery so we could also check Congenital 8 (2. Logistic multivariate analyses to determine the factor associated with persistent long-term warfarin therapy revealed old age (p 0. The medications given to the patients after surgery were warfarin, beta blocker, amiodarone, antiplatelet agent, and digoxin in descending order (Table 3). The A total of 2,257 patient-years of follow-up data was ob number of patients with warfarin until the end of follow-up tained. The patients who were off warfarin therapy were followed up for 1,577 patient-years and patients on Table 2. During the follow-up, 2 deaths and 1 thromboembolic event occurred in the off Operative Outcomes No. For thromboembolic events, the event rates were Quadrangular/triangular resection 152 (41. Moreover, off-warfarin does not show a sig ni cant risks for thromboembolic stroke and death ni cant risk of thromboembolic event and death in pa without warfarin therapy. Most of the patients mitral valve repair in patients with preoperative atrial remain in sinus rhythm and were able to stop taking brillation. Echocardiographic evaluation of mitral durability following valve repair in rheumatic In these regards, long-term warfarin therapy is mainly mitral valve disease: impact of maze procedure. The Cox-maze pro In our study we found that the incidence of death and cedure for lone atrial brillation: a single-center experience thromboembolic event is very low in comparison with over 2 decades. Linearized rate is a simple method to term outcome of modi ed maze procedure combined with calculate rates about an event, including over time [14]. We could not perform multivariate simpli ed with cryoablation to improve left atrial function. Operative from a study population and longer follow-up period results after the Cox/maze procedure combined with a mitral might resolve this limitation. Cox maze procedure strategies for this study cohort had not been uniform and for chronic atrial brillation associated with mitral valve had varied among attending physicians including the de disease. The Cox maze ideally prospective randomized trials, are needed in procedure in mitral valve disease: predictors of recurrent atrial brillation. Received for publication Feb 5, 2018; accepted for publication Feb 11, 2018; available ahead of print March 16, 2018. The 95th percentile tricuspid regurgitation during left-side valve for the upper margin is 39 mm in both men and surgery. In this issue 4 from an oblong to more circular shape, so the discrepancy of the Journal, David and colleagues successfully challenge 5 10 that assertion. The guidelines add pulmonary hypertension to the clinical factors to consider, and emerging is 65 mm. Correlation with echocardiographic measure data would indicate that atrial brillation may cause valve ments is typically accurate within 5 mm. It is reported that this 70 mm and colleagues cannot be considered to be de nitive in corresponds to 40 mm as measured by echocardiography this sense, but it looks as though the late clinical problems 9 will be unusual. Secondary tricuspid regurgitation Heart Association task force on practice guidelines. J Thorac Cardiovasc or dilatation: which should be the criteria for surgical repair. Tricuspid valve tethering predicts residual tricuspid regurgitation after the development of tricuspid regurgitation after mitral valve repair for mitral tricuspid annuloplasty. With these shifting demographics come far-reaching and wide-ranging implications for our society, not the least of which is the potentially crippling effect of chronic and costly diseases Cost of Valve Disease that become more prevalent with age. References Heart valve disease is a leading type of cardiovascular disease that becomes more common with age, and imposes a signifcant burden on patients and their families. If diagnosed in time, heart valve disease can usually be successfully treated in patients of all ages. Advances in detection, valve repair and replacement through less-invasive procedures, and prevention of post-operative complications are all leading to better outcomes and sur vival in heart valve disease patients. The Alliance for Aging Research publishes the Silver Book : Chronic Disease and Medical Innovation in an Aging Nation to promote national policies for investments in research and innovation, which will ultimately bend the cost curve on chronic diseases of aging. First launched in 2006, the Silver Book has become a trusted resource for policymakers, thought leaders, academics, and health advocates across the nation who are looking for the latest data on chronic diseases of aging and innovation in the feld. The Silver Book is an almanac of com pelling statistics and key fndings extracted from dense reports and technical studies and provides essential information in a single, easy-to use, and well-referenced resource. Note that information pertaining spe cifcally to the older population is in silver type. Vuyisile Nkomo and colleagues estimates that in 2000 there were approximately fve Amillion Americans with heart valve disease. Based on current population estimates and other leading studies, that number is now somewhere between 8.

