William C. Mabie, MD

• GHS Professor of Clinical Obstetrics and Gynecology
• University of South Carolina School of Medicine-Greenville
• Greenville Hospital System University Medical Center
• Greenville, South Carolina

Inhalation anthrax is the form most likely to result in serious illness and death in a bioterrorism attack medicine quiz generic betoptic 5 ml without a prescription. It occurs following inhalation of spores that become deposited in the alveolar spaces treatment 5 alpha reductase deficiency discount betoptic 5ml with mastercard. The spores are phagocytosed by alveolar macrophages and are transported to regional lymph nodes where they germinate medications safe for dogs cheap betoptic 5 ml amex. Postal outbreaks indicate that with prompt initiation of appropriate antibiotic therapy symptoms 5 weeks 3 days buy discount betoptic 5 ml on-line, survival may be 50% hb treatment buy discount betoptic 5ml online. Vaccination and Prevention · Currently there is a single vaccine licensed for use; produced from a cellfree culture supernatant of an attenuated strain of B symptoms diagnosis buy 5ml betoptic amex. As a bioweapon, plague would likely be delivered via an aerosol leading to primary pneumonic plague. In such an attack, person-to-person transmission of plague via respiratory aerosol could lead to large numbers of secondary cases. Given the infectious nature and the 10­ 30% mortality of smallpox in unimmunized individuals, the deliberate release of virus could have devastating effects on the population. In the absence of effective containment measures, an initial infection of 50­ 100 persons in a first generation of cases could expand by a factor of 10 to 20 with each succeeding generation. About 12­ 14 days following initial exposure the patient develops high fever, malaise, vomiting, headache, back pain, and a maculopapular rash that begins on the face and extremities and spreads to the trunk. Historically, about 5­ 10% of naturally occurring cases manifest as highly virulent atypical forms, classified as hemorrhagic and malignant. Both forms have similar onset of a severe prostrating illness characterized by high fever, severe headache, and abdominal and back pain. In the hemorrhagic form, cutaneous erythema develops followed by petechiae and hemorrhage into the skin and mucous membranes. While certain antiviral agents, such as cidofovir, have in vitro activity against V. Smallpox is highly infectious to close contacts; patients who are suspected cases should be handled with strict isolation procedures. Past and current experience indicates that the smallpox vaccine is associated with a very low incidence of severe complications (see Table 205-5, p. Nonhuman primate studies indicate that infection can be established with very few virions and that infectious aerosol preparations can be produced. Contamination of the water supply is possible, but the toxin would likely be degraded by chlorine used to purify drinking water. Category B and C Agents (See Table 31-2) Category B agents are the next highest priority and include agents that are moderately easy to disseminate, produce moderate morbidity and low mortality, and require enhanced diagnostic capacity. It is important to note that these categories are empirical, and, depending on future circumstances, the priority ratings for a given microbial agent may change. Prevention and Preparedness As indicated above, a diverse array of agents have the potential to be used against a civilian population in a bioterrorism attack. The use of both nerve agents and sulfur mustard by Iraq against Iranian military and Kurdish civilians and the sarin attacks in 1994­ 1995 in Japan underscore this threat. In this section only vesicants and nerve agents will be discussed as these are considered the most likely agents to be used in a terrorist attack. Secondary infection may occur due to bacterial invasion of denuded respiratory mucosa. Exposure to higher concentrations produces progressively more severe conjunctivitis, photophobia, blepharospasm pain, and corneal damage. Larger bullae should be debrided and treated with topical antibiotic preparations. Intensive care similar to that given to severe burn patients is required for pts with severe exposure. Inhibition of this enzyme allows released acetylcholine to accumulate, resulting in end-organ overstimulation and leading to what is clinically referred to as cholinergic crisis. Initial manifestations include miosis, blurred vision, headache, and copious oropharyngeal secretions. Once in the muscle, the agent enters the circulation and causes the symptoms described above. Respiratory support: Death from nerve agent exposure is usually due to respiratory failure. Atropine rapidly reverses cholinergic overload at muscarinic synapses but has little effect at nicotinic synapses. The only class of drugs known to have efficacy in treating nerve agent­ induced seizures are the benzodiazepines. Food and Drug Administration for the treatment of seizures (although other benzodiazepines have been shown to work well in animal models of nerve agent­ induced seizures). The first is the use of radiologic dispersal devices that cause the dispersal of radioactive material without detonation of a nuclear explosion. Types of Radiation Alpha radiation consists of heavy, positively charged particles containing two protons and two neutrons. Table 31-4 Antidote Recommendations Following Exposure to Nerve Agents Antidotes Other Treatment Patient Age Mild/Moderate Effectsa Severe Effectsb Infants (0­ 2 yrs) Atropine: 0. The rad is the energy deposited within living matter and is equal to 100 ergs/g of tissue. Types of Exposure Whole-body exposure represents deposition of radiation energy over the entire body. Whole-body exposure from gamma rays, x-rays, or high-energy neutron particles can penetrate the body, causing damage to multiple tissues and organs. External contamination results from fallout of radioactive particles landing on the body surface, clothing, and hair. Alpha particles do not penetrate the skin and thus would produce minimal systemic damage. Gamma emitters cannot only cause cutaneous burns but can also cause significant internal damage. Internal contamination will occur when radioactive material is inhaled, ingested, or is able to enter the body via a disruption in the skin. The respiratory tract is the main portal of entrance for internal contamination, and the lung is the organ at greatest risk. Prodrome occurs between hours to 4 days after exposure and lasts from hours to days. The latent stage follows the prodrome and is associated with minimal or no symptoms. Mobilizing agents are most effective when given immediately; however, they may still be effective for up to 2 weeks following exposure. It is useful to characterize the chest pain as (1) new, acute, and ongoing; (2) recurrent, episodic; and (3) persistent, sometimes for days (Table 32-1). Oppressive, constrictive, or squeezing; may radiate to arm(s), neck, back Crushing, sharp, pleuritic; relieved by sitting forward Very sharp, pleuritic Pleuritic, sharp; possibly accompanied by cough/hemoptysis Intense substernal and epigastric; accompanied by vomiting ± hematemesis "Tearing" or "ripping"; may travel from anterior chest to mid-back Less severe, similar pain on exertion; + coronary risk factors (Chap. Approach to the Patient A meticulous history of the behavior of pain, what precipitates it and what relieves it, aids diagnosis of recurrent chest pain. Figure 32-2 presents clues to diagnosis and workup of acute, life-threatening chest pain. Evaluation of acute pain requires rapid assessment of likely causes and early initiation of appropriate therapy (see Chap. Characteristic Features of Abdominal Pain Duration and Pattern these provide clues to nature and severity, although acute abdominal crisis may