Robert Arntfield, MD

Treat underlying sexually transmitted infection (this does not influence the course of joint disease) medications before surgery cyklokapron 500mg visa. Skin and mucous membranes (in 80% of cases) Lupus may be confined to the skin as discoid or subacute cutaneous lupus; typically a raised symptoms multiple myeloma order 500 mg cyklokapron mastercard, scarring rash on the face symptoms kidney stones cheap 500 mg cyklokapron with visa, scalp or limbs symptoms 8 dpo discount cyklokapron 500 mg with amex. Clinical presentation includes: hypertension haematuria proteinuria nephrotic syndrome acute kidney injury end-stage renal disease. Antiphospholipid antibodies: anticardiolipin antibodies and lupus anticoagulant occur in up to one-third of cases and are a marker for thrombosis. They may cause lens opacities, which resolve on stopping treatment, and rarely irreversible retinal degeneration. Cyclophosphamide and mycophenolate mofetil are reserved for cases of organ- or life-threatening disease. Patients with the antiphospholipid syndrome (see below) require antithrombotic therapy. Additional vascular and thrombotic risk factors should be actively reduced in all groups. Five-year survival is > 90%, although patients with renal involvement have a higher mortality rate. Death usually results from active generalised disease, sepsis or cardiovascular complications. It is an autoimmune disorder characterised by the excessive deposition of collagen and other matrix proteins in various organs, including the skin. Skin involvement is both truncal and acral; visceral involvement may include the heart, lungs, kidneys, gastrointestinal tract. Systemic sclerosis without scleroderma: a small number of patients have visceral disease without cutaneous involvement. It may occur in isolation (primary) or in association with a connective tissue disease or rheumatoid arthritis (secondary). Physiotherapy relieves joint stiffness and helps maintain muscle strength/function. Prostaglandins, phosphodiesterase type 5 inhibitors and endothelin antagonists may help reduce progression of pulmonary hypertension and digital ulceration. Penicillamine may be of value; trials of other immunomodulators and alkylating agents are ongoing. Babies born to mothers with Sjogren syndrome who are Ro antibody positive are at risk of congenital heart block. Slit lamp examination with Rose Bengal staining confirms dryness and corneal damage. Management Treatment is predominantly symptomatic with artificial tears and saliva and meticulous oral hygiene. Corticosteroids and other immunosuppressive agents may be required for extraglandular complications. Awarenessofthepossibledevelopment of lymphoma is important for long-term surveillance. Autoantibody profile: one-third of all patients with polymyositis or dermatomyositis do not have any detectable auto-antibodies. Proximal muscle weakness and associated stiffness are common; mild pain and muscle tenderness may occur. Involvement of other striated and smooth muscle groups may result in cardiac and/or respiratory failure, oropharyngeal dysfunction and dysphagia. Intravenous immunoglobulin may help, especially if the initial response to treatment is poor and/or there is evidence of respiratory compromise. Rheumatology Occasionally more aggressive immunosuppressive therapy is required for pulmonary involvement. The disease may remit spontaneously, particularly in younger subjects, but relapse/progression is a feature in at least half of all cases. Underlying malignancy determines the outcome if polymyositis or dermatomyositis is associated with malignant disease. Investigations and treatment are generally along the lines of the individual component disorders. Vasculitides these are a heterogeneous group of disorders characterised by vascular inflammation. The cause remains unknown, although flare-up of disease is often associated with intercurrent infection. Various organs can be affected including skin, lungs, kidneys, joints, eyes and the nervous system. Normal biopsy appearances do not exclude the condition, as skip lesions may occur. Aortic arch angiography: reveals diffuse narrowing of the aorta and main arteries. T Treatment should be started without delay, and intravenous methylprednisolone may be used in the early stages if there is visual involvement. Surgical intervention may be required for critical carotid or renal artery stenosis, or significant aortic regurgitation. It has an estimated annual incidence of between 1 and 10 cases per 10 million population. Kawasaki disease this condition typically affects children, causing fever, mucocutaneous features. Systemic disease is treated with a combination of corticosteroid and cytotoxic chemotherapy. Renal impairment, proteinuria > 1 g per 24 h and visceral involvement are adverse prognostic markers. Localised inflammation, usually in the upper or lower respiratory tract, is followed by the development of a systemic vasculitis and glomerulonephritis. It affects both sexes equally, can occur at any age (commonly in middle age) and has an estimated annual incidence of between 10 and 20 per million population. Prognosis the 5-year survival rate is > 80%, although