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Equipment and supplies for use in managing medical emergencies must be readily accessible and functional. To ensure health and safety for patients, students/residents, faculty and staff, the physical facilities and equipment should effectively accommodate the clinic and/or laboratory schedule. Policies must be provided to all students/residents faculty and appropriate support staff and continuously monitored for compliance. Additionally, policies on bloodborne and infectious diseases must be made available to applicants for admission and patients. Intent: the program may document compliance by including the applicable program policies. The program demonstrates how the policies are provided to the students/residents faculty and appropriate support staff and who is responsible for monitoring compliance. Applicable policy states how it is made available to applicants for admission and patients should a request to review the policy be made. Students/Residents, faculty and appropriate support staff must be encouraged to be immunized against and/or tested for infectious diseases, such as mumps, measles, rubella and hepatitis B, prior to contact with patients and/or infectious objects or materials, in an effort to minimize the risk to patients and dental personnel. All students/residents, faculty and support staff involved in the direct provision of patient care must be continuously recognized/certified in basic life support procedures, including cardiopulmonary resuscitation. Intent: Continuously recognized/certified in basic life support procedures means the appropriate individuals are currently recognized/certified. The use of private office facilities as a means of providing clinical experiences in advanced specialty education is not approved, unless the specialty has included language that defines the use of such facilities in its specialty-specific standards. Practice management and elective experiences may be undertaken in private office facilities. Prosthodontics Standards -18 3-1 Physical facilities must permit students/residents to operate under circumstances prevailing in the practice of prosthodontics. Intent: the intent is to ensure that the didactic rigor and extent of clinical experience exceeds pre doctoral, entry level dental training or continuing education requirements and the material and experience satisfies standards for the specialty. The level of specialty area instruction in certificate and degree-granting programs must be comparable. Intent: the intent is to ensure that the students/residents of these programs receive the same educational requirements as set forth in these Standards. Documentation of all program activities must be ensured by the program director and available for review. If an institution and/or program enrolls part-time students/residents, the institution must have guidelines regarding enrollment of part-time students/residents. Part-time students/residents must start and complete the program within a single institution, except when the program is discontinued. The director of an accredited program who enrolls students/residents on a part time basis must ensure that: (1) the educational experiences, including the clinical experiences and responsibilities, are the same as required by full-time students/residents; and (2) there are an equivalent number of months spent in the program. Advanced level instruction may be provided through the following: formal courses, seminars, lectures, self-instructional modules, clinical assignments and laboratory assignments. If time is devoted to this activity, it should be carefully evaluated in relation to the goals and objectives of the overall program and the interests of the individual student/resident. Intent: Students/Residents will have the didactic background that supports the various aspects of comprehensive prosthodontic therapy they provide or guide during their clinical experiences with dentate, partially edentulous and completely edentulous patients. This fundamental didactic background is necessary whether the student provides therapy or serves as the referral source to other providers. It is expected that such learning would be directly supportive of requisite clinical curriculum proficiencies and competencies. Prosthodontics Standards -21 Intent: Students/Residents will have in depth knowledge in all aspects of prosthodontic therapy to serve their leading role in the management of patients from various classification systems such as the Prosthodontic Diagnostic Index for edentulous, partially edentulous and dentate patients. Critically evaluating