occasionally present insidiously or on a background of chronic pain. Intestinal pain tends to be crampy; when originating proximal to the ileocecal valve, it usually localizes above and around the umbilicus. Pattern of radiation may be helpful: right shoulder (hepatobiliary origin), left shoulder (splenic), midback (pancreatic), flank (proximal urinary tract), groin (genital or distal urinary tract). Associated Symptoms Look for fevers/chills (infection, inflammatory disease, infarction), weight loss (tumor, inflammatory diseases, malabsorption, ischemia), nausea/vomiting (obstruction, infection, inflammatory disease, metabolic disease), dysphagia/odynophagia (esophageal), early satiety (gastric), hematemesis (esophageal, gastric, duodenal), constipation (colorectal, perianal, genitourinary), jaundice (hepatobiliary, hemolytic), diarrhea (inflammatory disease, infection, malabsorption, secretory tumors, ischemia, genitourinary), dysuria/hematuria/vaginal or penile discharge (genitourinary), hematochezia (colorectal or, rarely, urinary), skin/joint/eye disorders (inflammatory disease, bacterial or viral infection). Predisposing Factors Inquire about family history (inflammatory disease, tumors, pancreatitis), hypertension and atherosclerotic disease (ischemia), diabetes mellitus (motility disorders, ketoacidosis), connective tissue disease (motility disorders, serositis), depression (motility disorders, tumors), smoking (ischemia), recent smoking cessation (inflammatory disease), ethanol use (motility disorders, hepatobiliary, pancreatic, gastritis, peptic ulcer disease). Physical Examination Evaluate abdomen for prior trauma or surgery, current trauma; abdominal distention, fluid, or air; direct, rebound, and referred tenderness; liver and spleen size; masses, bruits, altered bowel sounds, hernias, arterial masses. Rectal examination for presence and location of tenderness, masses, blood (gross or occult). Routine Laboratory and Radiologic Studies Choices depend on clinical setting (esp. Symptoms that raise the suspicion for a serious cause are listed in Table 34-2; serious causes are summarized in Table 34-3. Ruptured aneurysm (instant onset), cluster headache (peak over 3­ 5 min), and migraine (onset over minutes to hours) differ in time to peak intensity. Migraine Classic Migraine Onset usually in childhood, adolescence, or early adulthood; however, initial attack may occur at any age. Migraine Migraine without aura Migraine with aura Ophthalmoplegic migraine Retinal migraine Childhood periodic syndromes that may be precursors to or associated with migraine Migrainous disorder not fulfilling above criteria 2. Tension-type headache Episodic tension-type headache Chronic tension-type headache 3. Cluster headache and chronic paroxysmal hemicrania Cluster headache Chronic paroxysmal hemicrania 4. Miscellaneous headaches not associated with structural lesion Idiopathic stabbing headache External compression headache Cold stimulus headache Benign cough headache Benign exertional headache Headache associated with sexual activity 5. Headache associated with head trauma Acute posttraumatic headache Chronic posttraumatic headache 6. Headache associated with vascular disorders Acute ischemic cerebrovascular disorder Intracranial hematoma Subarachnoid hemorrhage Unruptured vascular malformation Arteritis Carotid or vertebral artery pain Venous thrombosis Arterial hypertension Other vascular disorder 7. Focal neurologic disturbances without headache or vomiting (migraine equivalents) may also occur. Common Migraine Unilateral or bilateral headache with nausea, but no focal neurologic symptoms. Headache associated with substances or their withdrawal Headache induced by acute substance use or exposure Headache induced by chronic substance use or exposure Headache from substance withdrawal (acute use) Headache from substance withdrawal (chronic use) 9. Headache associated with noncephalic infection Viral infection Bacterial infection Other infection 10. Headache associated with metabolic disorder Hypoxia Hypercapnia Mixed hypoxia and hypercapnia Hypoglycemia Dialysis Other metabolic abnormality 11. Headache or facial pain associated with disorder of facial or cranial structures Cranial bone Eyes Ears Nose and sinuses Teeth, jaws, and related structures Temporomandibular joint disease 12. Cranial neuralgias, nerve trunk pain, and deafferentation pain Persistent (in contrast to ticlike) pain of cranial nerve origin Trigeminal neuralgia Glossopharyngeal neuralgia Nervus intermedius neuralgia Superior laryngeal neuralgia Occipital neuralgia Central causes of head and facial pain other than tic douloureux 13. Headache not classifiable unilateral, worse with activity; associated with photophobia, phonophobia, multiple attacks. General principles of pharmacologic treatment: (1) response rates vary from 60­ 90%; (2) initial drug choice is empirical- influenced by patient age, coexisting illnesses, and side effect profile; (3) efficacy of prophylactic treatment may take several months to assess with each drug; (4) when an acute attack requires additional medication 60 min after the first dose, then the initial drug dose should be increased for subsequent attacks. Triptans are widely used also, but recurrence of head pain after the first dose (40­ 78%) is a major limitation. For prophylaxis, amitriptyline is a good first choice for young people with difficulty falling asleep; verapamil is often a first choice for prophylaxis in the elderly. Table 34-3 Symptoms of Serious Underlying Causes of Headache Cause Symptoms Meningitis Intracranial hemorrhage Brain tumor Temporal arteritis Glaucoma Nuchal rigidity, headache, photophobia, and prostration; may not be febrile. May present with prostrating pounding headaches that are associated with nausea and vomiting. Should be suspected in progressively severe new "migraine" that is invariably unilateral. Onset generally in older patients (50 years) and frequently associated with visual changes. The erythrocyte sedimentation rate is the best screening test and is usually markedly elevated. Cluster Headache Characterized by episodes of recurrent, nocturnal, unilateral, retroorbital searing pain. Typically, a young male (90%) awakens 2­ 4 h after sleep onset with severe pain, unilateral lacrimation, and nasal and conjunctival congestion. Diurnal periodicity (recurrent pain during the same hour each day of the cluster) occurs in 85%. Prophylaxis with lithium (600­ 900 mg qd) or prednisone (60 mg for 7 days followed by a rapid taper). Other Headaches Post-Concussion Headache Common following motor vehicle collisions, other head trauma; severe injury or loss of consciousness often not present. Cough Headache Transient severe head pain with coughing, bending, lifting, sneezing, or stooping; lasts from seconds to several minutes; men women. Facial Pain Most common cause of facial pain is dental; triggered by hot, cold, or sweet foods. Trigeminal neuralgia consists of paroxysmal, electric shock­ like episodes of pain in the distribution of trigeminal nerve; occipital neuralgia presents as lancinating occipital pain. Diseases of upper lumbar spine refer pain to upper lumbar region, groin, or anterior thighs. Neurologic exam- search for focal atrophy, weakness, reflex loss, diminished sensation in a dermatomal distribution. Usually unilateral; bilateral with large central disk herniations compressing multiple nerve roots- may cause cauda equina syndrome. Stenosis results from acquired (75%), congenital, or mixed acquired/congenital factors. Symptomatic treatment adequate for mild disease; surgery indicated when pain interferes with activities of daily living or focal neurologic signs present. Vertebral fractures from trauma result in wedging or compression of vertebral bodies; burst fractures involving anterior and posterior spine elements can occur.

