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Further history revealed only occasional consumption of nuts with daily servings of tea and polyethylene glycol pulse pressure 65 midamor 45mg discount. Discussion: Oxalate nephropathy can result from primary (genetic) or secondary mechanisms arrhythmia definition medical cheap midamor 45mg without a prescription. The most common secondary causes include increased intestinal oxalate availability ("enteric" hyperoxaluria) and increased dietary consumption blood pressure chart with pulse rate generic 45 mg midamor otc. A basic medical history can reveal risk factors for enteric hyperoxaluria arrhythmia access buy midamor 45mg amex, while a thorough review of diet and supplements is often deferred arteria hyaloidea cheap midamor 45mg fast delivery, delaying the diagnosis blood pressure chart age 35 buy cheap midamor 45 mg line. In some cases a single cause is not identified, and instead a combination of dietary and pharmacologic factors are to blame. We present 1 case of oxalate nephropathy most likely caused by high-dose Vitamin C, and another case with a less clear etiology aside from vague dietary and medication factors. She developed progressive hypoxia and blood-tinged sputum concerning for pulmonary/renal syndrome and was treated with immunosuppression and plasma exchange. Additional patient history elucidated recent acquisition of a pet cat and multiple scratches. The case demonstrates how renal biopsy and social history remain vital diagnostic tools in patients presenting with non-specific systemic illness. He was given blood, intravenous fluids and right percutaneous nephrostomy was place but creatinine rose to 5mg/dl so renal biopsy was done. The specimen had 120 glomeruli and 12 were sclerosed There was focal organizing arterial and arteriolar thrombi. The interactions and mechanisms that regulate this effect are of great interest as targets for clinical intervention. However, the downstream effects on splenic structure and function that lead to protection are still not fully understood. Vagus nerve stimulation was triggered optogenetically using blue light to target the vagus nerve of mice expressing channelrhodopsin-2 under control of the vesicular glutamate transporter 2 promoter. Monocyte and neutrophil representation remained relatively stable, but eosinophils displayed a marked reduction of ~60%. Conclusions: Cholinergic stimulation triggers reorganization of immune cell populations and alterations in gene expression that are likely important for regulating the inflammatory environment. Additional characterization and functional studies are currently underway to fully identify the importance of observed changes. Background: Reprogramming of immune cell metabolism have been associated with the development of kidney injury. Conclusions: the pro-inflammatory status of macrophages relays on glycolysis in CaOx nephropathy. Toxicity from antiviral drugs is a major cause of kidney disease in these individuals. A high-content image analysis pipeline was established, using automated microscopy and machine learning, to quantify transport function, using dome formation as a readout. Metabolism was evaluated by antibody staining for mitochondrial morphology and autophagy. Results: We screened numerous treatment regimens and generated phenotypes matching those observed in patients, including transport inhibition and mitochondrial hypertrophy. Renal pathology, including fibrosis, mesangial matrix expansion, and tubular hypertrophy were significantly higher in 0-copy and A71915-treated 2-copy mice but minimally in 4-copy mice compared with controls. Inhibiting lipogenesis causes G2/M cell cycle arrest, which can cause maladaptive tubular repair. Overall survival (glioma transplant model) and tumor growth and weight (colon and pancreatic tumor xenograft models) were assessed. Radiolabeled [3H]-thymidine incorporation was used as a measure of cell proliferation. We define patterns of maladaptive proximal tubule repair and characterize important signatures in immune cell composition and activation in regenerating vs. Using spatial transcriptomics clustering, we compared the affected clusters, including the cortical collecting duct, S3 outer stripe proximal tubule, and thick ascending loop of Henle. The identified regions housed specific cell types with differences in enriched pathways. The neutrophil and macrophage spatial distribution indicate how those models respond to injury. Further classification, annotation, and visualization were facilitated by Partek and R statistical packages. Balzer,1,2 Yawen Yang,1,2 Ziyuan Ma,1,2 Rojesh Shrestha,1,2 Matthew Palmer,3 Katalin Susztak. Background: After acute injury the kidney has the ability to regenerate and repair to a certain extent. On the other hand, maladaptive injury response leads to kidney fibrosis and chronic kidney disease. We are only beginning to understand the complex interactions of epithelial, stromal and immune cells involved in these adaptive processes. Kidney function, structure, bulk and single cell gene expression analysis was performed on day 1, 3 and 14. We used gene regulatory network and trajectory analyses to define key drivers of successful and failed regeneration. Proximal tubules showed distinctly different differentiation signatures for successful repair vs. Anonymized retrospective data from the electronic health record were collected between Sep 2016-Dec 2018. Roxadustat, a hypoxia-inducible factor prolyl hydroxylase inhibitor, treats anemia by enhancing erythropoietin synthesis and increasing iron availability via reducing hepcidin and increasing iron transport. Results: Overall, 4277 patients were evaluated (roxadustat N=2391; placebo N=1886). Roxadustat reduced hepcidin and increased both transferrin and serum iron (Figure). Coyne,4 Roberto Pecoits-Filho,5 Chaim Charytan,6 Maksym Pola,7 Lona Poole,8 Gopal Saha,8 Willis Chou,8 Tyson T. Results: Least-squares mean treatment differences favored the roxadustat group at Week 12 (all p-values <0. Betweengroup differences were larger in subgroups with lower (ie, worse) baseline scores. Significantly fewer patients required rescue therapy during roxadustat