Charles H. Brown IV, MD

• Resident
• Department of Anesthesiology and Critical Care Medicine
• Johns Hopkins Hospital
• Baltimore, Maryland

Other Federal gastritis joghurt macrobid 50 mg with amex, State gastritis symptoms how long do they last buy 100mg macrobid with amex, and Local Funding Although insurance coverage is critical to improving access to and integration of services for individuals with substance use disorders gastritis diet æóêîâà macrobid 100mg overnight delivery, it is unlikely to cover all the services that such individuals may need gastritis diet sweet potato purchase macrobid online from canada, such as crisis services gastritis symptoms patient cheap 100mg macrobid with visa. Uninsured Individuals Research has shown that uninsured individuals have higher unmet medical needs than do insured individuals gastritis daily diet macrobid 50 mg overnight delivery, and those without insurance also have higher rates of substance use disorders than do individuals with insurance gastritis flare up diet cheap macrobid 50mg with visa. These funds also fnance treatment for people without insurance and support community prevention activities chronic gastritis raw food purchase macrobid 50 mg on-line. Grants are used to increase screening, counseling, workplace wellness See Chapter 3 Prevention Programs programs, and community prevention. Prevention should be seen as an appropriate health cost to be covered by insurance. Current funding options for community prevention, described below, include grants from hospital and health system foundations, hospital-based community beneft programs, tax earmarks, and targeted state programs. Hospital and Health System Foundation Grants Foundations formed from the conversion of tax-exempt non-proft hospitals and health systems into for-proft entities are required by federal law to invest in health-related activities within the community area served by that hospital. Tax-exempt hospitals must: (1) conduct a community health needs assessment at least once every 3 years; (2) involve public health experts and representatives of the community served by the facility in the needs assessment; (3) make the results of the assessment available to the public; (4) develop an implementation strategy to address each of the community health needs identifed through the assessment; and (5) report yearly to the Internal Revenue Service. Although hospitals have fexibility in their defnition of community served by the facility, they are expected to defne community by the geographic location, not by the demographic or geographic profles, of patient discharges. Many states also have community beneft programs that must be synchronized with the requirements of the Affordable Care Act. It was renewed for seven years in 2009, and the one-quarter of one-cent sales tax generates over $20 million per year. The funds are used for a variety of prevention, treatment, and anti-drug and drug-related crime prevention programs. In addition, Florida and Indiana, among other states, earmark alcohol taxes for child and adolescent substance use-related services. Funded through a one-time $57 million assessment, the Trust Fund is used to reduce the prevalence of preventable health conditions and lower health care costs. Grantees have a strong focus on extending care beyond clinical sites into the community. However, several key challenges must be addressed if integration is to be fully successful. The Infrastructure of the Substance Use Disorder Treatment System Is Underdevelopedthe Congressional Budget Ofce currently estimates that by 2026, 24 million Americans who would otherwise be uninsured will obtain health insurance coverage as a result of the Affordable Care Act. Fifty-fve percent of addiction treatment patients in expansion states are receiving care in organizations that at least have contractual linkages to some medical or health home arrangement. Because these organizations have traditionally been organized and fnanced separately from general health care systems, the two systems have not routinely exchanged clinical information. For example, private, for-proft treatment facilities were signifcantly more likely to be early adopters of buprenorphine therapies than were their public or private non-proft peers. Medical homes are most likely to pursue contractual arrangements with large and technologically sophisticated organizations that are best equipped to meet their needs for timely clinical and administrative information. Yet, the same patterns may harm smaller providers, some of whom offer the only culturally competent services for particular patient groups, such as services tailored for specifc racial and ethnic populations, sexual and gender minorities, or women in need of trauma-related residential services. For example, one study found that only three percent of United States treatment programs used it for opioid use disorders. A recent study found that raising this limit further, rather than increasing the number of specialty addiction programs or waivered physicians, may be the most effective way to increase buprenorphine use. Major pediatric medical organizations, including the American Academy of Pediatrics, strongly recommend addressing these issues regularly at each well-adolescent visit and appropriate urgent care visits. The Affordable Care Act requires health plans to cover, at no out-of-pocket cost to families, the preventive care services outlined in this schedule. Bright Futures discusses how to incorporate screening into the preventive services visit for these age groups. The Joint Commission Requirements mandate that hospitals offer inpatients brief counseling for alcohol misuse and follow-up, and measure the provision of counseling as one of the core measures for hospital accreditation. The Health Care Workforce Is Limited in Key Ways Workforce Shortages Data on the substance use workforce are incomplete. Nevertheless, it is clear that the workforce is inadequate, as evidenced by its uneven geographic distribution (with rural areas underserved), access barriers for adolescents and children, and recruitment challenges across the treatment feld. A recent study documented stafng models in primary care practices and determined that, even among those designated as patient-centered medical homes, fewer than 23 percent employed health educators, pharmacists, social workers, nutritionists, or community service coordinators, and fewer than half employed care coordinators. In practice, the Block Grant is used broadly, and Medicaid less and only with a subset of providers. It is not yet clear whether the integration of substance use disorder treatments in general health care will help to address salary structure. Composition and Education An integrated health and substance use disorder treatment system requires a diverse workforce that includes substance use disorder specialists, physicians, nurses, mental health treatment providers, care managers, and recovery specialists. As substance use disorder treatment and general health care become more integrated, clinical staff in both systems will need to expand their scope of work, operate in an integrated manner with a variety of populations, and shift their treatment focus as needed. Health care professionals moving from the specialty workforce into integrated settings will require specifc training on treatment planning and care coordination and an ability and willingness to work under the leadership of medical staff. This transition to a highly collaborative team approach, offering individually tailored treatment plans, presents challenges to the traditional substance use disorder treatment workforce that is used to administering standard programs of services to all patients. Working in teams with the broad mandate of improved health is not currently commonplace and will require collaboration among professional and certifcation bodies. Incorporating peer workers, who bring specifc knowledge of patients experiences and needs and can encourage informed patient decision making, into teams will also require further adjustment. Improving the Quality of Health Care for Mental and Substance Use Conditions also discussed the shortage of skills both in specialty substance use disorder programs and in the general health care system. Workforce Development and Improvementthe Annapolis Coalition on the Behavioral Health Workforce provided a framework for workforce development in response to the challenges described above,318 focusing on broadening the defnition of workforce to address needed changes to the health care system. Currently, 66 organizations license and credential addiction counselors,319,320 and although a consensus on national core competencies for these counselors exists,321 they have not been universally adopted. Credentialing