The cardiac function curves are shifted up and to the left by an increase in contractility and a decrease in afterload; they are shifted down and to the right by a decrease in contractility and an increase in afterload symptoms 10 weeks pregnant discount 5ml betoptic overnight delivery. The vascular function curves graph central venous pressure as a function of cardiac output medications with dextromethorphan order betoptic 5ml with amex. A decrease in blood volume or venous tone shifts the vascular function curves to the left; an increase in blood volume or venous tone shifts the vascular function curves to the right treatment 1st 2nd degree burns purchase betoptic 5 ml on line. The point at which the two curves intersect represents the central venous pressure and cardiac output of the cardiovascular system medicine 911 buy betoptic 5 ml visa. The increase in systolic Ca2+ concentration overcomes the decreased affinity of troponin for Ca2+ medicine gabapentin 300mg capsules generic 5ml betoptic with amex, resulting in an increased contractility medicine you can take while pregnant discount betoptic 5ml amex. A decrease in venous compliance, caused by sympathetic stimulation, increases venous return to the heart, which also increases stroke volume by a Frank-Starling mechanism. The increased stroke volume, coupled with an increase in heart rate, cause an increase in cardiac output. Systemic arterial pressure also increases in response to the increase in cardiac output. However, the fall in total peripheral resistance, which is caused by dilation of the blood vessels within the exercising muscles, results in a decrease in diastolic pressure. The pulmonary vessels undergo passive dilation as more blood flows into the pulmonary circulation. Because vessel Y has half the resistance of vessel Z, it has twice the blood flow. The blood flowing through vessel X is the sum of the blood flowing through vessels Y and Z (2 + 1 = 3). The increase in intracranial pressure stimulates the vasomotor center and produces an increase of systemic blood pressure that may lead to a restoration of cerebral blood flow. The increased blood pressure induces bradycardia mediated by the baroreceptor reflex. Increasing the systolic pressure developed by the heart (ventricular transmural pressure) or increasing the end-diastolic volume will increase wall stress. Wall stress will also be increased if total peripheral resistance is increased or mean arterial blood pressure is increased because, under both conditions, the heart will have to develop more pressure. Manifestations of this negativity include the appearance of Q waves and failure of progression of the R wave in the precordial leads. During aerobic exercise, vasodilation of blood vessels in the working muscles increases skeletal muscle blood flow. Blood flow to the gut, the kidneys, and the nonexercising muscles is reduced by sympathetic constriction of the arterioles leading to these organs. Pulse pressure increases with hypertension because hypertension causes aortic compliance to decrease. Whether the hypertension is a result of an increased cardiac output or an increased peripheral resistance, the higher arterial pressure is caused by an increase in arterial blood volume. The increased blood volume stretches the arterial wall, making it stiffer and decreasing its compliance. Stroke volume is decreased with tachycardia, hemorrhage, and heart failure, reducing pulse pressure in all three cases. In aortic stenosis, the ejection of blood from the ventricle is slowed and the increase in arterial blood volume during systole is less than normal. The reflex response includes an increase in sympathetic nervous system activity, which would cause an increase in heart rate and myocardial contractility, both of which would tend to increase cardiac output. Sympathetic stimulation would also cause constriction of both the arterioles and venous vessels. Sympathetic stimulation of the venous vessels would cause a decrease in venous compliance. Because of the high rate of metabolism in the heart compared with its blood flow, it has the highest arteriovenous O2 difference of any major organ of the body under normal conditions. The heart can extract a large amount of oxygen because of its high capillary density. Blood flow to the kidney and skin is far in excess of their metabolic needs, so little oxygen is removed from the blood as it passes through these organs. Under normal conditions, the arteriovenous O2 difference in skeletal muscle is quite low, but can increase substantially during vigorous exercise. Under normal circumstances an increase in contractility will increase oxygen demand, but in a dilated heart, an increase in contractility actually decreases oxygen demand. In heart failure, positive inotropic agents reduce oxygen demand by reducing enddiastolic volume (preload) and thus the wall stress that must be developed by the heart with each beat. Reducing volume decreases wall stress because, according to the law of Laplace, the wall stress is proportional to the product of force and radius (which is proportional to ventricular volume). The right and left ventricles are in series with one another such that the right and left ventricular outputs are essentially equal. Because the two ventricles beat at the same rate, their stroke volumes are the same. The resistance of the pulmonary vasculature is much lower than that of the systemic circulation, however, yielding much lower pressures in the pulmonary artery than the aorta (mean Pulmonary Artery Pressure = 15 mmHg; mean Aortic Pressure = 90 mmHg). Thus, the afterload and stroke work are greater on the left side than on the right side. Because the same cardiac output is ejected into a higher resistance, peak systolic pressure is higher on the left side (120 mmHg) than on the right side (25 mmHg). Only about 10% of the blood volume is within the pulmonary circulation at any one Cardiovascular Physiology Answers 249 time, whereas approximately two-thirds of the blood volume is stored within the systemic veins and venules. The ductus arteriosus empties into the aorta just distal to the left subclavian artery. Because blood is oxygenated in the placenta, pulmonary blood flow in the fetus serves only a nutritive, not a gas exchange, function for the developing lungs, and thus only about 5­10% of the cardiac output flows through the lungs. Soon after birth with the onset of extrauterine respiration, the pulmonary vascular resistance falls, allowing blood to flow from the pulmonary artery to the lungs. The high oxygen tension in the blood of the baby causes the resistance of the ductus arteriosus to increase, with functional closure occurring within several hours after birth. When the ductus arteriosus does not close, it is called a patent ductus arteriosus. If there is normal oxygenation with a normal regression of the pulmonary vasculature after birth, blood flow will reverse across the ductus arteriosus after birth, flowing from the aorta to the pulmonary artery. The left-to-right shunt persists throughout the cardiac cycle yielding the characteristic thrill and continuous murmur with late systolic accentuation at the upper left sternal edge. Cyanosis does not occur with a left-to-right shunt; however, the chronic increase in blood flow through the lungs may induce structural changes in the pulmonary vasculature leading to obstruction and pulmonary hypertension (Eisenmenger syndrome). The resultant right-toleft flow across the ductus causes