Amani M. Allen PhD, MPH

• Faculty Headshot for Amani Allen
• Executive Associate Dean
• UC Berkeley School of Public Health
• Associate Professor Community Health Sciences and Epidemiology

https://publichealth.berkeley.edu/people/amani-allen/

Retinal detachment (simple) is always due to break in the retina through which fluid seeps in breast cancer awareness month buy cheap ginette-35 2mg on-line, raising the retina from its bed menopause water retention trusted 2 mg ginette-35. Complicated cataract (posterior cortical) is due to the disturbance to the nutrition of the lens menstrual seizures ginette-35 2 mg visa. In pathological myopia women's health clinic gillette wy discount ginette-35 2 mg fast delivery, the patient should avoid an occupation where close work is necessary pregnancy 0-2 weeks cheap ginette-35 2 mg otc. Spectacles-Myopia is treated by prescribing suitable correcting spherical concave lenses for constant use pregnancy 7dpo cheap ginette-35 2 mg amex. In low degree of myopia, spectacles are rarely required for near work (after the Errors of Refraction 51 Temporal and supertractional nasal crescent presbyopic age). It should be undercorrected to avoid very bright and clear retinal images which are uncomfortable. Hygiene of eyes-Proper position, good illumination and correct distance from the book (about 25 cm) while reading is essential. Radial keratotomy-Multiple peripheral cuts are made in the cornea in order to flatten the increased curvature of the cornea. Excimer laser-It reshapes and flattens the central part of the cornea (photorefractive keratectomy) iii. Epikeratophakia-It is a procedure in which a lenticule of donor tissue of desired power is used to alter the surface topography of cornea. Keratomileusis-A disc of cornea is freezed and placed on a lathe machine and keratomileusis (grinding) is performed. Absence of lens or aphakia-It is a classical example of acquired high hypermetropia. Treatment-It is treated by prescribing suitable correcting spherical convex lenses. Regular Astigmatism Normally cornea is flatter from side to side (horizontal meridian) perhaps because of the pressure of the eyelids. Regular astigmatism is present when the two principal meridians are at right angles. Thus, the more curved meridian will have more convergent power than the less curved. If the retina is situated at A to E, the image will be blurred as rays never come to a focus in a single point. Retinal plane at A Compound hypermetropic astigmatism Both the foci are behind the retina. Retinal plane at B Simple hypermetropic astigmatism Vertical meridian-Emmetropic Horizontal meridian-Hypermetropic Retinal plane at C and D Mixed astigmatism [circle of least diffusion] Vertical meridian-Myopic Horizontal meridian-Hypermetropic Retinal plane at E Simple myopic astigmatism Vertical meridian-Myopic Horizontal meridian-Emmetropic Retinal plane at F Compound myopic astigmatism Both the foci are in front of the retina 2. Partial or full thickness keratoplasty may be done depending on the depth of opacity as a last resort. When there are symptoms, suitable cylindrical lenses are prescribed for constant use. Mixed astigmatism has good prognosis as "circle of least diffusion" falls upon or near the retina. Astigmatism [against the rule]-The surgical scar at the corneoscleral junction in the upper part of the cornea flattens the vertical meridian of the cornea. Aphakic eye Correction with convex lens Symptom There is gross dimness of vision because of acquired high hypermetropia. A linear semicircular corneo-scleral scar mark is seen in the upper half of cornea. There is greater refraction at the periphery of spherical lens than near the centre. Contact Lens Advantages There is minimum retinal image magnification, therefore it is useful in unilateral aphakia. Diplopia or seeing double objects may be present in severe cases and unilateral aphakia. Alternating vision-The hypermetropic eye is used for distance and the myopic eye is used for near. It is treated by prescribing suitable correcting lenses for refractive difference of up to 2-3 D. The vision improves if the book is held further away from the ordinary reading distance, i. The average eye glass adds for various age group In myopia-There is delayed onset of presbyopia. Presbyopia is treated by prescribing suitable convex spherical lenses for near work. This correction for near work is added to the correcting lenses for the distant vision. Auto-refractometer-Refraction is tested automatically using electronic and computer technology. Mydriatics in Refraction the pupil is dilated by a suitable mydriatic depending on the age of patient. In children-Atropine ointment application three times a day for 3 days is preferred up to 8 years of age as it paralyses the ciliary muscle. Streak retinoscopy Neutralisation When the shadow moves with the mirror, progressively stronger convex lenses are put in the trial frame until, i. Similarly, when the shadow moves against the mirror, progressively stronger concave lenses are put in the trial frame until the point of reversal is reached. The correction for near vision by convex spherical lenses is made over 40 years of age usually. Spectacles In children spectacles with large round or oval lenses should be ordered as they may look over them. For distant vision, the lenses are centred properly so that the optical centres are opposite the pupil. Photochromatic lenses become dark automatically in bright light and remain white in dim light. When the lens is moved in front of the eye, the objects move in the opposite direction. When the lens is moved in front of the eye, the objects move in the same direction ii. The axis of a cylindrical lens is parallel to that of the cylinder of which it is a part. When the lens is moved in the direction of the axis, Convex cylinder there is no movement of the objects. When the lens is moved in a direction at right angles to the axis Convex cylinder-The objects move in the opposite direction. Contact Lenses Principle Contact lens alters the vergence power of the anterior surface of the eye. Unilateral aphakia-It prevents diplopia as there is no refinal image magnification. Keratoconus or conical cornea-It provides regular corneal surface and mechanical support. Occupational In athletes-There is less chances of serious injury, better optics and wider field. Cosmetic It improves the cosmetic appearance specially in young marriageable girls. The aim of astigmatic keratotomy is to flatten the more curved meridian by asymmetrical incisional surgery. To achieve this various considerations are kept in mind such as the number and position of the transverse incisions. The central part of the cornea (optical zone) is reshaped by the laser after corneal epithelial debridement. Excimer laser photorefractive keratectomy directly alters the central cornea Method Excimer lasers (excited dimer) act by tissue modelling (Photoablation). It is a source of far ultraviolet radiation which allows removal of corneal tissue with the accuracy of a fraction of a micron. Laser energy has been used to perform radial keratotomy as the laser incision is more accurate and predictable than a diamond knife incision. Disadvantages There may be residual corneal haze in the centre affecting clear vision. In this procedure a 160 micron hinged corneal flap is lifted from the central 8 to 9 mm of cornea with the help of a microkeratome. This flap is folded to the side and the excimer laser is then used to remove tissue from the exposed surface, correcting myopia and astigmatism. It reinforces the posterior capsule to hold the vitreous phase thus minimising incidence of retinal detachment. Method the donor lenticule of the desired power is sutured into the keratectomy with 10-0 nylon sutures. This disc is placed on a lathe machine equipped with freezing apparatus and keratomileusis (grinding) is performed. Recently Coherent Schwind laser and fourth generation fractile mask spiral lasers are under trial which will further decrease the corneal ablation time. In retinoscopy using a plane mirror, when the mirror is tilted to the right the shadow in the pupil moves to the left in a. Optical condition of the eye in which the refraction of the two eyes differs is a. Incident parallel rays come to a focus posterior to the light sensitive layer of retina in b. It is exposed to dust, wind, heat and radiation and therefore prone to get infected. The palpebral conjunctiva is adherent to the tarsus and cannot be easily dissected. Fornices-These are folds of the conjunctiva formed by the reflection of the mucous membrane from the lids to the eyeball. Plica semilunaris-It is a crescentic fold of the conjunctiva situated at the inner canthus. The stroma-It consists of blood vessels, connective tissue, glands such as glands of Krause, glands of Wolfring and goblet cells. Structure of conjunctiva Blood Supply the anterior and posterior conjunctival arteries and veins. Sensory nerves-These are branches of ophthalmic and maxillary division of the 5th cranial nerve. Bacteriology Most of the organisms normally present are non-pathogenic but some are morphologically identical with pathogenic types. Non-pathogenic bacteria-Diplococcus, Corynebacterium xerosis, Staphylococcus albus, etc. Conjunctival Reactions Hyperaemia-It is seen maximum in the fornices and minimum at the limbus. Oedema and chemosis-It is due to swelling of the conjunctiva as a result of exudation from capillaries. Bleeding Fibrinous exudate is situated over and within the conjunctival epithelium It cannot be peeled off easily. Lymphadenopathy the preauricular nodes are enlarged in viral and chlamydial infections. Histological examination of the secretion and scrapings of the epithelium taken by a platinum loop and stained with Giemsa stain and Gram stain. Conjunctival culture-It is taken from lid margin and conjunctival sac with sterile cotton tipped applicators. Antibiotic drops-Antibiotic drops commonly used to treat conjunctivitis include the following: i. Norfloxacin is a quinolone antibiotic with broad spectrum activity and low toxicity. Other antibiotics include chloramphenicol, gentamicin, framycin, tobramycin, neomycin, polymyxin, etc. Antibiotic ointments-Ointments provide higher concentration of antibiotic for longer period than drops. As they cause blurred vision during the day, ointments are used at night or during sleep.