for prevention specialists exists through the International Certifcation & Reciprocity Consortium,322,323 but core competencies for prevention professionals have not been developed. Without a comprehensive, coordinated, and focused effort, workforce expansion and training will continue to fall short of the challenge of meeting the needs of individuals across the continuum of service settings. Of particular note is the National Health Service Corps, where, as of September 2015, roughly 30 percent of its feld strength of 9,683 was composed of behavioral health providers, meeting service obligations by providing care in areas of high need. The development of the workforce qualifed to deliver these services and services to address co-occurring medical and mental disorders will have signifcant implications for the national workforces ability to reach the full potential of integration. Protecting Confdentiality When Exchanging Sensitive Information Effectively integrating substance use disorder treatment and general health care requires the timely exchange of patient health care information. In the early 1970s, the federal government enacted Confdentiality of Alcohol and Drug Abuse Patient Records (42 U. These privacy protections were motivated by the understanding that discrimination attached to a substance use disorder might dissuade people from seeking treatment, and were enacted in the context of patient methadone records being used in criminal cases. Given the long and continuing history of discrimination against people with substance use disorders, safeguards against inappropriate or inadvertent disclosures are important. Disclosures to insurers or to employers can render patients unable to obtain disability or life insurance and can cost patients their jobs. However, exchanging treatment records among health care providers has the potential to improve treatment and patient safety. Because of privacy regulations, it is likely that physicians were not aware of their patients substance use disorders. Promising Innovations That Improve Access to Substance Use Disorder Treatment Clearly, integrating health care and substance use disorder treatment within health care systems, as well as integrating the substance use disorder treatment system with the overall health care system, are complex undertakings. In so doing, they are broadening the focus of interventions beyond just the treatment of severe substance use disorders to encompass the entire spectrum of prevention, treatment, and recovery. Medicaid Innovations Medicaid is not only an increasing source of fnancing for substance use disorder treatment services, it has become an important incubator for innovative substance use disorder fnancing and delivery models that can help integrate substance use disorder treatment and mainstream health care systems. Within the substance use disorder treatment beneft, and in addition to providing the federally required set of services, states also may offer a wide range of recovery-oriented services under Medicaids rehabilitative services option. These services include therapy, counseling, training in communication and independent living skills, recovery support and relapse prevention training, skills training to return to employment, and relationship skills. Nearly all states offer some rehabilitative mental health services, and most states offer the rehabilitation option for substance use disorder services. The agency is providing technical and program support to states to introduce policy, program, and payment reforms to identify individuals with substance use disorders, expand coverage for effective treatment, expand access to services, and develop data collection, measurement, and payment mechanisms that promote better outcomes. Health Homes Health homes are grounded in the principles of the primary care medical home, which focuses on primary care-based coordination of diverse health care services, and patient and provider engagement. The Affordable Care Act created an optional Medicaid State Plan beneft allowing states to establish health homes to coordinate care for participants who have chronic health conditions. Health homes operate under a whole-person philosophy that involves integrating and coordinating all primary, acute, behavioral health, and long-term care services to address all the individuals health needs. Benefciaries with chronic conditions are eligible to enroll in health homes if they experience (or are at risk for) a second chronic condition, including substance use disorders, or are experiencing serious and persistent mental health conditions. These arrangements emphasize integration of care, targeting of health home services to high-risk populations with substance use and mental health concerns, and integration of social and community supports with general health services. The Oregon Health Authority publishes regular reports on quality, access, and progress toward benchmarks in both prevention and treatment. Federally Qualified Health Centers Increased insurance coverage and other provisions of the Affordable Care Act have sparked important changes that are facilitating comprehensive, high-quality care for people with substance use disorders. These community health centers emphasize coordinated primary and preventive services that promote reductions in health disparities for low-income individuals, racial and ethnic minorities, rural communities, and other underserved populations. Community health centers provide primary and preventive health services to medically underserved areas and populations and may offer behavioral and mental health and substance use services as appropriate to meet the health needs of the population served by the health center. Because they provide services regardless of ability to pay and are required to offer services on a sliding scale fee, they are well-positioned to serve low-income and economically vulnerable patients. These systems have the capacity to easily provide information in multiple languages and to put patients in touch with culturally appropriate providers through telehealth. These incentives have worked:the care coordination and population and National Electronic Health Record Survey found that as of 2014, public health; and maintain privacy and more than 80 percent of primary care physicians had adopted security of patient health information. A system to providers, and they can support care coordination by that provides health care professionals, facilitating communications between primary and specialty staff, patients, or other individuals 363 with knowledge and person-specifc care providers across health systems. Clinical decision information, intelligently fltered or support tools can also help support improvements in care presented at appropriate times, to and include clinical guidelines, diagnostic support, condition enhance health and health care. For example, educational and training materials including clinical guidelines for physicians. Many health systems have additional information on wikis for patients and providers. Although research suggests that patients with substance use disorders are not using patient portals as much as individuals with other conditions,365 they have great potential for reaching patients. These programs currently lag and are likely to continue to lag behind the rest of medicine. They are designed to help identify patients (as well as providers) who are misusing or diverting. This technology represents a promising state-level intervention for improving opioid prescribing, informing clinical practice, and protecting patients at risk in the midst of the ongoing opioid overdose epidemic. Additional research is needed to identify best practices and policies to maximize the efcacy of these programs. Now these disease registries are being developed for substance use disorders, such as opioid use disorder. For example, law enforcement and emergency medical services in many communities are already collaborating in the distribution and administration of naloxone to prevent opioid overdose deaths. These efforts require a public health approach and the development of a comprehensive community infrastructure, which in turn requires coordination across federal, state, local, and tribal agencies. A number of states are developing promising approaches to address substance use in their communities. One recent example is Minnesotas 2012 State Substance Abuse Strategy, which includes a comprehensive strategy focused on strengthening prevention; creating more opportunities for intervening before problems become severe; integrating the identifcation and treatment of substance use disorders into health care reform efforts; expanding support for recovery; interrupting the cycle of substance use, crime, and incarceration; reducing