the toes, but not the fingers, to become cyanotic and clubbed, a finding termed differential cyanosis. The widening of a vessel associated with aneurisms can also produce bruits but these are not relieved by endarterectomy. With the onset of exercise, there is an increase in contractility, which shifts the cardiac function curve up. Also accompanying the onset of exercise are decreases in total peripheral resistance and venous compliance, both of which shift the vascular function curve to the right and increase its slope. The point at which the cardiac function and venous function curves intersect (C) represents the central venous pressure and cardiac output of the cardiovascular system under these conditions. Point E represents the end of the filling phase and the beginning of the isovolumic contraction phase. At this point, the pressure in the left ventricle increases above the pressure in the left atrium, causing the mitral valve to close. The retrograde flow of blood against the closed mitral valve produces the first heart sound. Systole is defined as the period between the first and second heart sounds and includes the isovolumic contraction and ejection phases. Aortic pressure continues to fall during the isovolumic contraction phase so that the rise in aortic blood pressure (which begins at point D) lags behind the beginning of systole. At this point, the pressure in the left ventricle falls below the pressure in the aorta, and the aortic valve closes. The retrograde flow of blood against the closed aortic valve produces the second heart sound. Point A represents the end of the isovolumic relaxation phase and the beginning of the filling phase. At the point the pressure in the left ventricle falls below that in the left atrium, the mitral valve opens and blood begins to flow into the left ventricle. Immediately after birth, flow through the ductus switches, with blood flowing from the aorta to the pulmonary artery. The ductus arteriosus is a systemic blood vessel, and Cardiovascular Physiology Answers 251 thus it constricts in response to high oxygen tensions and dilates in response to hypoxemia (the opposite of the pulmonary vasculature). Ductal sensitivity to oxygen is age-dependent, however, and thus closure of the ductus arteriosus due to progressive constriction may be delayed in premature infants. Once these light chains are phosphorylated, myosin and actin interaction can occur and vascular smooth muscle shortens and develops tension. Although b-adrenergic receptor agonists may lower blood pressure by relaxing vascular smooth muscle, they also increase the rate and strength of the heart beat. Titin contains two types of folded domains that provide muscle with its elasticity. The resistance to stretch increases throughout a contraction, which protects the structure of the sarcomere and prevents excess stretch. The arteriolar vessels produce the largest resistance to blood, and thus the greatest energy loss and pressure drop occur as the blood passes through them. The perfusion pressure is directly related to the aortic pressure at the ostia of the coronaries. Myocardial 252 Physiology vascular resistance is significantly influenced by the contractile activity of the ventricle. During systole, when the ventricle is contracting, vascular resistance increases substantially. Flow is highest just at the beginning of diastole because, during this phase of the cardiac cycle, aortic pressure is still relatively high and vascular resistance is low due to the fact that the coronary vessels are no longer being squeezed by the contracting myocardium. From the right atrium, about twothirds of the inferior venal caval flow (67% O2 saturation) is diverted across the foramen ovale to the left atrium. A patient with diabetes mellitus presents with gastroesophageal reflux disease accompanying gastroparesis. Solids empty more rapidly than liquids Meals containing fat empty faster than carbohydrate-rich food Hyperosmolality of duodenal contents initiates a decrease in gastric emptying Acidification of the antrum increases gastric emptying Vagal stimulation decreases receptive relaxation in the upper portion of the stomach 312. Her condition has worsened in the past month as the date she has scheduled for her licensure examination approaches. Contractile frequency is constant from duodenum to terminal ileum Peristalsis is the only contractile activity that occurs during feeding Migrating motor complexes occur during the digestive period Vagotomy abolishes contractile activity during the digestive period Contractile activity is initiated in response to bowel wall distention 313. An 18-year-old male with pernicious anemia lacks intrinsic factor, which is necessary for the absorption of cyanocobalamin. Stomach Duodenum Jejunum Ileum Colon 253 Copyright © 2008 by the McGraw-Hill Companies, Inc. A 42-year-old salesman presents with the chief complaint of intermittent midepigastric pain that is relieved by antacids or eating. The gastric acid hypersecretion can be explained by an increase in the plasma concentration of which of the following? A 27-year-old female comes to the emergency room because of a 2-day bout of profuse watery diarrhea. The patient is diagnosed with acute secretory diarrhea and dehydration, likely due to Escherichia coli. Which of the following sodium reabsorptive pathways is inhibited by the enterotoxin? Sodium-glucose-coupled cotransport Electroneutral NaCl transport Electrogenic sodium diffusion Sodium-hydrogen countertransport Sodium-bile salt cotransport 317. This acid-base and electrolyte disorder can occur with excess fluid loss from which of the following organs? As a result, which of the following gastrointestinal motor activities will be affected most? Secondary esophageal peristalsis Distention-induced intestinal segmentation Orad stomach accommodation Caudad stomach peristalsis Migrating motor complexes 319. A 35-year-old male smoker presents with burning epigastric pain that is most pronounced on an empty stomach. A paroxysmal rise in serum gastrin in response to intravenous secretin further supports a diagnosis of Zollinger-Ellison syndrome. Acidification of the antrum Administration of an H2-receptor antagonist Vagotomy Alkalinization of the antrum Acidification of the duodenum 320. A 42-year-old male develops a gastric carcinoma affecting the proximal third of his stomach. He is scheduled for a partial gastrectomy of the affected region, which will primarily affect which of the following processes? Which of the following is true regarding the pharmacological blockade of histamine H2 receptors in the gastric mucosa? It inhibits both gastrin- and acetylcholine-mediated secretion of acid It inhibits gastrin-induced but not meal-stimulated secretion of acid It has no effect on either gastrin-induced or meal-stimulated secretion of acid It prevents activation of adenyl cyclase by gastrin It causes an increase in potassium transport by gastric parietal (oxyntic) cells 256 Physiology 322. Endoscopy and biopsy reveal a small-bowel malignancy, indicating surgical resection. Removal of proximal segments of the small intestine would most likely result in a decrease in which of the following? Basal acid output Maximal acid output Gastric emptying of liquids Gastric emptying of solids Pancreatic enzyme secretion 323. After consultation with a surgeon, it is recommended that she undergoes a parietal cell vagotomy. Subsequently the patient experiences nausea and vomiting after ingestion of a mixed meal.

