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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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George J Dover, M.D.
https://www.hopkinsmedicine.org/profiles/results/directory/profile/0002545/george-dover
Clinical outcomes and secondary diagnoses for infants born with hypoplastic left heart syndrome treatment 3rd degree heart block calcitriol 0.25 mcg without prescription. Prolonged versus short course of indomethacin for the treatment of patent ductus arteriosus in preterm infants medicine zyprexa 0.25 mcg calcitriol with mastercard. Factors associated with permanent closure of the ductus arteriosus: a role for prolonged indomethacin therapy hb treatment generic calcitriol 0.25mcg with mastercard. Evolutional aspects of children and adolescents with surgically corrected aortic coarctation: clinical treatment e coli calcitriol 0.25mcg with visa, echocardiographic, and magnetic resonance image analysis of 113 patients. Combined pulmonary and aortic valve stenosis-prenatal diagnosis and posnatal interventional therapy. Aortic valvar atresia, interrupted aortic arch, and quadricuspid pulmonary valve: a rare combination. Red blood cell transfusions for preterm infants: the role of evidence-based medicine. Disseminated intravascular coagulation current concepts of etiology, pathophysiology, diagnosis, and treatment. Renal venous thrombosis in neonates: prothrombotic risk factors and long-term follow-up. Guidelines for the evaluation of heart failure in the fetus with or without hydrops. Non-immune hydrops fetalis-prognostic factors based on fetal echo (analysis in 230 cases). Subcommittee on hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Predischarge bilirrubin, gestational age may predict risk for hyperbilirrubinemia. Kernicterus: epidemiological strategies for its prevention through systems-based approaches. Research on prevention of bilirubin-induced brain injury and kernicterus: National Institute of Child Health and Human Developmentconferenceexecutivesummary. Cost-effectiveness of strategies that are intended to prevent kernicterus in newborn infants. Gastric residuals and their relationship to necrotizing enterocolitis in very low birth weight infants. Maternal preeclampsia is associated with increased risk of necrotizing enterocolitis in preterm infants. Oral immunoglobulin for preventing necrotizing enterocolitis in preterm and low birth-weight neonates. Necrotizing enterocolitis in the premature infant: neonatal nursing assessment, disease pathogenesis, and clinical presentation. C-Reactive Protein in the diagnosis, management and prognosis of neonatal necrotizing enterocolitis. Necrotizing enterocolitis: the evidence for use of human milk in prevention and treatment. Neonatal short bowel syndrome as a model of intestinal failure: Physiological background for enteral feeding. Enteral nutrition in children with short-bowel syndrome: current evidence and recommendations for the clinician. Interdisciplinary management of infantile short bowel syndrome: resource consumption, growth, and nutrition. Guideline for the evaluation of cholestatic jaundice in infants: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. A multicenter study of the outcome of biliary atresia in the United States, 1997 to 2000. Duodenal atresia and stenosis: reassessment of treatment and outcome based on antenatal diagnosis, pathologic variance, and long-term follow-up.
On examination the bulge is easily reducible and does not descend into the scrotum symptoms strep throat buy 0.25mcg calcitriol with visa. Which of the following changes is most concerning for possible strangulation requiring emergent repair of the hernia A 36-year-old man is in your intensive care unit on mechanical ventilation following thoracotomy for a 24-hour-old esophageal perforation treatment centers for depression discount 0.25mcg calcitriol mastercard. Which of the following findings on upper endoscopy would be most suspicious for stress gastritis Multiple symptoms parkinsons disease buy cheap calcitriol 0.25mcg, shallow lesions with discrete areas of erythema along with focal hemorrhage in the antrum b medicine 031 quality calcitriol 0.25mcg. Multiple, shallow lesions with discrete areas of erythema along with focal hemorrhage in the fundus c. Multiple deep ulcerations extending into and through the muscularis mucosa in the antrum d. Multiple deep ulcerations extending into and through the muscularis mucosa in the fundus. Single deep ulceration extending into and through the muscularis mucosa in the fundus 351. A 35-year-old man presents with right upper quadrant pain, fever, jaundice, and shaking chills. Ultrasound of the abdomen demonstrates gallstones, normal gallbladder wall thickness, and common bile duct of 1. An 88-year-old man with a history of end-stage renal failure, severe coronary artery disease, and brain metastases from lung cancer presents with acute cholecystitis. After a weekend drinking binge, a 45-year-old man presents to the hospital with abdominal pain, nausea, and vomiting. On physical examination, the patient is noted to have tenderness to palpation in the epigastrium. A 54-year-old man presents with sudden onset of massive, painless, recurrent hematemesis. Upper