trafcking, production, and sale of illegal drugs; and measuring the impact of various interventions. These measures are important steps for reducing the impact of prescription drug misuse on Americas communities by preventing and responding to opioid addiction. However, given the large number of Americans with untreated or inadequately treated opioid use disorders and the current scarcity of treatment resources, there is concern that the lack of funding for the bill will prevent this new law from having a substantial impact on the nations ongoing opioid epidemic. This group is composed of medical directors from seven state agencies, including the Department of Labor and Industries, the Health Care Authority, the Board of Health, the Health Ofcer, the Department of Veterans Affairs, the Ofce of the Insurance Commissioner, and the Department of Corrections. In 2007, the group developed its frst opioid prescribing guideline in collaboration with practicing physicians, with the latest update released in 2015. States and localities efforts to expand naloxone distribution provide another example of building a comprehensive, multipronged, community infrastructure. Many communities have recognized the need to make this potentially lifesaving medication more widely available. For example, community leaders in Wilkes County, North Carolina, implemented Project Lazarus, a model that expands access to naloxone for law enforcement, emergency services, education, and health services, and reduced the county overdose rate by half within a year. North Carolina also passed a law in 2013 that implemented standing orders, allowing naloxone to be dispensed from a pharmacy without a prescription. A few states have passed legislation to make naloxone more readily available without a prescription if certain procedures are followed. This program was expanded to all interested pharmacies in 2013 and formalized in regulation in 2014. The need to engage individuals in services to address their opioid use is a critical next step following an overdose reversal. This becomes increasingly challenging as naloxone kits are distributed widely, rather than when distribution is limited to health care and substance use disorder treatment providers. In 2013, the State of Vermont implemented an innovative treatment system with the goal of increasing access to opioid treatment throughout the state. This model, called the Hub and Spoke approach, met this need by providing physicians throughout the state with training and supports for providing evidence-based buprenorphine treatment. Recommendations for Research A key fnding from this chapter is that the traditional separation of specialty addiction treatment from mainstream health care has created obstacles to successful care coordination. Research is needed in three main areas: $ Models of integration of substance use services within mainstream health care; $ Models of providing ongoing, chronic care within health care systems; and $ Models of care coordination between specialty treatment systems and mainstream health care. In each of these areas, research is needed on the development of interventions and strategies for successfully implementing them. Outcomes for each model should include feasibility, substance use and other health outcomes, and cost. Although a great deal of research has shown that integrating health care services has potential value both in terms of outcomes and cost, only a few models of integration have been empirically tested. Mechanisms through the Affordable Care Act make it possible to provide and test innovative structural and fnancing models for integration within mainstream health care. This research should cover the continuum of care, from prevention and early intervention to treatment and recovery, and will help health systems move forward with integration. Studies should focus on patient-centered approaches and should address appropriate interventions for individuals across race and ethnicity, culture, language, sex, sexual orientation, gender identity, disability, health literacy, and for those living in rural areas. So as not to limit health care systems to services for those with mild or moderate substance misuse problems and to offer support for individuals with severe problems who are not motivated to go to specialty substance use disorder treatment, it is also important to study how to implement medication and other evidence-based treatments across diverse health care systems. This chapter pointed out that when substance use problems become severe, providing ongoing, chronic care is required, as is the case for many other diseases. Little research has studied chronic care models for the treatment of substance use disorders. Research is needed to develop and test innovative models of care coordination and their implementation. Finally, the chapter pointed out the gap in our understanding of how to implement models of care coordination between specialty addiction treatment organizations and social service systems, which provide important wrap-around services to substance use disorder patients. This area of research should involve institutions that provide services to individuals with serious co-occurring problems (specialty mental health agencies), individuals with legal problems (criminal justice agencies and drug courts), individuals with employment or other social issues, as well as the larger community, determining how to most effectively link each of these subpopulations with a recovery-oriented systems of care. Best care at lower cost:the path to continuously learning health care in America. Opioid prescribing after nonfatal overdose and association with repeated overdose: A cohort study. Rapid growth and bifurcation: Public and private alcohol treatment in the United States. Psychoactive substance use disorders among seriously injured trauma center patients. Alcohol and drug use disorders among adults in emergency department settings in the United States. The prevalence and detection of substance use disorders among inpatients ages 18 to 49: An opportunity for prevention. Integrating addiction medicine into graduate medical education in primary care:the time has come. Contemporary addiction treatment: A review of systems problems for adults and adolescents. Why physicians are unprepared to treat patients who have alcoholand drugrelated disorders. Identifcation of and guidance for problem drinking by general medical providers: Results from a national survey. Barriers to the implementation of medication-assisted treatment for substance use disorders: the importance of funding policies and medical infrastructure. Buprenorphine maintenance treatment of opiate dependence: Correlations between prescriber beliefs and practices. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. The impact of the coverage gap in states not expanding Medicaid by race and ethnicity.

As rectal temperature readings may be affected by the presence or absence of stool in the rectum and peculiarities of local blood flow gastritis y reflujo order macrobid on line, oral temperature readings are considered to be the best reflector of core temperature gastritis symptoms tagalog generic macrobid 50mg visa. Tympanic temperature measured with a probe against the tympanic membrane as commonly employed by anesthesiologists is very accurate compared with other core temperature measurements chronic gastritis message boards buy 100mg macrobid with visa. Recently infrared ear thermometers have become popular because they give very rapid readings gastritis diet indian quality 50mg macrobid. However these commonly available infrared ear thermometers used in clinics gastritis cure home remedies buy cheap macrobid 100mg on-line, hospital wards gastritis hernia purchase 100mg macrobid visa, and homes are somewhat inaccurate and show significant variation between measurements gastritis hiatal hernia diet order macrobid 50mg with mastercard. I have also encountered falsely elevated readings in multiple patients especially when the instrument is older or malfunctioning gastritis diet 3 days safe 50 mg macrobid. Therefore, an unexpected elevated reading from an infrared ear thermometer should be confirmed with an oral or rectal measurement before embarking on an investigation of fever. Once it is proven that the patient has a fever, infrared ear readings may be used to measure trends in temperature associated with therapy of the basic process as long as one remembers that ear readings are variable and less accurate. Axillary temperature accuracy can be improved by keeping the thermometer in place for 5 to 12 minutes and holding the arm flexed against the body for the entire period. Therefore if tactile fever is reported, later confirmation of either elevated temperature or an abnormal clinical