treatment vs. The effect was consistent in all subgroups and especially pronounced in patients with baseline Hb <8. In the roxadustat arm, significant erythropoiesis was noted with mean Hb increases of 1. All initial changes in iron parameters plateaued by wks 16-20, and remained unchanged thereafter. Reticulocyte Hb content at wk 20 were at baseline level, and it was maintained at Weeks 28- Week 52. Maintenance of reticulocyte Hb content level during treatment reassures sufficient iron availability during erythropoiesis with roxadustat. Patients were randomized to receive roxadustat or placebo with periodic dose evaluation/ titration. Transfusion was allowed at any time if it was deemed a medical necessity by the Investigator. When patient-exposure data were stratified by achieved Hb levels, the risk for transfusion increased as Hb levels decreased (Table). The incidence rate of transfusion increased approximately 4-fold in patients with Hb between 8. Background: Inflammation is a common cause of decreased responsiveness to erythropoiesis-stimulating agents. Roxadustat, an oral hypoxia-inducible factor prolyl hydroxylase inhibitor, treats anemia by inducing endogenous erythropoietin production and increasing iron utilization via reducing hepcidin. Roger,2 Roberto Manllo-Karim,3 Maksym Pola,4 Stefan Tham,5 Lynda Szczech,6 Carol A. The cumulative percentage of patients with Hb 10 g/dL for at least 2 consecutive visits was analyzed monthly over 12 months of roxadustat treatment, using the number of patients remaining on roxadustat treatment at each time point as the denominator. Among patients still on roxadustat treatment, the cumulative percentage of patients with Hb 10 g/dL for at least two consecutive visits was 38. Among patients still receiving roxadustat treatment at 12 months, the cumulative percentage with confirmed Hb 10 g/dL was 99. Of note, recent research suggests that iron utilization plays a key role in bone turnover in hemodialysis patients. Patients were switched from intravenous epoetin to oral roxaduastat therapy (100 mg 3 times weekly), with no dose change in any of the iron supplements, calcimimetics or vitamin D formulations being used, and were assessed after 8 weeks of roxaduastat therapy for improvements in anemia, as well as for changes in parameters related to iron metabolism and bone turnover. Patients were randomized to receive roxadustat or epoetin alfa with periodic dose evaluation/ titration. The incidence rate of transfusion was calculated based on Hb level categorized as: <8. Data were evaluated for the on-treatment period + 28 days after the last dose of study drug. When patient-exposure data were stratified by achieved Hb level, the risk for transfusion increased as Hb levels decreased (Table). The incidence rate of transfusion increased approximately 5-fold in patients with Hb <10 g/dL vs. Sepah,1,2 Yusuke Yamaguchi,3 Tetsuro Otsuka,3 Yoshikatsu Majikawa,3 Michael Reusch,4 Tadao Akizawa. Nonclinical data had suggested that hypoxia-inducible factor stabilization may promote angiogenesis, increasing the risk of retinal pathologies. We herein report the 24-week ophthalmological findings from two phase 3 studies of roxadustat in Japan. Ophthalmological assessments (funduscopic photograph, optical coherence tomography) were performed by centralized grading; visual acuity was assessed locally. Results from the ophthalmological funduscopic photograph assessments are reported in Table 1. No meaningful changes occurred in visual acuity or retinal thickness in the treatment groups of either study. A final analysis of this study (including 52-week data) will be presented at the congress. Poster Thursday Anemia and Iron Management a Any evidence of retinal hemorrhage, from "No" at baseline to "Yes," and/or an increase from baseline in the total number of retinal hemorrhages. Metabolic shift from oxidative phosphorylation toward glycolysis in myotubes in vitro was previously reported. Exercise ability was also assessed by treadmill exhaustion test, forelimb grip test, and electric-pulse-induced isometric plantar flexion torque measurement after a single dose or chronic 5-week treatment, in addition to which muscle weight and muscle fiber-type were also measured. Mice treated with the agent for 5 weeks showed higher blood hemoglobin levels and improved exercise endurance in treadmill exhaustion test, while the treatment provided comparable results in isometric plantar flexion torque measurement. In the A+ group, >75% of caregivers described anemia as being moderate or severe, and >90% of patients had received anemia treatment in the past month (oral iron, 45. Further studies are needed to better understand its full extent and explore support strategies for caregivers. Background: Several jurisdictions have adopted a more conservative approach to anemia in patients receiving dialysis amid safety concerns from target hemoglobin trials. In this retrospective national cohort study, we sought to examine the association between the era of anemia management and major clinical outcomes in incident dialysis patients in Canada. Methods: the Canadian Organ Replacement Register was used to identify 35,945 adult patients who initiated hemodialysis or peritoneal dialysis from Jan 1 2007 to Dec 31 2015. Time at risk started on day 90 of dialysis and continued for a minimum of 12 months to capture outcomes via data linkage with hospital discharge diagnoses. Patients were categorized into 3 time periods anchored to landmark target hemoglobin trials and publication of anemia guidelines: Era 1 (Jan 2007-Dec 2009); Era 2 (Jan 2010-Dec 2012); Era 3 (Jan 2013-Dec 2015). Patient survival has improved over time, likely for reasons other than anemia management. An increasing number of patients are starting dialysis with a hemoglobin <80g/L, which represents a substantial shift in practice and merits further investigation in terms of patient-centered outcomes. The median number of days from anemia diagnosis to first anemia treatment was 48 days. Michalopoulos,1 Marjolaine Gauthier-Loiselle,2 Myrlene Sanon,1 Elizabeth Serra,2 Rebecca Bungay,2 Diana Clynes,3 Martin Cloutier,2 Erin Kahle,3 Annie Guerin,2 Youssef M. Outcomes were summarized descriptively for caregivers of patients with anemia (A+) and without anemia (A-). Nearly 90% identified themselves as the primary caregiver; 60% were aged 35 to 64 years and >70% were female. Kumar,3 Juan Jose Garcia Sanchez,2 Hungta (tony) Chen,3 Kamyar Kalantar-Zadeh,4 James A. Median annual number of transfusions doubled (2 vs 1) and annual transfusion cost was 50% greater in patients with vs without baseline anemia, respectively. Methods: A lifetime Markov model was developed to estimate the economic impact of anemia. Costs associated with anemia treatment such as erythropoiesis-stimulating agents or supplemental iron were not considered. Therefore, anemia management, aligned with clinical guidelines, has the potential for better outcomes for both the patient and the healthcare system.