the results of treatment; and Prosthodontics Standards -22. Effectively utilizing the professional services of allied dental personnel, including but not limited to, dental laboratory technicians, dental assistants, and dental hygienists. Clinical experiences must include a variety of patients within a range of prosthodontic classifications, such as in the Prosthodontic Diagnostic Index for edentulous, partially edentulous and dentate patients. Clinical experiences must include rehabilitative and esthetic procedures of varying complexity. Clinical experiences must include treatment of geriatric patients, including patients with varying degrees of cognitive and physical impairments. This may include defects, which are due to genetic, functional, parafunctional, microbial or traumatic causes. Intent: Students/Residents will be proficient in the use of adjustable articulators to develop an integrated occlusion for opposing arches; complete and partial coverage restorations, restoration of endodontically treated teeth, fixed prosthodontics, removable partial dentures, complete dentures, implant supported and/or retained prostheses, and continual care and maintenance of restorations. Students/Residents will diagnose and treat patients using advances in science and technology. Intent: Surgical procedures should include contouring of residual ridges, gingival recontouring, placement of dental implants, and removal of teeth. Prosthodontics Standards -23 4-19 Students/Residents must be competent in oral/head/neck cancer screening and patient education for prevention. Intent: Students/Residents will be competent in clinical identification of potential pathosis and referralto aspecialist. Students/Residents will also educate patients to promote oral/head/neck cancer prevention. Prosthodontic programs that encompass a minimum of forty-five months that include integrated maxillofacial prosthetic training: all sections of these Standards apply; b. Prosthodontic programs that encompass a minimum of thirty-three months: all sections of these Standards apply except sections 4-20 through 4-26 inclusive; and c. Twelve-month maxillofacial prosthetic programs: all sections of these Standards apply except sections 4-5 through 4-19, inclusive. Maxillary defects and soft palate defects, which are the result of disease or trauma (acquired defects); b. Mandibular defects, which are the result of disease or trauma (acquired defects); c. Maxillary defects, which are naturally acquired (congenital or developmental defects); d. Mandibular defects, which are naturally acquired (congenital or developmental defects);. Facial defects, which are the result of disease or trauma or are naturally acquired; f. Prosthodontics Standards -24 4-22 Instruction must be provided at the familiarity level in each of the following: a. Graduates from institutions in Canada accredited by the Commission on Dental Accreditation of Canada; and c. Graduates of international dental schools who possess equivalent educational background and standing as determined by the institution and program. Specific written criteria, policies and procedures must be followed when admitting students/residents. Intent: Written non-discriminatory policies are to be followed in selecting students/residents. These policies should make clear the methods and criteria used in recruiting and selecting students/residents and how applicants are informed of their status throughout the selection process. Admission of students/residents with advanced standing must be based on the same standards of achievement required by students/residents regularly enrolled in the program. Transfer students/residents with advanced standing must receive an appropriate curriculum that results in the same standards of competence required by students/residents regularly enrolled in the program. Periodically, but at least semiannually, evaluates the knowledge, skills, ethical conduct and professional growth of its students/residents, using appropriate written criteria and procedures; b. Provides to students/residents an assessment of their performance, at least semiannually; c. Advances students/residents to positions of higher responsibility only on the basis of an evaluation of their readiness for advancement; and d. Maintains a personal record of evaluation for each student/resident which is accessible to the student/resident and available for review during site visits. Additionally, all advanced specialty education students/residents must be provided with written information which affirms their obligations and responsibilities to the institution, the program and program faculty.

