Ziad F. Gellad, MD

• Associate Professor of Medicine
• Core Faculty Member, Duke-Margolis Center for Health Policy
• Member in the Duke Clinical Research Institute

https://medicine.duke.edu/faculty/ziad-f-gellad-md

Past medical history the prodromal phase but are present for only a brief period of should be reviewed cholesterol conversion chart uk us generic 160 mg fenofibrate with visa, and a history of any prodromal or associated time (12 to 24 hours) high cholesterol diet chart generic fenofibrate 160 mg without a prescription. Exami The classic rubella (German measles) rash consists of dis 8 nation should include a general assessment of the patient to de crete pink macular lesions that appear initially on the face termine the severity of the illness cholesterol lowering foods american heart association purchase 160mg fenofibrate otc, including vital signs and height and spread in a head-to-toe progression how is cholesterol ratio determined purchase fenofibrate 160 mg overnight delivery. Tachycardia and tachypnea in a patient with fever and in the truncal region and remain as discrete macules on the rash may indicate sepsis cholesterol ratio target order fenofibrate american express, particularly if there is altered mental extremities cholesterol medication diarrhea purchase 160 mg fenofibrate with amex. Papular acrodermatitis (also called Gianotti-Crosti syn 9 Note the distribution of the rash and lesion morphology drome) is a characteristic outbreak of discrete, fat-topped, 2 and color, as well as the presence and characteristics of any dark or dusky papules, usually 1 to 10 mm in size. The term macular sions erupt symmetrically on the face, buttocks, and extensor describes fat lesions, papular describes raised or palpable le surfaces of limbs; palms and soles can be afected. Low-grade sions, and the term morbilliform (classically used to describe fever may or may not occur. It is a recognized reaction to im the rash of measles) describes coalescence of maculopapular munizations and viral infections. Scarlatina (scarlatiniform rash calized, symmetric or asymmetric, centripetal (more lesions on or scarlet fever) describes a difuse, fne papular, ashy? or the trunk, less on the extremities and face), or centrifugal (more sandpaper? rash that tends to develop initially on the neck and lesions on the distal extremities and face, less on the trunk). The rash may be concentrated in creases (axillae, characteristics of the rash and associated symptoms frequently antecubital fossae, inguinal), where it takes on a linear petechial suggest a diagnosis. It begins as a red macule or papule at the site of the tick bite and expands to an average diameter of 15 cm. It Fifh disease (also called erythema infectiosum) is caused may be a uniform erythematous macule or demonstrate central 4 by human parvovirus B19. The macules frequently evolve into pete 5 fantum, exanthema subitum, or sixth disease) is an acute chial (and sometimes purpuric) lesions. Chapters 174, 176, 657 Rheumatic feverRheumatic fever 1414 Nelsons Essentials, 6e. Chapters 97, 195 Drug reactionDrug reaction Adapted from Smith S: Infections characterized by fever and rash. The ehrilichioses (Ehrlichia chafeensis, a benign phenomenon (not associated with thrombocytopenia), Anaplasma phagocytophilum, Ehrlichia ewingii) are other zoo usually due to enteroviral infection. A history of tick exposure is ofen, but not always, raised and petechial or purpuric. It Manifestations of staphylococcal infections range from may, however, be limited to the diaper region in young infants. It appears on the trunk and extremities (but festations ranging from sunburn-like erythroderma (difuse, not the face), is not pruritic, and will become more evident involving non?sun-exposed areas), intraepidermal blistering upon warming of the skin. Limited involvement of one mucosal surface quent severe dermatitis (including severe erythroderma, some may occur. Pruritic, clear fuid?flled vesicles develop mucosal surfaces (mouth, eye, urogenital, esophageal) for diag initially on the scalp and face and spread to the trunk, with nosis. Recurrent infections (zoster) Petechiae are tiny dark (red or purple) pinpoint lesions that follow a dermatomal pattern. Purpura are larger dark (pur ple or brown) nonblanchable lesions that may or may not be Erythema nodosum is a hypersensitivity reaction that 24 manifests as discrete, tender, nodular lesions on the ex raised (palpable). Fever may precede or be mediate and careful evaluation because they may indicate poten tially life-threatening infections, especially in a child younger coincident with the development of the lesions. Sepsis due to Neisseria meningitides (as well as is ofen unknown; recognized causes include infection, in fammatory bowel disease, connective tissue disease, and other organisms) is of particular concern. The skin appears infl tion is likely to be localized (to an extremity [owing to compres trated, and the borders are raised and frm. Other tests may be considered, depending on clinical presentation; remember, fever and petechiae in a child Fever only rarely precedes pityriasis rosea, but the rash 27 may quickly evolve into a critical illness. A solitary oval herald may be associated with many infections, including viral ones. The presence of purpura defnitely warrants an urgent frequently described as a Christmas tree? pattern on the evaluation. Bacterial causes include group A Chapter 60 b-hemolytic streptococci or oral anaerobes such as Fusobacte rium. Tuberculosis is increasing in incidence in chil (3) malignancy by primary origin in the node or secondary to dren and is usually associated with hilar adenopathy, with the metastases; and (4) rare lipid storage disorders. The age of the child may indicate skin test and a chest x-ray may confrm tuberculosis. In toddlers, adenopathy is usu culosis, or who are clinically suspected to have tuberculosis, on ally due to either focal infections that drain to the afected node or immunosuppressive therapy, or who have immunosuppressive systemic viral infections. Children at increased risk of disseminated dis predispose children to opportunistic infections or malignancies. Birth and travel Cervical adenitis is usually due to atypical mycobacteria, 6 history may indicate exposure to endemic infections. An indeterminate tuberculin skin test socioeconomic status or ethnicity), family diet. With modern methods of milk pasteurization, ease, toxoplasmosis from kitty litter). Lymphogranuloma venereum Cat-scratch disease, caused by a gram-negative bacillus, 7 may cause inguinal lymphadenopathy. An acute onset may sug Bartonella henselae, occurs afer exposure to a scratch or gest infection, whereas an insidious onset accompanied by sys bite of a cat, with development of a papule at the site of trauma, temic symptoms. The On physical examination, all areas that may be involved must be lymph nodes usually regress spontaneously within several palpated, including cervical, preauricular and postauricular, axil weeks. Some 10% may have a purulent drainage that is culture lary, epitrochlear, inguinal, and supraclavicular. If needed, diagnosis can be confrmed by lar lymphadenopathy is usually a red fag for mediastinal tumors or biopsy of the node showing granulomas, central necrosis, and infections or for metastatic abdominal tumors. Tender, nonerythematous, sof nodes may indicate a Kawasaki disease is determined clinically in children by 8 viral or a systemic infection. Firm or hard, rubbery, nontender noting 5 consecutive days of high fever accompanied by at nodes may indicate infltrating tumors. Hard, matted, fxed, non least four of the following fve conditions: cervical lymphade tender nodes indicate tumor or fbrosis afer acute infection. Common viral agents include adenovirus, parainfuenza, infuenza, rhinovirus, If any of the red fags? are present, malignancy is suspected 9 and enterovirus. Syphilis caused by the spirochete Treponema palli dehydrogenase, alkaline phosphatase, and uric acid levels. Close thy; in secondary syphilis there is usually generalized lymph clinical follow up should be done to watch for progression of node involvement. Pruritus, hemolytic anemia, and common in the newborn and is more common in older children chest pain afer alcohol ingestion are clues. Disseminated tuberculosis may present as by lymph node biopsy and/or bone marrow aspiration. Non generalized lymphadenopathy, pulmonary infltrates, and systemic Hodgkin lymphoma usually occurs