X

Loading



STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS

William A. Weiss, MD, PhD


https://profiles.ucsf.edu/william.weiss

War Other intentional injuries Total 67 heart disease widowmaker cheap propranolol 80 mg free shipping,887 38 cardiovascular quizlet buy propranolol 80 mg with mastercard,736 13 coronary heart wants generic propranolol 40mg fast delivery,174 15 cardiovascular disease doctors purchase 40 mg propranolol amex,977 58 coronary heart line buy 20mg propranolol mastercard,937 5 arteries move blood order 20 mg propranolol otc,096 15,778 412 37,651 18,455 10,005 2,955 5,495 3,985 32,130 4,695 17,452 3,265 1,938 4,780 24,952 116 563 33 122 138 49 68 3,612 13,949 1,551 4,751 8,331 5,214 235 2,747 135 167,094 121,111 35,063 7,608 15,041 10,295 9,695 43,410 45,983 20,255 18,897 6,502 329 0­4 3,566 49 1,134 2,383 7,636 91 259 7 7,279 999 333 - 665 501 209 12 0 0 72 124 11,975 63 266 21 64 70 24 39 1,824 6,533 732 2,340 988 962 - - 25 8,193 7,822 1,224 289 1,024 938 1,034 3,313 370 3 259 91 17 5­14 1,935 19 1,546 370 879 67 154 30 628 347 285 - 63 227 450 80 3 0 176 190 319 0 0 0 0 0 0 0 29 172 10 106 633 628 - - 5 14,022 12,781 3,358 322 1,727 878 1,700 4,795 1,240 376 779 71 15 15­29 2,738 168 2,056 514 2,686 401 634 40 1,611 744 593 0 150 306 1,369 181 387 135 202 464 371 0 0 0 0 0 0 1 60 219 5 85 511 380 29 96 7 37,737 22,914 8,492 1,051 2,336 905 1,893 8,238 14,822 4,379 7,703 2,632 109 30­44 3,410 1,556 930 924 5,094 685 2,131 42 2,236 1,053 808 12 233 298 3,786 291 1,536 1,488 251 220 95 0 0 0 0 0 0 0 6 58 1 29 305 167 55 77 6 27,329 16,768 6,496 1,429 1,547 769 1,103 5,426 10,560 3,689 4,535 2,258 79 45­59 8,403 6,144 793 1,465 8,203 1,009 3,828 58 3,307 3,908 1,182 2,277 449 274 4,338 411 2,414 999 220 294 59 0 0 0 0 0 0 0 10 25 1 23 786 274 21 486 5 14,796 10,264 3,539 1,348 1,161 409 622 3,184 4,533 2,372 1,569 563 28 60­69 7,418 5,776 323 1,319 4,118 487 1,776 26 1,829 1,626 933 346 347 147 2,120 215 1,430 188 70 217 21 0 0 0 0 0 0 0 2 9 0 9 662 139 8 514 2 4,598 3,317 973 378 560 123 169 1,114 1,281 811 302 157 11 70­79 6,618 5,216 194 1,208 2,531 306 818 21 1,386 1,259 717 236 306 123 1,136 121 723 59 32 200 12 0 0 0 0 0 0 0 0 5 0 6 147 71 4 71 1 2,124 1,600 429 95 456 63 75 481 523 377 106 35 5 80+ 2,497 1,866 54 578 830 96 148 7 579 518 285 84 148 63 249 28 106 14 8 92 4 0 0 0 0 0 0 0 0 2 0 2 23 19 1 2 1 623 496 88 17 202 17 22 150 127 84 29 12 2 Totala 36,585 20,795 7,030 8,761 31,977 3,142 9,749 232 18,854 10,453 5,136 2,955 2,362 1,939 13,657 1,341 6,600 2,884 1,030 1,802 12,855 63 267 21 64 70 24 41 1,932 7,023 750 2,599 4,054 2,640 118 1,245 52 109,420 75,962 24,598 4,930 9,013 4,103 6,618 26,700 33,457 12,092 15,282 5,818 265 232 Global Burden of Disease and Risk Factors Colin D. We also gratefully acknowledge the support of David Evans, director of the Global Program on Evidence for Health Policy. While it is not possible to name all those who contributed to this effort, we would like to note the considerable assistance and inputs provided by Carla AbouZahr, Elisabeth Aahman, Jan Barendregt, Maureen Birmingham, Jennifer Bryce, Mercedes de Onis, Chris Dye, Jacques Ferlay, Anthony Gerbase, Ken Hill, Yvan Hutin, Gareth Jones, Hilary King, Eline Korenromp, Daniel Lavanchy, Silvio Mariotti, Mike McKenna, Catherine Michaud, Chris Nelson, Tomoko Ono, Donatella Pascolini, Margie Peden, Bruce Pfleger, Paola Pisani, Annette Pruss-Ustun, Juergen Rehm, Serge Resnikoff, Sue Robertson, Gojke Roglic, Kate Strong, Deborah Symmonds, Theo Vos, Neff Walker, Catherine Watt, and Lara Wolfson. Tunis, Tunisia:Ministry of Public Health, Salah Azaiz Institute, and National Institute of Public Health. Ankara: Turkish Ministry of Health and Baskent University, Refik Saydam Hygiene Presidency, School of Public Health. Summarizing Population Health: Directions for the Development and Application of Population Metrics. The Burden of Disease and Mortality by Condition: Data, Methods, and Results for 2001 235 Frick, K. Peace and Conflict 2003: A Global Survey of Armed Conflicts, Self-Determination Movements, and Democracy. Application of Regional Cancer Survival Model to Estimate Cancer Mortality Distribution by Site. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Summary Measures of Population Health: Concepts, Ethics, Measurement, and Applications. The Burden of Disease and Mortality by Condition: Data, Methods, and Results for 2001 237 Murray, C. Report prepared for the World Health Organization Parasitic Diseases and Vector Control. MauritiusHealthSectorReform,NationalBurdenof Disease Study, Final Report of Consultancy. Port Louis, Mauritius: Ministry of Health and Ministry of Economic Planning and Development. Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death, 9th rev, vol. Report of the Ad Hoc Committee on Health Research Relating to Future Intervention Options. Global Prevalence and Incidence of Selected Curable Sexually Transmitted Infections: Overview and Estimates. The Burden of Disease and Mortality by Condition: Data, Methods, and Results for 2001 239. World Development Report 2003: Sustainable Development in a Dynamic World: Transforming Institutions, Growth, and Quality of Life. Murray Chapter 4 Comparative Quantification of Mortality and Burden of Disease Attributable to Selected Risk Factors Majid Ezzati, Stephen Vander Hoorn, Alan D. Murray Detailed descriptions of the level and distribution of diseases and injuries and their causes are important inputs into strategies for improving population health. A substantial body of work has focused on quantifying causes of mortality and, more recently, the burden of disease (Murray and Lopez 1997; Preston, 1976; see also chapter 3 in this volume). Data on disease or injury outcomes alone, such as death or hospitalization, tend to focus on the need for curative or palliative services. Reliable and comparable analyses of risks to health are critical for preventing disease and injury. Investigators have frequently analyzed morbidity and mortality due to risk factors in the context of methodological traditions of individual risk factors and for selected populations (Kunzli and others 2000; Leigh and others 1999; McGinnis and Foege 1993; Peto and others 1992; Single and others 1999; Smith 2000; Smith, Corvalan, and Kjellstrom 1999; Willet 2002). As a result, most estimates have been affected by the following shortcomings, which limit comparability: · the causal attribution of morbidity and mortality due to risk factors has been estimated relative to arbitrary exposure levels without standardizing baseline exposure across risk factors. For example, the implicit baseline for the burden of injuries attributable to occupational factors has been "no work," because estimates have been based on occupational registries intended to register all injuries, regardless of whether they are avoidable (Leigh and others 1999). As a result, attributable burden could only be calculated for those risk factor and disease combinations for which epidemiological studies had been conducted. Furthermore, we have attempted to use consistent and comparable criteria for evaluating the scientific evidence on prevalence, causality, and magnitude of hazardous effects across risk factors. As a result, the unified framework for describing population exposure to risk factors and their consequences for population health is an important step in linking the growing interest in the causal determinants of health across a variety of disciplines from