appearance is needed before embarking on an etiologic investigation (4). The first comprehensive study of temperature variation was published in 1868 by Carl Wunderlich (5,6). It is still the most comprehensive study and involved nearly one million observations in 25,000 subjects. He demonstrated that normal individuals have a range of temperature readings and that there is a diurnal variation with the lowest daily reading falling between 2 and 8 a. More recent studies using more modern instruments found normal oral temperature to vary between 35. Temperature was lowest at 0600 hours and peaked in late afternoon between 1600-1800. The mean difference between lowest and highest daily temperatures in these adult subjects was 0. For each individual, there existed a characteristic narrow range or normal set-point of body temperature showing diurnal variation of 0. Body temperature is affected very little by environmental conditions but to a greater degree by vigorous exercise. For a population of normal adults, the range of oral body temperature measurements is wider than the individual variation of 0. A systematic review of articles published from 1939-1990 showed the range for normal oral temperatures to be somewhat wider 33. Page 170 There has been less systematic study of normal temperatures in children. It has been suggested that preschool children have a more exaggerated diurnal difference in than adults with higher temperatures late in the afternoon or after physical activity (8). A third study found no evidence for temperature elevation with tooth eruption or the 5 days preceding (12). The idea that teething causes fever is a widespread folk belief shared by a majority of parents and pediatric dentists but by less than 10% of pediatricians (13). It remains somewhat uncertain exactly where the febrile range begins but oral temperatures greater than 37. Many lay people and health care professionals regard oral temperature readings between 37 and 38 degrees C (98. Certain individuals may have temperature elevations greater than this while being entirely well especially in late afternoon or after vigorous exercise. The presence of sustained fever of any degree indicates a problem which may need evaluation. Recognizing the presence of fever is of significance, but concern about the height of the fever is of less importance since the height of fever by itself is of limited diagnostic value. Physiology of Fever: Fever producing substances are divided into two categories: those produced outside the body (exogenous pyrogens) and those produced inside the body (endogenous pyrogens). Exogenous pyrogens are usually microorganisms, their components or their extracellular products. Endogenous pyrogens are host cell derived cytokines which are the principal central mediators of the febrile response. The secretion of endogenous pyrogens is induced by both exogenous pyrogens and many endogenous molecules such as antigen-antibody complexes, complement, steroid metabolites, certain bile acids, and many lymphocyte derived molecules. The most prominent currently recognized pyrogenic "pro-inflammatory" cytokines include interleukin-1, tumor necrosis factor alpha, and interferon gamma. Regulation of cytokine secretion is very complex with many interactions between individual molecules and classes of molecules. The initial cytokine mediated rise of core temperature is only one facet of the febrile response. Hematologic alterations include changes in leukocytes, lymphocytes, platelets and decreased red blood cell formation. Many acute phase proteins are secreted during the febrile response, some of which play a role in modulating inflammation and tissue repair. Pyrogenic cytokines act upon the preoptic region of the anterior hypothalamus of the central nervous system and upon peripheral tissues through specific receptors and pathways which are not yet delineated to produce changes in body temperature and also to limit the height of the fever rise. Thermoregulatory neurons involved in the febrile response are known to be completely inhibited at 41 to 42 C (105. Pyrogenic cytokines are balanced or "braked" by anti-inflammatory cytokines, arginine vasopressin, hypothermic neurochemicals, hypothermic peptides and even some of their shed soluble receptors. Thus, there is a complex and changing interplay of factors influencing the thermoregulatory set-point which causes it to change frequently resulting in the frequent changes in body temperature characteristic of most fevers. Patterns of Fever: In the febrile state, the temperature is not controlled as tightly as the 0. There are several patterns of fever, some of which are associated with particular disease processes. Intermittent fevers are characterized by temperature patterns which dip into the normal range one or more times per day. Remittent fevers demonstrate wide swings in temperature but always remain above 38 (100. Hectic or "septic" or "high spiking" fevers show wide swings between highs and lows and may be either intermittent or remittent depending upon whether the low is in the normal range. Sustained fevers have temperatures that are always in the febrile range but vary less than 0. The pattern of fever has some value in diagnosis although exceptions to the associations are very common. Remittent fevers are associated with many viral infections, acute rheumatic fever, endocarditis with lower grade pathogens and Kawasaki syndrome. Hectic fevers suggest bacterial septicemia, endocarditis with high grade pathogens, occult or deep tissue abscesses, peritonitis, toxic shock syndrome and Kawasaki syndrome. Sustained fevers are associated with typhoid fever, nosocomial infection of devices such as intravenous lines and cerebral spinal fluid shunts. Relapsing fevers are characteristic of malaria, dengue, brucellosis and rat-bite fever. Knowledge of the patterns of fever is useful in documentation and in describing the patient to others. It is important not to describe a patient as "afebrile" unless the temperature is in the normal range for at least an entire 24 hour period. Afebrile literally describes a patient with the "absence of fever," not just a patient whose temperature has briefly fallen into the normal range before it rises again. It is also imprecise to describe a "spiking fever" or a fever "spike" unless the temperature rises several degrees in a short period of time such as 4 hours or less. Height of Fever and Response to Antipyretics: There is a weak correlation between height of fever and the severity of infection or whether it is viral or bacterial. However, this correlation is so weak that it is not clinically useful, because there is too much overlap between the viral and bacterial infection groups. Some highly lethal infections such as gram-negative bacterial septicemia may have only modest fever or even, most ominously, hypothermia. There is a slightly increased likelihood (from about 4% to 8%) of occult bacteremia in young (6-18 months) children with temperatures over 40. However the overwhelming majority of children with high fever have non focal and presumed viral infections. Whether viral or bacterial, serious or trivial, five prospective studies in children have shown that temperature elevations had the same degree of response to antipyretic therapy (14-18). Therefore response or lack of temperature response to antipyretics usually does not distinguish between viral or bacterial infection or between trivial or serious infection. Children with severe bacteremic infection still appeared clinically ill after successful fever reduction while the clinical appearance of children with Page 171 non-severe infections improved (18). A temperature rise is accomplished by increasing heat generation primarily through shivering and decreasing heat dissipation by shunting blood away from the skin surface. Non-shivering thermogenesis is accomplished through many other metabolic processes especially those in brown fat. Patients with a rising temperature are hyperalert, feel jumpy or jittery, complain of cold sensations and have shivering, chills or violent rigors. Temperature lowering is associated with increased heat dissipation at the skin surface with dilatation of surface vessels and sweating which causes further evaporative cooling. Patients feel hot and have profound lassitude which inhibits muscle activity and prevents heat generation. The rate at which the temperature changes determines the severity of these symptoms. Chills and shivering are increased and made much more uncomfortable if external cooling is applied. Temperature elevations higher than this are not caused by response to an infecting agent but are usually associated with profound failure of thermoregulation such as exposure to extreme heat (heat stroke), severe brain injury with damage to the