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Future generations of Englishmen based their concept of justice and liberty on the principles of the Magna Carta. As these meetings occurred, the House of Lords and the House of Commons began to take shape. After the war, the English began to see a representative government as the most enlightened form of government in the world. Therefore, he did not have to call Parliament into session to secure funds for his ventures. In May 1497, the king allowed John Cabot, a Venetian mariner living in London, to sail under the English fag in an attempt fnd a northern route to Asia. He made a second voyage in 1498, funded in part by the king because he expected to reap the fnancial rewards of the journey. Though Spain and Portugal began the process of colonization, England found itself in the midst of a political and a religious crisis for much of the sixteenth century. The intellectual currents of the Renaissance played a role in this change, but so too did the practices of the church, including clerical immorality, clerical ignorance, and clerical absenteeism. In an effort to force the church to clarify its teachings on salvation, Luther wrote the ninety-fve theses. Church authorities subsequently sent Luther a letter giving him two months to recant his statements. The decision to become Protestant or remain Catholic in many cases had as much to do with politics as it did with faith. During the course of their marriage, Catherine had six children, but only one survived, a daughter named Mary. At a time when the church was already under fre from the Protestants, such a move would further weaken it. However, Thomas Cranmer, appointed the archbishop of Canterbury in 1532, harbored Protestant sympathies. When that marriage failed to produce a male heir, Henry tried again with Jane Seymour. After Jane died in childbirth, Henry went on to have three more wives but no more children. Meanwhile, Parliament passed a series of succession acts, which made Edward the rightful heir followed by his older sisters, Mary and Elizabeth. Relying on the advice of Thomas Cranmer and Thomas Cromwell, Henry decided to break with the pope, a decision leading Parliament to pass the Act in Restraint of Appeals and the Act of Submission of the Clergy. Doctrinally speaking, the Church of England, called the Anglican Church, made few changes. Edward was strongly Protestant and wanted to make signifcant changes that would mirror the religious changes on the continent. She pushed Parliament to repeal the legislation that created the Church of England, and she executed several hundred Protestants. When Elizabeth succeeded Mary, she sought to achieve a balance between the Protestants and Catholics in England. Her policies leaned toward Protestantism, but she asked only for outward conformity from her subjects. The Church of England retained the ceremony of the Catholic service, but the priests said mass in the vernacular and could marry. They also led to the rise of the Puritans in England who would play an instrumental role in English colonization in the New World in the seventeenth century. Page | 44Page | 44 Page | 44 Chapter two: the Global Context the French monarchy had little political reason to turn to Protestantism in the early sixteenth century. It made Catholicism the offcial religion of France but also gave the French king the right to appoint church authorities in his country. In fact, given the religious stability in the 1520s, Francis looked for possible ways to catch up with the Spanish in the realm of overseas exploration and colonization. In 1524, he sponsored a voyage by Giovanni da Verrazzano to stake a claim in the New World and discover the Northwest Passage. During his voyage, Verrazano explored the Atlantic coastline from modern-day South Carolina to New York. Nevertheless, the discoveries did not inspire Francis to support a permanent settlement in Canada at that time. Some members of the French nobility became Protestants in order to show their independence from the crown. The Catholic-Protestant split in France led to a series of religious riots, the worst of which occurred on St. Shortly after the marriage of Margaret of Valois to Henry of Navarre, Catholics led by Henry of Guise viciously attacked Protestants in Paris. A group of Catholic moderates fnally ended the strife when they concluded that domestic tranquility was more important than religious doctrine. Moreover, the deaths of two of the Henrys left only the Protestant Henry of Navarre standing. Then, he issued the Edict of Nantes in 1598, which granted French Protestants, the Huguenots, the liberty of conscience and the liberty of worship. When the barbarian invasions stopped in the twelfth century, English and French rulers sought to consolidate their control. While they managed to exert greater infuence over their subjects, they also found themselves frequently at odds with one another and facing religious strife at home as the Protestant Reformation took hold in Europe. By the late sixteenth century, England and France, both of which had only firted with overseas exploration to that point, had become sovereign states under the rule of strong monarchies. Thus, as the new century dawned, both seemed posed to start their colonial ventures and carry their rivalry to the New World. First, emerging European explorations and global trade networks began with European contact with and exploration of Africa. Early Portuguese exploration started trade networks in gold, ivory, and slaves that invigorated the European economy. Later, trade expanded to incorporate the Americas, transforming into the Triangle Trade that Page | 46Page | 46Page | 46 Chapter two: the Global Context encompassed the Trans-Atlantic slave trade network. In many ways, contact and trade with Africa created the Atlantic World, the network of connections that linked the Americas, Europe, and Africa economically, politically, culturally, religiously, and environmentally. At the beginning of the sixteenth century, Africa was a continent of tremendous diversity and home to hundreds of cultures, languages, and political states. Western and Central Africa were greatly infuenced by the changes wrought by the slave trade. Southern Africa was the frst region to experience the phenomenon of European migration when the Dutch established Cape Colony in 1652. Northern and eastern Africa had been linked to the wider world through trade networks such as the Indian Ocean and Mediterranean, as well as through the spread of Islam and Christianity.