natural, physical, and medical sciences to the social sciences and humanities. We note that risk assessment as defined here is distinct from intervention analysis, whose purpose is to estimate the benefits of a given intervention or group of interventions in a specific population at a particular time. Rather, risk assessment aims at mapping alternative population health scenarios that arise from changes in the distribution of exposure to risk factors, irrespective of whether exposure change is achievable using existing interventions. The alternative visions of population health in turn contribute to identifying those risk factors for which effective or cost-effective interventions should be implemented or new interventions should be developed. In counterfactual analysis, the effects of one or a group of diseases or risk factors is estimated by comparing the current or future disease burden with the levels that would be expected under some alternative hypothetical scenario, referred to as the counterfactual, including the absence of or reduction in the diseases or risk factors of interest (see Maldonado and Greenland 2002 for a discussion of the conceptual and methodological issues involved in the use of counterfactuals). In theory, causal attribution of the burden of disease to risk factors can be done using both categorical and counterfactual approaches. For example, researchers have used categorical attribution for attributing diseases and injuries to occupational risk factors in occupational health registries (Leigh and others 1999) and motor vehicle accidents to alcohol use. However, categorical attribution to risk factors overlooks that many diseases have multiple causes (Rothman 1976). Using the theoretical-minimumrisk exposure distribution as the counterfactual has the advantage of providing an indication of potential gains in population health from reducing the risk from all levels of suboptimal exposure in a consistent way across risk factors. The criteria for selecting risk factors included the following: · they were likely to be among the leading causes of the disease burden globally or regionally; · they were not too specific, for example, every one of the hundreds of air pollutants or fruits and vegetables, or too 242 Global Burden of Disease and Risk Factors Majid Ezzati, Stephen Vander Hoorn, Alan D. Outcomes in italic are those that are likely to be causal but not quantified due to lack of sufficient evidence on the magnitude of hazardous effect. The resulting hemoglobin levels vary across regions and age-sex groups because the other risks for anemia (for example, malaria) vary. The theoretical-minimum-risk exposure level for alcohol is zero, the global theoretical minimum. Specific population subgroups or diseases may have a non-zero theoretical-minimum-risk exposure (see figure 4. We selected only a relatively small number of exposures for quantification, largely determined by the availability of data and scientific research about their level and health effects in different parts of the world. Given the close interrelationships among diet, exercise, and physiological risks on the one hand, or among water, sanitation, and personal hygiene on the other, the exact definition of what a risk factor is requires careful attention. Similarly, the assessment of unsafe sex separately from that of non-use and use of ineffective methods of contraception does not override their close linkages. Rather, we focused the analysis on risk factors for which we were likely to be able to satisfactorily quantify their population exposure distributions and health effects using existing scientific evidence and available data and for which intervention strategies are available or might be envisioned. Estimating Population Attributable Fractions to the risk factor were reduced to the counterfactual distribution. The alternative (counterfactual) scenario used is the exposure distribution that would result in the lowest population risk, referred to as the theoretical-minimumrisk exposure distribution (Ezzati and others 2002; Murray and Lopez 1999). For example, some deaths from childhood pneumonia may have been avoided by preventing exposure to indoor smoke from household use of solid fuels, childhood underweight, and zinc deficiency (which itself affects weight-for-age); and some cardiovascular disease events may be due to a combination of smoking, physical inactivity, and low fruit and vegetable intake. The work included collecting primary data and undertaking a number of reanalyses of original data, systematic reviews, and meta-analyses. To increase comparability while acknowledging the fundamental differences in exposure and hazard quantification across risk factors, the criteria for using the scientific evidence included consistency of exposure variables used in exposure data sources with those used in epidemiological studies on hazard, population representativeness of exposure data, and study design for estimating the magnitude of hazardous effects (including minimizing the effects of confounders). Data sources, models, and assumptions used to extrapolate exposure or relative risk across countries or regions are described in detail in chapters devoted to individual risk factors elsewhere (Ezzati and others 2004). External reviewers anonymously peer reviewed each risk factor chapter, including conducting re-reviews as appropriate. In this reanalysis, estimates of mortality and disease burden attributable to risk factors were needed in World Bank regions (see map 1 inside the front cover). For six risk factors (childhood underweight, high blood pressure, high cholesterol, overweight and obesity, smoking, and indoor smoke from household use of solid fuels), country-level data were available and allowed reestimating exposure directly for World Bank regions. Theoretical-Minimum-Risk Exposure Distributions the theoretical-minimum-risk exposure distribution was zero for risk factors for which zero exposure could be defined and reflected minimum risk, such as no smoking. For the latter risk factors, we used the lowest levels observed in specific populations and epidemiological studies to choose the theoretical-minimum-risk exposure distribution. For example, counterfactual exposure distributions of 115 mmHg for systolic blood pressure and 3. Alcohol has benefits as well as causing harm for different diseases depending on the disease and on patterns of alcohol consumption (Corrao and others 2000; Puddey and others 1999). This was because despite its benefits for cardiovascular diseases in some populations, the global and regional burden of disease due to alcohol use was dominated by its impacts on neuropsychiatric diseases and injuries that are considerably larger than these benefits. Finally, for factors with protective effects, namely, fruit and vegetable intake and physical activity, we chose a counterfactual exposure distribution based on a combination of levels observed in high-intake populations and the level to which the benefits may continue given current scientific 246 Global Burden of Disease and Risk Factors Majid Ezzati, Stephen Vander Hoorn, Alan D. The leading causes of mortality and the disease burden include risk factors for communicable, maternal, perinatal, and nutritional conditions (Group I as defined in chapter 3), such as undernutrition; indoor smoke from household use of solid fuels; unsafe water, sanitation, and hygiene, whose burden is primarily concentrated in low-income regions