thermoregulatory center, and adverse reactions to anesthetics or neuroleptic drugs (malignant hyperthermia). There are no reports of brain damage caused by fever as a response to infection in a previously normal individual. Concerns have been expressed that fever may pose an increased stress in seriously ill individuals by increasing metabolic activity, heart rate, and respiratory rate. Some animal infection studies have demonstrated a direct association between fever and survival (21-25). Other animal model infection studies demonstrated an increase in mortality if fever was suppressed with antipyretics (26-28). These types of studies have flaws which reduce their applicability to humans especially because some are done in cold blooded animals, some induce elevated temperature with external warming and some use uncommon pathogens. Some studies of patients with severe bacterial infections have shown a direct positive correlation between height of fever and survival (29 34). A controlled study in children with varicella demonstrated both a shorter duration of fever and more rapid healing of lesions in placebo recipients than those treated with acetaminophen. The magnitude of the effect was approximately equal to the effect of antiviral therapy on varicella (35). Two common cold studies showed more severe respiratory symptoms and longer duration of rhinovirus shedding when fever was suppressed with aspirin or acetaminophen (36,37). Current clinical practice is that fever reducing drugs are employed routinely, often before any investigation as to the nature or cause of the fever is carried out. The rationale supporting this practice is that it is harmless and increases patient comfort. Indeed, antipyretics are often requested for and given to patients who are perfectly comfortable and have very modest temperature elevation. Patients often initiate antipyretic therapy on their own without medical consultation. It would be unreasonable to seek medical evaluation for all fevers so some degree of discretion needs to be permitted to patients. Some precautions need to be considered when recommending routine antipyretic treatment: 1. However, fatal liver damage from unintentional overdose of acetaminophen for fever has been reported. Case control studies indicate that treatment of the fever of streptococcal toxic shock syndrome with ibuprofen is associated with increased mortality (38-39). Ibuprofen causes platelet inhibition and upon occasion, significant gastrointestinal hemorrhage. If patients appear to be very uncomfortable from fever, it is reasonable to administer antipyretics. Antipyretic therapy may also be useful in a febrile child who appears slightly ill with a non-focal examination suggesting a benign illness. Another rationale for the routine use of antipyretic therapy in children under 5 years is that it will reduce the likelihood of febrile seizures. Many febrile seizures occur early in the course of illness with the seizure being the first sign that the child is febrile. In these cases, there is no opportunity for antipyretics to lower the temperature. A study of children with a history of febrile seizures found the recurrent seizure rate to be 5% in children treated with phenobarbital and antipyretics while 25% of those treated with placebo and antipyretics had a recurrent seizure (40). Two placebo controlled studies using standard and high dose acetaminophen during fever failed to show a benefit for the active drug in preventing seizure recurrence (41,42). We have no way of determining which normal child will be affected, but all children do not appear to be at equal risk for febrile seizures. Only 2% of children ever have a seizure while exposure to high body temperature is virtually universal by age 5 years. Although the literature fails to provide evidence that antipyretic therapy prevents recurrent febrile seizures, these seizures are very emotionally distressing to parents. When seizures occur despite appropriate use of antipyretics, parents should be counseled that they did all that was appropriate so that they will not employ excessive treatment with the next febrile illness or suffer unnecessary grief. Approach to the febrile child: There are several clinical decision rules that are commonly employed in pediatric practice. Highly experienced clinicians may be able to identify low risk individuals who may fit the decision rule, but are unlikely to benefit from their recommendations. Empiric antibiotics and hospitalization are recommended routinely for this age group; however, children in the 4 to 8 week range have been treated as outpatient in some patient series if the following conditions are met: 1) the sepsis work-up is negative, 2) empiric antibiotics. Girls under 24 months of age and boys under 6 months of age with temperatures greater than 39 degrees C (102. Uncircumcised males are at a higher risk (although the magnitude of this additional risk is controversial). Some children Page 172 in this age group present with predominant respiratory symptoms. Occult bacteremia: Children from 3 months to 36 months of age with a temperature greater than 39 degrees C (102. The risk of this is less than 4% and most cases, result in spontaneous resolution, even without antibiotic therapy. Otitis media is often diagnosed in febrile children, but it is likely that most cases of otitis media cause only mild degrees of fever. Clinical appearance (does the child appear to be toxic, lethargic, excessively irritable, or very ill appearing) is the most reliable clinical predictor of sepsis after 2 to 3 months of age. Fever is a complex and highly regulated host response to a microbial or inflammatory stimulus. Fever is most often related to infection but is also seen prominently in auto-immune and neoplastic disease. Although fever is often uncomfortable, it is not medically harmful to the host and may be beneficial. Her son will not become brain damaged as a result of his fever which is a natural and possibly helpful response to an as yet undiagnosed infection. It is unlikely that her son will have a seizure or "go into convulsions" both because it is statistically unlikely and because he has been febrile for several hours without having had a seizure. His fever will not continue to rise much as he has already approached the natural ceiling for the febrile response. It is more important at this point to assess the cause of the fever with a physical examination and any diagnostic testing which may be indicated, rather than to administer antipyretics. Drastic external cooling measures such as a cooling blanket or a cold water bath are absolutely not indicated and will certainly make the child feel worse (44). He should not be given another dose of acetaminophen as he has already received double doses. His mother must be told that giving more acetaminophen than indicated in future illnesses could cause liver damage. Acetaminophen and ibuprofen appear to be equally effective and safe in fever reduction in children (45,46). There is no reported clinical trial of the safety and efficacy of combining these agents in the symptomatic treatment of fever in children. Since our patient does not appear to be uncomfortable, it is not necessary to give him ibuprofen at this time. Simply dressing him minimally and offering him extra fluids without expecting him to eat solid foods is all that is required for fever treatment. Since he has a normal physical examination and has been previously immunized with Haemophilus influenzae b and pneumococcal conjugate vaccines, he is at very low risk for serious bacterial infection. Once his underlying illness has been fully addressed, ibuprofen therapy may be offered if he appears uncomfortable. It should be stressed that antipyretic therapy is entirely optional and should be given only if he needs relief of noxious fever related symptoms. In evaluating any patient with fever it is of paramount importance to remember that fever is a sign of disease and not the disease process itself.