up to 50% of patients will suffer one or more relapses during this time. Superadded infection and renal and respiratory failure are major causes of long-term morbidity. Approximately 50% of patients have associated lung involvement presenting as haemoptysis, pleurisy or asthma. Other features include arthralgia, vasculitic or purpuric rashes, hypertension, mononeuritis multiplex and peripheral neuropathy. There is an eosinophilia in peripheral blood and eosinophils predominate in the inflammatory infiltrates, which may be granulomatous. Females are affected more commonly than males; the estimated incidence is 10 per million. Hypersensitivity (leucocytoclastic) vasculitis this is characterised by inflammation of small vessels, resulting in palpable purpuric skin lesions which coalesce to form plaques or ecchymoses, especially on the lower limbs. It typically occurs between the ages of 3 and 15 years, more commonly affects males and is rare in adults, in whom the prognosis is worse. A palpable purpuric rash develops over the buttocks and legs, with arthritis, abdominal pain with bloody diarrhoea and glomerulonephritis which is indistinguishable from IgA nephropathy. A leucocytoclastic necrotising vasculitis with IgA deposition is demonstrable at the dermo-epidermal junction in skin biopsies, and there is mesangial IgA deposition in the kidneys. Episodes are usually self-limiting (days or weeks) but relapses may occur, especially in the elderly and those with nephritis. Evidence of progressive renal involvement is an indication for high dose corticosteroid/immunosuppressive therapy. Correct sample collection and transport to the laboratory (at 37 C) is essential if cryoglobulinaemia is suspected. Skin and/or renal biopsy should be performed to determine the extent of renal involvement.

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The general peritoneal cavity is divided into a greater sac and lesser sac medications on airline flights buy cyklokapron 500 mg mastercard, the two communicating through the foramen of Winslow treatment of scabies order 500mg cyklokapron with amex. The greater sac is subdivided into the subdiaphragmatic (subphrenic) spaces symptoms ibs order 500 mg cyklokapron otc, pelvis and general peritoneal cavity symptoms of flu 500 mg cyklokapron. There are seven subdiaphragmatic spaces, four intraperitoneal and three extraperitoneal. The general peritoneal cavity is divided by the transverse colon and mesocolon into supra- and infra-colic compartments. These anatomic divisions have a bearing on the localisation of intraperitoneal infection. It envelops the inflamed organ to localise the infection such as a perforated sigmoid diverticulum. It will show the site of the collection of pus such as a paracolic abscess and the cause such as perforated diverticulitis. Once the patient has recovered, detailed investigations are carried out and the pathology dealt with definitively. All patients should be thoroughly resuscitated by correction of fluid, electrolyte and acidbase disturbance; an indwelling urinary catheter and a nasogastric tube are inserted and the patient started on the appropriate broad-spectrum antibiotic to cover aerobic and anaerobic organisms. If the patient is not promptly and effectively managed, septic shock might follow. Assessing the patient early will give an idea as to the need for nutritional support, which will help toward quicker recovery. Therefore, they do not have the natural protection to localise peritonitis; the surgeon should therefore consider early surgery. E Diagnostic smears for acid-fast bacilli are positive in less than 3% of patients. Laparoscopy with peritoneal biopsy and macroscopic intraperitoneal findings confirms the diagnosis. The disease originates from the ileocaecal region, spreading via the mesenteric lymph nodes or directly from the bloodstream usually from the miliary form of the disease. The diagnosis of bile peritonitis is usually made at laparotomy unless the patient had an operation on the biliary tract in the recent past. If the patient has not had an operation, the most common cause is perforated cholecystitis. This is because it is the most dependent site, and postoperatively the patient usually sits up. Also one of the most common causes is after an operation for pelvic appendicitis and tubo-ovarian infections causing pelvic inflammatory disease. While the clinical presentation might be insidious, the patient develops swinging pyrexia, looks toxic and typically complains of pain in his right shoulder tip when the right subphrenic or subhepatic spaces are involved. This is because pus collection under the right dome of the diaphragm causes irritation of the diaphragmatic peritoneum and pain travels along the sensory fibres of the phrenic nerve. This classically produces referred pain to the right shoulder tip in the distribution of C4. Open operation is almost obsolete, the interventional radiologist having taken over the task. B, D In a patient with normal body habitus, for ascites to be clinically diagnosed there must be more than 1. However, shifting dullness cannot be elicited when there is a huge amount of fluid as there would be no free space in