Ensure wearers understand the need for continued hand hygiene and correct removal of gloves medicine 5513 order betoptic 5ml with amex. New Controls Rating 11 Intolerable Tolerable with mitigation Use of gloves 12 Use of goggles Increased potential for cross contamination due to false sense of protection medicine bow national forest cheap 5 ml betoptic amex. Impaired visibility due to fogging Increased sickness treatment refractory cheap 5 ml betoptic with amex, reduced operational crew complement Tolerable with mitigation Tolerable Impaired or delayed reaction to abnormal/emergency situation N/A 13 Tolerable with mitigation Advise crew to remove goggles during emergency situations medicine 3 times a day discount betoptic 5ml. Potential Infection spread to high risk/vulnerable passenger Provide instruction for crew to clean wheelchair prior to use medicine of the wolf 5 ml betoptic. N/A Tolerable with mitigation Tolerable 12 Guidance for Cabin Operations During and Post Pandemic Not controlled whern downloaded or printed Edition 5 ­ 18 May 2021 Risk Probability Probability Risk Ownership Severity No Event Hazard (worst case scenario) Severity Consequence Existing Controls Rating Mitigation Action Provide alternative individual briefing methods to hearing impaired passengers treatment toenail fungus order 5 ml betoptic otc. Identify individual corcumstances where passenger non compliance may be approved in advance. New Controls Rating 15 Crew members/ assistance staff wearing masks Passenger with medical condition which prevents use of face covering Hearing impaired passengers unable to receive information Complaint from other passengers Potential claims for Discrimination N/A Tolerable Tolerable Increased potential for dispute between passengers or between passengers and crew members enforcing compliance N/A 16 Tolerable with mitigation Tolerable 17 Flight crew monitoring and service on high risk routes Multiple visits to cockpit crew from crew members exposed to passengers Increased sickness, reduced operational crew complement Tolerable with mitigation Tolerable 13 Guidance for Cabin Operations During and Post Pandemic Not controlled whern downloaded or printed Edition 5 ­ 18 May 2021 Risk Probability Probability Risk Ownership Severity No Event Infected passenger using lavatories on high risk routes. Hazard Contaminated lavatory surfaces (worst case scenario) Crew member/s become infected. Severity Consequence Existing Controls Periodic checks of lavatories during flight. Rating Mitigation Action Increased frequency of lavatory checks and cleaning during flight. New Controls Rating 18 Tolerable with mitigation Tolerable Passenger use of lavatories 19 Congregation of passengers waiting to use lavatories Increased passenger/crew sickness, reduced operational crew complement Congregation of passengers in lavatory areas not desirable for security reasons Tolerable with mitigation Passengers to be encouraged not to queue for lavatories. Tolerable 20 Cabin crew rest facilities in passenger cabin Insufficient separation between crew and passengers during rest periods Physical distancing not maintained. Increased sickness, reduced operational crew complement Tolerable with mitigation N/A Screen and protect seats allocated for cabin crew rest from passenger access. Tolerable 21 Movement and interaction between cabin crew and passengers on high risk routes Increased sickness, reduced operational crew complement Provide reduced onboard service. Tolerable with mitigation Tolerable 14 Guidance for Cabin Operations During and Post Pandemic Not controlled whern downloaded or printed Edition 5 ­ 18 May 2021 Risk Probability Probability Risk Ownership Severity No Event Removing masks/face coverings while eating and drinking on high risk routes Hazard Exposure to potential infection (worst case scenario) Increased sickness, reduced operational crew complement Severity Consequence Existing Controls Removal of masks for short periods is not a significant concern. Rating Mitigation Action Advise passengers that the removal of masks for short periods to eat and drink is permitted. New Controls Rating 22 Tolerable with mitigation On high risk routes, cabin crew to eat and drink separately in private spaces and clean environment where possible. Tolerable 15 Guidance for Cabin Operations During and Post Pandemic Not controlled whern downloaded or printed Edition 5 ­ 18 May 2021 2. Operators should conduct Covid related risk assessments to help determine whether additional mitigations are required in relation to services, policies or procedures. Airlines should consider their own risk assessment processes and criteria in conjunction with any local regulatory recommendations or requirements. Stage 0 · Multiple travel restrictions and minimal transport of passengers Stage 1 · Initial increase of passengers. Airlines may be required by Health Authorities to adopt some of these layers of protection in various degrees and these requirements will likely vary frequently according to local transmission rates. Airlines should therefore plan their operating processes and procedures in such a manner as to be able to increase or decrease measures rapidly according to latest information available, which may vary by route, airport or country of operation. There remains the possibility that a vaccinated person may encounter a mild infection and may transmit the virus to others. Any requirements for other layers of protection and measures such as wearing of masks onboard aircraft should be continued for all passengers and crew, whether vaccinated or not. Mandating 2 vaccinations would discriminate against those individuals who are not able to get vaccinated due to medical reasons or who are unwilling to do so due to ethical or other concerns. Moreover, such a policy would also risk discriminating against those markets where vaccines may take longer to become widely available. As a general principle, travelers to a country should not be subject to stricter conditions than the measures applying for residents. Typically, such exemptions allow for the extension of cabin crew recurrent expiries for a predetermined period, subject to ongoing review. The following might be considered as potential mitigations for extended cabin crew qualification if accepted by the regulator: · · · · Additional distance learning/e-learning for cabin crew refresher training; Interactive webinars or safety training sessions from Safety Training teams; Webinars on changes to existing services or onboard requirements; Enhanced cabin crew Safety Q&A at pre-flight briefings. Edition 5 ­ 18 May 2021 18 Guidance for Cabin Operations During and Post Pandemic Not controlled whern downloaded or printed Where an exemption has been agreed, the number of cabin crew who are exempted for the period of the crisis will require recurrent training around the same time in the future and on a yearly basis. Operators should therefore consider this and identify a plan with their regulator in order to reduce the peak of training in the future and maintain the required number of trained and qualified crew in operation during peak travel times. Alternative training methods such as webinars, distance learning and e-learning may need to be discussed and accepted by regulators. The number of delegates per class may need to be reduced to ensure this is possible. This includes portable breathing equipment, oxygen masks, life vest mouthpieces and any other item which is used near the face of the delegate. If physical distancing techniques are required to be implemented in training facilities, demonstration of evacuation procedures in cabin mock-ups may need to be restricted or limited. A suitable cleaning and sanitization program for cabin crew training equipment and facilities should be implemented. In some cases, temporary exemptions and alleviations to practical training elements have been granted by regulators, however these do not apply to initial training. Therefore newly recruited cabin crew are still required to undertake the practical training sessions and use the appropriate equipment. While transmission of a virus is ongoing in the region of operation, the availability of cabin crew exposed to the virus may impact the number of cabin crew who are operationally fit for service. Airlines should consider this in their scheduling programs and may need to temporarily increase the number of standby cabin crew. Other aspects which might impact the scheduling availability of cabin crew as services resume might include: · · · · Requirements for day/s off post vaccination. Returning cabin crew from furlough or other employment will likely require some retraining; Quarantine/isolation requirements for crew returning to home base from overseas. Additionally, quarantine requirements may prevent crew from being able to leave the aircraft upon arrival and they may be required to return to base immediately. Flight duty time limitations need to be considered carefully to ensure that cabin crew are suitably rested before operating the commercial flight with passengers. The following should be considered in the planning process: · · · · Where cabin crew are required to remain on board the aircraft during extended turnarounds, power, lighting and heating/cooling should remain available at all times. Seating