He is instructed to rest and apply ice massages to the area gastritis diet juice purchase 100mg macrobid mastercard, focus on stretching his hamstrings gastritis diet webmd discount macrobid 50mg mastercard, and to take acetaminophen gastritis eating plan cheap macrobid 50 mg online. He is permitted to ambulate normally and jog briefly gastritis root word discount 100mg macrobid, but he must stop if any pain occurs stomach ulcer gastritis symptoms effective 100 mg macrobid. Traction apophysitis of the tibial tuberosity was first described independently by both Osgood and Schlatter in 1903 (1) gastritis symptoms natural remedies cheap 100 mg macrobid overnight delivery. This disease is usually seen in adolescents or older children 11-15 years of age gastritis bile reflux diet buy cheap macrobid 100mg on line, with a male to female predominance of 3:2 (2) gastritis in the antrum cheap macrobid online amex. Girls present earlier because the secondary ossification center of the tibial tuberosity appears 2 years earlier. Osgood-Schlatter is seen in children/teens who are very active in sports requiring strenuous quadriceps muscles such as basketball and volleyball. Jumping puts the most force on the quadriceps and the insertion of the patella tendon into the tibial tuberosity. Osgood-Schlatter is also common in running sports such as soccer, baseball and football, but less so than with the jumping sports. This disease is seen more often on the left side and 25% of patients have a bilateral appearance. The exact etiology remains controversial, although repetitive trauma is the most widely accepted theory. Other less likely theories include avascular necrosis of the tibial tuberosity (although blood supply is abundant), infection (although patients are afebrile and without leukocytosis), and degeneration of the patella with heterotopic ossification (although histological studies show no tendon necrosis and normal tendon insertion) (2,3). Growth of the proximal tibia is unique because it involves two growth centers in close proximity: the proximal tibial physis and the tibial tuberosity apophysis. An apophysis is a growth plate, which does not contribute to the length of the bone. It is common for a tendon to insert over an apophysis, such as in the tibial tuberosity (patella tendon), calcaneus (Achilles tendon), etc. The cartilage growth plate of the apophysis is a weak spot which is susceptible to microseparation with trauma or overuse (pulling, traction). Southwick and Ogden described the development of the tibial tuberosity in 7 stages; 3 prenatal and 4 postnatal. Stages 1-3 involve fibrovascular ingrowth and vascularization of the area with anterior outgrowth. Postnatal stages include a separate and distinct tibial tuberosity growth plate (stage 4) that later joins with the tibial growth plate (stage 7). There is a distinct secondary ossification center in the distal portion of the tuberosity (stage 5). During maturation (stage 6) there is a coalescence of the proximal tibial epiphyseal ossification center with the tuberosity ossification center. Therefore, because of its unique anatomy and vascular supply, combined with excessive pulling forces of the extensor mechanism, there is a failure of the secondary ossification center, ultimately leading to the disease. The pain is localized to the anterior aspect of the proximal tibia over the tibial tuberosity. Although patients may complain of pain with full extension of the knee (especially against force), they have full range of motion. Patients may often have symptoms for 6-12 months prior to seeking medical attention. Although the tibial prominence may be highly indicative of Osgood-Schlatter in many cases, a full knee exam should be performed to rule out other intra-articular pathology. Unless other pathology is suspected, radiographs of the knee are usually unnecessary, since this is largely a clinical diagnosis. In more severe cases, lateral radiographs of the knee will often show a decrease in homogeneity of the infrapatellar fat pad, soft tissue swelling, and a prominence/fragmentation of the tibial tuberosity. The differential diagnosis includes acute stress fracture, contusion of the tibial tuberosity, prepatellar bursitis, and patellar tendonitis. Some have termed Osgood-Schlatter as a "tendonitis" of the patellar tendon insertion. Some consider the two terms, tendonitis and apophysitis to often be interchangeable. Despite the ominous sounding name, the end result is often the same with or without treatment; therefore, alleviating parental fear is important (2). Treatment is mainly symptomatic and involves reducing forceful use of the quadriceps, which equates to playing less, resting more during games and practices, and less jumping. Corticosteroids are not used because subcutaneous atrophy and fat pad necrosis may occur. If the pain is severe, a knee immobilizer may be used to allow for both decreased tension over the patellar tendon by limiting extension. A cylinder cast was used in the past; however, a knee immobilizer is better because it allows for removal to prevent atrophy and stiffness, and allows the patient to shower. Being skeletally immature, these patients are at risk for subluxation of the patella, patella alta (high riding patella), nonunion of the bony fragment of the tibia, and premature fusion of the anterior part of the epiphysis leading to genu recurvatum (hyperextension of the knee). If patients remain symptomatic, surgery may be performed (rarely), usually after reaching skeletal maturity. After acute symptoms resolve, gradual strengthening exercises of the extensor mechanism using isometric or short-arc terminal extension techniques should be performed. The use of knee pads to prevent reaggravation of contusions should be stressed to both patients and parents. Page 632the prognosis for this disease is good with spontaneous healing usually occurring. As the disorganized ossification fuses with the beaklike portion of the epiphysis, symptoms diminish (4). Although the symptoms may decrease with activity reduction, local tenderness may persist. In the adult, a local prominence of the tibial tuberosity may remain; however, this is usually painless. The patient states he has gradually noticed this pain since the beginning of basketball season 2 weeks ago. The pain is a dull, 5/10 ache over his right heel that is worse with running, especially when running on the hardwood floor. There is minimal soft tissue swelling and moderate tenderness to palpation over the back of the right calcaneus. Radiographs of his right heel are obtained, which demonstrate no specific abnormality. He does have an open growth plate (apophysis) over the Achilles tendon insertion region, but this is noted to be normal for his chronologic and bone age. He is instructed to rest from athletic activity for 4 weeks, but he is permitted to ambulate normally. A heel wedge is placed in his right shoe, which he later reports helps to alleviate the pain. After 4 weeks, he focusses on stretching and strengthening exercises for his calves and hamstrings. This disease is commonly seen in children 8-13 years old and is more prevalent in runners, especially soccer and basketball players who play on hard or artificial surfaces, or football/baseball players who play with cleats which permit them to gain excess traction into the ground. Tension is placed on the calcaneus by the strong shearing forces caused by the plantar fascia and triceps surae. Associated pathology thought to predispose to this disease includes internal tibial torsion, forefoot varus, and tight heel cords (6,7). Clinically these patients present with heel pain over the posterior calcaneus near the Achilles tendon insertion. They may have an antalgic gait secondary to pain, but in most instances, their gait is normal during medical evaluation. Most of their pain and discomfort is sustained during athletic activity when stress on the Achilles tendon insertion is maximal. Radiographs may show a sclerotic and fragmented calcaneal apophysis in severe cases, but most often, radiographs are normal. By raising only the heel, tension is reduced on the Achilles tendon insertion site on the calcaneus. Once acute symptoms have resolved, patients should begin stretching and strengthening exercises of the hamstring and calf muscles. If conservative measurements fail after 6-8 weeks, a bone scan or other studies to seek more occult sources of pain should be considered. Little League Elbow this is a 13 year old right handed boy who presents to the clinic with a chief complaint of right elbow pain. The patient has noticed a gradual onset of pain over the past two months since baseball season started. He is the star pitcher for his little league team and pitches full games twice per week. He has complained of pain during practices, but has been told to continue practicing; "no pain, no gain. Radiographs of his right elbow are obtained and show a minimally displaced right medial epicondyle fracture. Despite initial apprehension, the patient and his parents decide to cease activity. Because there is minimally displacement (<2mm), a posterior splint is applied for 2 weeks. Six weeks later, after radiographic evidence of union, the patient is allowed to start a specific throwing program. The league commissioner decides that each team must keep an accurate pitching record of the number of pitches thrown per game. The community sports medicine physician is also asked to educate coaches and parents about the importance of identifying little league elbow early. The term "Little League elbow" is used to describe a