the peritoneal cavity for the fluid to be shifted. As a means of treating ascites by intervention, a peritoneovenous shunt is considered only rarely in selected cases. It occurs when there is a disturbance between the plasma and peritoneal colloid and hydrostatic pressures. When the amount of protein in the ascitic fluid is >25 g/L it is called an exudate, while it is called a transudate when the protein content is <25 g/L. Capillary hydrostatic pressure is increased when there is a generalised water retention, as in heart failure, liver cirrhosis, portal vein thrombosis, or hepatic vein obstruction (Budd-Chiari syndrome); plasma colloid osmotic pressure is lowered in starvation, intestinal malabsorption, abnormal protein loss, or defective protein synthesis as in the cirrhotic. A, B, C, D Secondary tumours of the peritoneum are much more common and referred to as carcinomatosis peritonei (peritoneal metastases) and usually a terminal event. Pseudomyxoma peritonei, a rare condition and more common in women, arises from a primary tumour of the appendix that implants on to the ovaries. It fills the abdomen with yellow jelly-like mucinous material that might be encysted in the form of mucinous cystic tumours. Adenocarcinoma of the appendix resembles ovarian mucinous adenocarcinoma, and hence it is thought that most ovarian mucinous tumours are seeded from the appendix. Good palliation is obtained by repeated debulking laparotomies when carried out in specialist units. Peritoneal loose bodies are benign small lumps found loose in the peritoneal cavity incidentally at laparotomy. It is the outcome of an appendix epiploica that has undergone torsion and become detached following necrosis. D, E Major research has been ongoing for many years for the prevention of adhesions. Although there has been reduction in adhesion formation, the findings do not translate to reduction in adhesion-related clinical problems. The outcomes of several trials have shown that the use of barrier products has reduced the incidence, extent and severity of adhesions, but this was not reflected in the clinical outcome in reducing the incidence or surgical intervention for intestinal obstruction. Sclerosing encapsulating peritonitis, which is the result of long-term peritoneal dialysis, is a form of severe adhesions that produces bowel obstruction. Ischaemic tissue inhibits fibrinolysis, as it does not have the ability to break down fibrin; hence all attempts must be made to prevent ischaemia. Reducing the production of ischaemic tissue by good surgical technique is the hallmark in the prevention of adhesions. Further, the advent of laparoscopic surgery has resulted in reduction of readmissions for problems related to adhesions. A, B, C, E Torsion of the omentum is a diagnosis made at an emergency operation carried out for a mistaken diagnosis of acute appendicitis. Usually the sufferer is a middle-aged obese man who presents as an emergency with pain and tenderness in the right iliac fossa. At operation there is a gangrenous mass, which is a black piece of twisted omentum. The normal appendix is usually removed at the same time to prevent confusion in diagnosis in the future, as the patient would have a gridiron incision. Injury to the mesentery is the aftermath of blunt abdominal injury occurring as a result of the seat belt crushing against the anterior abdominal wall from deceleration injury from a road-traffic accident. This causes a tear in the mesentery with haemorrhage and bowel ischaemia, which will require resection and end-to-end anastomosis. Acute nonspecific ileocaecal mesenteric adenitis is a classical differential diagnosis of acute appendicitis especially in children. It is suspected when there is shifting tenderness that is poorly localised and there are symptoms of upper-respiratory infection with cervical, axillary and groin lymphadenopathy. In situations where the diagnosis remains uncertain and acute appendicitis cannot be ruled out, an emergency appendicectomy has to be carried out. Mesenteric cysts can be chylolymphatic (commonest type), enterogenous, dermoid and urogenital remnant; the diagnosis might be confused with congenital hydronephrosis. It can be the result of a lymphoma or secondary lymph nodal deposits from a testicular tumour or other malignancies. In the majority a cause of the fibrosis cannot be found and hence is called idiopathic retroperitoneal fibrosis. The condition can cause involvement of both ureters, causing them to be pulled 539 61: the peritoneuM, oMentuM, Mesentery and retroperitoneal spaCe medially and lying in front of the vertebral bodies. This happens when it is an inflammatory aneurysm, which involves the left ureter causing hydronephrosis and hydroureter. Such an aneurysm is very adherent to the neighbouring structures particularly the duodenum. A retroperitoneal abscess is a psoas abscess that tracks along the psoas sheath down into the femoral triangle to the lesser trochanter. Clinically a fluctuant mass is palpable in the iliac fossa and the femoral triangle that exhibits cross fluctuation. In developing countries it is still commonly seen, as the cause is vertebral tuberculosis resulting in a cold abscess.