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These purposes are best accomplished through surveillance system s that use m ultiple data sources, possess accurate and precise diagnostic criteria, perform timely data analysis, provide timely dissemination of the data, and use personal identifiers for Surveillance follow-up and data linkage. It is important to collect this information given the variation in these characteristics and in the prevalence of some birth yearly births. The major activities of these centres are to participate in the National Birth Defects Prevention Study and expand and improve the birth-defect surveillance systems in their respective states. For example, 36 cooperative agreements have been awarded to enhance state-based birth-defect surveillance activities. These cooperative agreements provide the opportunity for state-based birth-defect surveillance system s to share data and increase the information on rare birth defects and geographical variation. Furthermore, distinct subgroups within these conditions seem to exist according to severity, sidedness, and associated anomalies. The reasons the number of ratios was different, malformation by malformation, were that several registries did not contribute data for a few malformations and some expected ratios were not computable. The number of computed ratios was very high so a certain number (about 5%) of significant ratios can be expected by chance. Some situations could even be intermediate between the above-mentioned macro and micro ethnicity, as for instance those of Finland (Saxen and Lathi, 1974) or the Philippines (M urray et al. Up to 1982, the rates of Canada-National and Atlanta were virtually identical, but since that time the Canadian rate increased and the Atlanta rate decreased slightly. Programmes in southern Europe and Israel have rates around 6 per 10 000, while the Scandinavian, and the Asian programmes, as well as Canada have rates twice as high. The rate of total cleft lip apparently differs in different populations, and it is likely that genetic factors play a decisive role for this difference. In England-Wales, Japan, and Atlanta very high rates existed at the beginning of the observation period followed by a marked decrease down to the approximate level of most other programmes. A tendency to an increase is seen in Sweden, France-Strasbourg, and perhaps to a lesser extent in some other programmes. The terminology related to disturbances in tooth eruption is also reviewed and clari ed. The sequential and timely eruption of teeth is critical to the timing of treatment and the selection of an orthodontic treatment modality. True and signi cant deviations from ac seems to be considerable confusion concerning their cepted norms of eruption time are often observed in usage. A delay moment of appearance of any part of the cusp or crown in eruption can directly affect the accurate diagnosis, through the gingiva. Emergence is synonymous with overall treatment planning, and timing of treatment for moment of eruption, which is often used as a clinical the orthodontic patient. Common factors well re ected by the number of published reports on the in the etiology of impacted teeth include lack of space subject, but there is considerable controversy regarding due to crowding of the dental arches or premature loss of deciduous teeth. Frequently, rotation or other posi From the School of Dental Medicine, Tufts University, Boston, Mass. However, most of these reports Retarded eruption Arrested eruption refer to comparisons of observed eruption times with Primary failure of eruption the chronologic standards set by population studies. Impaired eruption Primary or idiopathic failure of eruption is a Depressed eruption 13 Noneruption condition described by Pro tt and Vig, whereby Submerged teeth nonankylosed teeth fail to erupt fully or partially Reinclusion/inclusion of teeth because of malfunction of the eruption mechanism. Paradoxical eruption this occurs even though there seems to be no barrier to eruption, and the phenomenon is considered to be due 13-15 to a primary defect in the eruptive process. In these cases, used interchangeably to describe a clinical condition radiographic examination discloses the teeth in the that might have represented ankylosis, impaction, or jaws. In 1962, teeth and inclusion/reinclusion of teeth refer to a 10 Gron showed that, under normal circumstances, tooth clinical condition whereby, after eruption, teeth become eruption begins when 3/4 of its nal root length is ankylosed and lose their ability to