endoscopy is performed and reveals bleeding from a lesion in the proximal stomach that is characterized as an abnormally large artery surrounded by normal-appearing gastric mucosa. Which of the following is the most appropriate surgical management of this patient During an appendectomy for acute appendicitis, a 4-cm mass is found in the midportion of the appendix. Which of the following findings is most likely to be associated with the carcinoid syndrome It demonstrates a large gallstone in the cystic duct but also a polypoid mass in the fundus. Which of the following is an indication for cholecystectomy for a polypoid gallbladder lesion An alcoholic man has been suffering excruciating pain from chronic pancreatitis recalcitrant to analgesics and splanchnic block. A patient who has a total pancreatectomy might be expected to develop which of the following complications Which of the following is the most appropriate management strategy for this patient A 61-year-old woman with a history of unstable angina complains of hematemesis after retching and vomiting following a night of binge drinking. Endoscopy reveals a longitudinal mucosal tear at the gastroesophageal junction, which is not actively bleeding. Which of the following is the next recommended step in the management of this patient Expectant management Questions 362 to 365 Select the most appropriate diagnosis for each patient. On laboratory findings he has elevated levels of bilirubin and alkaline phosphatase. Ultrasound demonstrates gallstones, normal gallbladder wall thickness, no pericholecystic fluid, and a common bile duct of 1. A 36-year-old woman presents with right upper quadrant abdominal pain and jaundice. On laboratory results she has leukocytosis and elevated levels of bilirubin and alkaline phosphatase. On laboratory results he has no leukocytosis and normal levels of bilirubin, alkaline phosphatase, amylase, and lipase. Ultrasound demonstrates gallstones, normal gallbladder wall thickness, no pericholecystic fluid, and a common bile duct of 3 mm. On laboratory results she has no leukocytosis with normal levels of bilirubin and alkaline phosphatase. Questions 366 to 369 Select the most appropriate surgical procedure for each patient. A 37-year-old man with a 10-year history of ulcerative colitis who has a sessile polyp 10 cm from the anal verge with high-grade dysplasia. A 60-year-old woman with recurrent squamous cell carcinoma of the anus after chemoradiation. A 68-year-old woman with fecal incontinence who presents with a large fixed adenocarcinoma 3 cm from the anal verge. A 33-year-old man with a history of Crohn disease presents with severe abdominal pain and fever. On examination, his heart rate is 130 beats per minute, blood pressure 105/62 mm Hg, and temperature 38. Omeprazole provides excellent suppression of mealstimulated and nocturnal acid secretion and seems very safe for short-term therapy. Prolonged administration in laboratory animals has been associated with significant hypergastrinemia, hyperplasia of enterochromaffinlike cells, and carcinoid tumors. Of these patients, those with a platelet count between 30,000 and 50,000/L have an increased risk for more severe thrombocytopenia. Patients with a platelet count lower than 30,000/L or less than 50,000/L with significant bleeding or risk factors for bleeding should be treated. Initial medical treatment with prednisone (1 mg/kg), and intravenous immunoglobulin is used in patients with severe bleeding or preoperatively prior to splenectomy. Splenectomy is indicated in patients who have severe symptomatic thrombocytopenia, patients in whom remission is achieved only with toxic doses of steroids, patients with a relapse after initial steroid therapy, patients with persistent thrombocytopenia for more than 3 months and a platelet count less than 30,000/L, and possibly in patients with a persistent platelet count of less than 10,000/L after 6 weeks of therapy. The platelet count can be expected to rise shortly after splenectomy, and prolonged remissions are expected in approximately two-thirds of cases. Often affecting older patients, they may present with symptoms mimicking those of acute appendicitis. A thorough initial workup and follow-up are necessary because of the high rate of synchronous and metachronous tumors. The safest and most effective treatment for this condition is surgical treatment with an esophagomyotomy. However, symptoms always recur and patients need to undergo repeated procedures with the associated risk of perforation. Surgery results in improvement in more than 90% of patients, compared with only 70% of patients treated by forceful dilatation. In patients undergoing emergent colectomy for toxic megacolon, total abdominal colectomy without resection of the rectum can be performed initially. Avoiding the mucosectomy preserves the anal transition zone and provides superior postoperative continence. Therefore, a mucosectomy is not routinely performed for patients without rectal dysplasia. Pseudocysts are nonepithelialized fluid collections that can present at earliest 4 to 6 weeks after an episode of acute pancreatitis. The treatment for infected pancreatic pseudocysts is similar to that for pancreatic abscesses-percutaneous catheter drainage with antibiotics.