as supraclavicular, cervical, or symptoms. About half of children with acute lymphoblastic Sinus histiocytosis is a rare disorder with massive cervical 12 leukemia present with adenopathy at the time of diagnosis. Sys lymphadenopathy, fever, elevated erythrocyte sedimenta temic signs and symptoms. Examples malignancies, including disseminated neuroblastoma, rhabdo 13 include serum sickness from drugs such as cephalosporins myosarcoma, and thyroid cancer, may occur as localized or gen or the drug itself. Examination of the peripheral blood smear is also important and may reveal the diagnosis. Other fndings may include spherocytes (spherocytic anemia, immune-mediated hemolytic anemia), sickle cells (sickle cell anemia), and Howell-Jolly bodies (asplenia). Target cells may be seen in patients with iron defciency, ues of hemoglobin and hematocrit vary with age and gender so hemoglobinopathies, and thalassemia. A term infant has a normal hemo The American Academy of Pediatrics recommends univer 3 globin level of 15 to 21 g/dl, followed by a physiologic nadir of sal screening for anemia at age 1 year with determination of 9. Iron-defciency anemia may be normocytic increased menstrual blood losses, pregnancy, and in prematurity. An increase in hemoglobin of 1 g/dl within Impaired absorption of iron may be associated with malabsorp 2 to 4 weeks confrms the diagnosis. Laboratory confrmation tive syndromes such as infammatory bowel disease or celiac of iron-defciency anemia by a low transferrin saturation (low disease. A neonatal history of serum iron, high total iron-binding capacity), and low ferritin hyperbilirubinemia may indicate a congenital hemolytic anemia, may be considered in children who are at low risk and have especially if there is a family history of anemia, splenectomy, or unexplained iron defciency. Children with In general, anemia (unless acute) may be asymptomatic until b-thalassemia major (Cooley anemia) present during infancy the hemoglobin level is less than 7 to 8 g/dl. Clinical features with severe anemia, increased reticulocyte count, and features can include pallor, fatigue, irritability, and decreased exercise of bone marrow expansion. Chronic hemolytic anemias hemoglobin H disease with a moderate hemolytic anemia, micro may cause expansion of bone marrow with prominent cheek cytosis, reticulocytosis, and splenomegaly; or as a-thalassemia bones, frontal bossing, and dental malocclusion. Lymphadenopathy and hepatosplenomegaly H and a-thalassemia major disease usually occur in Asians. Microcytic anemia is associated with lead poisoning (plum 5 bism) as iron defciency enhances the absorption of lead. Be Anemias may also be categorized based on reticulocyte cause ferritin is an acute phase reactant and may be infuenced counts, which are afected by the underlying cause. It is therefore expressed as the corrected reticulocyte myelitis), autoimmune disorders. The peripheral Trombocytopenia usually appears frst, with subsequent de smear shows hypochromic microcytic red blood cells mixed velopment of granulocytopenia and then macrocytic anemia. Tere may be icterus, spleno Acquired red cell aplasia may be due to acute infections, megaly, gallstones, and signifcant family or neonatal history. A more severe Laboratory fndings include abnormal cell morphology; increased form of transient red blood cell hypoplasia (aplastic crisis) may red blood cell distribution width, indirect bilirubin, urine urobi occur in patients with hemolytic anemias afer infection with linogen, and lactate dehydrogenase; decreased serum haptoglo parvovirus B19, which causes erythema infectiosum (ffh disease). Transient erythroblastopenia of childhood is a temporary arrest of red blood cell production and occurs predominantly in children A positive antiglobulin (Coombs) test indicates an immune 16 aged 6 months to 3 years. Isoimmune hemolytic anemia is the most temporary suppression of erythropoiesis results in reticulocyto common cause of neonatal anemia. Hemoglobin cause of administration of Rh immune globulin to Rh-negative levels are usually between 6 to 8 g/dL, neutropenia may be pres mothers. When it occurs it causes severe hemolysis and can occur ent and platelet counts are normal or elevated. The marrow infltration and normocytic anemia with throm direct Coombs test result is positive, and spherocytes are seen on bocytopenia and either leukocytosis or leukopenia. Paroxysmal cold hemoglobinuria phenicol, anticonvulsants, cytotoxic drugs, sulfonamides), toxin and, rarely, infectious mononucleosis also cause anemia with cold related. Tese may include hemoglobin electrophore 12 mented neutrophils due to vitamin B12 or folate defciency sis, glucose-6-phosphate dehydrogenase screening, and osmotic is quite rare in children. Malabsorption of vita min B12 may be due to a rare intrinsic factor defciency. Sickle cell disease may occur Folate defciency may be caused by decreased absorption combined with hemoglobin C or b-thalassemia, causing a less due to resection or infammatory disease of the small bowel or severe disorder. Characteristic fndings include bite cells? and inclusion folate requirements may occur in chronic hemolytic anemia bodies called Heinz bodies. It may be seen along with thrombocytopenia in dissemi penia and physical stigmata such as thumb and radial anoma nated intravascular coagulation, hemolytic-uremic syndrome, lies, growth failure, short stature and skin fndings. Renal, cardiovascular seen with large hemangiomas) and thrombotic thrombocytopenic and gastrointestinal malformations also occur. Chapter 61 u Anemia 235 Membrane defects include hereditary spherocytosis and manifestations such as fatigue, lightheadedness, tachycardia, 21 elliptocytosis. Components of the hemostatic mechanism include ratory results may be normal in von Willebrand disease. Testing platelets, anticoagulant proteins, procoagulant proteins, and may include a quantitative assay for von Willebrand factor components of the vessel walls. If the History should include age and acuity at onset of bleeding, patient is taking medications that might interfere with hemo? 1 stasis, all tests should be done or repeated afer stopping the triggers, whether bleeding was immediate or delayed, and whether it was prolonged or exaggerated. Bleeding time indirectly measures platelet number, must be determined, such as nosebleeds requiring cautery or function and platelet?vessel wall interaction; it has low sensitiv? packing or surgeries requiring transfusions. Perinatal history screen for platelet function abnormalities but there are problems should include details regarding bruising or petechiae, bleeding with sensitivity and specifcity. A history of vitamin K administration and Vitamin K defciency is common in neonates, malnour? 3 maternal drugs should be obtained. In adolescent girls a history ished children, those receiving broad?spectrum antibiot? of dysfunctional uterine bleeding would be important. Hemorrhagic tailed family history should be obtained, including maternal disease of the newborn is rarely seen anymore because of pro? obstetric history of bleeding. Acute mucocutaneous bleeding may indicate Inhibitors may be directed against a specifc coagulation 4 idiopathic thrombocytopenic purpura. Various fndings on physical examination may be transmitted as X?linked traits; therefore, family history of bleed? helpful in determining the etiology. Hemo? cate endocarditis; arthropathy is suggestive of hemophilia; joint philia A or B usually occur as bleeding into muscles or joints laxity is seen with Ehlers?Danlos syndrome; and thumb or and easy bruising. The most common cause of lifelong symptoms of mucocuta? 6 The critical evaluation for a bleeding disorder should begin neous bleeding is von Willebrand disease due to defciency 2 with a few specifc laboratory tests. If other tests are normal and time is prolonged when fbrinogen levels are low (hypofbrino? examination does not suggest other nonhematological etiolo? genemia or afbrinogenemia), with dysfunctional fbrinogen gies (see Footnote 12), platelet aggregation studies should be (dysfbrinogenemia), or due to factors, which interfere with f? considered to evaluate for other less severe platelet function brin formation. Although the blood is inco? agulable, hemorrhage is rarely spontaneous and usually occurs Many nonhematological conditions can mimic bleeding 12 with trauma or surgery. Disorders of the vessel walls or their supporting tissues coagulant proteins, and platelets.