Socioeconomic parameters such as age hypertension stage 1 jnc 7 midamor 45 mg lowest price, race heart attack mike d mixshow remix discount 45 mg midamor amex, employment status heart attack jack johnny b bad purchase midamor 45 mg line, and education level were taken at the beginning of the study blood pressure yoga purchase midamor 45 mg with mastercard. Especially blood pressure medication guidelines cheap midamor 45 mg overnight delivery, the more severe patient is heart attack jack black widow purchase 45mg midamor with visa, the lower blood flow into circuit due to hypotension can lead to decrease circuit lifespan. Results: the results showed that first circuit clotting was significantly related to serum bicarbonate (r=0. Blood pressure, infection, blood flow of circuit showed no relationships with circuit lifespan. The use of heparin and nafamostat increased circuit lifespan compared to non-anticoagulant. Poster Thursday Hemodialysis and Frequent Dialysis - 4 Home Hemodialysis Patient Loss: A Quality Improvement Initiative to Review Technique Failure in Alberta Kidney Care - South Bailey Paterson,1 Victoria Riehl-Tonn,2 Elena Qirjazi,1 Jennifer M. Our primary objective of this study is to survey these key stakeholders to identify these barriers. We performed a qualitative analysis to identify common themes and implementation barriers. Machine set-up, take-down, and establishing access were thought to be essential services. Frontline nurses have identified several important barriers to implementation which we will acknowledge and address when deploying our assisted home program over the upcoming year. We used claims data to estimate distributions of facility-level home dialysis prevalence and kidney transplant incidence. In each dialysis facility with 132 adult patient-months, we estimated the percentage of patient-months with any home dialysis treatment. Using Part A claims in 2017, we also estimated the number of kidney transplants among dialysis patients in the facility. Results: We identified 6263 dialysis facilities and 3,645,655 dialysis patient-months. The distribution of facility-level home dialysis prevalence exhibited three features, as displayed: (1) over 54% of facilities with exactly 0% home dialysis prevalence; (2) among facilities with any home dialysis utilization, a unimodal distribution with peak prevalence near 12%; and (3) a small subset of facilities (4%) with home dialysis prevalence >90%. Conclusions: In patients with Medicare fee-for-service coverage, facility-level home dialysis prevalence exhibits a nonnormal distribution, while kidney transplant incidence typically manifests few (or no) events per year. Alternative methodology should consider assessments in regional clusters of facilities. Introduction: Heparin-free hemodialysis is usually obligatory in immediate postoperative states, bleeding diathesis and in critically ill patients. Conventionally, this is achieved through normal saline flushes, and regional citrate anticoagulation. He required emergent pericardiocentesis for cardiogenic shock from hemorrhagic pericardial effusion. Its clinical consequences include extraskeletal vascular and valvular calcifications, changes in bone metabolism resulting in renal osteodystrophy, and an increased risk of cardiovascular morbidity and mortality. The results of treating secondary hyperparathyroidism by Etelcalcetide in a special cohort of the patients for 6 consecutive months are illustrated in the graph. Conclusions: this study showed that Etelcalcetide is efficient and well tolerated in this special group of sick, highly comorbid, bed and home bound home hemodialysis patients. Poster Thursday Home Hemodialysis A Pilot Evaluation of Thiol Metabolome in Peritoneal Dialysate as an Indicator of Peritoneal Fibrosis Patricia Q. Low molecular weight thiols have been implied in the epithelial to mesenchymal transition, a process known to occur in peritoneal fibrosis. This study aimed to evaluate thiol metabolome in peritoneal dialysate and its relationship with peritoneal fibrosis. Thiol metabolome definition: total, free and protein bound fractions of glutathione, cysteine, cysteinylglycine and glutamylcysteine. Methods: Peritoneal fibrosis was evaluated in biopsy specimen, performed during the placement of Tenkhoff catheter. Thiol related metabolome in peritoneal dialysate was assessed by high performance liquid chromatography+fluorescence detection. Conclusions: There is a thiol metabolome profile that can be measured in intraperitoneal dialysate fluid, that is related to fibrosis and rich in oxidized cysteine. This preliminary data might also support the existence of cysteine-dependent mechanisms of intraperitoneal fibrosis. But, the profile, treatment charactestics could be different from the western context but it remains unknown. The addition of race and payer improved the discrimination of logistic regression, with black race and concurrent Medicaid enrollment as negative predictors of home dialysis utilization. Reliable treatment strategies that successfully prevent progressive peritoneal fibrosis are still lacking. Focusing on identifying and addressing modifiable conditions may help to keep more patients dialyzing at home. Background: Increasing home dialysis utilization is an aim of the Advancing American Kidney Health Initiative. We also assessed the extent to which race and payers-possible