Precocious puberty in females is commonly due to the premature onset of normal puberty medications guide calcitriol 0.25 mcg overnight delivery. Deciding whether to treat a girl who is simply going through puberty early needs further consideration medicine youth lyrics purchase calcitriol 0.25mcg line. In gonadotropin independent cases treatment plant discount calcitriol 0.25 mcg free shipping, the source of excess sex steroids needs to be identified medications jfk was on order calcitriol 0.25mcg free shipping. Premature breast development (thelarche) this usually affects females between 6 months and 2 years of age. The site of injection of gonadotropin superagonist treatment to suppress his sexual development is coveredbytheplaster. Therewasnopubichair growth, sweatiness or body odour and her height was in the midparental range. Her bone age was onlymildlyadvanced(21months)andapelvicultra sound showed a prepubertal uterus, small volume ovarieswithtwocystsintheleftovary. Premature pubarche (adrenarche) Thisoccurswhenpubichairdevelopsbefore8yearsof ageinfemalesandbefore9yearsinmalesbutwithno other signs of sexual development. It is most com monlycausedbyanaccentuationofthenormalmatu ration of androgen production by the adrenal gland (adrenarche). Delayed puberty Delayed puberty is often defined as the absence of pubertal development by 14 years of age in females and15yearsinmales. In older boys, lowdose intramuscular testosterone will accelerate growth as well as induc ing secondary sexual characteristics. The production of testosterone and its metabolite, dihydrotestosterone, results in the devel opment of male genitalia. Childrenaffected with constitutional delay in growth and puberty are shortduringchildhood,withadelayinsexualmatura tionandhavedelayedskeletalmaturityonboneage. Eventually the target height will bereachedasgrowthinaffectedchildrenwillcontinue forlongerthanintheirpeers. Theconditionmaycause considerable psychological upset from teasing, poor selfesteemanddisadvantageincompetitivesport. Before the most appropriate sex of rearing is decided upon, the karyotype needs to be determined, adrenal and sex hormone levels measured, and ultrasound of the internalstructuresandgonadsperformed. Inmanydisordersofsexualdifferentia tion,ithasbeenusualtoraisethechildasafemale,as itiseasiertofashionfemaleexternalgenitalia,whereas it is not possible surgically to create an adequately functionng penis. In girls, karyotype should be performed to identify Turner syndrome, and thyroid and sex steroid hor monesshouldbemeasured. For this reason, there is a move toward delaying definitive surgery to allow the affected indi vidualtogiveinformedconsenttoanyreconstructive procedures. This is a controversial area and is best managedbyexperiencedmultidisciplinaryteams. Its incidence is about 1 in 5000 births, and it is commoner in the offspring of consanguineous marriages. Over90%haveadeficiencyoftheenzyme 21hydroxylase, which is needed for cortisol bio synthesis. About80%arealsounabletoproducealdos terone, leading to salt loss (low sodium and high potassium)(Fig. Inthefetus,theresultingcorti sol deficiency stimulates the pituitary to produce There may be a family history of neonatal death if a saltlosingcrisishadnotbeenrecognisedandtreated. Diagnosis this is made by finding markedly raised levels of the metabolic precursor 17hydroxyprogesterone in the blood. After detailed explanation with her parents, she was started on oral hydrocortisone and fludrocortisone replacement therapy and oral saltreplacement(NaCl). Her growth, biochemistry and bone age were monitored frequently at followup and she attained normal adult height. Psychological counselling and support were offered around puberty and further genitalsurgerywasneededbeforeshebecamesexu allyactive. Males in a saltlosing crisis require saline,dextroseandhydrocortisoneintravenously. Thelongtermmanagementofbothsexesiswith: Prenataldiagnosisandtreatmentarepossiblewhen a couple have had a previously affected child. Females require surgery to reduce clitoro megalyandavaginoplastybeforesexualintercourseis attempted. Females often experience psychosexual problems, which may relate to the high androgen levelsexperiencedinuteropriortodiagnosis. Even modest energy deprivationduringperiodsofrapidbraingrowthand differentiation is thought to lead to an increased risk of adverse neurodevelopmental outcome. The nutritional vulnerability of infants and children Infantsandchildrenaremorevulnerabletopoornutri tion than are adults. Body weight (%) 100 80 60 40 20 0 Carbohydrate Fat Protein Water Preterm infant (1. The smaller the child, the less the calorie reserve and the shorter the period the child will be able to withstand starvation. High nutritional demands for growth the nourishment children