group of pathologic entities in and around the elbow joint in young throwers. The mechanism includes pitching, tennis serving, volleyball spiking/serving, football and javelin throwing. This valgus stress results in lateral compression and medial traction on the elbow. The injury has expanded to include (9): 1) Medial epicondylar fragmentation and avulsion. The physical stresses associated with throwing produce exceptional forces in and about the elbow in the throwing athlete of any age. These forces include tension, compression, and shear localized to the medial, lateral, and posterior aspects of the elbow (10). Compression overload on the lateral articular surface: early and late cocking phases. Posterior medial shear forces on the posterior articular surface: late cocking and follow through phases. A comprehensive history is important and should include age, handedness, activity level, sport played, and history of trauma. The age of the thrower can be helpful in the differential and is divided into three groups: 1) childhood (terminates with appearance of all secondary centers of ossification), 2) adolescence (terminates with fusion of all secondary centers of ossification to their respective long bones), and 3) young adulthood (terminates with completion of all bone growth and achievement of final muscular development) (9). During childhood, pain to the medial epicondyle secondary to microinjuries at the apophysis and ossification center is common. Valgus stress of the elbow results in an avulsion fracture of the entire medial epicondyle. Some athletes develop enough chronic stresses to cause delayed union/malunion of the medial epicondyle. By young adulthood, the medial epicondyle is fused and injuries tend to occur to muscular attachments and ligaments. Also neurological and vascular exams with attention to the ulnar nerve should be performed. Common findings include an immature elbow with elbow enlargement, fragmentation, and beaking or avulsion of the medial epicondyle. Posterior lesions present with hypertrophy of the ulna causing chronic impingements of the olecranon tip into the olecranon fossa. The American Academy of Pediatrics and youth baseball organizations have made recommendations to reduce the risk of overuse elbow injuries in young athletes by providing leagues and coaches with guidelines limiting the number of pitches per day or per game, a young athlete can throw. It is far preferable to prevent these injuries, than it is to recover from these injuries. Playing through such pain worsens the injury, so this practice should be discouraged. A basic strategy to reduce the risk of these injuries is to restrict further elbow throwing stress for the remainder of the day once the onset of pain occurs. If disability continues for an extended period of time, throwing should be disallowed until the next season. Medial epicondylar fractures occur with substantially more acute valgus stresses applied through violent muscle contraction causing an avulsion fracture of the medial epicondyle. This causes a painful elbow with tenderness over the medial epicondyle and elbow flexion contracture that may exceed 15 degrees. When radiographic evidence of union is noted, a specific progressive throwing program is started. Medial ligament rupture to the ulnar collateral ligament is not common in young athletes and is seen more in adults. Patients may have medial tenderness for months to years before the ligament is injured, usually in a sudden catastrophic event. If the injury is detected early, conservative treatment including rest and alternating heat/ice is recommended. It is a self-limiting condition where the capitellum epiphysis essentially assumes a normal appearance as growth progresses. They present with elbow pain and a flexion contracture of greater than or equal to 15 degrees. These patients should be seriously counseled about the dangers of continued throwing and are urged to abstain. Posterior extension and shear injuries are uncommon in young throwers but the incidence increases with age. If there is lack of apophyseal fusion, rest and immobilization can produce good results. Partial avulsion of the olecranon requires surgical reattachment of the olecranon and triceps. They can be seen not just in baseball pitchers but also in quarterbacks, tennis players, volleyball players and javelin throwers. Because the biomechanics of throwing are complex, the physical stresses can cause a group of pathologic entities to include the medial, lateral, and posterior aspects of the elbow. Preventing these types of injuries involves teaching proper throwing mechanics, keeping an accurate pitching count, predetermining a stopping point based on number of pitches thrown, and recognizing early warning signs and stopping once the pain starts. Although many of these injuries have been blamed on throwing curve balls, some studies have shown that a properly thrown curve ball causes no more injuries than the traditional fastball (11,12,13). He was playing in a roller hockey game when a hockey stick was swung high and struck him in the face. Ophthalmology is consulted and further evaluation for the hyphema includes an intraocular pressure measurement, which is found to be normal. The patient and parents are told to limit his activity for the first 72 hours without television or video games. His immunization records are current and the patient is sent home with a narcotic analgesic and follow-up in 3 days. The next season, he is sporting a new pair of safety goggles to every game and practice. Orbital injuries are common injuries in athletes, especially those in high-risk sports with high-speed objects such as sticks, bats, balls, pucks, or aggressive body contact. Males are at higher risk for orbital fractures because of their increased incidence of trauma. The aperture of the bony architecture surrounding the eye does not allow an object with a radius of greater than 5 cm to penetrate the globe (14). The thin orbital floor (maxilla) and the medial wall (ethmoid) are the weakest portions of the orbit. A direct blow to the bony rim may not cause a bony rim fracture, but can be enough to increase intraorbital pressures (as the globe is compressed) resulting in a "blowout fracture" of the weakest point of the orbital wall, which is usually the floor of the orbit. Sphenoid: posterior orbit Related anatomical structures that can be injured during an orbital fracture include the optic nerve, periorbital fat, extraocular muscles, and the inferior orbital nerve. These injuries are multiple and can include corneal abrasion, lens dislocation, iris disruption, choroid tear, scleral tear, ciliary body tear, retinal detachment, hyphema, ocular muscle entrapment, and globe rupture. The patient should be questioned regarding epistaxis or clear fluid from nares or ears, loss of consciousness, visual problems, hearing problems, malocclusion, and facial numbness or tingling. Other specific questions regarding the eye include the presence of diplopia, painful eye motion (entrapment or periorbital edema), photophobia, flashes of light (retinal detachment), or blurred vision (hyphema, vitreous hemorrhage, retinal detachment) (14,16,17). This includes visual acuity, inspection for abrasions, laceration, foreign bodies, changes in pupillary dimension or reactivity to light. Any change in visual acuity, blood in the anterior chamber, or change in the shape of the iris should warrant a consult with an ophthalmologist. They should have their supraorbital ridge and frontal bone palpated for step-off fractures, and their hard palate and teeth palpated for stability. Evaluate the supraorbital, infraorbital, inferior alveolar, and mental nerve distributions for anesthesia. These patients may present with ecchymoses, enophthalmos of the globe (sunken eye), vertical dystopia (a change in vertical position of the pupil in relation to the unaffected side), or numbness in the area on the ipsilateral cheek supplied by the infraorbital nerve. Although a "black eye" was once felt to be a relatively benign injury for which medical attention was often not sought, many instances of periorbital ecchymoses are due to orbit fractures. Radiographically, routine facial views include Waters, Caldwell, and lateral projections (14,15,16).

Syndromes

• Acute gout is a painful condition that often affects only one joint.
• Infection (a slight risk any time the skin is broken)
• Alcohol is involved in more than one out of three rapes.
• Hallucinations
• Those who have not received the vaccine in the past may still get the series of three shots. Talk to your health care provider.
• Impotence (in men)
• Complete blood count (CBC)
• Inability to move, other than to blink eyes ("locked in" syndrome)
• Is it harder to control your urine when you run, jump, or walk?