The use of bisphosphonates is implicated in the development of osteonecrosis of the jaw; clinicians must be alert to complaints of jaw and tooth pain in these patients women's health clinic nambour discount ginette-35 2mg with visa. Routine dental care contemporary women's health issues for today and the future pdf order ginette-35 2mg online, preferably by a dentist experienced in the treatment of radiation effects breast cancer lumps purchase ginette-35 2 mg visa, is necessary women's health for pregnancy discount ginette-35 2 mg line. Taste changes menstrual extraction pregnancy purchase 2mg ginette-35 mastercard, dysphagia menstrual type cramps during pregnancy ginette-35 2mg sale, and limited mouth opening can all lead to weight loss; referral to a dietician can be helpful. Patients who have undergone abdominal, pelvic, lower thoracic, or lumbar spine irradiation are at risk for developing radiation enteritis and are at risk for dehydration, malabsorption, and metabolic disturbances. Symptoms often occur shortly after eating and are unpredictable; which may lead to the patient becoming homebound. Dietary modifications, such as increased fiber intake and avoidance of problem foods; and use of antidiarrheal agents are helpful in controlling symptoms. Surgical resection of bowel may lead to a malabsorptive diarrhea with a decrease in the absorption of electrolytes and bile salts. Short bowel syndrome occurs when 200 cm or more of bowel is resected (Coleman, 2010). Patients who have had partial gastrectomies may experience Copyright 2014 by the Oncology Nursing Society. Symptoms of dumping syndrome include facial flushing, lightheadedness, fatigue, and postprandial diarrhea following consumption of sugars and processed starches (Lee, Kelly, & Wassef, 2007). Dietary modifications and supplementation of fat-soluble vitamins are often necessary. Treatment-related causes of constipation include adhesions due to surgical procedures, narrowed intestinal lumen due to surgery or radiation, and autonomic neuropathy due to chemotherapy. Taxanes, vinca alkaloids, platinum analogs, epothilones, proteasome inhibitors, and thalidomide are all associated with the development of peripheral neuropathy. Patients who have preexisting neuropathy due to diabetes or chronic alcohol use are at higher risk for chemotherapy induced peripheral neuropathy. Musculoskeletal Effects Many cancer survivors are at risk for osteoporosis related to hormonal manipulation of their cancers. It is well known that postmenopausal women are at risk for developing osteoporosis due to the loss of estrogen and its protective effects on bone density; women who have had oophorectomies are at risk for the development of osteoporosis at earlier ages than had they gone through natural menopause. This effect is most pronounced in the first two years of use, so bone density measurements should be done prior to starting these drugs and after six months to one year of use. Tamoxifen and other selective estrogen receptor modulators preserve bone density; tamoxifen may be the endocrine therapy of choice for postmenopausal women with preexisting osteopenia or osteoporosis. Men treated for prostate cancer with androgen deprivation therapy or orchiectomy and men treated for testicular cancers are also at risk for the development of osteoporosis and should be screened. Steroids, such as prednisone and dexamethasone, are used in some chemotherapy regimens and may lead to the development of osteoporosis, avascular necrosis, and other long-term effects. All patients at risk for osteoporosis should be encouraged to get adequate amounts of calcium and Vitamin D, either through diet or supplementation. Those with osteopenia or osteoporosis usually require treatment with bisphosphonates or other bone-strengthening medications. Patients on bisphosphonates should have thorough periodic dental examinations and inform providers immediately if experiencing jaw or tooth pain. Endocrine and Neuroendocrine Effects Patients and healthcare providers are aware that chemotherapy, surgery, radiation therapy, and hormonal therapies may result in infertility, but may not be familiar with the range of effects on the endocrine system as a whole. It is well known that postmenopausal women are at increased risk for hyperlipidemia, and coronary artery disease due to the loss of the protective effects of estrogen. Women who experience premature menopause as a result of cancer treatment may Copyright 2014 by the Oncology Nursing Society. Testosterone deficiency in men resulting from orchiectomy and androgen deprivation therapy also predisposes them to the development or worsening of hyperlipidemia and should be screened and treated. Testicular cancer is often diagnosed in men in their 20s or early 30s; screening for cardiovascular disease and hyperlipidemia should start approximately five years after treatment is completed (Efstathiou and Logothetis, 2006) Cranial irradiation and surgical resection of tumors often damages the pituitary gland, leading to hypopituitarism. Some chemotherapeutic agents, glucocorticoids, megestrol acetate, and interferon may also cause pituitary dysfunction. Growth hormone deficiency is often the earliest manifestation of pituitary dysfunction and causes reduced bone mineral density, decreased lean mass, increased adiposity, abnormal lipid profiles, and insulin resistance. Hyperprolactinemia is also implicated in the development of osteoporosis, as well as menstrual irregularities, erectile dysfunction, and insulin resistance. Damage to the hypothalamus-pituitary-thyroid axis from cranial irradiation also results in central hypothyroidism and gonadotropin deficiency. Adrenocorticotropic hormone deficiency is one of the least common, but most serious of the pituitary hormone disorders resulting from cranial irradiation or prolonged glucocorticoid therapy. Patients at risk for treatment-associated hypopituitarism should be screened periodically after completion of treatment and treated for any deficiencies. Primary hypothyroidism may result from cranial and neck irradiation, or from various drugs used in cancer treatment. Peripheral Neuropathy and Other Chronic Pain Syndromes Chronic pain syndromes may be the result of surgery and radiation therapy; often a neuropathic component exists. Breast cancer survivors treated with breast-conserving surgery and radiation therapy may experience breast pain lasting long after treatment ends. Healthcare Maintenance and Screening for Second Cancers Health and wellness promotion is important for all survivors. Healthy diet, weight management, and exercise enhance well-being and reduce the risks of developing diabetes, cardiovascular disease, other chronic diseases, and second cancers. Smoking and alcohol use are implicated in the development of some cancers; smoking cessation and counseling regarding alcohol use can help reduce the risk. Many survivors have ongoing pulmonary effects of treatment and should have yearly influenza immunizations, as well as periodic immunization against pneumococcus. Those who have had stem cell transplants require immunization, usually beginning three to six months after transplantation. Screening for Second Cancers Second and higher order primary cancers often occur several years, even decades, after treatment for the primary cancer. There is little question that younger cancer survivors should undergo screening for second cancers, but there is not necessarily a consensus regarding screening for second primaries when the cancer survivor is an older adult. The concern is that older patients