require, per unit body size, isgreatestininfancy(Table12. The risk of growth failure from restricted energy intake is therefore greater in the first 6 months of life than inlaterchildhood. Evensmallbutrecurrentdeficitsin early childhood will lead to a cumulative deficit in weightandheight. Infantsarepronetorecurrent infections, which reduce food intake and increase nutritional demands. Following surgery, after a brief anabolic phase, catecholamine secretion is increased, causingthemetabolicrateandenergyrequirementto increase. Urinarynitrogenlossesmaybecomesogreat that it is impossible to achieve a positive nitrogen balance and weight is lost. After uncomplicated surgery,thisphasemaylastforaweek,butitcanlast several weeks after extensive burns, complicated surgery or severe sepsis. Thereafter, previously lost tissue is replaced and a positive energy and nitrogen balance can be achieved. Height is adversely affected by lower socioeconomic status and increasing number of chil dren in families. Disease in adult life Evidencesuggeststhatundernutritioninuteroresult ingingrowthrestrictionisassociatedwithanincreased incidence of coronary heart disease, stroke, non insulindependent diabetes and hypertension in later life(Fig. The mecha nism is unclear, but it is recognised that fetal undernutrition leads to redistribution of blood flow and changes in fetal hormones, such as insulinlike growth factors and cortisol. Alternatively, it may be the rapid, postnatal growth (catchup) seen in babies suffering from intra terine growth restriction that is u thecausalfactor. Many studies have drawn attention to the delayed development seen in children suffering from protein energy malnutrition due to inadequate food intake, although inadequate psychosocial stimulation may also contribute. Infant feeding Breast-feeding Therecanbenodoubtthatbreastmilkisthebestdiet for babies, although the popularity of breastfeeding has frequently reflected fashion. Preterm infantscanbebreastfed,butthemilkwillneedtobe expressed from the breast until the infant can suck. Breastfeedingisrestrictiveforthe mother, as others cannot take charge of her baby for anylengthoftime.
Modern designs focus on creating a healing environment with materials and furnishings that reduce noise medicine 831 purchase calcitriol 0.25mcg without prescription, glare medications that cause hyponatremia buy 0.25 mcg calcitriol, stress medications bladder infections calcitriol 0.25 mcg visa, and have natural lighting medicine number lookup buy discount calcitriol 0.25 mcg. Optimal designs enhance workflow efficiency and facilitate effectiveness of patient care. Both the semi-closed and closed 12 unit models are referred to as "high-intensity" units. The admitting physician may request an intensivist consultation to assist in guiding management decisions, but is not required to do so. The nurse manager is responsible for setting nurse practice standards, education, and for assuring cooperation with physicians and other ancillary staff. Care bundles currently exist for a variety of situations, including sepsis management, central line placement, prevention of ventilatorassociated pneumonia, indwelling urinary drainage catheters, and many other clinical situations. Each provider, working within the team concept, plays a vital role in attaining the best patient outcomes possible. Hand hygiene Maximal barrier precautions Chlorhexidine skin antisepsis Optimal catheter site selection, with avoidance of using the femoral vein for central venous access in adult patients 5. Daily review of line necessity, with prompt removal of unnecessary lines Physicians provide the daily care and management of the majority of critically ill patients. Intensivists are physicians with an additional 1 to 2 years of subspecialty training in critical care medicine. To date, the benefit of one coverage model over the other has not been conclusively demonstrated. Above this ratio, both the quality of care delivered and job satisfaction decline. Administer 30 mL/kg crystalloid for Bundle (initial resuscitation) hypoperfusion 2. Additional fluids should be guided by clinical examination and available physiologic variables or dynamic measures of fluid responsiveness 4. Any required source control intervention should be implemented as soon as possible 3. Crystalloids are recommended for fluid resuscitation over albumin, hydroxyethyl starches or gelatins 4. Review urinary catheter necessity daily and remove promptly medical management decisions, performing procedures, order writing, and coordination of care. Studies have shown that physician extenders can provide high quality and cost-effective care when working within a collaborative medical care team model. Fulltime nurses generally work 40-hours per week with nurse