of South Asia and Sub-Saharan Africa; and unsafe sex. Undernutrition is the single leading global cause of health loss, as it was in 1990 (the 2001 results disaggregate undernutrition into underweight and micronutrient deficiencies). Even though the prevalence of underweight has decreased in most regions in the past decade, it has increased in Sub-Saharan Africa (de Onis, Frongilla, and Blossner 2000; de Onis and others 2004), where its effects are disproportionately large because of simultaneous exposure to other risk factors for childhood disease. The burden of disease attributable to unsafe water, sanitation, and hygiene has declined since 1990, mostly because of a worldwide decline in mortality from diarrheal disease, which is partly a result of improved case management interventions, particularly oral rehydration therapy. The increase in the global burden of disease attributable to smoking since 1990 mostly reflects the increased accumulated hazards of this risk, which is most noticeable in developing countries, but the increase is also partially due to methodological changes based on new evidence on the magnitude of the hazard after correction for confounding (Ezzati, Henley, Lopez, and others 2005; Ezzati, Henley, Thun, and others 2005; Ezzati and Lopez 2003; Thun, Apicella, and Henley 2000). The large increase in the burden of disease due to high blood pressure is likely to be an outcome of major methodological improvements, that is, relative risks that account for regression dilution bias and choice of theoretical-minimum-risk exposure distribution based on epidemiological evidence versus clinical definitions. The disease burden attributable to underweight and micronutrient deficiencies in children was equally distributed among males and females, but the total all-age disease burden from iron and vitamin A deficiencies was slightly greater among females because of the effects on maternal mortality and morbidity conditions. Other diet-related risks, physical inactivity, environmental risks, and unsafe sex contributed almost equally to the disease burden in males and females. Approximately 77 to 86 percent of the disease burden from addictive substances occured among men, reflecting the social and economic forces that have so far made addictive substances more widely used by men, especially in developing countries. Women suffered an estimated twothirds of the disease burden from child sexual abuse and all of the burden caused by non-use and use of ineffective methods of contraception. The estimated disease burdens from childhood undernutrition and unsafe water, sanitation, and hygiene were almost exclusively among children under five years of age. For these risks, more than 90 percent of the total attributable burden occurred in this age group, with the exception of iron deficiency, where adults bore more than 40 percent of burden, especially women of childbearing age. The disease burdens attributable to overweight and obesity and smoking were almost equally distributed among adults below and above the age of 60 years. The disease burdens attributable to other diet-related risks and physical inactivity were higher among those older than 60 (see also chapter 5). More than 90 percent of the disease burden attributable to non-use and use of ineffective methods of contraception, illicit drug use, and child sexual abuse and more than 75 percent of the disease burden attributable to alcohol use and unsafe sex occurred in adults younger than 60. Mortality High blood pressure Smoking High cholesterol Childhood underweight Unsafe sex Low fruit and vegetable intake Overweight and obesity Physical inactivity Alcohol use Indoor smoke from solid fuels Unsafe water, sanitation, and hygiene Zinc deficiency Urban air pollution Vitamin A deficiency Iron-deficiency anemia Contaminated injections Illicit drug use Unmet contraception need Child sexual abuse 0 2,000 4,000 Attributable deaths (thousands) b. Note: the figure shows estimated mortality and disease burden attributable to each risk factor considered individually, relative to its own theoretical minimum risk exposure distribution. Consequently, the burden due to groups of risk factors will usually be less than the sum of individual risks. Numbers show percentage of total death or disease burden in each age group or for each sex. The figures are the ratio of deaths in each age group or for each sex to the total alcohol-attributable deaths and disease burden. Because the beneficial effects of alcohol are age dependent (more benefits for cardiovascular diseases in older ages) and because the benefit-harm ratio is larger for women than for men (smaller alcohol-attributable burden from injuries), the ratios in younger ages or for males are larger than 100 percent and those in older ages or for females are negative. This illustrates the large, and at times neglected, disease burden from risks that affect young adults, especially in lowand-middle-income countries, with important consequences for economic development. Only a small fraction of the disease burden from the risk factors considered was among those aged 5 to 14 years. This was because some of the leading conditions that affect this age group, such as motor vehicle accidents and other injuries and depression, have complex and heterogeneous causes that could not easily be included in the risk-based framework used. For other leading diseases of this group, such as diarrhea and lower respiratory infections, most epidemiological studies have focused on children younger than five and do not provide estimates of hazardous effects for older children. Leading causes of the burden of disease in low- and middleincome countries include the risk factors affecting the poor and associated with communicable, maternal, perinatal, and nutritional conditions (Group I)-such as childhood a. The relative contribution of unsafe sex was disproportionately larger in Sub-Saharan Africa (17. This makes unsafe sex a leading cause of the burden of disease in this region together with childhood underweight (17. The outcomes of these two risk factors were mostly communicable, maternal, perinatal, and nutritional conditions, which dominate the disease burden in highmortality developing regions. In addition to their relative magnitude, the absolute loss of healthy life years attributed to risk factors in low- and middle-income regions is enormous. In other words, they would like to know what fraction of the disease burden is related to a particular risk factor or group of risk factors independent of changes in other risk factors. As Mathers and others (2002) discuss, additive decomposition is not generally a property of counterfactual attribution, because many diseases are caused by the interaction of multiple determinants acting simultaneously (Rothman 1976; Rothman and Greenland 1998; Walter 1980; Yerushalmy and Palmer 1959). With multiple attribution, a reduction in one risk factor would seem to make other, equally important, risk factors potentially irrelevant from a perspective with limited scope in relation to interpreting quantitative results. It also necessitates the development of methods to quantify the effects of joint counterfactual distributions for multiple risk factors. Estimating the joint effects of multiple distal and proximal risks is particularly important, because many factors act through other intermediate factors (Murray and Lopez 1999; Yerushalmy and Palmer 1959) or in combination with other factors.