may not tolerate treatment as well as younger individuals. Age should not be the only criteria on which to make screening decisions; performance status can be more important than age in determining if a particular individual is a candidate for treatment if a second primary is found. It is important for patient and provider to thoroughly discuss all concerns and to periodically revisit the issues. Patients who have recently completed difficult treatment regimens may initially decide that they will never undergo such treatment again, but may feel differently when faced with a new cancer. It is often difficult to tease out which of these are caused by cancer treatments versus genetic, environmental, and other factors that may have led to the development of the initial malignancy. Family history may suggest the presence hereditary predisposition to certain cancers, as can age at diagnosis. Patients whose cancers occur at younger ages than usual or whose families contain cancer clusters should be referred for genetic counseling and testing. The presence of a mutation is often important in guiding screening and risk reduction for siblings or children of cancer survivors. The risk of cancer recurrence is higher in the first few years after treatment, whereas second primaries may not manifest themselves for many years. Screening for recurrence is considered part of surveillance, whereas screening for new primaries is considered secondary screening. Based on information from National Comprehensive Cancer Network, 2013a; National Comprehensive Cancer Network, 2013d; National Comprehensive Cancer Network, 2013e; National Comprehensive Cancer Network, 2013j. Certain treatment modalities increase the risk of secondary primary cancers in cancer survivors. Anthracyclines/Herceptin the anthracyclines can cause cardiac toxicity because of oxidative stress of the myocardial cells, which will induce apoptosis (Arozal et al. This can lead to congestive heart failure, arrhythmias, and left ventricular dysfunction. Because of the cardiotoxic effects of these agents, they have a maximum cumulative dose. If the cumulative dose exceeds above the maximum dose established for each agent the probability of developing cardiac dysfunction increases greatly. Therefore if at all possible, these agents should be avoided or careful monitoring of cardiac function must occur during administration. Other agents not in the anthracycline family can increase the risk of cardiac dysfunction so other agents with cardiotoxicities should be avoided. If cardiac toxicities do occur with anthracycline therapy, Copyright 2014 by the Oncology Nursing Society. Finally, side effects may not present immediately during exposure to the agents but may occur years after therapy has completed. Trastuzumab-related cardiac dysfunction is different from chemotherapy-induced cardiac dysfunction in that it does not generally cause death and is reversible once the drug is stopped. If cardiac dysfunction does occur with the administration of trastuzumab, once the agent is discontinued cardiac function will usually recover to normal, and the agent can often be restarted (Carver et al. Studies are also looking at the use of biomarkers such as brain neutriarectic peptides, and troponins that may indicate myocyte damage earlier (Horacek et al. Bleomycin Bleomycin has been known to cause pulmonary toxicity and Raynaud phenomenon. Injury of the alveolar capillary barrier, neutrophil accumulation, and induction of pro-inflammatory cytokines in turn causes pulmonary fibrosis. Because of the risk of pulmonary fibrosis, the maximum lifetime dose is 400 units. If patients who have received bleomycin must undergo surgical procedures with administration of anesthesia, the use of high-dose oxygen therapy must be limited to reduce the risk of postoperative ventilation failure. High levels of oxygen are used during scuba diving, so this activity should also be limited or avoided (Zaniboni, Prabhu, & Audisio, 2005). There have been some case reports of gangrenous digits after the administration of bleomycin (Chaudhary & Haldas, 2003). Renal toxicities are associated with the platinum-based agents especially cisplatin. Cisplatin is turned into a much more potent toxin, which in turn causes cell apoptosis, inflammation, and necrosis. To ensure that long-standing renal insufficiency does not occur, careful monitoring of renal function and electrolytes and administration of diuretics and fluids are imperative during treatment. However, patients may still develop long-term renal insufficiency despite these measures. Optimization of renal function, avoidance of nephrotoxic agents, and strict management of comorbidities that can contribute to renal insufficiency, such as hypertension and diabetes, are necessary (Polovich, Whitford, & Olsen, 2014). Immunomodulators the uses of lenalidomide and thalidomide have been associated with an increased risk of developing secondary malignancies such as lymphomas and acute myeloid leukemia. Ongoing studies are continuing to look into this phenomenon (Ormerod, Fausel, Abonour, & Kiel, 2011). In most cases if the drug is stopped or dose reduced, the neuropathies will resolve without any other intervention. Current studies are ongoing looking at the use of glutamine and glutathione in peripheral neuropathy treatment. Safety modifications to reduce falls due to decreased proprioception and deep tendon reflexes should be employed (Polovich, Whitford, & Olsen, 2014). Vinca Alkaloids Mixed sensory and motor neuropathies are often dose limiting and may continue to worsen even after agent discontinuation. Constipation, mega colon, and paralytic ileus have occurred due to the autonomic neuropathy (Polovich, Whitford, & Olsen, 2014). Alkylating Agents these agents are known to cause gonadal dysfunction, which can affect both hormones and fertility. This may be due to the rapid proliferation of urothelial cells observed in hyperplastic urothelium caused by Copyright 2014 by the Oncology Nursing Society. The lowest dose of the agent should be used, and those patients who have received more than 20 grams of cyclophosphamide should undergo routine urinalysis every three to six months to screen for microhematuria (Vlaovic & Jewett, 1999). It has also been associated with the development of acute leukemia in patients treated with cyclophosphamide for lymphomas (Ng, La Casce, & Travis, 2011). Rituximab One study showed an increase risk for myelodysplasia or acute leukemia with the addition of rituximab to high sequential therapy for lymphoma patients. Bone Marrow Transplant Patient who have received allogeneic bone marrow transplants are at risk for secondary malignancies along with graft versus host disease. The most common is nonmelanoma skin cancers and squamous cell cancer of the buccal cavity. Management of Long-Term Side Effects Thyroid Screening Patients who have undergone radiation therapy to the neck for lymphoma, head and neck malignancies, or radioactive iodine will need to have lifelong monitoring for thyroid dysfunction. Cognitive Impairment Cognitive impairment is commonly referred to by many patients, survivors, and providers as "chemobrain. It can have a profound impact on the quality of life after treatment has been completed. Some studies have tested the use of psychostimulants but have failed to show benefit (Raffa, 2011). Other studies have looked at the use of cognitive training, but these have been small samples and lacked a comparison group. More randomized controlled studies are needed to examine at effect evidence based interventions.