allocation on commercial flights should enable cabin crew to rest as appropriate; When identified as positioning outside of the maximum permitted Flight Time Limitations, cabin crew should not be assigned any safety related duties onboard. Exemptions may be granted by regulators and these are normally dependent on risk assessment and identification of potential mitigations aimed at preventing the onset of fatigue. Where a country requires that incoming cabin crew are required to quarantine upon arrival, airlines may need to consider alternative operational methods in order to position outbound cabin crew back to home base immediately, subject to flying duty time limitations (see 2. This document includes precautions to be taken at home base, on duty and during layover. Cabin crew who have recovered from infection may experience a loss of smell and/or taste (anosmia). Protects others from inhaling potentially infected respiratory droplets Risks May negatively impact the use of oxygen masks by passengers and crew. May cause fogging of spectacles, visors or goggles, resulting in reduced visibility for the wearer. Removal, replacement and repositioning of masks can spread contamination on the hands. Masks with exhalation valves (also known as respirator valves), which allow exhaled air out of the mask for comfort, are not recommended and some regulators require that passengers only wear surgical masks. Masks should be safely removed and replaced at regular intervals in accordance with health recommendations. Clear fabric and transparent face masks are available and can be used if permitted within the regulation or risk assessment. This policy should be clearly communicated so that passengers are able to acquire the appropriate item in time for their flight. Passengers should be encouraged to provide their own suitable face covering to be shown to check in staff. The publicized airline policy should include: · · · · Details of persons who may be exempted from wearing a face covering What type of face covering is acceptable. When the face covering is required to be worn; What will happen to passengers who do not present themselves at the airport with the required face covering. Masks or face coverings need to be removed for eating and drinking and airlines should reassure passengers that this is permitted, necessary and safe. Limiting the duration the covering is removed will help to minimize any potential risk of exposure. Some passengers, such as children under 5 years old, those with breathing difficulties, dementia or autism may not be able to tolerate the use of face coverings or masks for a lengthy period, if at all. Airlines should consider this within their risk assessment process and identify whether additional questions are necessary at prescreening stage, and whether any exceptions can be made within their policy. In some cases, passengers have carried official looking cards stating that they have a medical exemption from wearing masks due to a disability and that if the airline enforces compliance, this is a violation of disability rights. Where a passenger presents these to the airline, an appropriate assessment or pre-screening should be made. Where exceptions are genuinely made, other passengers may need to be advised of the reasons and additional steps to mitigate the risks in order to reassure them and prevent disputes between passengers. Pre-flight passenger safety briefings to passengers may need to include a reminder for passengers to remove face coverings in a depressurization incident. Where this is the case, masks should always be worn by the crew member/s caring for the patient and by those in close proximity to them. Waste bins in lavatories can be used for this purpose inflight, unless health authorities or the airline risk assessment determines that they are required to be treated as biohazardous waste. The use of gloves by cabin crew during services is already commonplace but is not a substitute for regular and thorough handwashing, as contaminants on gloves can also be spread in the same manner as on bare hands. Gloves should not be worn for long periods and should be disposed of carefully and correctly to avoid cross contamination, followed by thorough hand washing. These products vary in size and features but are known in some cases to include: · · · · · An enclosed breathing hood for the wearer; Enclosed form fitting mask; Breathing tubes; Power supply: Air purifying filter; 23 Guidance for Cabin Operations During and Post Pandemic Not controlled whern downloaded or printed Edition 5 ­ 18 May 2021 Operators should be aware of the availability of such devices and consider whether they will permit them to be used onboard, according to their own risk assessment. Risks for consideration include among others: · · · · Lithium battery power supply and compliance with Dangerous Goods regulations; Trailing breathing tubes/hoses and any potential impact on evacuation; Wearers accessibility to oxygen masks during depressurization; Compliance with health regulations and use of appropriate masks. Airlines that wish to add alcohol-based hand sanitizer to the items carried in galleys or installed in lavatories will need to request authorization from their civil aviation authority (State of the Operator) in accordance with the provision that is set out in Part 1;2. However, the safety data sheet from the manufacturer of the hand sanitizer should be checked for the classification; the quantity of hand sanitizer in each container and the number of containers to be carried on the aircraft; what steps will be taken to ensure that the hand sanitizer is kept away from sources of heat or ignition; provision of information to crew members on the carriage of the hand sanitizer. For example, that crew members will be advised on the procedures through a bulletin or other appropriate method. Hand sanitizers containing alcohol must not be installed or carried adjacent to any source of heat, such as ovens, water heaters, Inflight Entertainment systems etc. The term "medicinal or toiletry articles" is intended to include such items as hair sprays, perfumes, colognes and medicines containing alcohols. Note: the total net quantity of all such articles carried by each passenger or crew member under the provisions of 2. Release valves on aerosols must be protected by a cap or other suitable means to prevent inadvertent release of the contents. Episodes of ill health associated with a case of suspected communicable disease; ii. One or two universal precaution kits per aircraft would typically be adequate for normal operations; additional kits would be carried at times of increased public health risk. The contents of an aircraft universal precaution kit would typically include: · · · · · · · · · · Dry powder that can convert small liquid spill into a granulated gel; Germicidal disinfectant for surface cleaning; Skin wipes; Face/eye mask (separate or combined); Gloves (disposable); Impermeable full-length long-sleeved gown that fastens at the back; Large absorbent towel; Pick-up scoop with scraper; Bio-hazard disposal waste bag; Instructions. Some airlines have conducted further risk assessments during operations while the Covid-19 situation is ongoing and have enhanced the contents of their Universal Precautions Kit according to the risks they have identified. Such enhancements may include increasing the number of wipes, amount of surface cleaning disinfectant, and increase or upgrade of face masks included. Aircraft manufacturers provide operators with guidance on approved sanitization processes and cleaning fluids. Airlines may need to consider additional cleaning and sanitization schedules in accordance with Health Authority requirements. During times of pandemic or public health emergency on high risk routes: · · the frequency of checks may need to be enhanced or increased according to risk, either on a per use basis. It is recommended that cabin crew undertake cleaning of passenger touch surfaces using appropriate disinfectant cleaning wipes. The use of alcohol-based sprays should be avoided inflight as these could introduce potentially flammable vapours and/or activate lavatory smoke detectors. To minimize any possibility of cross infection, where pillows, cushions, sheets, blankets or duvets are provided, these should not be used by multiple persons unless coverings are laundered or changed. Some airlines issue each crew member with their own provisions and the cabin crew members are responsible for ensuring that they are removed and bagged after use. Where this is the case, each cabin crew member should install their own bedding items before their rest period and remove them hygienically afterwards. Where bassinets are permanently installed on the aircraft as part of equipment, they should also be sanitized after each use. Where bassinets are part of the inflight product and are removed from the aircraft during turnaround, they should be clearly identified as used, and sanitized by the provider before replacement. The use of commercially available non-bleaching antibacterial wipes may be acceptable and airlines might consider providing additional wipes for passengers and/or crew, to mitigate the potential for damage caused by non-approved cleaning materials and provide an element of consumer reassurance.