systemic barriers to home dialysis-account for this variation. Policy makers eager to promote home dialysis should temper expectations of improved outcomes and reduced spending. We used dialysis start day as an instrumental variable to mitigate selection bias when comparing outcomes and costs of the two modalities. We assessed the potential role of selection bias in prior studies by repeating the same analyses using traditional regression methods. Matching was performed in a 1:1 ratio according to year of dialysis initiation (+/- 2 years), age (+/- 2 years), gender, race, and reported cause of kidney disease. Patient vetting incorporated multidisciplinary evaluation of support systems and socio-economic and cultural determinants of health within their specific ecosystem. Expedited referral to an expert surgeon for laparoscopic catheter insertion was crucial. These findings may support future studies on the current use of lower volumes with newer catheters. Background: Due to increased risk for infection, fluid leak, metabolic complications and poor uremic solute clearance, concerns have been raised in using peritoneal dialysis in obese patients. Treatment goals were achieved based on relevant parameters and there were no increases of treatment related complications compared to non-obese patients. There were no differences in patient characteristics between pre- and post-policy cohorts. Outcomes were compared across exposure groups using models adjusted for age and sex. The primary outcome was all-cause mortality and the main exposure of interest was a cumulative dose of statin. For defining the cumulative dose for statin, the definition of defined daily dose by World Health Organization was used. Clinical data were collected at baseline and at 3, 6, 9, 12, 18, 24, 30, 36, 48, 72, 96, and 120 months after dialysis. The following variables were tracked: crude mortality rate and causes, hospitalization variables (number of hospitalization days per patient; number of hospitalization episodes per patient; number of days per hospitalization episode; causes of hospitalization), peritonitis rate (episodes/ year at risk and patient months at risk to a peritonitis episode) and transplantation rate. Few analyses have compared outcomes between patients utilizing these two dialysis initiation routes. Methods: All data for this retrospective study were derived from deidentified electronic health records. Background: Increasing the number of dialysis patients who start and maintain home therapies is an urgent national priority. Family members may assist with moving dialysate bags, catheter care, dialysis machine set-up and connections, and medication administration. Understanding and supporting caregivers is an important driver of successful home dialysis, necessary to inform program content and activities. This study describes associations between patient reported family member assistance with healthcare tasks, and modality persistence. A baseline survey assessing family assistance with healthcare tasks at home was administered during a routine outpatient visit. Results: this sample of N=100 patients was 57% male, 31% African American, and 4% Hispanic/other. Also, 16% reported help with one or two tasks, 28% help with three tasks, 25% help with five tasks. Patients who selfidentified as Black/Hispanic/other reported less family member assistance than whites (51% vs. More work is needed to better characterize the caregiver role and its impact on health outcomes specific to home dialysis. Poster Thursday Peritoneal Dialysis - 1 approach to identify individual risk factors leading to the index hospitalization and targeted interventions are not directly designed into clinic workflow. Based on these categories, we created a list of potential contributory risk-factors for admission. We also surveyed providers to determine key clinical components for a clinic checklist to encourage early recognition of the risk-factors. Such admissions included peritonitis (34%), hypervolemia (19%), electrolyte derangement (13%), hypotension (13%), hypertension (10. Ultimately, through utilization of this tool, we hope to unify our practice pattern in the clinic to reduce admission rates by prompting proactive, not reactive, interventions. Eligible patients include frail, mostly elderly patients who are symptomatic from advanced kidney disease and have residual kidney function. Conclusions: Our results demonstrate a frail, elderly population with multiple comorbidities. Background: Readmission rates are a component of quality metrics in home dialysis follow-up. However, a systematic Poster Thursday Peritoneal Dialysis - 1 Outcomes of Urgent-Start Peritoneal Dialysis in a Retrospective Cohort Gonzalo Matzumura Umemoto, Frank J. Methods: A retrospective analysis of patients that underwent urgent start peritoneal dialysis from 2013 to 2019 at the Washington University Home Modalities Dialysis Clinic was conducted. Cox proportional hazard model was applied to investigate the primary endpoint, and logistic regression analysis was used to assess the secondary endpoint. Results: the study population included 407 males and 275 females, with a mean age of 60. In univariate analysis, hyperuricemic patients presented higher levels of albumin (p=0. The same applied when the study population was categorized as gouty/nongouty patients. Clinical evaluation showed a maintained general status, diffuse non-palpable purpura and tonsillopharyngitis. Malaria prophylaxis (A-P) had been prescribed by his general practitioner and accurately taken. There was no indication in switching the patient to hemodialysis since extracorporeal clearance of proguanil is limited due to high protein binding (75%) and very high distribution volume (42L/kg). Treatment is based on discontinuing the drug, administration of folinic acid and supportive care. Poster Thursday Peritoneal Dialysis - 1 Phase Angle and Extracellular Mass to Body Cell Mass Ratio in Peritoneal Dialysis Ana T. Our population is prone to a poorer cardiovascular prognosis and eventually malnutrition, considering these cut-offs. The endpoints included all-cause mortality, cardiovascular mortality and cardiovascular events. Multivariable