A3146 A Novel Method of Treating Bronchopleuro-Cutaneous Fistula with an Endobronchial Valve/P menopause 2 week period buy 2 mg ginette-35 overnight delivery. A3147 Novel Use of Spyscope for Placement of Bronchial Catheter in Right Upper Lobe Bronchus to Control Bleeding During Cryobiopsy/R pregnancy 21 weeks generic ginette-35 2mg fast delivery. A3149 Adenoid Cystic Carcinoma of Trachea Treated with Bronchoscopic Resection Followed by Radiotherapy/K menopause and weight gain cheap 2 mg ginette-35 with visa. P301 Discussion: 11:15-12:00: authors will be present for individual discussion 12:00-1:00: authors will be present for discussion with assigned facilitators pregnancy day by day calendar ginette-35 2 mg line. A3130 Proliferative Membranous Bronchial Webs: A Rare Complication of Lung Transplantation/S menstruation meaning ginette-35 2 mg on line. A3132 Fogarty Balloon Bronchoplasty: A Non-Surgical Approach for Distal Broncholithiasis/T women's health clinic edinburg tx purchase 2 mg ginette-35 otc. A3135 Incidental De-Novo Diagnosis of a Pulmonary Embolism by Endobronchial Ultrasound/M. A3137 Hemoptysis Due to a Bleeding Bronchial Dieulafoy Lesion Treated Successfully with Arterial Embolization and Argon Plasma Coagulation/J. A3138 Excessive Dynamic Airway Collapse in a Young Woman with Hypermobility-Type Ehlers-Danlos Syndrome/N. A3152 Custom Stent Planning for Complex Airway Disease: A Novel "State-of-the-Art" Approach/M. A3155 Incidentally Discovered "Rock Garden"Tracheobronchoplastica Osteochondropathica with Associated Left Sided Breast Adenocarcinoma and Severe Esophageal Strictures: A Rare Case Report/G. A3158 Occult Foreign Body Aspiration Presenting as Recurrent Pneumonia with Complicated Parapneumonic Effusion/S. A3160 Broncholithiasis: A Rare Cause of Hemoptysis Resolved Using Rigid Bronchoscopy and Cryotherapy/A. A3162 P329 P314 Management of a Case of Tracheobronchopathia Osteochondroplastica Causing Airway Obstruction/I. P318 Discussion: 11:15-12:00: authors will be present for individual discussion 12:00-1:00: authors will be present for discussion with assigned facilitators. P333 Successful Management of Exercise-Induced Laryngeal Obstruction with Manual Laryngoscopy in Community Hospital/S. A3179 Pericardial Effusion and Cardiac Hypokinesis Associated with Long-Standing, Multi-Organ System Sarcoidosis/M. A3181 Evaluation of Vocal Cord Dysfunction Using Bedside Ultrasonography and Bronchoscopy/D. A3163 Snare Electrocautery and Laser Bronchoscopy for a Rare Cause of Endobronchial Metastasis/K. A3164 Pulmonary Arteriovenous Malformation in the Setting of Fibrosing Mediastinitis/S. A3165 Primary Pulmonary Alveolar Proteinosis in a Patient with Chronic Lymphoblastic Leukemia/J. A3168 Multiple Pulmonary Abscesses as a Late Complication of Pulmonary Arteriovenous Malformation Embolization/P. A3169 Serial Bronchoscopic Cryobiopsies Allowing Extubation in a Patient with Central Airway Obstruction from Peripheral T-Cell Lymphoma/B. A3185 Non-Cardiogenic Pulmonary Edema Resulting from Naloxone Reversal of Opioid Overdose: A Case Report/F. A3188 Case Report: Tracheal Adenoid Cystic Carcinoma Misdiagnosed as Asthmacase Report: Tracheal Adenoid Cystic Carcinoma Misdiagnosed as Asthmacase Report: Tracheal Adenoid Cystic Carcinoma Misdiagnosed as Asthma/K. A3189 Ketamine as an Alternative Agent for Conscious Sedation in the Hypoxic Patient/M. A3190 Anterior Myelomeningocele Without Neurospine Involvement: A Rare Posterior Mediastinal Pathology/Y. A3192 Natural Course of Dapsone Induced Methemoglobinemia with Conservative Management/N. A3195 An Extremely Rare Case of Diffuse Alveolar Hemorrhage in a Patient with Scleroderma and Previously Undiagnosed Granulomatosis with Polyangiitis/A. A3198 Acute Hypoxemic and Acute on Chronic Hypercapnic Respiratory Failure in a Patient with Obesity Hypoventilation Syndrome After Perineural Catheter Interscalene Block Following Rotator Cuff Surgery/M. A3200 Tracheobronchial Aspiration in Adults: A Rare but Life Threatening Condition/S. A3202 Masquerade Dance of the Myxoma Ball: An Unexpected Cause of Acute Dyspnea/E. A3205 When Lungs Become Bone: A Rare Case of Idiopathic Dendriform Pulmonary Ossification/E. A3206 Rethinking the Thrombophilic Workup a Case of Severe Vitamin B12 Deficiency/S. A3209 Sterile Surprise: Aseptic Abscesses as Initial Presentation of Inflammatory Bowel Disease/R. A3210 Surgical Management of Tracheal Stenosis in an Adult Patient with Jarcho Levine Syndrome/M. A3211 Double-Bogey: How a Worsening Golf Game Uncovered a Chylothorax, Profound Lymphadenopathy and Progressing Chronic Lymphocytic Leukemia/C. A3212 Novel Case of Undifferentiated Hypoxia Leading to Adulthood Diagnosis of Fontainebleau Hemoglobinopathy/K. A3213 Laryngeal Myxedema: An Uncommon Presentation of Upper Airway Obstruction and Respiratory Failure/A. A3229 An Uncommon Complication of a Common Procedure: A Case Describing a Fatal Mediastinal Hematoma Following Central Venous Catheter Placement/R. A3231 Aortopathy Complicated by Spontaneous Chylothorax in a Patient with Turner Syndrome/R. A3235 Salmonella Swimming Up-(Blood)-Stream: A Case of Salmonella Empyema in an Immunocompetent Patient/I. A3238 Pleural Effusion Secondary to Superior Vena Cava Stenosis in the Setting of End Stage Renal Disease/A. A3215 the Protective Role of Pleural Fistulae in the Containment of Esophageal Rupture/M. A3216 Bilothorax: A Rare Complication After Percutaneous Transhepatic Biliary Drainage Placement/D. A3218 Recurrent Chylous Pleural Effusion in a Patient with Thoracic Duct Agenesis and Mediastinal Lymphadenopathy/M. A3220 Fighting with Every Fiber of His Being: A Case of Fibrous Mediastinitis Causing Superior Vena Cava Syndrome with Pleural Effusion/M. A3221 Maleficent Multiple Myeloma: A Case of Myelomatous Pleural Metastases with Effusion/M. A3227 Peripheral Eosinophilia and Eosinophilic Pleural Effusion Resulting from Spontaneous Pneumothorax/A. A3252 Epithelioid Mesothelioma Presenting as Incidental Hydropneumothorax, A Case Series/Y. A3253 Re-Expansion Pulmonary Edema After Drainage of