shift lengths ranging from 8 to 12 hours. The specific duties of each professional support staff member are outlined in Table 2. In this paper, it was disclosed that nearly 100,000 patients die each year as a result of medical errors. Collaborates with the critical care team to identify the nutritional needs of each critically ill patient, creating nutritional programs tailored to the specific requirements of the patient. Focus is mainly on the psychosocial elements of care, including facilitating discharge planning of socially complex patient situations, transitions of the patient from the acute care setting to lower levels of care, dealing with difficult family situations, hospice placements, nursing home placements, providing emotional support related to critical illness and crisis intervention, managing barriers to safe and timely discharge planning, arranging post-discharge follow-up. Multidisciplinary rounds have been shown to improve efficiency, outcome, and reduce the cost of 16 Physical Therapist Occupational Therapist Clinical Dietitian Speech Therapist Social Worker care. These models utilize large databases of patient information that compare outcomes among similar groups of critically ill patients. Halpern N, Pastores S: Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs. Critical care medicine beds, use occupancy, and costs in the United States: A methodological review. Thompson D, Hamilton D, Cadenhead C, et al: Guidelines for intensive care unit design. Nighttime intensivist staffing, mortality, and limits on life support: A retrospective cohort study. Kerlin M, Small D, Cooney E, et al: A randomized trial of nighttime physician staffing in the intensive care unit. Needleman J, Buerhaus P, Pankratz S, et al: Nurse staffing and inpatient hospital mortality. Curtis J, Cook D, Wall R, et al: Intensive care unit quality improvement: A "how-to" guide for the interdisciplinary team. A care bundle refers to the use of a limited set of evidencebased interventions consistently applied to a specific clinical situation b. Consistent use of care bundles have not conclusively demonstrated improved patient outcomes d. A care bundle exists for the placement and care of an indwelling urinary catheter 3. Has not been demonstrated to appreciably reduce the incidence of medical errors 4. The National Patient Safety Foundation defines safety as "avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the processes of health care. Patient safety emphasizes harm prevention by creating resilient systems that work in non-routine operating conditions. Quality improvement, on the other hand, is often framed in terms of its success, which explains the abundance of information on quality initiatives relative to that of safety data. A few health care systems have successfully adopted these strategies, while other attempts have been unsuccessful, generating controversy over their usefulness. High hazard industries, such as commercial air travel, nuclear power, and naval aviation, are another area from which safety concepts have been adopted. Many of these organizations are able to deliver consistently high performance in situations that have a low tolerance for error. Leape and Berwick posited that the culture of medicine is one of the biggest impediments to patient safety progress. Crit Care 2011; 15:314 22 individual performance and a commitment to research contributed to significant advances in modern medicine. Surviving Sepsis Campaign) has improved efficiency, reduced costs, and decreased complications. Enacting a comparable policy would cost little, place minimal burden on nursing staff, and potentially save countless lives. Thus, the key to improved outcomes will involve better integration of the current technology. Incremental biomedical advancement pales in comparison to the conceivable harm reduction buoyed by a culture supporting multidisciplinary communication and quality improvement at every level. Progress is slow, but cultivating a highly collaborative working environment with safety and quality as the top priority will bring us closer to the ultimate goal of zero patient harm. Institute of Medicine: Crossing the Quality Chasm: A New Health System for the 21st Century. Mazzocato P, Savage C, Brommels M, et al: Lean thinking in healthcare: a realist review of the literature. Design systems that help prevent errors, or make errors visible so they can be intercepted b. Standardizing patient rooms such that the same equipment is found in the same spot c. Neuropathic pain should be treated with other agents such as gabapentin or carbamazepine. While pain is a subjective experience, there are significant physiological and psychological consequences of untreated pain.
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