Treatment of Localized Lesions of Canine Atopic Dermatitis With Tacrolimus Ointment: a Blinded Randomized Controlled Trial cholesterol lowering food tips buy line fenofibrate. Annals of the New York Academy of Sciences 1983; 420 (Defined Immunofluorescence and Related Cytochemical Methods) 353-60 cholesterol upper limit fenofibrate 160 mg without a prescription. Evaluation of Adrenal Function in Small-Breed Dogs Receiving Otic Glucocorticoids cholesterol test ireland buy 160 mg fenofibrate overnight delivery. Advances in Veterinary Dermatology: proceedings of the Third World Congress of Veterinary Dermatology the cholesterol in eggs order 160 mg fenofibrate fast delivery, 11-14 September 1996 cholesterol lowering foods uk best purchase fenofibrate, Edinburgh cholesterol lowering foods for breakfast cheap fenofibrate 160 mg otc, Scotland. A Retrospective Study of Dysplastic Hair Follicles and Abnormal Melanization in Dogs with Follicular Dysplasia Syndromes or Endocrine Skin Disease. Compendium on Continuing Education for the Practicing Veterinarian 1979; 1 227-36. Skin Diseases of the Dog and Cat: Clinical and Histopathologic Diagnosis, Second Edition. Practical Applications of Topical Therapy for Allergic, Infectious, and Seborrheic Disorders. An Evaluation of the Clinical, Cytological, Infectious and Histopathological Features of Feline Acne. Feline Acne and Results of Treatment with Mupirocin in an Open Clinical Trial: 25 Cases (1994?96). These protocols reflect the most recent clinical evidence-based medicine practices and have been adapted for use in district and general hospitals in Egypt. Both the accreditation process for hospitals and the National Guidelines for Infection Control were taken into consideration in their design. The purpose of the protocols is to standardize clinical management among practitioners in providing quality integrated maternal, newborn, family planning and reproductive health services. It is planned to use them as the basis for didactic and on-the-job training for existing and new physicians and nurses. They can be used by individual providers and/or provider teams to conduct self-assessments and by their supervisors to perform routine monitoring. A coordinating committee including one or two university professors in addition to a Takamol relevant staff member was established for each protocol to coordinate the efforts of the revision/update. It is our sincere hope that this set of protocols will contribute to improving the health and well being of women and children in our country. Neonatal Care Protocol for Hospital Physicians iv Table of Contents Table of Contents Introduction. Components of the Integrated Perinatal Care in Hospitals Notification of deliveries? Integrated perinatal service system should include a Notification Form used to inform the neonatal team as soon as the obstetric patient is admitted and evaluated, giving a potential timeline for delivery. Neonatal Care Protocol for Hospital Physicians 4 Chapter 1: Integration of Perinatal Care Neonatal resuscitation? The process of delivery may be long and hard, but the loud and clear cry of a newborn is an indescribable joy. The ability to keep the newborn breathing, its nose and mouth clear, and its heart beating, are life-saving skills that must be professionally practiced by the delivery attendant. In an emergency, there is no time for panic; certain emergency steps must be initiated at once. Critical interventions within the first 20 seconds can be life saving, resulting in a happy mother returning home with a healthy neonate. Every delivery should be attended by at least one person whose only responsibility is the baby, and who is capable of initiating resuscitation. Self-inflating bag (suitable for neonates, approximately 750 ml) with a pressure-release valve, and a reservoir. Oxygen source with flowmeter and tubing, adjusted at a flow of 5-8 L/minute Intubation equipment? Neonatal Care Protocol for Hospital Physicians 6 Chapter 1: Integration of Perinatal Care > Waste receptacle and safety box are available. Umbilical cord care: fix the cord clamp, 2 inches away from the umbilicus and cut the cord 3-5 cm from the abdomen using clean and sterile scissors or scalpel. Neonatologists should conduct daily maternity rounds for the care of babies rooming in with their mothers. All neonatologists and obstetricians should have a monthly joint morbidity and mortality conference. Neonatal Care Protocol for Hospital Physicians 7 Chapter 2 Prenatal Diagnosis and Fetal Assessment Chapter 2: Prenatal Diagnosis and Fetal Assessment Prenatal Diagnosis and Fetal Assessment Prenatal Diagnosis of Fetal Disease Prenatal diagnosis involves a variety of techniques to determine the health and condition of an unborn fetus. Screening tests Screening tests are performed by analysis of maternal serum during pregnancy. These include high-resolution ultrasound and possibly amniocentesis followed by chromosome analysis. Amniotic fluid is removed from around the fetus via a needle guided by ultrasound. Assessment of Fetal Well-being Antepartum tests rd these tests are not used until the 3 trimester; fetuses may not respond appropriately earlier in gestation. Neonatal Care Protocol for Hospital Physicians 12 Chapter 2: Prenatal Diagnosis and Fetal Assessment Fetal movement monitoring? Periods of inactivity for more than one hour are unusual in a healthy fetus and should direct attention to the possibility of fetal compromise. This is associated with a very low perinatal mortality rate in the week after the test. Neonatal Care Protocol for Hospital Physicians 14 Chapter 2: Prenatal Diagnosis and Fetal Assessment Doppler ultrasonography of fetal umbilical artery blood flow It is a non-invasive technique to assess placental resistance expressed as resistance index. Poorly functioning placentas with extensive vasospasm or infarction have an increased resistance to flow that is particularly noticeable in fetal diastole. This indicates a functioning sympathetic parasympathetic nervous system interaction. The onset, nadir, and recovery of the deceleration occur after the beginning, peak, and end of the contraction, respectively. Neonatal Care Protocol for Hospital Physicians 15 Chapter 2: Prenatal Diagnosis and Fetal Assessment? As the uteroplacental insufficiency/hypoxia worsens: (i) Beat-to-beat variability will be lost, (ii) Decelerations will last longer, (iii) They will begin sooner following the onset of a contraction, (iv) They will take longer to return to baseline, and (v) the rate to which the fetal heart slows will be lower. Neonatal Care Protocol for Hospital Physicians 16 Chapter 3 Maternal Disorders Affecting Fetus or Newborn Chapter 3: Maternal Disorders Affecting Fetus or Newborn Maternal Disorders Affecting Fetus or Newborn High risk neonates, as an outcome of high risk pregnancies and/or problematic pregnancies, are in need of close observations immediately after birth. An active partnership between obstetric and neonatal teams should be developed for the management of high-risk pregnancies and newborns. Analgesia Neonatal Care Protocol for Hospital Physicians 19 Chapter 3: Maternal Disorders Affecting Fetus or Newborn? Prominent goiter is only occasionally present at birth in infants with familial dyshormonogenesis. Pendred syndrome is a familial organification defect associated with sensorineural deafness. If not, rd the neonate should have newborn screening done from the beginning of the 3 to th the end of the 7 day of life and this should be documented in the record and reported to the