Less than 1 Liter: A Case Report and Literature Review/A. A3254 An Uncommon Cause of a Unilateral Pleural Effusion: Esophageal Stent Migration/S. A3255 A Rare Case of Pleurodesis Achieved with Bilateral Tunneled Pleural Catheters in a Patient with Pancreatic-Pleural Fistula/N. A3260 Tension Hydrothorax Causing Cardiac Arrest: A Rare Complication of Malignant Effusions/C. P411 P412 Discussion: 11:15-12:00: authors will be present for individual discussion 12:00-1:00: authors will be present for discussion with assigned facilitators. A3271 Evaluation of a Wireless Pulse Oximeter to Improve Comfort with FreeO2 (Automated Oxygen Titration and Weaning)/F. A3273 Are Guidelines Regarding Alpha-1 Antitrypsin Deficiency Management Concordant A3296 Effects of Roflumilast on Chronic Bronchitis Symptom in Patients of Chronic Obstructive Pulmonary Disease/H. A3297 Prescription Status and Clinical Outcomes of Methylxanthines and Leukotriene Receptor Antagonists in Mild-to-Moderate Chronic Obstructive Pulmonary Disease/J. A3301 Chronic Obstructive Pulmonary Disease Pharmacological Treatment Effectiveness/A. A3302 Investigation of the Proper Use of Steroids During Admissions for Acute Exacerbation of Chronic Obstructive Pulmonary Disease at a Community Teaching Hospital/W. A3310 Assessment of Patient Experiences with Respimat in Everyday Clinical Practice/C. A3320 Pharmacokinetics and Safety of Budesonide/Glycopyrrolate/Formoterol Fumarate in Adults with Moderate-to-Severe Chronic Obstructive Pulmonary Disease: A Phase I, Open-Label, Single-Center Study/P. A3321 Clinical Efficacy of a Selective Phosphodiesterase-4 Inhibitor (Roflumilast) in Patients with Chronic Obstructive Pulmonary Disease and Metabolic Syndrome/G. A3322 Safety and Efficacy of Roflumilast in Chronic Obstructive Pulmonary Disease: An Updated Meta-Analysis of Randomized Controlled Trials/M. A3323 Safety of Inhaled Corticosteroid Withdrawal in Elderly Patients Hospitalized for Chronic Obstructive Pulmonary Disease Exacerbation: A Nationwide Cohort Study in Japan/T. A3325 Effect of Age on Efficacy and Safety of Multiple Inhaler Triple Therapy with Umeclidinium Added to Fluticasone Furoate/Vilanterol in Chronic Obstructive Pulmonary Disease/T. A3330 Inhaled Corticosteroids Dose Regimens: Therapeutic Relevance of Lipophilicity, Solubility, Dissolution and Absorption from the Lung/P. A3331 Effect of Endoscopic Lung Volume Reductions in Patients with Severe Emphysema - Single Center Experience/M. A 6 Month Prospective Cohort Crossover Study with Patients Acting as Their Own Controls/S. A3342 Performance of Contemporary Portable Oxygen Concentrators Across Diverse Breathing Behaviours/D. A3347 Does Inhaler Continuity and Familiarity Provide Clinical Benefits for Management of Patients with Chronic Obstructive Pulmonary Disease or Asthma A3348 Domiciliary Noninvasive Positive Pressure Ventilation Prolongs Time to Death in Patients with Chronic Obstructive Pulmonary Disease/H. A3349 Effects of Inhaler Therapy on Mortality in Patients with Tuberculous Destroyed Lung and Airflow Limitation/H. P536 Discussion: 11:15-12:00: authors will be present for individual discussion 12:00-1:00: authors will be present for discussion with assigned facilitators. A3355 the Management and Outcomes of Patients with Both Interstitial Lung Disease and Lung Cancer/K. A3356 the Role of Infection in Acute Exacerbation of Idiopathic Pulmonary Fibrosis/D. A3357 Analysis of the Clinical Characteristics of 176 Patients with Pathologically Confirmed Cryptogenic Organizing Pneumonia/D. A3359 Non-Acidic Reflux Correlates with Disease Severity in Idiopathic Pulmonary Fibrosis/Y. A3362 the Comparision of High Resolution Tomography Patterns in Familial Pulmonary Fibrosis/D. A3364 Changes in Pulmonary Function Test Results Within 1st 2 Years of Monitoring as Predictor of Long Term Decline in Pulmonary Function/K. A3365 Cardiopulmonary Exercise Testing as a Longitudinal Clinical Tool in Interstitial Lung Disease Management/L. A3367 P188 P176 Postoperative Acute Exacerbation of Interstitial Pneumonia in Pulmonary <and> for > Non-Pulmonary Surgery: A Retrospective Study/T. A3374 Clinical Features of Smoking-Related Unclassifiable Interstitial Pneumonia/A. A3375 Contributory Factors and Prevalence of Obstructive Sleep Apnea in Patients with Interstitial Lung Disease in Korea/J. A3378 Retrospective Analysis of Prognostic Factors for Acute Exacerbation of Idiopathic Interstitial Pneumonias/K. A3381 Clinical Courses of Asymptomatic Patients with Mild Idiopathic Pleuroparenchymal Fibroelastosis/M. A3383 White Blood Cell Count and Hospitalization as Additive Prognostic Indicators in Idiopathic Pulmonary Fibrosis/A. A3384 Serial Change in the White Blood Cell Count as a Prognostic Indicator in Idiopathic Pulmonary Fibrosis/A. A3385 Weight Loss as a Predictor of Mortality in Patients with Interstitial Lung Disease/J. A3368 Acute Exacerbation of Idiopathic Interstitial Pneumonias: Retrospective Analysis of Survivors/T. A3388 Clinical Significance of Desaturation During a 6-Minute Walk Test in Patients with Idiopathic Interstitial Pneumonia Without Hypoxemia at Rest/Y. A3390 Clinical Features of Pathologically Proven Acute Fibrinous and Organizing Pneumonia/M. A3391 Prognosis of Adults with Idiopathic Pulmonary Fibrosis Without Effective Therapies: A Systematic Review and Meta-Analysis/Y. A3392 Prevalence and Distribution of Depressive Mood Disorders in the University of Utah Interstitial Lung Disease Patient Population/S. A3394 Diabetes Insipidus After Discontinuation of Vasopressin Infusion for Treatment of Shock: Increased Incidence After Cardiothoracic Intervention/N. A3399 Palliative Care Utilization in In-Hospital Cardiac Arrest at an Urban Academic Medical Center/D. A3400 the Burden of Co-Morbidities and Organ Failure Is Strongly Associated with Mortality After Intensive Care Unit Cardiac Arrest/D. A3401 Changes in Goals of Care Immediately Following In-Hospital Cardiac Arrest in Seriously Ill Adults/P. A3402 Characteristics of Inpatient Extracorporeal Cardiac Arrest Teams in the United States of America/O.