Cox regression was used to identify the associations between ambulatory blood pressure and endpoints. Subsequently, multivariable logistic regression was conducted to identify factors associated with elevated pulse pressure. We recorded essential demographic, clinical and laboratory data at baseline, 6, 12 and 24 months. In peritoneal dialysis, patients with high peritoneal transport tend to have enhanced clearance of small solutes and shows low ultrafiltration capacity and higher inflammatory state, that impacts negatively in nutritional status. Weight and height were measured using standard procedures and body composition was assessed by multifrequency bioelectrical impedance analysis. Intervention studies to elucidate the best nutritional approach should be designed to improve nutritional status in this population. With the CloudCath monitoring system, the intent is to automatically and quantitively monitor the turbidity of the effluent fluid. We evaluated the CloudCath monitoring device which includes a cloud-based algorithmic solution for early detection of the patient condition associated with peritonitis. In some cases, the device was able to provide indicators of impending peritonitis, before standard laboratory values met accepted diagnostic criteria peritonitis. Conclusions: Early detection of peritonitis can lead to earlier clinical intervention and a better clinical response, relative to the current standard of care. Funding: Commercial Support - CloudCath Poster Thursday Peritoneal Dialysis - 1 Hazard ratio of peritonitis, adjusted for case mix. Hence, there are no definitive evidence based recommendations to support which technique may be superior. Secondary outcome was death and transplant censored complication free catheter survival at 1 year. Death and transplant censored complication free catheter survival rate at one year was 87.
Prophylactic intrapar tum antibiotics given intravenously to the mother can prevent group B streptococcus infection in the newbornbaby prehypertension blood pressure values discount midamor 45 mg mastercard. Nosocomially acquired infections are an inherent risk in a neonatal unit prehypertension treatments and drugs generic 45mg midamor amex,andallstaffmustadherestrictlytoeffectivehand hygienemeasurestopreventcrossinfection heart attack 90 percent blockage order 45 mg midamor mastercard. Inneona tal intensive care arterial disease cheap midamor 45 mg free shipping, the main sources of infection are indwelling central venous catheters for parenteral nutrition blood pressure medication recreational order midamor 45 mg free shipping,invasiveprocedureswhichbreaktheprotec tivebarrieroftheskin blood pressure kit trusted 45 mg midamor,andtrachealtubes. Coagulase negative staphylococcus (Staphylococcus epidermidis) is the most common pathogen, but the range of Listeria monocytogenes infection Fetal or newborn Listeria infection is uncommon butserious. Theorganismistransmittedtothemother in food, such as unpasteurised milk, soft cheeses 174 and undercooked poultry. It causes a bacteraemia, often with mild, influenzalike illness in the mother, and passage to the fetus via the placenta. Maternal infection may cause spontaneous abortion, preterm deliveryorfetal/neonatalsepsis. Characteristicfeatures aremeconiumstainingoftheliquor,unusualinpreterm infants, a widespread rash, septicaemia, pneumonia andmeningitis. If the skin surrounding the umbilicus becomes inflamed, systemic antibiotics are indicated. This can be removed by applying silver nitrate while protecting the surrounding skin to avoid chemical burns,orbyapplyingaligaturearoundthebaseofthe exposedstump. Gram-negative infections Earlyonset infection is acquired in the same way as groupBstreptococcalinfection. Lateonsetinfectionis usually from infected central venous lines, but occa sionally from seeding to the circulation from the intestines. Theriskto aninfantborntoamotherwithaprimarygenitalinfec tion is high, about 40%, while the risk from recurrent maternalinfectionislessthan3%. Pres entationisatanytimeupto4weeksofage,withlocal ised herpetic lesions on the skin or eye, or with encephalitisordisseminateddisease. Mortalitydueto localiseddiseaseislow,but,evenwithaciclovirtreat ment, disseminated disease has a high mortality with considerablemorbidityafterencephalitis. Ifthemother is recognised as having primary disease or develops genitalherpeticlesionsatthetimeofdelivery,elective Caesarean section is indicated. Women with a history ofrecurrentgenitalinfectioncanbedeliveredvaginally as the risk of neonatal infection is low and maternal treatment before delivery minimises the presence of virusatdelivery. A more troublesome discharge with redness of the eye may be due to staphylococcal or streptococcal infection and can be treated with a topicalantibioticeyeointment,e. Purulent discharge with conjunctival injection and swellingoftheeyelidswithinthefirst48hoflifemay beduetogonococcalinfection. Thedischargeshould be Gramstained urgently, as well as cultured, and treatment started immediately, as permanent loss of vision can occur. Chlamydia trachomatis eye infection usually presents with a purulent discharge, together with swellingoftheeyelids(Fig. The vaccination course needs to be completed during infancyandantibodyresponsechecked. Hypoglycaemia Hypoglycaemiaisparticularlylikelyinthefirst24hof lifeinbabieswithintrauterinegrowthrestriction,who are preterm, born to mothers with diabetes mellitus, 1 2 3 Neonatal medicine 175 4 10 Neonatal medicine are largefordates, hypothermic, polycythaemic or ill foranyreason. Growthrestrictedandpreterminfants have poor glycogen stores, whereas the infants of a diabetic mother have sufficient glycogen stores, but hyperplasiaoftheisletcellsinthepancreascauseshigh insulin levels. Manybabiestoleratelowbloodglucose levels in the first few days of life, as they are able to utiliselactateandketonesasenergystores. In infants at increased risk of hypoglycaemia, blood glucose is regularly monitored at the bedside. The concentration of the intravenous dextrose may need to be increased from 10% to 15% or even 20%. High concentrationintravenousinfusionsofglucoseshould begivenviaacentralvenouscathetertoavoidextrava