transferring hospital. Neonatal Care Protocol for Hospital Physicians 22 Chapter 3: Maternal Disorders Affecting Fetus or Newborn > Measurement of maternal or neonatal antithyroid antibodies may be required to confirm the diagnosis of maternal antibody?mediated hypothyroidism. All infants treated should have trial off medication at 3-4 years to determine if this condition is transient or permanent. It is given immediately after preparation (morning undivided dose) half an hour before feeding. The signs and symptoms subside spontaneously after 3 weeks to 6 months, depending on the severity of the disease. Neonatal Care Protocol for Hospital Physicians 24 Chapter 3: Maternal Disorders Affecting Fetus or Newborn Congenital Infections Congenital infections are either transmitted via the placenta during pregnancy or acquired from birth canal at the time of labor. Mid or late trimester infections are more likely to infect the fetus (30-50%) but the effects are milder. Rubella Virus Infection Infection of the fetus is chronic, so congenitally infected infant will shed virus at a high titer for many months. Infant born vaginally to a mother with a first episode or primary genital infection has a risk of infection 33-50%. Neonatal Care Protocol for Hospital Physicians 28 Chapter 3: Maternal Disorders Affecting Fetus or Newborn > Rooming-in with mother in isolation, if possible. Fetal varicella syndrome this form occurs in 2% of infants born to women who develop varicella during the first or second trimester of pregnancy. Neonatal varicella infection this form occurs after transplacental maternal varicella in late gestation. Neonatal varicella can be a serious illness, depending on the timing of maternal varicella and delivery. Neonatal Care Protocol for Hospital Physicians 29 Chapter 3: Maternal Disorders Affecting Fetus or Newborn Clinical manifestations Manifestations may be mild with vesicles on the skin, or severe (Table 3-2). Clinical manifestations Usually subtle and the baby may be completely asymptomatic. Clinical manifestations Usually asymptomatic during the neonatal period but may present with lymphadenopathy and/or hepatosplenomegaly. Neonatal Care Protocol for Hospital Physicians 31 Chapter 4 Neonatal Resuscitation Chapter 4: Neonatal Resuscitation Neonatal Resuscitation Most newborn babies are vigorous. Only about 10% require some kind of assistance and only 1% needs major resuscitative measures (intubation, chest compressions, and/or medications) to survive. Within seconds after birth, fluid in the alveoli is absorbed, air enters the lungs, blood vessels in the lung relax, pulmonary blood flow increases, and umbilical arteries and vein constrict, thus increasing blood pressure. Primary and Secondary Apnea When a fetus/newborn first becomes deprived of oxygen, an initial period of attempted rapid breathing is followed by primary apnea and dropping heart rate that will improve with tactile stimulation. If oxygen deprivation continues, secondary apnea ensues; it is accompanied by a continued fall in heart rate and blood pressure. Secondary apnea cannot be reversed with stimulation; assisted ventilation must be provided, resulting in a rapid improvement in heart rate. Risk Factors the majority of, but not all, neonatal resuscitations can be anticipated by identifying the presence of antepartum and intrapartum risk factors associated with the need for neonatal resuscitation (Table 4-1). Either that person or someone else who is immediately available should have the skills required to perform a complete resuscitation. When resuscitation is anticipated, additional personnel should be present in the delivery room before the delivery occurs. Neonatal Care Protocol for Hospital Physicians 35 Chapter 4: Neonatal Resuscitation Equipment? Check resuscitation supplies and equipments (Refer to Chapter 1) > Suction equipment > Bag-and-mask equipment > Intubation equipment > Umbilical vessel catheterization tray with (3. All newborns require initial assessment to determine whether resuscitation is required. Neonatal Care Protocol for Hospital Physicians 36 Chapter 4: Neonatal Resuscitation Steps of Neonatal Resuscitation the Apgar score (Refer to Appendix 1) is assigned at 1, 5, and, occasionally, 10-20 minutes after delivery. The Apgar score is not used to determine when to initiate resuscitation or in making decisions about the course of resuscitation. Suction the mouth first, and then the nose gently and briefly by suction bulb or a large bore suction catheter (Figure 4-1). If the infant is vigorous (has strong respiratory effort, good muscle tone, and heart rate >100 beats/minute): suction the mouth and nose only, and proceed with resuscitation as required. Figure (4-3): Initial steps of resuscitation in presence of meconium Stimulate the infant to breathe If the infant is still apneic, tactile stimulation is performed by slapping or flicking the soles of the feet or by gently rubbing the back once or twice. Evaluate Evaluate respiration, heart rate (counted in 6 seconds then multiplied by 10) and color. The first few breaths will often require higher pressures (30-40 cmH2O) and longer inflation time than subsequent breaths (15-20 cmH2O). The duration of the downward stroke of the compression is shorter than duration of the release and chest compressions and ventilation are well coordinated. Neonatal Care Protocol for Hospital Physicians 41 Chapter 4: Neonatal Resuscitation Figure (4-5): the two-thumb encircling hands method for chest compressions (A) is preferred over the two-finger method (B)? After 30 seconds of well coordinated chest compressions and ventilation, suspend both ventilation and compression, and check the heart rate: > If heart rate is >100 beats/minute, discontinue compressions and gradually discontinue ventilation, if the newborn is breathing spontaneously. A person experienced in endotracheal intubation should be available to assist at every delivery. Vocal cords should appear as vertical stripes on each side of the glottis or as an inverted letter "V" (Figure 4-6). A cardiac stimulant, that is indicated when the heart rate remains below 60 beats/minute, despite 30 seconds of assisted ventilation followed by another 30 seconds of coordinated chest compressions and ventilation. Neonatal Care Protocol for Hospital Physicians 44 Chapter 4: Neonatal Resuscitation Volume expansion? Indicated if an infant is not responding to resuscitation and appears in shock (pale color, weak pulses, persistently low heart rate, no improvement in circulatory status despite resuscitation efforts) and there is a history of condition associated with fetal blood loss. However, after prolonged resuscitation, it may be indicated for correction of documented severe metabolic acidosis. More commonly, the persistent cyanosis and bradycardia are caused by inadequate ventilation. Consider: > Brain injury (hypoxic ischemic encephalopathy) > Severe acidosis, congenital neuromuscular disorder > Sedation, secondary to maternal drugs > If a mother has recently received narcotics within 4 hrs of delivery and her infant fails to breathe, first assist ventilation with positive pressure, and then consider giving naloxone to the infant (0. Preterm babies are at additional risk for requiring resuscitation because of their: > Excessive heat loss > Vulnerability to hyperoxic injury > Immature lungs and diminished respiratory drive > Vulnerability to infection > Low blood volume, increasing the implications of blood loss Neonatal Care Protocol for Hospital Physicians 46 Chapter 4: Neonatal Resuscitation?