Catheterisation in Females the female urethra is comparatively short and straight and catheterisation is not usually difficult women's health big book of exercises pdf buy 2mg ginette-35 visa. The patient should be asked to lie with her thighs apart and her knees comfortably flexed menopause kim cattrall buy ginette-35 2mg mastercard. After introduction of the local anaesthetic gel into the urethra Contraindications Catheterisation is best avoided when urethral injury is suspected women's health clinic san antonio purchase 2mg ginette-35 free shipping. Urinary tract infections are very difficult to eradicate in the presence of a catheter women's health clinic ucf ginette-35 2mg cheap, and so if a patient has an infection women's health center worcester ma cheap ginette-35 2mg online, an indwelling catheter should be avoided when possible pregnancy for dads discount ginette-35 2 mg free shipping. If catheterisation is to be performed in the presence of associated haematuria, a three way catheter, with an additional channel to run in sterile fluid for irrigation and removal of clots in the catheter lumen may be used. The catheters are usually made of `latex" to make it as biologically inert as possible. If a catheter is to be kept in place for more than a few days, a silicone catheter is preferred. Procedures and after swabbing the perineum with an antiseptic solution, the external urethral meatus is exposed by separating the labia. Avoid the femoral artery since the femoral vein is larger than the artery and often blood is drawn from the vein, which gives erroneous results. Problems If the patient is tense or insufficient time has been allowed for the topical anaesthetic to take effect the catheter may be held up because of spasm of the urethral sphincter. If the patient is asked to try gently to void when the catheter tip reaches it, the sphincter may relax sufficiently to let the catheter through. There may be a failure of the catheter balloon to deflate when the catheter removal is attempted. The best way to deal with this problem is to use a fine wire stillette introduced down the inflation channel to burst the balloon. If this fails ultrasound guided percutaneous needle puncture of the balloon is recommended. An indwelling catheter almost always leads to a urinary tract infection within days or weeks. The effects of this can be minimised by regular bladder washouts with saline or dilute chlorhexidine solution. When an infection is established, even the most intensive antibiotic treatment is unlikely to make the urine sterile until the catheter is removed. Long term catheterisation is commonly associated with the formation of stones in the bladder. The Specimen It is important to record the volume of urine drained from the bladder after introduction of the catheter. To prevent injection of lignocaine into the artery, always apply suction to the syringe before injecting the local anaesthetic. With the bevelled edge facing upwards, the needle is advanced towards the brachial artery, with constant suction applied to the syringe. As the blood enters into the syringe, it may be seen to pulsate into the syringe with its own force. After the procedure, apply firm pressure over the site of puncture with a sterile gauze, and apply a crepe bandage over it. Blood sample is then injected directly into the blood gas electrodes from the syringe without transferring it into any other container. If a delay is inevitable, cooling the syringe and its contents in ice with subsequent rewarming to body temperature before analysis is done in order to minimise errors caused by continued metabolism of the white cells within the blood sample. Relief of upper airway obstruction (foreign body aspiration, acute epiglottitis, acute laryngeal oedema). Site of Puncture the brachial artery just above the elbow crease of the nondominant arm (left arm in a right handed individual) is preferred. Elective temporary tracheostomy: It is a planned procedure done under general anaesthesia as a 820 Manual of Practical Medicine removed every 1/2 hour for 48 hours and thereafter for every 1 to 2 hours. Humidification is necessary to prevent crusting of secretion and is done by instilling normal saline drops down the tracheostomy tube at regular intervals. The tracheostomy tube should not be disturbed for the first 48 hours and thereafter the inner tube is cleaned at regular intervals. Removal of Tube the tracheostomy tube can be removed once the patient can sleep for a night with the tube corked. Permanent tracheostomy: this procedure involves removal of the larynx (laryngectomy or laryngopharyngectomy) with the tracheal remnant being brought out to the surface as a permanent opening to the respiratory tract. It has only a very few indications like a large laryngeal tumour requiring emergency relief of the obstruction. Silver Jackson tube: It is used for temporary tracheostomy and has an inner and an outer tube. Redcliffe tube: It is a single right angled tube useful in patients with a thick and fat neck. Surgical emphysema around the root of the neck and upper chest due to tight suturing of the tracheostomy tube. Block of tracheostomy tube may occur if there is improper humidification or poor toileting. Elective Tracheostomy the patient is positioned with a sandbag or pillow under the shoulders in order to extend the neck and bring the trachea forwards. A horizontal incision is made through the skin and subcutaneous tissue down to the muscles. The pretracheal fascia is identified and a vertical incision is made through it between the third and fourth tracheal rings. A semicircular wall of the trachea is removed from either side and a tracheostomy tube is inserted through this defect. Emergency Tracheostomy Patient is positioned in a similar manner as in elective tracheostomy. One percent lignocaine is infiltrated from the cricoid cartilage to the manubrium of sternum, which is the line of incision. The first tracheal ring is palpated and a horizontal incision is made at the level of the second tracheal ring. There is increased secretion formation in the first 48 hours after the procedure and needs to be Endotracheal Intubation this is an emergency procedure for providing adequate ventilation in cases of respiratory failure. Transnasal: these are smaller tubes of sizes 6 and 7 and are passed through the nasal cavity. Procedure Oral Intubation the patient is positioned supine with his neck extended. Visualisation of the oropharynx, nasopharynx and vocal cords is done using a laryngoscope blade. The lateral flange of the blade is placed on the lateral aspect of the tongue so as to deflect the tongue to one side and obtain proper visualisation. The endotracheal tube of appropriate size is then introduced into the trachea through the vocal cords. The cuffed endotracheal tube is then inflated with the aim to keep the tube in position. Transnasal Intubation this is a blind procedure initially when the tube is introduced through the nasal cavity. The passage of the tube through the nasal cavity is facilitated by instilling 1% ephedrine drops in the nostrils. After entering the oropharynx, the tube can be guided through the vocal cords into the trachea by visualisation through a laryngoscope. Tracheal dilatation due to over-distention of the cuff leading to subsequent infection and stenosis. Bleeding time 5 to 10 minutes Clotting time 10 to 15 minutes Fibrin degradation products < 8 g/ml Fibrinogen 200 to 400 mg/dl Partial thromboplastin time (activated) 25 to 35 sec. Reproduction and dissemination of material in this information product for educational or other non-commercial purposes are authorized without any prior written permission from the copyright holders provided the source is fully acknowledged. Reproduction of material in this information product for resale or other commercial purposes is prohibited without written permission of the copyright holders. Introduction Present and future demands for plant nutrients in developing regions ix x xi 1 2 2. Food security and agricultural production Striving for food security Food security for a growing world population Food production prospects in developing countries Problems and possibilities Demands on agriculture for providing food security Nutrients in production and consumption cycles and nutrient transfers 5 5 7 11 14 17 19 3. Soil fertility and crop production Soils as a basis for crop production Soil constituents Soil properties and plant requirements Nutrients in soils and uptake by plants Dynamics of plant nutrients in soils Dynamics of major nutrients Assessment of available nutrient status of soils and plants Impact of soil