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Vitamin D-resistant states: in familial vitamin D-resistant (hypophosphataemic) rickets treatment is with oral phosphate supplements and calcitriol medicine organizer box effective cyklokapron 500mg. In uraemia there is failure of 1a-hydroxylation: treatment is with 1a-hydroxycholecalciferol or 1 treatment renal cell carcinoma generic 500 mg cyklokapron,25-dihydroxycholecalciferol medications known to cause seizures purchase cyklokapron 500 mg visa. Calcium supplements are not usually required unless there is severe osteomalacia or poor dietary intake medications you can take while nursing buy cyklokapron 500mg on-line. Deafness is common in patients with skull involvement; it may result from involvement of the ossicles or compression of the cochlea or internal auditory canal. Occlusion of other foramina of the skull leading to compression of other cranial nerves occurs less often; platybasia or flattening of the base of the skull may, rarely, lead to brainstem compression or obstructive hydrocephalus. Spinal involvement may cause cord compression, particularly in the cervical and thoracic regions. Less than 1% of patients develop osteogenic sarcoma in Pagetic bone (the pelvis and femur are the most common sites); it may be heralded by increasing pain. It is a disease chiefly of the elderly, and shows geographical variation, being more common in North America and Europe, but rare in Asia. Bone profile: increased osteoblastic activity is reflected in increased levels of serum alkaline phosphatase; serum calcium levels are usually normal. Expansion and disorganisation of bone with both lytic and sclerotic lesions are characteristic; there is cortical thickening and coarsening of trabeculae; the pelvis and lumbar spine are most frequently affected, followed by the sacrum, thoracic spine, skull, lower limbs and upper limbs. Bowing deformity occurs in weight-bearing long bones, and osteoarthritis is common in adjacent joints. Bone scintigraphy shows increased uptake at affected sites and helps to define the full extent of the disease. Clinical features the clinical features depend predominantly on the rapidity of onset and, to a lesser extent, on the magnitude of the rise in serum calcium levels. Severe hypercalcaemia, usually caused by malignant disease, with an onset over only a few weeks or months, may produce significant symptoms. Bisphosphonates: the mainstay of treatment in symptomatic patients; their role in asymptomatic patients remains controversial, but should be considered if complications due to hypervascularity or disease progression are likely. Calcitonin: can be given subcutaneously in those who are intolerant to bisphosphonates. Serum alkaline phosphatase and 24-h urinary hydroxyproline measurement can be used to monitor response to treatment. Urinary hydroxyproline levels reflect bone resorption and give a more rapid indication of response and an earlier warning of relapse. Hypercalcaemia True hypercalcaemia is defined as an elevation in free ionised serum calcium. However, ionised calcium is not always measured/available, and for practical purposes total calcium is therefore used in most clinical settings. Investigation After excluding iatrogenic causes, paired measurement of serum parathyroid hormone and serum calcium is the first key step in elucidating the underlying cause. Aetiology Primary hyperparathyroidism (see below) and malignancy are the commonest causes of hypercalcaemia. Tertiary hyperparathyroidism is normally easily distinguishable based on the clinical context, as is hyperparathyroidism due to lithium therapy. In addition, consideration should be given to screening for secondary complications of longstanding hypercalcaemia. Advice should be given to avoid factors that can aggravate hypercalcaemia (predominantly dehydration and medications). Further investigation should be undertaken to determine the cause, and then treatment targeted as appropriate. Adverse effects, including nausea/vomiting, abdominal pain, diarrhoea and flushing are common and limit its utility. Dialysis is reserved for severe hypercalcaemia or those with renal impairment/fluid balance problems. Secondary/tertiary hyperparathyroidism Secondary hyperparathyroidism is a physiological response to hypocalcaemia caused by another disorder. Serum calcium may be normal (compensated), frankly low, or even occasionally raised (see below). High serum phosphate levels, due to renal failure, may be seen in both secondary and tertiary hyperparathyroidism (this is in contrast to primary hyperparathyroidism where phosphate levels are typically low). Clinical presentation Primary hyperparathyroidism is commonly associated with mild hypercalcaemia that develops slowly over many months or even years. Patients are often asymptomatic, and the hypercalcaemia is discovered incidentally during investigation for other reasons. Moderate to severe hypercalcaemia may result in a variety of symptoms (see hypercalcaemia, p. Chronic hypercalciuria predisposes to renal calculi, nephrocalcinosis and, eventually, renal