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Presumably serum cholesterol chart purchase cheap fenofibrate line, exposure of the spores to the mucus led to alterations in the physiological structure of the mushroom-shaped plug and the overlying thin layer of tissue cholesterol foods bad purchase cheapest fenofibrate, which together sealed Chapter 3 Page 146 the coiled filament within the capsule (Figure 3 cholesterol levels around the world discount fenofibrate 160 mg free shipping. The polar filament could be seen articulating with the plug with two apparent prongs at this location and straddled the electron-lucent layer which encircled the remainder of the polar capsule hyper cholesterol anemia definition generic 160 mg fenofibrate with visa. As previously described cholesterol steroid cheap fenofibrate 160mg online, the outer membrane of the capsulogenic cell was discontinuous over the plug cholesterol gallstones buy fenofibrate with amex, allowing an exit point for the filament (Canning et al. This event was witnessed following gentle external prodding? of zooids, but was also described as occurring spontaneously, resulting in the slow ejection of mature worms? lasting 15 minutes. The authors reported that subsequent to such exits, the lophophore of the infected zooid was traumatised, resulting in malfunction of the lophophore retraction mechanism. Despite extensive observations (including many hours of video footage) of infected colonies of P. In addition, no zooids were recognised suffering from lophophore dislocation? as described in P. Individual zooids were seen to lose their complement of released spores within 12 hours of appearance. In the infected colony which was studied sequentially, the completion of developmental cycles of B. These stages matured, resulting in a new wave of maturation, a sequence which was ongoing, resulting in different life cycle stages of B. Although infection was maintained, the colonies continued to steadily increase in their number of zooid units. It had been suggested that the resultant stenosis of the connecting channel would result in the annexing of infected colonial zones, allowing newly developed zooids to remain uninfected and to continue development of a clonal bryozoan line (Canning et al. Moreover, although the colonies became fragmented as a result of the occlusion of the metacoel, newly developed zooids invariably showed subsequent signs of B. Thus, it appeared that if the bryozoan response was a protective mechanism as previously suggested, then it was seriously flawed. In light of these findings, it seemed more likely that the stenosis was a pathological sequel, triggered by traumatic effects of the parasite on bryozoan tissue. The resultant fragmentation of infected colonies was marked, with conspicuous differences in the apparent vitality between uninfected and infected colonies evident (Figure 3. Whereas Schroder (1910) illustrated the development of statoblasts in Buddenbrockia-infected P. In the current study, statoblasts were seen in zooids Chapter 3 Page 148 which had shown signs of parasitism since their earliest developmental stages, thus the statoblast formation could not have preceded B. Although statoblasts continued to be formed throughout infected colonies, markedly fewer were seen when compared to uninfected colonies adhered to the same Petri dish (Figure 3. The development of statoblasts fuels the hypothesis that malacosporean infection could be harboured in these asexual stages over the winter period; alternative possibilities being the survival of the parasites in the sole phylactolaemate genus (Fredericella) which overwinters as live zooids or the existence of reservoirs of infection in alternative hosts. Unfortunately, attempts at germinating statoblasts from infected colonies were unsuccessful, negating the possibility of witnessing true vertical transmission of infection in Bryozoa. Following comprehensive field studies involving the collection of numerous bryozoans from multiple sites, Canning et al. In the current study, no direct horizontal bryozoan transmission was observed despite repeated attempts involving the direct injection of B. These findings reinforce the assertion that additional hosts may be involved in the life cycle of Buddenbrockia. Whether these potential hosts would be in the form of other invertebrates or perhaps teleosts can only be hypothesised. However, due to morphological and developmental findings, it was judged by the authors that the malacosporean present was neither B. Indeed, several marked differences exist between the previously described malacosporean Chapter 3 Page 149 and B. The contrast of these observations to those of the current study supports their suggestion of the existence of a malacosporean species distinct but related to B. However, the possibility that the malacosporean parasite that they studied was a vermiform alternative manifestation of T. In the current study, no sign of malacosporean infection was seen in fish exposed to B. In light of the fact that the fish farm from which the infected bryozoans were collected also stocked common carp a species in which an unidentified myxozoan parasite possessing electron-dense bodies similar to those seen in the Malacosporea has been described (Voronin and Chernysheva 1993) it had been hoped to conduct an experimental transmission trial of B. While the former assertion has been supported by the current observations, the latter has been challenged by the maintenance of infection in P. The previous authors stated that sub-optimal laboratory culture conditions may have contributed to the premature demise of infected colonies. It would appear that this may also have led to the previous inability of colonies to develop statoblasts. In the current study, greater Chapter 3 Page 150 growth of infected bryozoans was witnessed following increased concentration of algal and protozoal components in the culture medium by centrifugation. This resulted in the production of a highly turbid culture medium, consistent with the water conditions described by Canning et al. In the current study, all of the cultured bryozoans both uninfected and infected died after three months of laboratory culture. As the uninfected colonies had been actively thriving until this point, it seems likely that the culture demise was due to a collapse in the culture system rather than a natural termination of infection. Thus, it could be concluded that under ideal culture conditions, bryozoans harbouring B. The observation of sequential developmental stages studied by light and electron-microscopy has revealed further details of malacosporean parasitism, while transmission trials have suggested that another (possibly teleost) host is involved in the life cycle. Further elucidation of the life cycles of the Malacosporea would be an aim in future research in trying to understand the complex dynamics of these intriguing parasites. Chapter 3 Page 151 Chapter 4: Developmental stages of Tetracapsuloides bryosalmonae (Myxozoa: Malacosporea) in phylactolaemate bryozoans (Bryozoa: Phylactolaemata) Chapter 4 Page 152 4. Introduction Although they were originally described almost 150 years ago (Allman 1856), relatively little is known of the developmental stages of malacosporean parasites within their bryozoan hosts. This first ultrastructural study of malacosporean development allowed the authors to propose a rudimentary structure for a malacosporean spore. The subsequent discovery of Tetracapsuloides bryosalmonae within bryozoans further intensified the momentum to elucidate the morphological characteristics of these now economically pertinent parasites (Anderson et al. Further ultrastructural studies have demonstrated the presence of various developmental stages of T. In addition, light microscopical studies of malacosporean development have revealed details of the morphological configuration of the parasites (Gay et al. However, artefacts inherent from the processing of material for transmission electron microscopy (Hayat 1981), the paucity of available spores of T. This suggested that exposure to a relatively low number of spores was capable of infecting trout; however, no quantification of the infectious dose could be deduced at that time. Within the Myxozoa, investigations into quantifying an infective dose of spores to fish have been documented for Myxobolus cerebralis (Markiw 1991, 1992), but no such information has previously been gathered for T. Success with such studies would allow further insight into the parasitic interaction between bryozoan and teleost hosts of this intriguing myxozoan. Between June 2002 and June 2004, eight field trips were made in the months between February and October. On each visit, multiple colonies (confirmed to be Fredericella sultana by colony and statoblast morphological analysis as described in Section 3. Maintenance and study of the bryozoans in the laboratory the resulting colonies were maintained in 5 L tupperware tanks as described in Section 2. Stages of malacosporean development were monitored by light microscopy as described in Section 3. After acclimatisation, the water flow was stopped to both tanks and the level reduced to 21 L with continuous vigorous aeration applied. To one of the tanks, one litre of culture media from a tank containing colonies of F. After 50 days maintenance at a water temperature of 18?C, the fish were overdosed -1 in 10 mg L benzocaine and euthanased by severing the spinal cord. The supernatant was discarded and the pellet flushed well with 600 l of 80% (v/v) isopropanol. The alcohol was discarded, taking care to conserve the pellet, Chapter 4 Page 157 and any excess alcohol was allowed to evaporate from the tube. For use, 390 l of