purchase propranolol 20mg amex

Salmonella Infections Other Than Gastroenteritis Ubiquitous in nature cardiovascular system responsibilities proven 80 mg propranolol, found primarily in the gastrointestinal tracts of 1317 wild and domestic animals; exceptions are S inflammatory diseases of blood vessels 2nd edition propranolol 40mg amex. Incubation period 5­20 days; early in course cardiovascular questions with rationale buy propranolol 80mg overnight delivery, there may be a brief period of diarrhea (invasion of mucosa by bacteria) followed by increasing fever cardiovascular ultrasound system 40 mg propranolol overnight delivery, malaise cardiovascular books buy propranolol 40mg cheap, headache cardiovascular disease purchase propranolol 20mg amex, cough, abdominal pain, constipation and confusion; symptoms peak in 10­14 days. Anorexia, weight loss and lassitude can persist for several months and in 10% relapses occur. Findings include bradycardia (50%), abdominal tenderness and distention, cervical adenopathy, hepatosplenomegaly (50%) and in 50%,an evanescent, pink, macular rash primarily on the trunk that lasts 3­4 days (rose spots). Hospitalized patients should be placed on routine barrier precau- tions if stools positive. Life cycle: S hematobium adults live in venules around the bladder, S mansoni in venules around lower colon and rectum (inferior mesenteric plexus), and S japonicum in venules around the superior and inferior mesenteric plexus. Eggs pass out in either the urine or stool, depending on worm location, and hatch in fresh water into miracidia, which penetrate snails. These penetrate skin and go via the circulation to the lungs, then to the portal circulation. After mating, the females move to the vesical, superior or inferior mesenteric plexus (dependant on species), where they lay eggs and start a new cycle. S hematobium found in tropical Africa and Egypt, S mansoni in tropical Africa, Egypt and parts of middle East, and South America, and S japonicum in Schistosomiasis China, Philippines, Indonesia. Exposure: skin exposure to fresh water contaminated with cercariae through swimming, wading, rafting. Katayama fever: seen in heavy infections 5­7 weeks after exposure, after pulmonary phase but before eggs seen. Fever, chills, nausea, vomiting, diarrhea, abdominal pain, urticaria, cough, headache may be present in varying degrees. Signs include fever, tachycardia, urticaria, hepatosplenomegaly, lymphadenopathy, eosinophilia, elevated IgE. Chronic phase: In S hematobium there is microscopic or gross hematuria, sometimes urgency, and in later stages symptoms due to ureteral obstruction or secondary urinary tract infection, often with salmonella. In S mansoni there is chronic abdominal discomfort or pain, low-grade diarrhea, sometimes passage of blood. All forms can develop portal hypertension, resulting in hematemesis, hepatosplenomegaly, dilated abdominal veins. Other tests: S hematobium: X-rays can show urinary tract deformity or obstruction. S mansoni and japonicum: barium enema can show polypoid changes in colon, irritability, and biopsy through 1326 Schistosomiasis sigmoidoscope can show eggs. Chest X-ray in Katayama syndrome may show scattered infiltrates, and in late stage of all 3 types may show fibrosis and pulmonary hypertension. Katayama syndrome confused with invasive stage of roundworms (hookworm, ascaris, strongyloides) and serum sickness. Chronic stage: S hematobium confused with other bladder pathologies, including cancer. S mansoni and japonicum confused with other helminthic infections, amebiasis, ulcerative colitis, carcinoma of colon. Hepatosplenic stage confused with other causes of portal hypertension: chronic hepatitis B or C, cirrhosis of any type. General Measures Fluids, transfusions as needed specific therapy Indications Probably all patients should be treated. Oxamniquine once; give after a meal (less efficacious treatment, dif- ficult to obtain) Side Effects & Complications Praziquantel: nausea, vomiting, abdominal pain, diarrhea may occur, usually in heavily infected patients, seldom in lightly infected. Schistosomiasis Oxamniquine: drowsiness and dizziness (in up to 15%), and mild 1327 fever on day 3­4 after administration (probably due to worm death) Contraindications to treatment: absolute: first-trimester pregnancy, patients clinically unstable (such as hemorrhage, sepsis, etc. Genitourinary disease: Ureteral obstruction often reverses with chemotherapy, and bacteriuria responds better after worm therapy. Granulomas, fibrotic lesions common in female genitalia, less in male, generally treated with excision. Pulmonary disease: presents as cor pulmonale, and some fibrosis, mainly around arterioles. S mansoni eggs may occur in spinal cord, usually low, causing paraplegia, usually seen early in infection. Salmonella-schistosome syndrome: chronic salmonella bacteremia can occur in all 3 schistosome infections, apparently due to salmonella attached to cuticle of adult worms. Ectopic eggs and worms can be found almost anywhere, responding to local excision or chemotherapy. Localized scleroderma (morphea, linear scleroderma) ­ involves only skin, subcutaneous tissue & muscle. Associated w/ exposure to bleomycin, ergot alkaloids, beta blockers, methysergide, vinyl chloride, vibrating tools. Skin hypopigmentation over clavicular areas, hyperpigmentation over distal arms Subcutaneous hard nodules around joint capsules (calcinosis, subcutaneous calcific deposits) Reflux esophagitis (due to esophageal dilatation & hypomotility) Contracted tight thickened skin­sclerodactyly in fingers, also forearms, face, trunk. Telangiectasias on lips, face, hands Joint pain & stiffness (mild inflammatory arthropathy). Avoid vasoconstrictive agents (decongestants, caffeine, beta blockers, ergot alkaloids, amphetamines). Signs & Symptoms Flat or elevated lesions Verrucous surface Sharply marginated "Stuck-on" appearance Small, multiple facial lesions in patients of color are known as dermatosis papulosa nigra. Incubation: 2­7 days before symptoms Signs & Symptoms Two stage: prodrome ­ fever, malaise, myalgias, can have diarrhea Respiratory phase (begins in 3­7 days) ­ nonproductive cough, dyspnea and can have progressive respiratory distress. Cholecystectomy can be done laparoscopically, most safely done with preoperative simple or exchange transfusion. Relatively asymptomatic adults can be seen every 6 months complications and prognosis Sickle trait is not a disease, and has no measurable morbidity or mortality associated with it. Those with increased morbidity (higher rates of pain, acute chest syndrome, pulmonary hypertension, etc. However, individual patients may be extremely symptomatic with high rates of pain crises, etc. Fatigue, worsening of congestive heart failure, syncope or near-syncope may occur. The longest P-P interval (pause) is shorter than 2 times the shortest P-P interval. In electrophysiology study, intracardiac recording records atrial depolarization but not sinus node activity. Adjustment of existing beta and calcium blockers, clonidine, and antiarrhythmic drug regimen. Pacemaker: cardiac perforation, lead dislodgement, infected pace- maker pocket, lead fracture, failure to sense, failure to pace, pulse generator depletion. Cat, Staph) Immunocompromised patients may have other infectious agents including fungus First line: Amoxicillin, trimeth/sulfa, erythromycin, and others Second line: Amoxicillin/clavulanate, cefaroxime, clarithromycin, azithromycin, clindamycin, levofloxacin, gatifloxacin, and others 1354 Sinusitis Adjunctive treatments r r r r r Topical steroids, decongestants, mucolytics as indicated Warm compresses Humidification Nasal saline Antipyretics Surgery r Maxillary sinus puncture for culture/treatment in selected cases r Recurrent acute sinusitis may be treated successfully with endoscopic or open techniques to reduce frequency, duration, intensity of infections Side Effects Medical r Allergy/reaction to antibiotic r Psuedomembranous colitis r Usual side effects of decongestants/steroids (see Rhinitis chapter) Surgery r Rare complication from maxillary sinus puncture r Rare orbital/intracranial or other complications of sinus surgery r Recurrence or persistence of