failure. In addition, in patients presenting with fragility fractures, there is a relatively high prevalence of previously undiagnosed primary hyperparathyroidism. In most cases this results from the development of a single autonomous parathyroid adenoma (90%); other causes include multiple adenomas (4%), hyperplasia of all four parathyroid glands (6%) and, rarely, parathyroid carcinoma (< 1%). Secondary hyperparathyroidism Traditionally, secondary hyperparathyroidism in the context of renal impairment is characterised by. Other specific changes include loss of the lamina dura of the teeth (25%) and osteitis fibrosa cystica with bone cysts (rare). Tumour localisation for operative planning Although preoperative localisation may be deemed unnecessary for an experienced parathyroid surgeon undertaking a conventional neck exploration in a previously untreated patient with primary hyperparathyroidism, recently there has been a resurgence of interest in preoperative imaging. This has been driven in large part by the move towards minimally invasive parathyroidectomy, in which only unilateral neck exploration is performed. In addition, preoperative localising strategies may be helpful in cases requiring surgical re-exploration. Technetium-sestamibi scanning: early phase images typically show both thyroid and parathyroid tissue, although asymmetric foci of increased radiotracer uptake may be seen in the presence of abnormal parathyroid tissue. If doubt remains as to whether an abnormality resides within parathyroid or thyroid tissue, then thyroid scintigraphy (using a radioisotope not taken up by the parathyroids), with subsequent overlay and subtraction of the superimposed images may help. Neck ultrasound: non-invasive, but requires a skilled operator; most adenomas are greater than 1 cm in size and homogeneously hypoechoic; hyperplastic glands are generally smaller and more difficult to detect. Surgery the definitive treatment for primary hyperparathyroidism is resection of the affected parathyroid gland(s). Most single/ipsilateral double adenomas can now be resected as a minimally invasive day case procedure; however, patients with suspected bilateral disease should be considered for conventional full neck exploration. Routine prescription of activated vitamin D and calcium supplements followed by early postoperative review (at approximately day 14) facilitates early discharge following surgery. Clinical features these are highly dependent upon the rapidity and severity of onset of the hypocalcaemia: rapid significant falls are classically associated with tetany, i. Symptoms range from mild to severe, from perioral paraesthesia through to laryngeal spasm and seizure activity. Papilloedema, lethargy, malaise and rarely psychosis are features of chronic hypocalcaemia. DiGeorge syndrome) Hypomagnesaemia Treatment with cinacalcet (calcimimetic) Activating mutations of the calcium-sensing receptor Drugs. Wherever possible, attention should be paid to identifying/treating the underlying cause. Chronic hypocalcaemia Currently, long-term therapy for hypoparathyroidism involves the use of vitamin D analogues (alfacalcidol 268 Metabolic disorders Clinical presentation this depends upon its speed of onset and its degree. Ectodermal changes: teeth, nails, skin and hair; there is an excessive incidence of cutaneous moniliasis in primary hypoparathyroidism.

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They should be treated with topical antiviral preparations such as aciclovir ointment medications janumet buy cyklokapron 500mg free shipping. Steroid eye drops cause marked worsening of the infection medicine valley high school cyklokapron 500 mg generic, which might result in severe corneal scarring medications 5113 generic 500mg cyklokapron overnight delivery. C Acute elevation of intraocular pressure results in an oedematous cornea and hard eye on palpation medicine 6 year order cyklokapron 500mg otc. The severe, visceral pain that accompanies acute glaucoma may cause vomiting, and the condition might be mistaken for an acute abdominal diagnosis. Prompt diagnosis, leading to prompt therapy with glucocorticoids, can prevent blindness due to bilateral arteritic anterior ischaemic optic neuropathy. A A superficial corneal flap is cut, and a layer of corneal stroma is ablated with an eximer laser. Tissue such as the posterior lens capsule, iris and vitreous bands might be divided. D the incision is made on the inner surface of the eyelid to avoid a visible scar. The incision is radial to the lid margin, in line with the affected meibomian gland, to avoid cicatricial shortening of the tarsal plate. C Contact the duty ophthalmologist Acute angle closure glaucoma causes severe pain, which may result in vomiting and be mistaken for an acute abdominal pathology. B Measure blood pressure, random blood glucose and full blood count Underlying causes for central retinal vein occlusions include hypertension, diabetes and hyperviscosity syndromes (and glaucoma). J Measure blood pressure, random blood glucose and request carotid duplex ultrasound In addition