sationintothetissues,whichmaycauseskinnecrosis and reactive hypoglycaemia. If there is difficulty or delayinstartingtheinfusion,orasatisfactoryresponse is not achieved, glucagon or hydrocortisone can be given. Typically, there are repetitive, rhythmic (clonic) movements of the limbs whichpersistdespiterestraintandareoftenaccompa nied by eye movements and changes in respiration. Ongoingorrepeated seizures are treated with an anticonvulsant, although their efficacy in suppressing seizures is much poorer thaninolderchildren. Incon trast to infants with hypoxicischaemic encephalopa thy,therearenootherabnormalclinicalfeatures. Otherwise,smallbowelobstructionpresents with persistent vomiting, which is bilestained unless the obstruction is above the ampulla of Vater. Mostare inheritedpolygenically,buttheymaybepartofasyn drome of multiple abnormalities. Adenoid ectomyisbestavoided,astheresultantgapbetween theabnormalpalateandnasopharynxwillexacerbate feeding problems and the nasal quality of speech. There may be difficulty feeding and, as the tongue falls back, there is obstruction to the upper airways which may result in cyanotic episodes. Gastrointestinal disorders Oesophageal atresia Oesophageal atresia is usually associated with a tracheooesophageal fistula. It occurs in 1 in3500livebirthsandisassociatedwithpolyhydram nios during pregnancy. There may be aspiration intothelungsofsaliva(ormilk)fromtheupperairways and acid secretions from the stomach. Continuous suction is applied to a tube passedintotheoesophagealpouchtoreduceaspira tionofsalivaandsecretionspendingtransfertoaneo natalsurgicalunit. Atresia or stenosisofthebowelandmalrotationaretreatedsur gically, after correction of fluid and electrolyte deple tion. Meconiummayinitiallybepassed,butsubsequentlyits passage is usually delayed or absent. Abdominal dis tension becomes increasingly prominent the more distalthebowelobstruction. In exomphalos (also called omphalocele), the abdominal contents protrude through the umbilical ring, covered with a transparent sac formed by the amniotic membrane and peritoneum. Ingastroschisis,thebowelprotrudesthrough a defect in the anterior abdominal wall, adjacent to Figure 10. Gastroschisiscarriesamuchgreaterriskofdehydra tion and protein loss, so the abdomen of affected infantsshouldbewrappedinseverallayersofclingfilm to minimise fluid and heat loss. A nasogastric tube is passed and aspirated frequently and an intravenous infusion of dextrose established. With large lesions, the intestine is enclosed in a silastic sac sutured to the edges of the abdominal wallandthecontentsgraduallyreturnedintotheperi tonealcavity. For parents of infants born too early, too small or too sick: Available at. Deviation from the normneedstoberecognisedandtheunderlyingcause identified and treated. Childhood phase Thisisaslow,steadybutprolongedperiodofgrowth that contributes 40% of final height. Thyroid hormone, vitamin D and steroids also affect cartilage cell division and bone formation. Fetal this is the fastest period of growth, accounting for about 30% of eventual height. Severe intrauterine growth restriction and extreme prematurity when accompanied by poor postnatal growthcanresultinpermanentshortstature. The same sex steroids cause fusion of the epiphyseal growth plates and a cessation of growth. If puberty is early, which is not uncommoningirls,thefinalheightisreducedbecause ofearlyfusionoftheepiphyses(seebelow). The infantile phase Growthduringinfancytoaround18monthsofageis also largely dependent on adequate nutrition. Thisphaseischaracterisedbyarapidbutdecelerating growth rate, and accounts for about 15% of eventual height. Bytheendofthisphase,childrenhavechanged from their fetal length, largely determined by the uterine environment, to their genetically determined height. Standardsfor a population should be constructed and updated every generation to allow for the trend towards earlierpubertyandtalleradultstaturefromimproved childhood nutrition. Thenewchartsarebased on the optimal growth of healthy children totally Calibration checked Head straight, eyes and ears level Gentle upward traction on mastoid process Knees straight Barefoot, with feet flat on floor Heels touching back of board 182 Figure 11. These charts allowforthelowerweightoftotallybreastfedinfants andarethereforelesslikelytoidentifysomebreastfed babiesasunderweightandmayalsoallowearlyiden tification of bottlefed babies gaining weight too rapidly. Height in a population is normally distributed and the deviation from the mean can be measured as a centileorstandarddeviation(Fig. Thebandson the growth reference charts have been chosen to be twothirds of a standard deviation apart and corre spond approximately to the 25th, 9th, 2nd and 0. A single growth parameter should not be assessed in isolation from the other growth parameters:e. Puberty Puberty follows a welldefined sequence of changes thatmaybeassignedstages,asshowninFigures11. The height spurt in males occurs later and is of greater magnitude than in females, accounting for the greater final average height of males than females. Theyarealsoassumedbyadultsto be younger than their true age and may be treated inappropriately. Familial Mostshortchildrenhaveshortparentsandfallwithin the centile target range allowing for midparental height. Constitutional delay of growth and puberty these children have delayed puberty, which is often familial, usually having occurred in the parent of the same sex. An affected child will have delayedsexualchangescomparedwithhispeers,and boneagewouldshowmoderatedelay. Only 1 in 50 children will be shorter than the 2nd centile and 1 in 250(4in1000)shorterthanthe0. Mostof thesechildrenwillbenormal,thoughshort,withshort parents, but the further the child is below these cen tiles,themorelikelyitisthattherewillbeapathologi cal cause. A height velocity persistently below the 25th centile is abnormalandthatchildwilleventuallybecomeshort. Adisadvantageofusingheightvelocitycalculationsis thattheyarehighlydependentontheaccuracyofthe height measurements and so tend not to be used outsidespecialistgrowthunits. Theheightcentileofachildmustbecomparedwith the weight centile and an estimate of their genetic