infection r Unusual surgical complications (eg, bleeding, anesthesia related) r Rarely may require hospitalization for persistent infection, complications Chronic Sinusitis Antibiotics for 3 weeks (same bacteria as acute sinusitis + anaerobes, higher incidence of Staph, Pseudomonas) Immunocompromised patients may have other infectious agents including fungus Treat with second line antibiotics as listed above Consider oral prednisone Topical nasal steroids Adjunctive Treatments Decongestants, mucolytics as indicated Humidification Nasal saline Surgery Sinusitis r Chronic sinusitis may be treated successfully with endoscopic or open techniques to reduce frequency, duration, intensity of infections Side Effects Medical r Allergy/reaction to antibiotic r Pseudomembranous colitis r Usual side effects of decongestants/steroids (see Rhinitis chapter) Surgery r Rare orbital/intracranial or other complications of sinus surgery r Usual surgical complications (eg, bleeding, anesthesia related) r Rarely require hospitalization 1355 follow-up Acute Sinusitis 1 month as needed. The diagnosis of spondyloarthropathy is almost certain if there is 1363 significant sacroiliitis. If assessment of spine is needed, a single lateral view of the lumbar & cervical spine will allow visualization of squaring of vertebrae, syndesmophytes or fusion as "bamboo spine. Risk of infection & high cost mandate reserving for refractory disease (For guideline, see "Publications" in. Total hip replacement for unrelieved hip pain or disability 1364 Spondyloarthropathies Spontaneous Bacterial Peritonitis Spine surgery for awkward flexion deformities Valve replacement for life-threatening aortic insufficiency Side Effects & Complications As in rheumatoid arthritis follow-up Assess adequacy of control of disease activity Monitor functional status every 3­6 months, more often w/very active disease (see "Assessment" in. The beta-lactam/beta-lactamase inhibitor combinations (ampicillinsulbactam, piperacillin-tazobactam, ticarcillin-clavulanate) are outstanding. Trimethoprim-sulfamethoxazole, clindamycin, or minocycline can be tried if the patient cannot tolerate Vancomycin. Quinupristin/dalfopristin (Synercid), linezolid, tigecycline, and daptomycin have activity against methicillin-resistant S. For uncomplicated right-sided endocarditis, can treat for 2 weeks if synergistic doses of gentamicin or tobramycin are concomitantly administered with nafcillin. Staphylococcal Infections Stasis Dermatitis 1375 follow-up For cases of bacteremia, may follow-up with blood cultures to ensure that bacteremia is cleared off antibiotics Recurrence of bacteremia suggests wrong diagnosis. The mortality is lower for young intravenous drug users with uncomplicated right-sided endocarditis; higher (20­45%) in the other cases (older patients, left-sided disease, prosthetic valve infections). Prevention Elimination of nasal carriage (using Mupirocin) may be helpful in preventing infection in high-risk populations (surgical or hemodialysis patients or those with recurrent disease). Using hospital infection control principles, nosocomial infection with Staphylococcus spp can be dramatically reduced. Accommodative esotropes may show variable strabismus, worse with near visual tasks. Amblyopia (loss of vision due to non-usage of eye) most likely in accommodative esotropia. Depth perception affected with misaligned eyes-may not recover with correction of strabismus. Vertical strabismus patients take an anomalous head position to keep eyes aligned and avoid double vision. Forced duction (traction on eye to palpate resistance to movement of eye) for restrictive disease diagnosis. Imaging Brain for suspected space-occupying lesion: cases late in onset (esotropia after age 5); other neuro signs, esp. Vertical strabismus (hypertropia) Myasthenia gravis may mimic any sort of strabismus. Causes of true vertical strabismus are 4th nerve palsy, Graves disease, blowout fracture, double elevator palsy (congenital fibrosis of inferior rectus muscle), orbit tumor. Differential includes strabismus, anisometropia (unequal refractive error), and occlusion. General Measures Measure severity of strabismus, measure refraction to see whether glasses are indicated. For exotropia, first try over-minus with glasses to induce accom- modative convergence. Side Effects & Contraindications Rate of reoperation at least 1/3 for congenital esotropia. Surgical complications include conjunctival cyst, change in eyelid position (especially for vertical strabismus surgery), endophthalmitis (rare). Streptococcal Infections Compliance with patching and glasses may be difficult in young follow-up After surgery, children still may develop amblyopia or need glasses. Also distinguish from diphtheria, epiglottitis, Neisseria spp and Mycoplasma Streptococcal skin infections may be difficult to those caused by S. In necrotizing fasciitis and other conditions that lead to streptococcal toxic shock syndrome, some advocate the addition of clindamycin (may suppress exotoxin production by group A streptococcus). In meningitis, Vancomycin is now indicated as empiric therapy with Ceftriaxone, given the increasing prevalence of penicillin-resistant pneumococcus. In streptococcal pharyngitis, therapy has a minimal effect on resolution of symptoms but prevent complications; consider treatment if clinical suspicion high even before definitive diagnosis by culture; benzathine penicillin G 1. Preventive Services Task Force recommends vaccines for individuals >65, or institutionalized people >50, or if over 2 years with cardiac, pulmonary disease, diabetes or asplenia Revaccination is not routinely recommended. Some filariform larvae re-invade through the small or large bowel or perianal skin. Re-invading larvae pass in 1386 Strongyloidiasis circulation to lungs, go to alveolae, migrate up bronchial tree and are swallowed, and mate in small intestine. Exposure: by contact of skin with feces, contaminated soil, or ingestion of food contaminated with larvae. Massive autoinfection (hyperinfection syndrome) occurs in immunocompromised patients (steroids, hematologic malignancies, starvation, immunosuppressive drugs, transplant patients, etc. Intestinal Phase: may have no symptoms, or may have varying degrees of epigastric pain, dyspepsia, bloating, diarrhea, sometimes with passage of blood in heavy infections. Hyperinfection syndrome: this may give exaggerated intestinal symptoms such as diarrhea, bloating, abdominal pain. If sufficient tissue invasion has occurred there may be fever, hypotension, inanition, pulmonary infiltrates, meningeal signs. Basic tests: urine: normal Specific tests: Stool O&P shows the larvae in 50­70% of cases. Organ- ism more easily seen using concentration methods: (1) the Baermann method (putting stool in gauze in funnel over warm water, larvae migrate to water), or, (2) a similar method using filter paper (Harada-Mori technique), or, (3) culture on nutrient agar (probably most sensitive but not readily available). Other tests: Larvae may be seen in duodenal juices using the Enterotest, or intubation. Intestinal symptoms are confused with ulcers, other causes of diarrhea, enteritis, colitis. In the hyperinfection state, gram negative sepsis, shock, meningitis, and pulmonary infiltrates direct attention away from a parasitic cause. Treatment Options Ivermectin for 1 or 2 days Thiabendazole for 2­3 days Albendazole for 5­7 days It is probably best to repeat the treatment in a week, if tolerated. Ivermectin and thiabendazole are approximately equivalent in effectiveness, curing about 90% with one course. Side Effects & Complications Ivermectin: well tolerated, may be itching, light-headedness Thiabendazole: side effects common, consisting of dizziness, nau- sea, vomiting, rash, occasionally Stevens-Johnson syndrome. Albendazole: well tolerated, may get mild intestinal complaints, light-headedness, rash. Contraindications to treatment: absolute: First trimester pregnancy in mild infection. Hyperinfection patients need attention to fluids, diarrhea, electrolytes, and frequently need multiple courses of treatment or even maintenance therapy.

Purchase propranolol 20mg amex. Cardiology Information : What Is Cardiovascular Disease?.