maintain the contin 18,19 established. However, at the moment of eruption, man uous eruptive potential as the jaws grow. This condition should not be confused and rst molars show root development less than 3/4 of with chronologic delayed eruption, because the erup 11 the expected nal root length. Becker suggests that tion was normal according to both chronologic and root development alone should be the basis for de ning biologic parameters (root formation), but the process the expected time of eruption for different teeth. Paradoxical eruption simply has been used if an erupted tooth has less root development than the to represent abnormal patterns of eruption and can 18 expected 3/4 of length, its eruption is deemed prema encompass many of the above conditions. It would then seem that Eruptive movements are closely related clinically with 434 Suri, Gagari, and Vastardis American Journal of Orthodontics and Dentofacial Orthopedics October 2004 1,2,10,20 tooth development. During eruption of mon supernumerary tooth is the mesiodens, followed 16,17 teeth, many processes take place simultaneously: the by a fourth molar in the maxillary arch. These parameters are currently used as the conical form has been associated with displace 22 clinical markers for orthodontic treatment planning. In this scheme, we sequentially examine alerting sign for diagnosing these conditions. Affected teeth exhibit a time for a speci c tooth (chronologic norm of erup delay or total failure in eruption. A second step includes determining the presence markedly altered, generally very irregular, often with or absence of a factor that adversely affects tooth evidence of defective mineralization. This will prompt the clinician to consider lateral incisors, and canines are the most frequently certain diseases that result in defects of tooth structure, affected teeth, in either the maxillary or mandibular size, shape, and color. If tooth development is unaf arch, and deciduous and permanent teeth can be affect 17 fected by any such factor, the third step is to consider ed. Any failure of the de ned as tooth eruption that has not occurred despite follicle of an erupting tooth to unite with the mucosa the formation of 2/3 or more of the dental root. Thus, if will entail a delay in the breakdown of the mucosa and a patient has chronologic delayed eruption, he or she constitute a barrier to emergence. Histologic studies might simply be of a dental age that does not t the have shown differences in the submucosa between norms (root length less than 2/3). Further division into ciency, drugs such as phenytoin) might cause an abun separate categories is also suggested to help in the dance of dense connective tissue or acellular collagen 33 classi cation and diagnostic scheme. Smith and Rapp, in a the process of normal eruption and the source of cephalometric study of the developmental relationship eruptive forces are still controversial topics. These obstructions can result from odontogenesis in the form of dilacerations or phys 35,36 many different of causes, such as supernumerary teeth, ical displacement of the permanent germ. In some instances, the traumatized decid crowding, displacement, rotation, impaction, or de uous incisor might become ankylosed or delayed in its American Journal of Orthodontics and Dentofacial Orthopedics Suri, Gagari, and Vastardis 435 Volume 126, Number 4 Fig 1. The eruption of the succedaneous teeth is X-radiation has also been shown to impair tooth often delayed after the premature loss of deciduous eruption. Ankylosis of bone to tooth was the most teeth before the beginning of their root resorption. Root formation can be explained by the abnormal changes that might impairment, periodontal cell damage, and insuf cient occur in the connective tissue overlying the permanent mandibular growth also seem to be linked to tooth 38,42 49,50 tooth and the formation of thick, brous gingiva. The in uence of nutrition on calci cation and been reported in all 4 quadrants, although the mandible eruption is less signi cant compared with other factors, is more commonly affected than the maxilla. Anky because it is only at the extremes of nutritive depriva losed teeth will remain stationary while adjacent teeth tion that the effects on tooth eruption have been continue to erupt through continued deposition of 51-53 shown. Nevertheless, delayed eruption is often alveolar bone, giving the clinical impression of infraoc reported in patients who are de cient in some essential 9,43,46,47 clusion.


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