ultra-pure water was added to an aliquot resulting in a working concentration of 2. The tubes were placed in a thermocycler (?T Gradient, Biometra, Goettingen) and heated to 94?C for 3 minutes, followed by 35 cycles of the following sequence: 94?C for 1 min, 55?C for 1 min, 72?C for 1 min, followed by a final incubation of 5 min at 72?C. Six l of 5 mg ml ethidium bromide was then added to the dissolved gel and mixed by gentle swirling. The solution was then poured into a horizontal gel caster (Flowgen) and one or two 20 tooth combs were inserted depending on the number of samples to be analysed. The bryozoans were then teased apart on microscope slides viewed with a dissecting microscope resulting in release of spores Chapter 4 Page 159 into the surrounding media. The slides were then placed on the stage of an inverted microscope, with attached microinjection and manipulation accessories as described in Section 3. Known numbers of spores from each withdrawal were then expelled into individual bijoux containers. To each of six replicate containers, one spore was added, while six replicate containers were also made with five and ten spores each. On the day of challenge, the water supply to each tank was suspended and the volume of each tank reduced to 2. The content of each container was added to its respective tank, with thorough rinsing of the bijoux with the tank water to allow maximum expulsion of the spores from bijoux to tank. The fish were maintained at 18?C for 56 days after which they were overdosed in -1 10 mg L benzocaine and euthanased by severing the spinal cord. Samples of kidney, spleen and liver were fixed in 10% neutral buffered formalin for 24 hours. Trial 2 A second experimental trial was undertaken including further modifications to the methodology in attempting to achieve more robust results than in the first trial. On this occasion, however, the collected spores were not counted as they were drawn into the micropipette but rather as they were slowly expelled onto individual cavity microscope slides viewed using an inverted microscope. Ice packs were placed on the microscope stage in an attempt to maintain the temperature of the specimens. One spore was added to each of six microscope slides, two spores being added to a further two slides, three spores to two slides, five spores to two slides, six spores to one slide, 14 spores to two slides, 15 spores to one slide and 16 spores to two slides. The fish were then maintained for 63 days at 18?C before being euthanased, sampled and examined as described in Section 4. Released spores were pipetted on to microscope slides, in preparation for fluorescent staining. Cover slips were then placed over the samples, and sealed with nail varnish to prevent evaporation of the medium. The slides were incubated in the dark for between 30 min and two hours to allow fluorescent staining of the spores and they were then examined by confocal laser scanning microscopy. In addition to laser excitation of fluorochromes, transmitted light was also used to visualise some of the samples. Sequences of images were taken along the optical Z axis using the confocal optical sectioning facility. Three-dimensional models of the spore were produced using spheres of various sizes to represent the components of the structure. Still and video images were captured of the spore in various positions, including dynamic rotational views. Following maintenance of the colonies in the laboratory at 18?C, signs of malacosporean development were invariably seen. The time interval between collection and identification of malacosporean parasite development varied from 2-38 days with a mean period of 22 days (Table 4. Following initial recognition of infection, characteristic spores were always observed within five days. More rapid appearance of infection was witnessed in colonies collected during the earlier part of the season (from February to April) than later in the year. This period of proliferation consistently included sexual development, resulting in the production of spermatozoa (Figure 4. These particles moved freely within the coelomic currents, with no attachments observed between parasite and host. Within a day, round stages of diameter 8-15 m could be seen attached to the bryozoan peritoneum (Figure 4. After a period of one to three days, irregularly-shaped bodies of 40-100 m diameter were seen circulating within the metacoel (Figure 4. Within three days, distinctly spherical bodies of approximate diameter 50-100 m (Figure 4. The range in size of the sacs presumably resulted from varying levels of maturity of the stages. At first, the refractive bodies appeared to be localised in peripheral zones within the sacs, but later these zones expanded, eventually coalescing. This gave the appearance of each sac containing a central lucent area surrounded by a shell of refractive bodies (Figure 4. Upon observation of some sacs that were moving less rapidly in the coelomic currents, protrusions could be seen from the external walls of the otherwise regularly spherical sacs (Figure 4. The protrusions varied in size from 15-50 m in diameter, some Chapter 4 Page 167 being relatively innocuous, while others took on more elaborate botryoid formations (Figure 4. Upon maturity, spore sacs of up to 350 m in diameter appeared to be packed full with refractive bodies (Figure 4. Within one or two days, many malacosporean spores could be seen swirling alongside other intact spore sacs in the metacoel (Figure 4. Their fast movement within the bryozoan host made examination difficult, although closer details could be discerned where spores became located in slow moving coelomic currents (Figure 4. In some bryozoan colonies, innumerable quantities of malacosporean spores could be seen circulating within the coelomic currents.

In an updated evalua methodological quality cholesterol medication atorvastatin side effects buy online fenofibrate, poor writing cholesterol definition in spanish cheapest generic fenofibrate uk, and ambiguous tion cholesterol pronunciation cheap fenofibrate 160mg visa, Manchikanti et al (161) cholesterol vs saturated fat cheap fenofibrate 160mg on-line, in an assessment of all presentation cholesterol lowering foods american heart association purchase fenofibrate in india, all of which essentially project a view that interventional techniques cholesterol levels elderly generic 160 mg fenofibrate, except for implantables, con these are not applicable to individual patients or are too tinuous epidurals, intraarticular injections, trigger point restrictive with a reductions in clinician autonomy and and ligament injections, peripheral nerve blocks, and that overzealous or inappropriate recommendations are vertebroplasty procedures, showed an overall increase not based on evidence. There were Management of conflict of interest significant variations and increases in procedures and Guideline development group composition specialties as illustrated in Figs. These instances may be strength of recommendations exacerbated due to burdensome, difficult to fol Articulation of recommendations low, and expensive regulations, and empowerment External review of insurers, hospitals, and non-physician providers Updating (93-100,105,111-133,161-175,191,217,324-326). Illustration of distribution of procedural characteristics by type of procedures from 2000 to 2011. Utilization of interventional techniques in managing chronic pain in the Medicare population: Analysis of growth patterns from 2000 to 2011. These guidelines were started to create a docu to provide a set of recommendations that can support ment to help practitioners by synthesizing the avail existing and future guidelines to provide appropriate able evidence. The authors stated that these clinical strategies to manage chronic spinal pain and improve practice guidelines for interventional techniques in the quality of clinical care. The membership consists the management of chronic pain were professionally of multiple specialties across the globe even though it developed utilizing a combination of evidence and is an American society. Utilization of interventional pain management techniques by specialty from 2000 to 2011 in Medicare recipients. Consequently, we have also undertaken extensive efforts to avoid direct, as well as 1. The panel was of interest with development group activity, by written instructed to answer questions and develop evidence disclosure. Disclosures reflected all current and planned pertaining to important aspects of spinal interventional commercial services, including services from which a techniques. Members of the panel were also requested clinician derives a substantial portion of income, non to develop comprehensive systematic reviews on various commercial, intellectual, institutional, and patient/ related subjects in preparation for spinal interventional public activities pertinent to the potential scope of the techniques guidelines (9-32,82-84). The majority of the participants reviews have the potential to improve the decisions attended multiple meetings. The committee Evidence assessment for systematic reviews was formulized the elements of the guideline preparation based on methodological quality assessment criteria process, including literature searches, literature synthe recommended for randomized trials, observational sis, consensus evaluation, open forum presentations, studies, and diagnostic studies (336-356). However, there were no patients, review process derived from evidence-based system patient advocates, or patient/consumer organizations atic reviews and meta-analyses of randomized trials, represented in the guideline development process, observational studies, and diagnostic accuracy studies which may be considered