buy discount propranolol 40 mg line

The "intact" cortex typically undergoes compression and plastic deformity due to radiographically invisible microfracture capillaries bandcamp safe propranolol 80 mg. Plastic deformity may hinder the ability to adequately correct angulation and hold the reduction at the fracture site (hence cardiovascular fitness activities propranolol 20 mg on-line, the practice of "completing" the fracture prior to reduction and immobilization) cardiovascular las vegas generic propranolol 80 mg overnight delivery. These bumps result when an axial compressive load causes microfracture and localized plastic deformity rather than a radiographically apparent cortical break coronary heart kc buy 20 mg propranolol visa. Fractures of the hand are relatively uncommon (5-7% of fractures) and only 1/3 involve a physeal injury capillaries connect arterioles to venules buy cheap propranolol 40 mg line. Rapid healing is the rule cardiovascular system notes purchase 80mg propranolol with amex, so prompt orthopedic referral is necessary (healing in malposition may make a minor injury more problematic). Pediatric Mallet Equivalent Top is a displaced Salter 1 injury of the distal phalanx, typical of the preadolescent. In the adolescent (with partial fusing of the epiphysis), a Salter 3 injury of the distal phalanx may occur with the same mechanism. Open fractures are cleaned and irrigated with minimal Pediatric Orthopedics Page 323 Notes debridement. Partial tip amputations are reapproximated and do remarkably well with even minimal remaining pedicle. Middle and proximal phalangeal fractures are most commonly Salter 1 or Salter 2 with the ring and small digit most commonly involved. Rotational deformities are best appreciated by examining the attitude of the nail beds with the phalangeal joints in flexion. Scaphoid fractures are not seen until 10 to 12 years of age, and as with adults, a high level of suspicion is required. Emergency management includes immobilization in a thumb spica splint with prompt follow-up. The mechanism is typically a fall on an outstretched hand with a hyperextended wrist. The most common pediatric orthopedic injury is the Salter 2 fracture of the distal radius. Distal radius fractures are typically Salter 1 or 2 physeal injuries, torus or Greenstick fractures of the distal metaphysis, or complete fracture (both radius and ulna). Complete fractures typically have the "dinner fork" deformity similar to adult Colles fractures. Occult wrist fractures may cause anterior displacement of the normal pronator quadratus fat pad seen on the lateral view along the volar aspect of the radial metaphysis. Always X-ray the entire forearm when a distal fracture is found, to rule out proximal injury. Emergency department reduction is indicated for severe deformity with tenting or compromise of overlying skin, or neurovascular compromise. Lesser degrees of deformity can be treated with immobilization and prompt referral. Pediatric Orthopedics Page 324 Notes Remember, in any physeal injury, multiple reduction attempts are not advised - each manipulation can further injure the physis. As in distal fractures, they are described as Greenstick, torus, or complete fractures, and further defined by the level (proximal third or middle third). As in adults, an obvious fracture of the ulna should prompt evaluation for radial head displacement (Monteggia fracture). Complete fracture in this area is particularly prone to refracture in the first six months. The Galeazzi fracture is a radial shaft fracture with a dislocation of the distal radioulnar joint. The elbow: the child with a swollen and/or painful elbow provides quite a diagnostic challenge. While the peak incidence for physeal injuries in general is between 10 and 13 years of age, most physeal fractures about the elbow occur in the more immature skeleton of the 5- to 8-year-old. Radiographic interpretation in this area is difficult due to the chronobiologic variation of secondary and epiphyseal ossification centers. However, the liberal use of comparison films is of great help in assessing these injuries. Capitellum 2 yr Radial Head 4 yr Internal (Medial) Epicondyle 6 yr Trochlea 8 yr Olecranon 10 yr External (Lateral) Epicondyle 12 yr Pediatric Orthopedics 1. A distraction force pulls the radial head from the annular ligament when the arm is pulled. The child refuses to use the affected extremity (most commonly the left), and often guards it from any motion. A strong history and otherwise unremarkable exam preclude the need for X-ray evaluation (which will appear normal). When history is lacking, X-rays are obtained to rule out a fracture prior to manipulation. The child quickly resumes normal use of the extremity and no immobilization is necessary. Age assists diagnosis - it is almost exclusive to those less Page 326 Notes than 10 years, peaking at 5 to 8 years, with males predominating over females 2 to 1. Extension-type supracondylar fractures make up 98% of these injuries and occur with the elbow hyperextended. Radiographic appearance may range from an obvious transverse fracture to only the presence of an exaggerated anterior fat pad, a posterior fat pad, or subtle posterior displacement of the distal humerus. To assess posterior displacement, the anterior humeral line is evaluated on the lateral elbow X-ray. It should intersect the ossification center of the capitellum in its middle third. Thorough and ongoing distal neurovascular exams are paramount with these injuries. Any forearm pain with passive movement of the wrist and fingers is indicative of compartment syndrome. Fractures with obvious neurovascular compromise require immediate reduction by applying forearm traction with the elbow in slight flexion. In all but minimally displaced supracondylar Page 327 Notes fractures without significant soft tissue swelling, hospitalization for neurovascular checks is appropriate. The injury is immobilized with a long arm posterior mold, the elbow at 70-90° of flexion to allow for swelling in the antecubital fossa without compromising arterial or venous flow. Any circumferential splint padding must be placed judiciously to avoid contributing to a compartment syndrome with iatrogenic compression of the dressing/splint. Closed reduction with percutaneous pinning may be used when the articular surface is not involved and displacement is <2 mm. The mechanism of injury is a varus stress to the elbow with traction on the lateral condyle by the extensors of the forearm. These can be nondisplaced, and present only with mild swelling and/or point tenderness. The medial epicondyle is a traction apophysis to which the flexors of the forearm are attached. These may occur as a pure avulsion injury when falling on the arm with hyperextended wrist and fingers, in association with posterior elbow dislocation (about 50% of the time), and, rarely, from a direct blow. The epicondyle becomes entrapped in the joint after reduction of a posterior elbow dislocation 15 to 20% of the time. The medial epicondyle must always be identified when a spontaneously reduced elbow dislocation is suspected, or in post-reduction views to prevent this entrapment from going unnoticed. Inability to reduce an elbow dislocation may be due to an entrapped medial epicondyle, mandating open reduction. Acute and delayed ulnar nerve dysfunction may occur, especially in cases of ulnar nerve entrapment (50%). No growth aberrancies are associated with injuries to this (or any other) traction apophysis. Immobilization in a posterior long arm mold and prompt orthopedic referral is indicated. Young pitchers present with tenderness and swelling at the medial epicondyle with a mild loss of elbow extension. Patients are hospitalized and kept non-weight bearing until operative intervention occurs. There is an association with endocrine disturbances Pediatric Orthopedics Page 329 Notes (hypothyroidism) but the vast majority occurs in the absence of such. At birth, the superior acetabulum is poorly developed, and dislocation of the femoral head can occur. These do not typically "present"; they are found on neonatal and well-baby exams, most commonly via the Ortolani maneuver (abduction of the flexed hip results in a click). Parents may note difficulty in abducting the hip for diapering, or asymmetric thigh skin folds indicative of limb length discrepancy. Presentation varies from pain to frank limp, usually of Page 330 Notes less than 2 weeks duration. The child appears well and allows passive range of motion of the hip, with pain only at end range. The vast majority