This may be performed 300 Handbook of Otolaryngology­Head and Neck Surgery transcutaneously medicine 0025-7974 generic 5ml betoptic with mastercard, under endoscopic guidance in the office medicine zolpidem order betoptic 5 ml with amex, or during operative microlaryngoscopy symptoms yeast infection buy betoptic 5ml low price. Open approaches (medialization laryngoplasty) involve making a thyroid ala window and placing preformed or surgeon-carved silastic implants symptoms kidney failure discount 5 ml betoptic visa, or layered polytetrafluoroethylene Gortex (W medications gout buy 5ml betoptic amex. Arytenoid adduction may be beneficial in some patients as an adjuvant to reduce posterior glottic gap symptoms 8 weeks cheap betoptic 5 ml with mastercard. Reinnervation of the thyroarytenoid muscle may assist in vocal fold tone and improved glottic closure. N Outcome and Follow-Up In the case of vocal fold paralysis, clinical recovery may require as long as 12 months. Therefore, serial evaluations may be necessary to document the recovery and to reevaluate for vocal issues benefiting from intervention. A functional voice initially may worsen over time as vocal fold atrophy and final fold position manifest. Vocal rehabilitation often involves a multidisciplinary approach combining the services of both otolaryngologists and speech-language pathologists. Vocal rehabilitation methods include resonant voice therapy, vocal function exercises, confidential voice therapy, manual circumlaryngeal reposturing, and Lee Silverman Voice Therapy. Comprehensive vocal rehabilitation often includes a combination of one or more therapeutic approaches. N Clinical Signs Signs of vocal disorders include perceptual, acoustic, and physiological variables. These variables are often defined by the patient as one or more of nine common symptoms of voice problems. Symptoms the nine most common symptoms of voice problems include hoarseness, vocal fatigue, breathiness of voice, reduced phonatory range, aphonia or total loss of voice, pitch breaks or inappropriate pitch level, strain, tremor, and pain. Differential Diagnosis Differential diagnosis of voice disorders must include evaluation of all perceptual, acoustic, and physiological variables to determine the most appropriate voice therapy approach. N Evaluation Evaluation of voice disorders should include evaluation of perceptual, acoustic, and physiological components of vocal function. Perceptual Evaluation Perceptual evaluation includes evaluation of pitch, loudness, quality, and other related features. Perceptual evaluation is often subjective based on the assessment of the voice by both the speech-language pathologist and the patient. The Voice Handicap Index is a quality of life instrument used by a patient to rank his or her voice in areas of functional, physical, and emotional impact of the voice (Table 4. This assessment can be completed with the use of voice analysis software including a Visi-Pitch or Computerized Speech Laboratory (both from Kay Elemetrics Corp. Assessment includes measurement of: G G G G G G G G Fundamental frequency Amplitude Signal-to-noise ratio Vocal rise and fall time Vocal tremor Maximum phonation time Frequency breaks Habitual pitch Physiological Evaluation Physiological evaluation relates to the aerodynamics, vibratory behaviors, and muscle activity of the vocal folds. This evaluation can be completed with videostroboscopic evaluation of the larynx, electroglottography, electromyography, and laryngeal endoscopy. The parameters of videostroboscopy include: G G G G G G G G G Evaluation of vocal fold edge and texture Degree of glottic closure Phase closure Vertical level Amplitude of vibration Mucosal wave Vibratory behavior Phase symmetry Periodicity 4. Laryngology and the Upper Aerodigestive Tract 303 N Treatment Options Several voice rehabilitation programs exist including general vocal hygiene, resonant voice therapy, vocal function exercises, confidential voice therapy, manual circumlaryngeal reposturing, and Lee Silverman Voice Therapy. This includes focus on adequate hydration, reduction and elimination of vocal abusive and misuse behaviors, proper warm up and cool down of the voice, adequate voice rest, modification of contributing environmental factors, and voice amplification. Resonant Voice Therapy Resonant voice therapy focuses on establishing adequate oral and nasal resonance of the voice. This includes tasks focusing through a hierarchy including lip and tongue trills, nasal humming (/mmmm/), nasal words, rote and structured tasks, and conversation. Vocal Function Exercises Vocal function exercises are a series of structured vocal exercises that are used to maintain or establish muscle balance within the larynx, strength, and ease of phonation. These exercises promote complete closure of the true vocal folds and are thought to encourage equal open and closed phases of the vocal folds. It is important to focus on these exercises as speaking tasks and not singing tasks. These exercises are not used primarily for speech tasks but are best when paired with another therapy approach such as resonant voice therapy. Confidential Voice Therapy Confidential voice therapy is used to reduce increased glottal closure by producing a glottal gap during phonation and creating a low-intensity, breathy vocal quality. Although focusing on creating a breathy vocal quality, this approach also accomplishes reduction of loudness, rate, and hyperfunction. This method usually works quickly to break muscle patterns that interfere with vocal production. Areas of focus include the base of tongue, cornu of the hyoid bone, thyrohyoid space, and the posterior borders of the thyroid cartilage. Voice production is then trained for similar use of the larynx during phonation without physical manipulation. The speechlanguage pathologist is required to undergo specialized training prior to instruction. The therapy course is based on an intensive program of four sessions per week for 1 month. N Outcome and Follow-Up Follow-up with repeat laryngeal visualization and follow-up with an otolaryngologist is recommended following a completed course of voice therapy, especially in cases involving vocal pathology such as vocal fold nodules, polyps, paresis, or paralysis. This ensures resolution of the pathology and determination of whether continued medical treatment is necessary. Understanding Voice Problems: A Physiological Perspective for Diagnosis and Treatment. Zenker diverticulum is a pouch that develops in the pharynx just above the upper esophageal sphincter. Typically, this causes dysphagia, regurgitation, halitosis, and generalized irritation. It typically manifests in a posterolateral fashion, with 90% appearing on the left side. It occurs more frequently in European countries or in patients of European heritage. N Clinical Signs and Symptoms Patients typically complain of dysphagia, regurgitation of undigested food, a feeling of food sticking in the throat, a globus sensation, and a persistent cough (especially after eating). Signs or symptoms may include aspiration, unintentional weight loss, and halitosis. Occasionally, a soft swelling may be palpable in the neck, typically in the left side. Questions should be asked pertaining to weight loss, regurgitation, halitosis, and signs or 306 Handbook of Otolaryngology­Head and Neck Surgery symptoms associated with aspiration, such as frequent choking and coughing. When performing a laryngoscopy, signs of laryngitis and pooling of saliva in the hypopharynx secondary to underlying cricopharyngeal hypertrophy may be seen. Imaging Video fluoroscopy with barium typically demonstrates the pouch especially near the end of the second