as a deficiency. Overall, good to fair evidence is logic quality or validity assessment were performed. Even though none of these instruments or sures were taken to avoid any conflicting opinions from criteria has been systematically assessed and the advan authors receiving funding from the industry. Patients ex the predetermined minimum number of studies was pect that their doctors and other health care providers available, and finally, analysis of evidence was based know what type of treatment to recommend. The analysis was conducted using 3 systematic reviews of the evidence are objective, trans levels of evidence, ranging from good, fair, and limited parent, and scientifically valid. Consequently, the high prevalence the theoretical basis of controlled diagnostic of chronic spinal pain, the numerous modalities of blocks is that if a patient genuinely has pain from a treatments applied in management of the problem, particular target structure, complete or near complete and the growing social and economic costs continue relief of that pain should be obtained consistently to influence medical decision-making. Despite its whenever that structure is anesthetized, and repeat commonality, both in primary care and tertiary care, ing the diagnostic block can increase the diagnostic it is often difficult to reach a definite diagnosis of accuracy by testing for consistency of response and the origin of spinal pain. If a particular structure is said to source of exponential growth in treatment modali be the target, it must be shown that the structure is ties is the inherent difficulty in obtaining an accurate anesthetized and either does or does not produce a diagnosis. In the search of a diagnosis, an inaccurate result within the distribution of that structure. Face or incorrect diagnosis, may lead not only to expen validity can be tested and established either by a study sive diagnostic ventures, but to treatment failures whose results can be replicated or by testing for face resulting in wasted health care dollars, and diver validity in each and every case. Fundamental be established by radiographic imaging with injection to proper treatment is an accurate diagnosis which of a contrast agent or by a physiological approach uti is based on the reliability of the test used to make lizing a detectable and testable function other than the diagnosis. Construct validity ventional techniques or interventional techniques measures if the test actually works or not, and how (415-422). For diagnostic interventional techniques, there is no conventional criterion standard, such as imaging 1. Thus, and nerve conduction studies in non-radicular pain, a Bogduk (383) has developed testing for construct precise cause of pain may be identified in only approxi validity of diagnostic blocks by other means. However, it such as the false-positive rates can be estimated by has been described that with application of controlled determining how often a diagnostic block is positive diagnostic interventional techniques, a diagnosis may in patients who should not, or demonstrably do not, become a reality in 85% of the patients rather than have the condition in question. Under these conditions, a true-positive Low back pain is the most common of all spinal, response would be the one in which the patient and even chronic, pain problems. Lumbar intervertebral obtained relief on each occasion that an active agent discs, facet joints, sacroiliac joints, ligaments, fascia, was used, but no relief when the inactive agent was muscles, and nerve root dura have been shown to be used. The blocks are performed on separate oc agnosed with physical examination, radiological assess casions using local anesthetic agents with different ment, and neurophysiological assessment (368,374,552 durations of action (383,384,415-422). For chronic low back pain without disc herniation proach, the consistency of response and the duration or radiculitis, the precision diagnostic blocks applied of response are tested. Failure to respond to the include lumbar facet joint nerve blocks, lumbar provo second block constitutes inconsistency, and indicates cation discography, and sacroiliac joint blocks, and to that the first response was false-positive. A response a lesser extent, lumbosacral selective nerve root blocks concordant with the expected duration of action of or transforaminal epidural injections in the diagnosis of the agent used strongly suggests a genuine, physi difficult radicular pain syndromes (11,17,33,36,374). Low back pain is treated based on diagnosis with various modalities including epidural injections, per 2. Facet joint interventions and sacroiliac ity of spinal pain problems and ability of diagnostic joint interventions are utilized in managing facet joint blocks to identify sources of chronic spinal pain. Removal or correction of structural abnormalities of the spine may fail to cure Chronic, persistent low back, lower extremity pain, and may even worsen painful spinal conditions (3,8 and radicular pain may be secondary to disc herniation, 38,82,139,177,195,196,202,207,232,260,261,295,367 disc disruption, disc degeneration, spinal stenosis, or 374,505-551). The degenerative processes of the spine post lumbar surgery syndrome resulting in disc-related and the origin of spinal pain are complex without cor pain with or without radiculitis. Herniated lumbar disc relation of radiographic changes to the clinical picture is a displacement of disc material (nucleus pulposus or and prognosis (8,413-504). The effectiveness of a large annulus fibrosis) beyond the intervertebral disc space. Finally there is increasing evidence supporting numerous treatment modalities for herniated disc pain, the use of spinal interventional techniques in managing following the description of disc herniation by Mixter chronic spinal pain (4-38). The are epidural injections including adhesiolysis, facet prevalence of a symptomatic herniated lumbar disc joint interventions, sacroiliac joint interventions, intra is about 1% to 3% (554) with the highest prevalence discal therapies, mechanical disc decompression, and among people aged 30 to 50 years (555), with a male implantable therapies. Lumbar disc displacement may present as in epidural fibrosis, sacroiliac joint pain, disc herniation, ternal disc disruption, disc prolapse, disc protrusion, disc discogenic pain, spinal stenosis, arachnoiditis, and facet extrusion, disc herniation, or simply discogenic pain. The joint pain, along with inappropriate surgery (8,519,522 estimated prevalence of lumbar radiculopathy or sciatica 524,526,612-626). Lumbar radiculopathy sec spine surgery with multiple authors describing a lack of ondary to disc herniation resolves spontaneously in 23% association (614-617), one study found that patients with to 48% of patients, but up to 30% to 70% will still have extensive epidural fibrosis were 3. Further, experimental studies have first described by Wirshow in 1857, the pathophysiology provided electrophysiological evidence of neurologic and the mechanism of pain due to disc herniation remain disturbances caused by peridural scar formation (622). However, the intervertebral disc multitude of other abnormalities including mechanical has been implicated as a source of spinal pain based tethering of nerve roots secondary to epidural fibrosis on decades of pre-clinical, clinical, and epidemiological in the vertebral canal (623,624), disturbances in blood research, though the precise mechanisms still continue flow (625), and expression of proinflammatory cytokines to be debated as the literature evolves (36,374,379 causing irritation of exposed dorsal root ganglion and 381,566-598). Further, based on controlled evaluations, triggering painful responses have been described (626). Further, in a study that paraspinal muscle spasms, tail contracture, pain behav sought to determine the prevalence of discogenic pain iors, tactile allodynia, epidural and perineural scarring, without assessing internal disc disruption, the reported and nerve root adherence to the underlying discs and prevalence rate was 26% (378). Spinal stenosis can be defined as a narrowing of the In any type of disc-related pain, spinal stenosis, or spinal canal, resulting in symptoms and signs caused by radiculitis, radiographic evidence of disc herniation or entrapment and compression of the intraspinal, vascular, spinal stenosis does not accurately diagnose low back or and nervous structures (374,599-603). Diagnosis based on history, physi trusion, and herniation combined with osteophytes and cal examination, and radiological imaging for other ori arthritic changes of the facet joints can cause a narrow gins such as small disc herniations has low sensitivity and ing of the spinal canal, encroachment on the contents specificity in determining whether or not the disc or spinal of the dural sac, or localized nerve root canal stenosis. Open discectomy and decompression, with or with Symptoms of central spinal stenosis may be related out fusion, are the most common surgical interventions to a neurovascular mechanism such as arterial flow in performed for disc herniation, spinal stenosis, and post cauda equina, venous congestion, and increased epi surgery syndrome. However, absolute indications for sur dural pressure (603-611); nerve root excitation by local gery, even though rare, include altered bladder function inflammation; or direct compression in the central and progressive muscle weakness (629). Thus, spinal stenosis is a multifactorial tion for surgery is to provide for the rapid relief of pain disorder, and clinical presentation can be variable with and to address the possibility of impending disability in or without neurogenic claudication manifested by pain the