to asking if the patient smokes, causes of arteriosclerosis should be sought. Therapy is based on reduction of cardiovascular risk factors, aspirin and assessment for possible carotid endarterectomy surgery. G Preseptal cellulitis Cellulitis of the eyelids is often due to underlying sinus disease. H Meibomian cyst Meibomian cysts are retention cysts of the meibomian glands and contain sebaceous material. They slowly resolve spontaneously but may be incised on the inner aspect of the eyelid and curetted, if desired. B Lacrimal sac mucocele A mucocele of the lacrimal sac occurs when proximal and distal outflow from the sac are occluded. Recurrent infection may occur, and the definitive treatment consists of dacryocystorhinostomy surgery. C Molluscum contagiosum Viruses shed from molluscum contagiosum lesions cause a recurring viral conjunctivitis. J Basal cell carcinoma Basal cell carcinomas are a common form of eyelid skin neoplasia. D Uveitis Anterior uveitis, in which the iris is inflamed, results in spasm of the pupil sphincter muscle and adhesions between the iris and the lens. J Herpes simplex keratitis Herpes simplex infection of the corneal epithelium typically causes a branching-patterned disturbance of the corneal epithelium. Steroid treatment must be avoided, as this will cause severe worsening of the condition and permanent scarring. C Subconjunctival haemorrhage Subconjunctival haemorrhages look dramatic but are of no functional significance. F Bacterial conjunctivitis Bacterial conjunctivitis is a common, self-limiting condition. Antibiotic eye drops slightly shorten the duration of the infection, but are unnecessary, as the condition is self-limiting. E Scleritis Scleritis is a form of connective tissue inflammation frequently associated with rheumatoid arthritis. The inflammation may be controlled with nonsteroidal anti-inflammatory drugs, but in more severe cases, glucocorticoids are needed. A Instil antibiotic ointment and place an eyepad over the eye After removal of a corneal foreign body, there is risk of infection and the eye is painful. Ultrasound examination can be done very gently, but there is a risk of causing further injury by pressing on the eye. C Instil local anaesthetic and perform irrigation of the cornea and the conjunctival sac with saline A large volume of saline should be used to irrigate the eye, until all traces of alkaline chemical have been removed. Alkaline substances are much more damaging than other chemicals, as they denature proteins and penetrate deeply into the tissue. H Arrange examination under anaesthetic and surgical repair as required It is very likely that the eye has been ruptured. D Genetics and the environment both play E Family history with a first-degree relative affected increases the risk to one in 100 live births. Which of the following statements regarding causal factors of cleft lip and palate are true A Environmental factors are less important for cleft palates than for cleft lip/palate. E An isolated cleft palate is more commonly associated with a syndrome than cleft lip alone. Which of the following statements regarding congenital abnormalities of cleft lip and palate are true A the most common congenital abnormalities of the orofacial structures are cleft lips, alveolus and palate. E Pierre Robin syndrome is associated with early respiratory and feeding difficulties. A In cleft lip there is disruption of the two groups of muscles of the upper lip and nasolabial region. D the secondary palate is defined as the structures anterior to the incisive foramen. B Hypoxia is more likely to occur in the awake Pierre Robin baby than during sleep. A In a complete cleft palate, the nasal septum and vomer are completely separated from the palatine processes. B In a cleft of the soft palate, the muscle fibres are oriented wrongly but insert into the posterior edge of the hard palate. C Minimal dissection to detach the abnormal soft palate muscles decreases facial growth abnormality. F Primary goal of palate repair is to prevent nasal regurgitation of food material. G Pushback techniques of palate lengthening are adequate for proper speech development. A Restoration of normal anatomy does not encourage normal facial growth in cleft surgery. E the Delaire method of repair of a cleft lip is the only satisfactory method for cleft lip closure. Which of the following statements regarding dental care in cleft patients are true B Orthodontic care should only be done in cases where dentition is diseased or poorly maintained. C An abnormal number of eruption problems of teeth rarely occur in cleft patients. D Early (6 to 12 months) prophylactic myringotomy and grommet insertion temporarily eliminate middle ear effusion. A Revisional lip surgery in previously repaired cleft lips should usually be delayed for 2 years unless the original muscle repair has been judged inadequate. D Alveolar bone grafts should be performed long before orthodontics are considered. E Alveolar bone grafts are useful in closing residual fistula of the anterior palate. 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