of septic arthritis cases are caused by strains of Staph, Strep and sometimes gram negatives. Avascular necrosis of the femoral head occurs due to repeated episodes of transient ischemia (of unknown etiology). Peak incidence is 6 years of age (3 to 10 years) with boys affected 4 times more than girls. Other contributing factors: trauma, alteration in coagulabilty of blood, endocrine and metabolic disorders. Patients present with hip pain or antalgic gait of insidious progression over weeks to months. X-ray may show flattening of the femoral head, subchondral lucency at the proximal epiphysis, and irregular calcification and fragmentation of the epiphysis. Multiple treatment approaches exist, all of which incorporate bracing to maintain abduction and flexion of the hip to contain the femoral head within the acetabulum. These are more common than other physeal injuries of the hip or about the knee, but less common than fractures of the ankles or upper extremities. Most commonly, these are Salter 2 injuries in the adolescent Pediatric Orthopedics Page 331 Notes 2. Repetitive microavulsion injuries occur with repeated traction of the patellar ligament during ossification of the tubercle. Most frequently affects males 11 to 15, who present with a history of intermittent pain and swelling at the tubercle, aggravated by running, jumping, etc. The lateral knee view shows enlargement of the tibial tubercle with small fragments seen anterior and superior in the patellar ligament. Treatment is symptomatic with cessation of the aggravating activity until bone maturity occurs. When present, a small radiographically innocuous appearing avulsion of the calcified distal pole may be associated with a large portion of the radiolucent articular cartilage (the "sleeve fracture"). Slightly aberrant biomechanics at the knee allow the patella to sublux laterally with tension of the quadriceps mechanism. Placing the hip in full flexion and the knee in full extension, the patella is pushed easily into normal position. X-rays after reduction is indicated to evaluate for an osteochondral fracture (5% incidence) especially from the medial margin of the patella. Fracture of the fibular and tibial shafts: Page 332 Pediatric Orthopedics Notes a. Vascular involvement is rare, but proximal metaphyseal fractures are at greater risk. Patients are immobilized in a long leg posterior splint and monitored for signs of compartment syndrome. Xray may reveal a subtle fracture line, and may require additional oblique views to visualize. Follow up for repeat xrays or bone scanning appropriate when initial x-rays are unremarkable. The common lateral sprain of the adult manifests itself as a Salter 1 injury of the distal fibula. The presence of tenderness over an open distal fibular physis gives a clinical diagnosis of a Salter 1injury. Fracture of the distal tibial physis occurs most frequently in boys age 11 to 15 and is typically Salter 2. The Tillaux fracture can occur in the presence of a partially fused distal tibial epiphysis. As skeletal maturity is approached, the central and medial portions of the distal tibial epiphysis fuse first. During this dynamic period of evolving bony architecture, a rotational stress can lead to avulsion of the lateral portion of the tibial epiphysis due to traction by the anterior tibiofibular ligament (a Salter 3 injury). The diagnosis is apparent on X-ray but the lateral ankle view must be closely inspected to rule out a triplane fracture (below), with its posterolateral tibial metaphyseal spike. The anterior tibiofibular ligament pulls the unused lateral epiphysis, resulting in a Salter 3 injury. These are more complex (and severe) than the Tillaux fracture, occurring in the sagittal, coronal, and transverse planes (hence, triplane). Plain films are often difficult to interpret, but the posterolateral spike of the distal tibial epiphysis is seen. In general, most Salter 1 and 2 injuries of the distal tibia and fibula are treated with closed reduction. Due to better imaging techniques, these are found more frequently than in the past, but overall are uncommon.

order 20 mg propranolol mastercard

Synonyms include neoplasm of brain cardiovascular grants cheap propranolol 40mg free shipping, glioma cardiovascular disease fibrosis buy propranolol 40mg low price, meningioma arteries below the knee discount propranolol 20 mg amex, astrocytoma capillaries that have a complete lining purchase propranolol 20mg online, oligodendroglioma heart disease signs and symptoms cheap 80 mg propranolol with visa, pituitary adenoma blood vessels arteries and veins purchase 40 mg propranolol free shipping, metastases to the brain, neuroma or subarachnoid cyst. Procedures: the indicated procedures or treatments may lead to stroke in or out of the hospital. If the neurologic symptoms had multiple onsets, answer in relation to the most important. The same logic applies to treatment with anticoagulants such as Heparin and Warfarin (Coumadin). These are anticoagulant medications which may lead to a hemorrhagic complication, such as cerebral (brain) hemorrhage. If anticoagulants are being used to treat something other than the acute neurologic syndrome that this form is evaluating, answer "Yes". If the patient presents with acute neurologic syndrome, and is placed on Heparin or Coumadin as treatment for this condition, answer "No". However, Therapeutic dosing of Lovenox is considered "Yes" whereas prophylactic use is "No". Other similar products which enter the market after the date of writing should be included. The next series of questions is to determine the specific neurologic signs or symptoms of stroke. These symptoms may have occurred prior to hospitalization, and prompted the patient to seek medical care, or may have occurred while the patient was in the hospital for a different illness. If a symptom is present, additional questions may be asked regarding duration or affected body part. We are interested in headache that is acute in onset or different in character, as opposed to a long standing history of headache with no change in pattern. If the patient had a new or an acute headache mark "Yes" and indicate whether "Severe" or "Mild/Moderate". Headache of interest here is a significant headache (which might indicate an intracranial process) rather than an inconsequential, mild headache. Vertigo is a sense of dizziness where the patient feels a spinning sensation like they are on a merry-go-round. A duration > 24 hours may be assumed if vertigo is experienced on consecutive days. A complaint of "stiff neck" is insufficient to count as "Yes" unless there is also stiffness to flexion. This would be mentioned in the physical exam and refers to as a test for meningeal irritation. A positive Brudzinski or Kernig sign occurs if a patient has pain along his spinal column that results from either neck flexion or leg extension. The question does not refer to the quality of conscious behavior but to the quantity of consciousness. These are different from dysarthria (see Question 40 below) which is slurred speech. This is tested by tasks of repetition, comprehension, reading, writing, and naming. Absent corneal reflex, nystagmus, decreased extraocular muscle strength, or abnormal pupils are "No". If the patient is alert, and double vision or diplopia are not specifically mentioned, record "No". Dysphasia = "no" here, "yes" in Q36 "Speech difficulty" alone is insufficient (= no). Tongue deviation = deviation to one side when patient is asked to protrude tongue. Frequently, facial weakness is described as a decrease or flattening of the nasolabial fold on the side of the weakness. Generally, the entire limb is involved, worse distally (fingers and toes) than proximally (shoulder and hips). If there is weakness, paresis, or paralysis, record the affected limb and duration. Similarly "leg" includes any part of the lower extremity such as toes and/or foot. Perioral numbness means numbness around the mouth and would be considered a positive response, unless resulted from hyperventilating. For perioral numbness, unless it is reported that one side is affected, choose answer B (both sides). Generally, the entire limb is involved, worse distally (fingers and toes) than proximally (hips and shoulder). This would be described under cerebellar or coordination portion of neurologic exam. We are not interested in abnormalities in gait that are simply the result of leg(s) weakness (=No). Answer no here for "gait difficulty," "imbalance," "difficulty with ambulation," and "gait problem", but include in Q46b, if