majority of patients whose recovery is unacceptably in the buttocks or legs when walking, which disappears low. While it appears that surgery provides good pain with sitting or lumbar flexion (603,609,610). In fact, bar spine and it should not be confused with radicular Carragee et al (550) showed poorer surgical outcomes in pain. The cardinal distinctions lie in the quality of pain patients with massive annular defects and in those with and its behavior. Table 1 shows the differences between an intact annulus and no identifiable fragment in a re radicular and somatic pain. Similarly, it was review of diagnostic procedures for neck and low back also shown that with sequestered or extruded lumbar disc pain, showed that a number of factors can be identified herniations, the prognosis was better than with contained which can assist the clinician in identifying sciatica due to disc herniations with single level microdiscectomy (631). However, they were Patients with contained disc herniations, a predominance unable to show any evidence based on history leading to of back pain, and smoking are expected to have poorer a diagnosis not related to radicular pain. Similarly, musculoskeletal examination may assist in the diagnosis lumbar spinal stenosis has been described as one of the of radiculopathy or radicular pain with identification of most frequent indications for spine surgery in patients disc herniation at various levels. Straight leg raising or cross straight leg stenosis, discogenic pain, or post surgery syndrome relies raising and motor examination may be crucial in the as mainly on conservative care combining physiotherapy, sessment of disc herniation. Table 2 shows the diagnostic structured exercise programs, analgesics, anti-inflamma features for various levels of nerve root involvement. Epidural injections including ad However, radiculitis may be seen not only with her hesiolysis and mechanical disc decompression with various niation of the nucleus pulposus, but also with central modalities may be alternative techniques prior to surgery and foraminal spinal stenosis, nerve root entrapment in patients with indications for surgery, in contained in the lateral recess, and other causes such as spondy disc herniations, mild to moderate symptomatic spinal lolisthesis, spondylolysis, facet joint cysts, and epidural stenosis, and post surgery syndrome. Multiple systematic fibrosis, internal disc disruption, or discogenic pain reviews with inappropriate assessment of interventional without involvement of other structures. In addition, radiologic evaluation often dif on history, and physical examination which includes ferentiates this from disc herniation. The pain may radiate into the ankle and test, crossed straight leg raising test, bowstring sign, occasionally into toes. Deyo et al (641) showed that sciatica often differentiates it from lumbar radiculopathy from was highly sensitive for a clinically important herniated disc herniation. Objective signs of nostic interventions applied include diagnostic selective numbness are reasonably sensitive, although numbness nerve root blocks and provocation lumbar discography. So Lumbosacral selective nerve root blocks and/or matic referred pain is mostly in the buttock or lower transforaminal epidural injections are used for the S62 Somatic or Referred Pain Radicular Pain Posterior segment or element Anterior segment Facet joint pain Disc herniation Segment Causes Sacroiliac joint pain Annular tear, discogenic pain Myofascial syndrome Spinal stenosis Internal disc disruption Symptoms Dull, aching, deep Sharp, shooting, superficial, lancinating Like an expanding pressure Like an electric shock Poorly localized Well localized Quality Covers a wide area Leg worse than back Back worse than leg Paresthesia present No paresthesia Well defined No radicular or shooting pain Radicular distribution Worse with extension Worse with flexion Modification Better with flexion Better with extension No radicular pattern Radicular pattern Low back to hip, thigh, groin Follows nerve distribution Radiation Radiation below knee unusual Radiation below knee common Quasi segmental Radicular pattern Signs Sensory Alteration Uncommon Probable Only subjective weakness Objective weakness Motor Changes Atrophy rare Atrophy possibly present Reflex Changes None Commonly described, but seen only occasionally Only low back pain Reproduction of leg pain Straight Leg Raises No root tension signs Positive root tension signs Adapted and modified from: Manchikanti L, et al. Clinical Aspects of Pain Medicine and Interventional Pain Management: A Comprehensive Review. Of these, 2 studies assessed contrast root pain specifically apply to a single symptom pain flow selectivity or flow patterns (647-649). In addition, 15 studies evaluated diag if a particular spinal nerve is responsible for causing nostic accuracy (650-656,659-666). Shah (643) questioned the anatomic selec Diagnostic selective nerve root blocks have often tivity and physiologic selectivity. Clinical Aspects of Pain Medicine and Interventional Pain Man agement: A Comprehensive Review. C = Conus medullaris; D = dural tube; E = epidural space; F = filum terminale; S = subarachnoid space. Nerve Motor Screening Herniation Pain Numbness Atrophy Reflexes Root Weakness Examination L3-4 L4 Low back; hip; Anteromedial Quadriceps Extension of Squat and rise Knee jerk anterolateral thigh, thigh and knee quadriceps diminished medial leg L4-5 L5 Above S1 joint; Lateral leg and Minor or Dorsiflexion of Heel walking None reliable hip; lateral thigh first 3 toes nonspecific great toe and and leg; dorsum foot of foot L5-S1 S1 Above S1 joint; hip; Back of calf; Gastrocnemius Plantar flexion of Walking on toes Ankle jerk posterolatera and lateral heel and and soleus great toe and foot diminished thigh leg; heel. Clinical Aspects of Pain Medicine and Interven tional Pain Management: A Comprehensive Review. In addition to the wide range previous reports (650,652,655,659,661-664,665), most in accuracy, most of the studies have been retrospective of which did not attempt to quantify false-positive re in nature, have had a small sample size, and have failed sults. In this and other studies, significant false-negative to describe their methodologies in detail. Almost in all the studies on the topic to date, the definition all studies were characterized by significant limitations. A majority lumbar spine is not high, confirming the hypothesis of of studies have analyzed the sensitivity, specificity, ac Shah (643). The value may be improved by using a nerve curacy, and predictive values because they focus on the stimulator and utilizing a meticulous injection technique results of diagnostic selective nerve root block on the with extremely low volume; however, this contention is presumed lesion level alone, and many employed con based on only one high quality study (656). They ar serve to reduce false-positive results (11,13,15,17,36 rived at a sensitivity of 57%, a specificity of 86%, an 38). Because of this, and the fact that no reference stan accuracy of 73%, a positive predictive value of 77%, dard such as a tissue or biopsy diagnosis can confirm and a negative predictive value of 71%. They confirmed the results, the validity of selective nerve root blocks the findings of other investigators that false-positives in the diagnosis of lumbosacral radiculitis has not been were frequently the result of overflow of the injectate established. In addition, the influence of potential con from the injected level into either the epidural space founding factors such as psychological disorders, opioid or to another level that was symptomatic. They also usage, age, and obesity have on the results of selective demonstrated that false-negative blocks were due to nerve root blocks have not been studied (33). In the study by Yeom et al being significant dermatomal overlap between adjacent (656), the evidence was shown to be only moderate, and nerve roots, even when the procedure is performed with the diagnostic value was relatively low compared with low volumes under fluoroscopic visualization, the injec Despite these obstacles, there is evidence that does In reference to accuracy, it is generally measured support the validity of selective nerve root blocks. Specificity is a early study performed on 105 patients with radicular relative measure of the prevalence of false-positives, pain, 57% of whom had undergone previous surgery, whereas sensitivity is the relative prevalence of false Haueisen et al (652) compared the diagnostic accuracy negative results. There are several factors that can lead of spinal nerve root injections with lidocaine to my to a false-positive selective nerve root block despite elography and electromyography with regard to surgi precautions, including the close proximity of numer cal findings and treatment outcomes. Among the 55 ous potential pain-generating structures that can be patients who underwent surgical exploration, selective anesthetized by the aberrant extravasation of local nerve root injections were accurate in identifying the anesthetic. Consequently, selective nerve root blocks surgical pathology in 93% of patients, which favorably are considered to have a higher degree of sensitivity compared to accuracy rates of 24% for myelography, than specificity. At follow-up periods ranging from one to 5 lective nerve root blocks range from 45% to 100% years, 49% of patients had minimal or no pain vs. The au ported finding a corroborative lesion at the time of thors concluded that in patients with surgically altered surgery in 87% of patients with a positive diagnostic anatomy, selective nerve root blocks are helpful in mak block.

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