fertility on crop productivity Fertility management of soils in different climate regions 43 43 45 49 60 65 66 74 83 85 iv 5. Sources of plant nutrients and soil amendments Mineral sources of nutrients (fertilizers) Organic sources of nutrients Biofertilizers (microbial inoculants) Soil amendments 91 92 119 130 136 6. Guidelines for the management of plant nutrients and their sources Preconditions for successful nutrient management Guidelines for nutrient management through fertilizers Guidelines for fertilizer application Guidelines for the application of organic manures Guidelines for the application of biofertilizers Application of soil amendments 193 193 196 208 223 226 232 8. Nutrient management guidelines for some major field crops Cereals and millets Grain legumes Oil crops Root and tuber crops Sugar crops Fibre crops Pastures 235 235 243 244 251 255 258 260 9. Plant nutrition, food quality and consumer health General aspects Plant nutrition and product quality Consumer health issues and food quality 281 281 285 292 11. Plant nutrition and environmental issues Basic effects of nutrient management on the environment Environmental aspects of plant nutrients Minimizing the negative environmental effect of nutrient use 299 299 302 310 Glossary Bibliography Units and conversion factors 315 339 347 vi List of figures 1. Ranges of exchangeable cation in soil for the interpretation of cation exchange data 12. General soil test limits used for classifying soils into different fertility classes 13. Critical nutrient concentrations for 90-percent yield for interpretation of plant analysis data 15. Average nutrient composition of some organic manures derived from the animal wastes 25. Nutrient-related constraints in relation to increasing yield, example of tea in south India ix 26. The impact of lime and fertilizer application to maize over 40 years in an acid soil at Ranchi, India 28. Buildup and maintenance approach for making fertilizer recommendations for maize 34. Suitable quantities of Rhizobium inoculant and sticker for inoculating legume seeds 38. The economics of incremental crop response to increasing rates of fertilizer application 40. Example of net returns and benefit-cost ratio as determined from the results of field trials 41. Essential mineral nutrient elements besides N and S, daily requirements and the effects of deficiencies 42. Chemical analysis of potentially hazardous elements in sedimentary phosphate rocks 45. Range in concentration of potentially useful and harmful elements in phosphate rock 46. Conditions favouring N losses and general strategies for minimizing such losses 149 150 154 155 157 160 161 167 180 184 190 228 233 267 270 293 299 301 308 308 309 313 x List of plates 1. Biogas plant, example from India 125 xi Preface An expanding world population and the urgency of eradicating hunger and malnutrition call for determined policies and effective actions to ensure sustainable growth in agricultural productivity and production. Assured access to nutritionally adequate and safe food is essential for individual welfare and for national, social and economic development. For biomass synthesis, which serves as the food resource for humans and animals, nutrient supply to plants is a prerequisite. Therefore, an adequate and appropriate supply of plant nutrients, is a vital component of a crop production system. Agricultural intensification, one of the basic strategies for enhanced food production, is dependent on increased flows of plant nutrients to the crops for securing high yields. Unless supported by adequate nutrient augmentation, the process of agricultural intensification would lead to land degradation and threaten the sustainability of agriculture. In the past two decades, it has been increasingly recognized that plant nutrient needs in many countries can best be provided through an integrated use of diverse plant nutrient resources. This guide on integrated plant nutrient management, dealing with various aspects of plant nutrition, is an attempt to provide support to the ongoing efforts directed at enhanced and sustainable agricultural production. Roy to the conceptualization, initiation, technical guidance, inputs, reviewing and editing of this publication is duly acknowledged. Misra in reviewing and providing constructive suggestions is most gratefully acknowledged. However, access to drinking-water and food, while easily obtained for some, is difficult for many. In addition to being physically available, these materials should also be of acceptable quality and continuously so. Throughout time, there have been periods of famine leading to suffering and starvation, making the fight against hunger and the diseases caused by malnutrition a permanent challenge. For many centuries until about 1800, the average grain yield was about 800 kg/ha, providing food only for a few people.

Individuals frequently develop blood clots pregnancy online test purchase ginette-35 2 mg fast delivery, which can cause life threatening thromboembolic episodes pregnancy test purchase ginette-35 2 mg on line. At least nine genetic defects have been shown to disrupt the major pathway in which methionine is metabolized menopause irregular bleeding order ginette-35 2 mg with visa. Cystathionine -synthase deficiency is the most common and results in high levels of serum methionine women's health clinic umich effective ginette-35 2 mg. Slightly less than 50% respond to vitamin B6 therapy womens health yakima buy cheap ginette-35 2 mg online, and those that do should continue throughout their life women's health clinic san antonio discount 2mg ginette-35 fast delivery. Treatment appears to reduce the risk of thromboembolic episodes, seizures, and mental disability and delays lens dislocation. Treatment must continue throughout life and people with homocystinuria should receive specialized treatment through a metabolic clinic that has experience in treating this disorder. The homocystinuria screening test may yield equivocal results for babies who have received hyperalimentation or other therapeutic infusions. The result will be reported as "invalid" and a followup screen will be recommended when treatment is concluded. Symptoms include poor feeding and failure to thrive, vomiting, lethargy, hypotonia or hypertonia and the characteristic maple syrup smell of their urine. Glucose and insulin infusions are commonly given during episodes of acute metabolic decompensation. Affected infants develop normally with early identification and proper dietary management. Although the exact pathogenesis of the damage to the central nervous system is still not clear, it seems likely that an increased concentration of phenylalanine in the blood is associated in some way with the neurodegenerative effects. Strict dietary restriction of natural protein is required to reduce high blood phenylalanine levels. Phenyl-Free) supplemented by low-protein foods and avoidance of aspartame (NutraSweet). Treatment should be started as soon as the diagnosis is confirmed and should be continued indefinitely to optimize normal physical and mental development. The staff consists of a pediatric biochemical geneticist, nutritionists, a social worker, and genetic counselor. It is especially critical that women of childbearing age maintain very strict dietary control. Women with high levels of phenylalanine during pregnancy are at increased risk of fetal loss, fetal brain damage, and other birth defects. A small percentage will be missed if the screening is done very early (prior to 12 hours of age). The result will be reported as "invalid" and a follow-up screen will be recommended when the infusion treatment is concluded. Deficiency of this enzyme causes a build-up of tyrosine and succinylacetone in the bloodstream. This is severely toxic to the liver, kidneys, heart and the nervous system, which can lead to multi-organ failure, seizures, coma and death. Early detection and treatment can reduce the mortality and morbidity associated with this disorder. Without early treatment, both forms may present with diarrhea, vomiting, poor weight gain, jaundice, enlarged liver, edema (swelling of the abdomen or feet), painful abdominal crises, irritability and a characteristic "cabbage-like" odor in the skin and urine. False negative results can occur when specimens are obtained following a blood transfusion. This condition can cause heart disease, mental disability, developmental delay in both motor and cognitive functions, and possibly death. Acute episodes are associated with refusal to feed, vomiting, listlessness, and lethargy, progressing to coma and death if not managed aggressively. Cardiomyopathy, liver