targetcentileandrangecalculatedfromtheheightof their parents. When treated,catchupgrowthrapidlyoccursbutoftenwith a rapid entry into puberty that can limit final height. Congenital hypothyroidism is diagnosed soon after birthbyscreeningandsodoesnotresultinanyabnor malityofgrowth. Growth hormone deficiency this may be an isolated defect or secondary to pan hypopituitarism. Craniopharyngioma usually presents in late childhood and may result in abnormal visual fields (characteristically a bitemporal hemianopiaasitimpingesontheopticchiasm),optic atrophy or papilloedema on fundoscopy. Laronsyndromeisaconditionduetodefectivegrowth hormone receptors resulting in growth hormone insensitivity. Thiseffectisgreatlyreduced by alternate day therapy, but some growth suppres sion may be seen even with relatively low doses of inhaled or topical steroids in susceptible individuals. Noniatrogenic Cushing syndrome is very unusual in childhood and may be caused by pituitary or adrenal pathology. Growthfailuremaybeverysevere,usually with excess weight gain, although normalisation of bodyshapeandheightoccursonwithdrawaloftreat ment or treatment of the underlying steroid excess. Thebackmaybeshortfromsevere scoliosis or some storage disorders, such as the mucopolysaccharidoses. Inadequatenutritionmaybeduetoinsuf ficient food, restricted diets or poor appetite associ ated with a chronic illness, or from the increased nutritional requirement from a raised metabolic rate. Chronicillnesseswhichmaypresentwithshortstature include: Examination and investigation Plottingpresentandpreviousheightsandweightson appropriate growth charts, together with the clinical features, usually allows the cause to be identified without any investigations. This condition may be extremely difficult to identify,butaffectedchildrenshowcatchupgrowthif placedinanurturingenvironment. Growth hormone treatment of short stature Growth hormone deficiencyistreatedwithbiosynthetic growth hormone, which is given by subcutaneous injection,usuallydaily. Itisexpensiveandthemanage ment of growth hormone deficiency is undertaken at specialistcentres. Turner syndrome may be particularlydifficulttodiagnoseclinicallyandshould be considered in all short females.
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Syndromes
Summary History Premonitory symptoms blood pressure number meanings 45mg midamor amex, aura hypertension organ damage buy 45mg midamor, character arrhythmia in child quality midamor 45mg, position hypertension nursing assessment buy 45 mg midamor mastercard, radiation blood pressure 30 over 60 cheap midamor 45mg without prescription, frequency arrhythmia cure 45 mg midamor overnight delivery, duration, triggers, relieving and exacerbating factors Seizures Aseizureisaclinicaleventinwhichthereisasudden disturbance of neurological function caused by an abnormal or excessive neuronal discharge. Febrile seizures Afebrileseizureisaseizureaccompaniedbyafeverin the absence of intracranial infection due to bacterial meningitis or viral encephalitis. Thisis morelikelytheyoungerthechild,theshorterthedura tion of illness before the seizure, the lower the tem peratureatthetimeofseizureandifthereisapositive familyhistory. Examination should focus on the cause of thefever,whichisusuallyaviralillness,butabacterial infection including meningitis should always be con sidered. Ifthere is a history of prolonged seizures (>5min), rescue therapywithrectaldiazepamorbuccalmidazolamcan besupplied. The diagnostic question is whether the paroxysmaleventsarethatofanepilepsyofchildhood or one of the many conditions which mimic it. Themostcommonpitfallisthatofsyncope leading to an anoxic (nonepileptic) tonicclonic seizure. Causes of funny turns Breath-holding attacks Temper Occur in some toddlers when they are upset. Attacks resolve spontaneously, but behaviour modification therapy, with distraction, may help. Reflex anoxic seizures Head trauma Cold food Fright Fever Occur in infants or toddlers. Commonest triggers are pain or discomfort, particularly from minor head trauma, cold food (such as ice-cream or cold drinks), fright or fever. Children may faint if in a hot and stuffy environment, on standing for long periods, or from fear. May sometimes lead to paroxysmal headache involving unsteadiness or light-headedness as well as the more common visual or gastrointestinal disturbance. It is a primary headache disorder of childhood occasionally due to a viral labyrinthitis. In focal seizures, the level of consciousness may be retained,consciousnessmaybelost,ortheseizuremay befollowedbygeneralisedtonicclonicseizure. Inthe newclassification,theterms,simpleorcomplexordis cognitive are no longer used and the impairment of consciousnessisnotclassifiedbutdescribed. Diagnosis the diagnosis of epilepsy is primarily based on a detailedhistoryfromthechildandeyewitnesses,sub stantiated by a video if available. Particular attention is focussedonanyspecifictriggersandifthechildhasany impairments,astheremaybeeducational,psychologi cal or social problems. This means that most large secondary schools will have about six children with an epilepsy. Epilepsy is a chronic neurological disorder character ised by recurrent unprovoked seizures, consisting of transient signs and/or symptoms associated with abnormal, excessive or synchronous neuronal activity in the brain. In the rigid tonic phase, children may fall to the ground, sometimes injuring themselves. Management Management begins with explanation and advice to helpadjustmenttothecondition. Aspecialistepilepsy nurse may assist families by providing education and continuing advice on lifestyle issues. Other investigations Metabolicinvestigationsmaybewarrantedwhenthere isdevelopmentalregressionorseizuresarerelatedto feeds or fasting. Genetic studies will become increas ingly helpful as certain epilepsy syndromes are now knowntobeduetogeneticdeletionscausingabnor malitiesofsodiumandotherionchannels. Thisdecision shouldbebasedontheseizuretype,frequency 1 2 Neurological disorders 475 3 Table 27. Most will subsequently lose skills and develop learning disability or epilepsy Often other complex neurological problems or history of infantile spasms. Also neurodevelopmental arrest or