acute. Paralysis of the 3rd Cranial Nerve affects muscles of the face used in raising eyebrows, eyelids. Other neurologic signs/symptoms: apraxia, acalculia, dyscalculia; agnosias - prosopagnosia, topographnosia, finger agnosia; agraphia; neglect syndrome or unilateral neglect. The following would not be included here (or elsewhere): dizziness; blurred vision; pain syndromes; delirium; frontal release signs, confusion, dementia, carotid bruits, nausea, vomiting. Acute changes in memory, cognitive status or behavior may be recorded here in some circumstances. This is a global question which can be answered by reviewing responses to question 16 or questions 3146b. If any sign or symptom lasts > 24 hours, or if the patient died within 24 hours of the onset of new symptoms, answer "Yes". Record the results of the first tube sent under Tube 1 (even if Tube #2 was actually sent first), and the results from the last tube sent under Tube 2. If only one tube was counted, record the results under Tube 1 regardless of what number the tube was. If this procedure was performed more than once, use the report you judge to be most pertinent for this case. Stenosis: Fill in appropriate code for both right and left internal carotid artery of the neck. The following qualitative terms should be answered as follows: Term Slight/Mild/Minimal Moderate Subtotal/high grade/tight/significant Severe (occluded = 100%) Answer 0 - 29% 30 - 69% 70 - 89% > or equal to 90% Record the exact stenosis for right and left internal carotid artery of the neck. If the exact stenosis is not clear, the existing categorical question should be specified in 48. If a description of brain tissue is included, record findings in Question 49 and Question 50 if applicable. However, if a description of brain tissue is included record findings in Question 52. Pick only one diagnosis: focus on the acute event and look for the strongest evidence if there is more than one finding indicated in the report. Exclusionary pathology includes: tumor; evidence of trauma such as fractured bones, coup and contrecoup injuries, soft tissue swelling over area of hematoma; subdural hematoma, epidural hematoma, and abscess or granuloma. Unrelated pathology or findings include: old stroke old surgery unruptured aneurysm generalized atrophy, encephalomalacia description of old surgery hydrocephalus normal variants - cavum septum pellucidum, calcification of falx/tentorium age appropriate atrophy atrophy normal for age B. Ischemic infarction - these are described as areas of low density (attenuation) in a typical vascular distribution. If this procedure was performed more than once use the report you judge to be most helpful to arrive at a diagnosis. Exclusionary pathology includes: tumor; evidence of trauma such as fractured bones, coup and contrecoup injuries, soft tissue swelling over area of hematoma; subdural hematoma, epidural hematoma, abscess or granuloma, and M. Subarachnoid hemorrhage - blood seen in Fissure of Sylvius, between the frontal lobes, in basal cisterns or within a ventricle with no associated intraparenchymal hematoma Intracerebral hematoma - blood clot within the brain parenchyma. Sometimes, subarachnoid hemorrhage and intracerebral hematoma (hemorrhage) are both present. Make use of ultrasound done at anytime during this admission and reported in the chart. If the exact stenosis is not clear, the existing categorical question should be specified in Questions 53. If the exact stenosis is not clear, the existing categorical question should be specified in 53. If report states "No plaque", "no stenosis", do not record zero in the "specify percentages" boxes. This is any operation performed post event by a neurosurgeon that involves opening the skull. This might be done to evacuate/remove a hematoma, clip an aneurysm, or relieve intracranial pressure, etc. If this procedure was performed more than once, post event, use the report you judge to be most pertinent for this case. If so, in Death Note (last progress note in chart), it should state if permission for autopsy was granted. If "Yes", record the value of the first, last and highest measurements of serum creatinine. If there is only one serum creatinine value, then "last" and "highest" values and dates are left blank. First serum creatinine: Record the initial serum creatinine measurement if one is present in the chart in 63a1. Last serum creatinine (if more than one): Record the last recorded measurement available in the medical record in 63a3. Highest of remaining values (if more than two) serum creatinine: In addition to recording the first and the last measured serum creatinine in the two preceding questions, the first highest of any remaining measurements is to be recorded in 63a5. If there are no serum creatinine measurements other than those recorded in Questions 63a1 (first) and 63a3 (last) then leave blank in 63a5 and 63a6. In addition, there are specific examples and instructions for each code on the following pages. In addition, there will be two possible responses for "nonstroke" pathology for each procedure. These refer to specific diagnoses, whose presence would eliminate a possible stroke case from analysis. These exclusions are described on the last page of the stroke criteria and mentioned specifically under each procedure below. The second type of nonstroke pathology includes all other types of unrelated findings and should only be coded if none of the other categories apply. This category is called "unrelated pathology" and coded C for all procedures with the exception of autopsy. Unrelated pathology includes: traumatic tap - grossly bloody or pinked tinged fluid that clears by final tube. Aneurysm - this should be described in vicinity of recent hemorrhage or associated with clot. The following qualitative terms should be answered as follows: Term Slight/Mild/Minimal Moderate Subtotal/high grade/tight/significant Severe (occluded = 100%) Answer 0 - 29% 30 - 69% 70 - 89% > or equal to 90% Record the exact stenosis for right and left internal carotid. Normal study - must check timing to determine when study was done in relation to symptom onset. Unrelated pathology or findings include: old stroke old surgery unruptured aneurysm generalized atrophy, encephalomalacia description of old surgery hydrocephalus normal variants - cavum septum pellucidum, calcification of falx/tentorium age appropriate atrophy atrophy normal for age Do not include these findings: Intracranial Atherosclerosis Dural Calcifications D. Hemorrhagic infarction should be recorded as "Infarction" if it is clear that infarction preceded the hemorrhage. Occasionally these occur within secondary rupture into the ventricle or subarachnoid space. You will have to determine and record only the primary condition that led to the secondary condition. If a range of stenosis overlaps two categories choose the one where most of the range falls. Moderately severe = E Moderate-severe = F Moderate-moderately severe = F Craniotomy A. Ruptured aneurysm - should describe evidence for recent bleed, or clot Intracerebral hematoma - if source is related to ruptured aneurysm, code D. Most neurologists will comment on five things: 1) Level of consciousness - (stupor, lethargy, coma: i. What is more important when coma is present is how to interpret the other symptoms requested by the stroke form. Therefore, the correct response for aphasia during coma is unknown, which is recorded as "No". If a patient is spontaneously moving one side of his body, or withdraws to stimuli on one side but not the other; this asymmetry would constitute hemiparesis, or weakness on one side. If the "coma" under consideration refers only to the postictal state mark "No" under coma. In stupor or lethargy, if there is asymmetry in response to visual threat, mark "Yes". Do not consider this "Yes" unless the patient, prior to or following coma, was able to complain of double vision. If the patient grimaces to pain on one side and withdraws on that side, but has no response to pain on the other side (no withdrawal and no grimaces) mark "Yes. Aphasia: inability to express thoughts properly through speech (expressive aphasia) or loss of verbal comprehension (receptive aphasia). Apraxia: inability to perform certain movements (without loss of motor power, sensation or coordination); loss of learned behavior. Astereognosis: loss of ability to recognize common objects by touching and handling them with eyes closed. Coma: decreased level of consciousness to the point of unresponsiveness to external stimuli, unable to be aroused.

References