stage of swallowing. This test is usually diagnostic and no further imaging exams are typically necessary. Pathology Zenker diverticulum is a herniation or false diverticulum of the esophageal mucosa posteriorly between the cricopharyngeus muscle and the inferior pharyngeal constrictor muscles. Although rare, it is important to recognize that a small percentage of patients with Zenker diverticulum may have a squamous carcinoma in the pouch (0. Laryngology and the Upper Aerodigestive Tract 307 N Treatment Options Medical In a medically infirm patient, Botox injections to the oropharyngeus muscle may be effective. Surgical Treatment is typically surgical and reserved for symptomatic patients or patients with aspiration and pneumonia. Surgical management of Zenker diverticulum entails division of the cricopharyngeus muscle to eliminate the potentially elevated pressure zone and elimination of the diverticular pouch as a reservoir of food and secretions. Operative intervention is usually undertaken when the diverticulum is at least 3 cm in length. Endoscopic treatment includes endoscopic identification of the pouch and stapler transection of the cricopharyngeal bar, or common wall between the pouch and the cricopharyngeal introitus are divided to make a common lumen. Open surgical techniques include open diverticulectomy, inversion, cricopharyngeal myotomy, or diverticulopexy in which the diverticulum is inverted and sutured to the prevertebral fascia. Am J Med 2003;115(Suppl 3A):175S­178S 308 Handbook of Otolaryngology­Head and Neck Surgery 4. Evaluation requires a detailed history, full head and neck examination, and often endoscopic evaluations and imaging studies. Swallowing therapy may be beneficial to those with upper aerodigestive tract dysfunction, who have no medically or surgically correctable problem. Dysfunction may be secondary to physical obstructive phenomena, neuromuscular weakness or discoordination. N Epidemiology Dysphagia affects all age groups, dependent on the etiology of the symptom. N Clinical Signs and Symptoms Patients may relate very specific aspects of the swallowing reflex that are problematic for them or may simply have a generic complaint of trouble swallowing. Dysphagia is associated with symptoms, including choking, gagging, globus, odynophagia, difficulty initiating swallow, drooling, aspiration, coughing, nasal reflux, and regurgitation. Weight loss may be a sign of dysphagia significant enough to reduce caloric intake, or potentially a neoplastic process. Children with dysphagia may have similar symptoms but also prolonged feeding times, repeated swallow efforts, or unusual posturing during feeding. Dysphagia may involve one or more of the phases of the swallowing reflex including oral preparatory, pharyngeal, or esophageal phases. Laryngology and the Upper Aerodigestive Tract 309 Differential Diagnosis G G G G Neurologic disorder. The oral cavity should be examined and note made of labial competence; salivary function; tongue mobility, symmetry, and strength; palatal motion; mucosal lesions or masses; and gag reflex. The pharyngeal examination should include mirror examination and/or flexible nasopharyngoscopy. In addition to examining for symmetry, mass effect, and mucosal lesion, the presence of pooled secretions is a key finding. Saliva and liquid or food residue in the vallecula, pyriform sinuses, and the postcricoid area indicate either an obstruction of material passage somewhere between the cricopharyngeus and stomach, or a sensory defect of the hypopharynx and larynx. A "wet voice" may indicate retained secretions in the hypopharynx and laryngeal introitus. The sensation, general mobility, and ability to completely close the vocal folds should be assessed. Neck examination should note symmetry, contour, presence of masses, and presence of laryngeal elevation with swallow. Normal presence of laryngeal crepitus (easy mobility and click encountered on moving the larynx over the cervical spine) should be elicited. Cervical films may demonstrate foreign bodies, cervical osteophytes, and air/ fluid levels in the cervical esophagus or diverticulum. Chest radiographs may show pneumonia or evidence of chronic aspiration, as well as esophageal air­fluid levels. The mainstay of evaluation is the modified barium swallow, or rehabilitation swallow. Cinefluoroscopic examination involves having the patient swallow contrast containing a coated material of different consistencies. This allows for an anatomic evaluation of the upper aerodigestive tract but also a 310 Handbook of Otolaryngology­Head and Neck Surgery functional assessment of bolus preparation, transfer, and transit. Rehabilitation maneuvers may be tried under fluoroscopy by the speech pathologist and feedback as to their effectiveness can be immediately ascertained. A flexible endoscopy is passed through the nose and positioned to visualize the oropharynx and hypopharynx and larynx during swallowing trials. Trailed substances are colored with food dye and the examination is recorded to ease assessment of rapid events and subtle findings. Sensory testing is accomplished via an air pulse delivered through the flexible laryngoscope and identification of the presence and strength of the laryngeal adductor reflex. Some otolaryngologists have adopted in-office, nonsedated transnasal esophagoscopy for assessing the esophagus. Esophageal manometry and pH probe testing may be adjuvants to assess for esophageal dysmotility and reflux issues. N Treatment Options Medical Dysphagia secondary to nonobstructive phenomena is typically managed with therapy techniques. Most of these techniques require voluntary action on the part of the patient, although some require little patient cognition. Techniques may involve head and neck positioning during the swallow, food-consistency changes, and sensory enhancement therapy. A speech pathologist with an interest in swallow rehabilitation should be consulted. Many patients perform better with various consistencies of food: dietary modification and thickening agents may help a patient maintain oral intake. If reflux is a component of the dysphagia or is thought to be the underlying etiology, medical therapy may be trialed. Surgical Surgery may be directed to obstructive phenomena such as tumors, strictures, webs, cricopharyngeal hypertonicity, or hypopharyngeal diverticulum. Vocal fold immobility that contributes to aspiration issues may benefit from medialization thyroplasty. If oral intake is deemed unsafe due to aspiration, feeding gastrostomy may be necessary. Laryngology and the Upper Aerodigestive Tract 311 N Outcomes and Follow-Up the etiology largely determines the treatment outcome and follow-up. Aspiration is an important source of morbidity in the neuromuscular impaired and debilitated. Chronic aspiration may have severe medical consequences and medical, sometimes surgical, interventions need to be enacted.

Purchase 5ml betoptic. Post-Acute Withdrawal Symptoms.

References

• Markham A. Telotristat ethyl: first global approval. Drugs 2017;77(7):793-798.
• Penfield W, Roberts L. Speech and Brain-Mechanisms. Princeton, NJ: Princeton University Press, 1959.
• Di Costanzo F, Gasperoni S, Manzione L, et al. Adjuvant chemotherapy in completely resected gastric cancer: a randomized phase III trial conducted by GOIRC. J Natl Cancer Inst 2008;100(6):388-398.
• Kushi LH, Folsom AR, Prineas RJ, et al. Dietary antioxidant vitamins and death from coronary heart disease in post-menopausal women. N Engl J Med 1996;334:1156.
• Kosaka T, Yatabe Y, Endoh H, et al. Mutations of the epidermal growth factor receptor gene in lung cancer: biological and clinical implications. Cancer Res 2004;64:8919-23.