regression and behaviour disorder Stare momentarily and stop moving, may twitch their eyelids or a hand minimally. A typical history is throwing drinks or cornflakes about in the morning as myoclonus occurs at this time. Remission unlikely 476 *Although called benign, may be specific learning difficulties in some children. Guidance regarding treatment options for different seizure types are shown in Table 27. Some children with epilepsy and their families need psychological help to adjust to the condition. Unrecognised absences may interfere with learning, which is an indication for being vigilant about `odd Inchildrenwithintractableseizures,thereareanumber ofradicaltreatmentoptions. Relativelyfew restrictionsarerequired,butsituationswherehavinga seizure could lead to injury or be fatal should be avoided. This includes avoiding deep baths (showers arepreferable)andnotswimmingaloneindeepwater. For adolescents, there may be issues to discuss arounddriving(onlyafter1yearfreeofseizures),con traception and pregnancy. There may also be issues withadherenceandprecipitationofseizuresbyalcohol andpoorsleeproutines. Information is available from selfhelp groups and organisations suchasEpilepsyAction. Children with epilepsy do less well educationally, withsocialoutcomesandwithfutureemploymentthan thosewithotherchronicillnessessuchasdiabetes. Twothirds of children with epilepsy go to a main stream school, but some require educational help for associated learning difficulties. A fewchildrenrequireresidentialschoolingwherethere are facilities and expertise in monitoring and treating intractableseizures. Inclini calpracticethefirstquestiontoaskwhenseeingachild withamotordisorderiswhetherthisisacentralora peripheral nervous system disorder. Disorders of these central movement control centres are: Cerebral palsy ThisisdescribedinChapter4. Peripheral motor disorders: the neuromuscular disorders Anypartofthelowermotorpathwaycanbeaffected inaneuromusculardisorder,sothatanteriorhorncell disorders, peripheral neuropathies, disorders of neu romusculartransmissionandprimarymusclediseases can all occur. Thekeyclinicalfeatureofa neuromuscular disorder is weakness, which may be progressive or static. Chil dren with myopathy often show a waddling gait or positive Gowers sign suggestive of proximal muscle weakness. Increasing fati guabilitythroughtheday,oftenwithophthalmoplegia andptosis,wouldbemoreconsistentwithdepletionat the motor endplate and a diagnosis of myasthenia gravis. This also allows antenatal testing and geneticcounsellingandoftenobviatestheneedforthe discomfortofperipheralneurophysiology. Disorders of the anterior horn cell Presentation is with weakness, wasting and absent reflexes. Diminished fetal movements are often noticed during pregnancy and there may be arthrogryposis(positionaldeformitiesofthelimbswith contracturesofatleasttwojoints)atbirth. Theremaybefleetingabnormalsensorysymptoms inthelegs,buttheprominentfeatureisanascending symmetrical weakness with loss of reflexes and auto nomicinvolvement. Sensorysymptoms,usuallyinthe distal limbs, are less striking than the paresis but can beunpleasant. Management of postinfectious polyneuropathy is supportive, particularly of respiration. The disorder is probably due to the formation of antibody attaching itselftoproteincomponentsofmyelin. Affectednervesmaybehypertrophicduetodemyeli nation followed by attempts at remyelination. Onsetisinthefirstdecadewith distal atrophy and pes cavus, the legs being affected morethanthearms. Althoughtheaetiologyisunclear,itisprob ably postinfectious with an association with herpes simplex virus in adults. Corticosteroids may be of value in reducing oedema in the facial canal during the first week; no benefit from aciclovir has been 1 2 Neurological disorders 481 3 Thesechildrenneversitunaided. Childrenwith type 2 spinal muscular atrophy can sit, but never walk independently. Themaincomplica tion is conjunctival infection due to incomplete eye closure on blinking. Theherpesvirusmayinvadethe geniculate ganglion and give painful vesicles on the tonsillar fauces and external ear, along with a facial nerveparesis. Hypertension should be excluded, as there is an associationbetweenBellpalsyandcoarctationofthe aorta. If the facial weakness is bilateral, sarcoidosis should be suspected, and this is also seen in Lyme disease. Thymectomy is considered if a thymoma is presentoriftheresponsetomedicaltherapyisunsat isfactory. About a quarter will show remission post thymectomyanduptohalfshowsomeimprovement. Muscle disorders the muscular dystrophies this is a group of inherited disorders with muscle degeneration,oftenprogressive. Duchenne muscular dystrophy Duchenne muscular dystrophy is the most common phenotype,affecting1in4000maleinfants. This site codes for a protein called dystrophin, which connects the cytoskeleton of a muscle fibre to the surrounding extracellular matrix through the cell membrane. Whereitisdeficient,thereareseveralaber rant intracellular signalling pathways associated with aninfluxofcalciumions,abreakdownofthecalcium calmodulin complex and an excess of free radicals, ultimately leading to myofibre necrosis. Children present with a waddling gait and/or lan guagedelay;theyhavetomountstairsonebyoneand run slowly compared to their peers. There is pseudohypertrophy of the calves because of replacementofmusclefibresbyfatandfibroustissue. In the early school years, affected boys tend to be slowerandclumsierthantheirpeers. Contractures, particularly at the ankles, shouldbepreventedbypassivestretchingandthepro visionofnightsplints. Walkingcanbeprolongedwith the provision of orthoses, in particular those which allowambulationbyleaningfromsidetoside. Attention to maintaining a good sitting posture helps to minimise the risk of scoliosis. Scoliosis is managed with a truncal brace, a moulded seatandultimatelysurgicalinsertionofametalspinal rod. Later in the condition, episodes of nocturnal hypoxia secondary to weakness of the intercostal musclesmaypresentwithlassitudeorirritability. Pres entationisusuallyafter10yearsofagewithophthal moplegia and ptosis, loss of facial expression and difficulty chewing.
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