complications, mental disability, developmental delay and muscle weakness may present later in life. This defect affects the transport of carnitine into the skeletal muscles, heart and kidneys, leading to an impairment of fatty acid oxidation. Normal carnitine transport is also essential in renal reabsorption of carnitine to maintain normal plasma carnitine levels. Treatment must begin immediately upon diagnosis before irreversible organ damage occurs. Therefore, when diagnostic work-up occurs for the infant, maternal samples for plasma acylcarnitine profile and blood free carnitine analyses should be collected concurrently. This responds well to oral therapy with metronidazole (an antibiotic effective against anaerobic bacteria). Administration of certain drugs such as valproic acid and other compounds like benzoic acid and pivalic acid can cause false positive test results. These conditions can damage the heart, brain, kidneys and vision and can rapidly progress to death. A severe, neonatal cardiac form characterized by early onset of heart disease (cardiomyopathy) and sudden infant death. Even with early detection and treatment, due to multi-system involvement and recurrent metabolic crises only a few patients have survived. It is characterized by failure to thrive, vomiting, episodes of low blood sugar levels, seizures, and lethargy. A later onset form is noted after childhood and generally presents with muscle pain and weakness induced by exercise and strenuous physical activities. In most patients, nerve sensations such as tingling precedes breakdown of muscle tissues. These three enzymes play important roles in the fatty acid oxidation pathway that produces energy during periods of metabolic stress and glycogen depletion after prolonged fasting. Treatment consists of avoiding fasting by eating frequent meals, reducing dietary fat, and carnitine supplementation. However, without these environmental triggers survival can continue through adulthood. Clinical signs are variable and may be confused with other fatty acid oxidation disorders. Infants may present with hypoglycemia, vomiting, and lethargy, which may progress to seizures, coma, and sudden death. Those affected need to avoid fasting by having frequent meals and limiting their intake of medium- and long-chain fatty acids. In circumstances where food cannot be tolerated, such as during an illness, intravenous glucose support may be required. Carnitine supplementation is sometimes prescribed to correct for secondary carnitine deficiency and to help eliminate toxic metabolites. The result will be reported as "invalid" and a followup newborn screen will be recommended when treatment is concluded. It is caused by a deficiency in the very long-chain acyl CoA dehydrogenase enzyme which results in the failure to break down very long-chain fatty acids (12-18 carbon molecules) for energy metabolism. This condition can damage the heart, muscles and kidneys, and can cause seizures or death. An infantile form characterized by non-specific signs and symptoms such as irritability, decreased muscular activity and lethargy. With early detection and treatment, cardiomyopathy can be resolved and death can be prevented. A later onset form manifested by muscle pains and weakness, which is induced by strenuous physical activities or prolonged episodes of fasting. If detected early and treatment is started, metabolic imbalances and complications to the kidneys can be prevented. When inconclusive, they are followed by enzyme studies in fibroblasts to establish a diagnosis. Administration of certain drugs such as valproic acid, antibiotics containing pivalic acid, and other compounds like benzoic acid and can cause false positive results. An illness or period of fasting can precipitate a metabolic crisis manifested by hypoglycemia and can lead to death. With early detection and treatment, the child has a better chance of normal neurodevelopmental outcomes. If the baby has abnormal diagnostic lab results, maternal samples may be requested as well. Acute episodes are associated with vomiting, diarrhea, failure to thrive, and seizures. Intercurrent infections or increased protein intake can precipitate a metabolic crisis leading to coma and death if left untreated. The frequency of decompensation falls with age and is not common after the age of ten. Treatment must begin immediately upon diagnosis before irreversible damage occurs. Families must be taught how to monitor urinary ketones to be alert for impending metabolic crisis. Typically between 2-18 months of age, a nonspecific illness such as a respiratory or gastro-intestinal infection, or even an adverse reaction to immunization may lead to an acute metabolic crisis progressing to neurologic complications. Early signs of an encephalopathic crisis include irritability, lethargy, and hypotonia. Hence, a metabolic decompensation must be treated aggressively to avoid permanent brain damage. With early detection and treatment, neurodevelopmental complications can be prevented but for patients who are already neurologically impaired, treatment can minimize further brain damage. This enzyme is active in the liver, kidneys, fibroblasts and leukocytes and helps break down lysine, hydroxylysine and tryptophan. This condition can cause brain damage and rapidly progresses to coma and death from cerebral edema or hemorrhage. Acute episodes are associated with nonspecific signs and symptoms such as vomiting, irritability, seizures, and lethargy progressing to coma and death. With early detection and treatment, infants can survive the neonatal period without serious complications or neurologic damage. A later-onset form occurs in the first year of life and is often triggered by respiratory infections or excessive consumption of protein. It presents with failure to thrive and recurrent episodes of vomiting, lack of appetite and lethargy. With early detection and treatment, mental disability, speech and other developmental delays can be avoided. Aspirin and benzoic acid will block the beneficial effects of glycine, and should be avoided. The result will be reported as "invalid" and a follow-up screen will be recommended when treatment is concluded. Metabolic imbalances can cause brain damage and rapidly progress to coma and death. Early detection and treatment reduces the mortality and morbidity associated with these disorders. However, even with treatment, the clinical presentation of these conditions varies. The early onset, severe form is characterized by poor feeding, vomiting, dehydration, respiratory distress, lethargy, seizures, posturing or poor muscle tone. Acute episodes are usually precipitated by fever, vaccinations or intercurrent infections and can lead to death. Many patients identified clinically showed poor nutritional status with growth disability and neurologic impairment. A late onset, milder form is often manifested by refusal to feed, vomiting, dehydration, respiratory distress, seizures, lethargy and can lead to death. It can be precipitated by excessive protein intake, fever or intercurrent infection. The milder forms have a better prognosis than the early-onset forms and patients will benefit from early detection and treatment through newborn screening. Propionic acidemia is caused by a deficiency in the propionyl Co-A carboxylase enzyme. The primary marker for methylmalonic acidemia and propionic acidemia is propionylcarnitine (C3). Acute episodes are associated with skin rashes, hair loss, vomiting, breathing problems, and seizures. If left untreated this may lead to poor growth, learning disabilities, and mental disability. With early detection and treatment, the child has a good chance of normal neurodevelopmental outcomes. Biotin is a B-complex vitamin (also known as vitamin B7 or vitamin H) that is essential in the metabolism of carbohydrates, proteins, and fats for energy production. Holocarboxylase synthethase catalyzes the transfer of biotin to four biotin-dependent enzymes, namely: 1) beta-methylcrotonyl Co-A carboxylase, 2) propionyl Co-A carboxylase, 3) pyruvate carboxylase, and 4) acetyl Co-A carboxylase. If the baby has abnormal diagnostic lab results, the specialists may want to test the mother as well. This usually presents itself as an enlarged clitoris and fusion of the labia majora over the vaginal opening. Occasionally the female infant may be so virilized at birth as to result in erroneous gender assignment. As with all disorders, providers should proceed with diagnostic testing if clinical symptoms are present despite the results of the newborn screening test.

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