Regular respirations are adequate if they can maintain a heart rate of >100 bpm and good (pink) color gastritis symptoms in toddlers order macrobid 50 mg with mastercard. Gasping gastritis diet and yogurt buy generic macrobid 50 mg online, apnea and central cyanosis generally indicate the need for additional interventions atrophic gastritis symptoms treatment buy 50mg macrobid amex. An uncompromised infant will maintain pink mucous membranes without supplemental oxygen gastritis diet plan uk order on line macrobid. Cyanosis of the distal extremities or acrocyanosis the gastritis diet order discount macrobid on line, is a normal finding at birth and should not be used to determine the need for supplemental oxygen gastritis japanese buy generic macrobid 50 mg. For the infant who is not vigorous at delivery gastritis vitamins order macrobid 50mg free shipping, the basic steps in newborn resuscitation include providing warmth curing gastritis with diet purchase 100 mg macrobid fast delivery, positioning and clearing the airway, drying and stimulating the infant and providing supplemental oxygen as needed. Warming the infant immediately after birth will decrease cold stress and oxygen consumption. This can be done by simply placing the infant under a radiant warmer, quickly drying the skin, removing wet linens and wrapping the infant in pre-warmed blankets. The airway is cleared first by positioning the infant supine or lying on its side with the head in a slightly extended position. If airway secretions are concerning, the infant can be suctioned, mouth first, then nose, with a bulb syringe or suction catheter. Additional stimulation may be provided by gently rubbing the back or flicking the soles of the feet if an infant fails to initiate effective respirations following drying and suctioning. These initial steps should be performed during the first 30 seconds of life and the infant should then be reevaluated for breathing, heart rate and color (1,2). Adequate ventilation is the most important and most effective step in cardiopulmonary resuscitation of the compromised newborn infant. Noticeable chest wall rise, bilateral breath sounds and improved color and heart rate are indications that ventilation is adequate. After 30 seconds of proper ventilation, breathing, heart rate and color should be reevaluated. If the baby is breathing spontaneously and the heart rate is greater than 100 bpm, positive pressure ventilation can be stopped. Chest compressions must be started and assisted ventilation continued until the myocardium recovers adequate function. Two people are required to administer chest compressions: one to administer compressions and one to continue ventilation. To perform chest compressions, enough pressure is applied to the lower third of the sternum to depress the sternum to a depth of approximately one third of the anterior-posterior diameter of the chest then released to allow the heart to refill. Reevaluation of respiration, heart rate and color should be done after 30 seconds of coordinated ventilation and chest compressions. If the heart rate is above 60 bpm, then chest compressions can be stopped, but assisted ventilation should continue until the heart rate is greater than 100 bpm and there is spontaneous breathing. However, if the infant is not improving, that is, the heart rate remains below 60 bpm despite 30 seconds of well coordinated ventilation and chest compressions, then epinephrine should be given. Epinephrine is a cardiac stimulant that increases contractility (inotropy) and heart rate (chronotropy) while causing peripheral vasoconstriction (alpha adrenergic effect). It can be administered through an endotracheal tube for absorption by the lungs into the pulmonary veins, which drain directly into the heart. Alternatively, epinephrine can be given into a catheter placed in the umbilical vein. This route will likely deliver more effective blood levels of the drug, but additional time is required to insert the catheter. Thirty seconds following administration, an increase in heart rate to more than 60 bpm should be observed. If the heart rate remains depressed (<60 bpm) repeat doses of epinephrine may be given every 3 to 5 minutes. In the meantime, good chest movement, equal bilateral breath sounds, and well coordinated chest compressions to an appropriate depth must all be ensured. If the infant displays pallor, poor perfusion and/or there is evidence of blood loss, hypovolemic shock should be considered in the infant who has not responded to resuscitative efforts. The recommended solution for acutely treating hypovolemia in the newly born infant is normal saline. Volume expanders must be given intravenously, usually through an umbilical vein catheter, although the intraosseous route can also be used. If the heart rate is detectable but remains below 60 bpm after administering adequate ventilation, chest compressions, epinephrine, and volume expanders, the possibility of metabolic acidosis should be considered. Moreover, mechanical causes of poor response including airway malformation, pneumothorax, and diaphragmatic hernia or congenital heart disease should also be considered. If the heart rate remains absent after 15 minutes of resuscitative efforts (establishing an airway, delivering positive pressure ventilation, administering chest compressions, administering epinephrine, addressing the possibilities of hypovolemia, acidosis, congenital airway malformation or congenital heart disease) discontinuation of resuscitation may be appropriate (2). A one minute Apgar score of 8 is usually due to a zero score for color since truncal cyanosis is still present at one minute. A 5 minute Apgar score of 9 is normal because acrocyanosis of the feet persists for some time past five minutes. Low Apgar scores at five and ten minutes may reflect birth depression and/or need for resuscitation. Page 83 Apgar Scoring Score 0 1 2 Heart rate Absent <100 >100 Respiratory effort Absent Slow, irregular Good, crying Muscle tone Limp Some flexion Active motion Reflex irritability No response Grimace Cough or sneeze Color Blue Extremities blue Completely pink Questions 1. International Guidelines for Neonatal Resuscitation: An Excerpt From the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science. Intrapartum risk factors: emergency cesarean section, non-reassuring fetal heart tones, use of general anesthesia, narcotics administered to mother within 4 hours of delivery, and abruptio placentae. Fluid in alveoli is absorbed and air fills the air sacs, umbilical cord is clamped disconnecting the infant from the placental circulation and pulmonary vasculature must relax allowing increased pulmonary blood flow and decreased right-to-left shunting. Three or more trained persons would ideally be available for an extensive resuscitation requiring medication administration. Ventilation of the lungs is the most important and most effective step in cardiopulmonary resuscitation of the compromised newborn infant. If the infant continues to be apneic, is gasping, has a heart rate of less than 100 bpm and/or has persistent central cyanosis despite 100% free flow oxygen, then positive pressure ventilation with a bag and mask should be administered. Three compressions should be administered for every one assisted ventilation so that 90 compressions plus 30 breaths are given each minute. It can be administered through an endotracheal tube or through an umbilical vein catheter. Maternal history is remarkable for a single prenatal visit in the first trimester. A decision is made to deliver the infant by cesarean section following maternal treatment with betamethasone. The risk factors identified in the above scenario include poor prenatal care, severe preeclampsia, prematurity, oligohydramnios, and intrauterine growth restriction. For the pediatrician, detailed knowledge of the maternal and pregnancy history is critical to providing timely and comprehensive care to the infant. A high risk pregnancy can be defined as any pregnancy where maternal and/or fetal conditions may lead to an adverse perinatal outcome. A pregnancy may be identified as high risk during the antepartum or intrapartum period. Indeed, lack of, limited, or late prenatal care, in and of itself, is a common high risk condition seen in urban perinatal centers. Screening tests for certain high risk problems such as diabetes, genetic conditions, and congenital anomalies are either routinely or selectively performed during the antepartum period for early recognition and intervention. This chapter will focus on a few of the more common pregnancy complications with an emphasis on neonatal outcome. The World Health Organization defines preterm delivery as a delivery that occurs between 20 and 37 weeks gestational age. After reviewing the list above, it is readily apparent that preterm delivery is the common denominator for many high risk conditions of pregnancy. Timely detection of preterm labor and delivery allows for prompt referral of the mother to a facility where more intensive surveillance, monitoring, and care for both mother and newborn can be accomplished (2). Studies assessing prevention methods such as education and surveillance programs and home uterine activity monitoring have demonstrated no benefit in reducing the frequency of preterm birth. Other strategies involved in the treatment of preterm labor are: cervical cerclage, tocolytics (beta sympathomimetics such as terbutaline and ritodrine, magnesium sulfate, prostaglandin synthetase inhibitors such as indomethacin), and antibiotics. Of these, the most frequently used methods at Kapiolani Medical Center for Women and Children are cerclage, terbutaline, magnesium sulfate, and antibiotics. Although it has been difficult to demonstrate the efficacy of tocolytics and antibiotics in clinical trials for preterm labor, these agents may provide a 48 hour latency period during which antenatal corticosteroids can be administered. It involves placing a suture circumferentially around the internal cervical os between 12-14 weeks gestation. Maternal risks associated with cerclage placement include the risk of anesthesia, bleeding, infection, rupture of membranes, maternal soft tissue injury, and spontaneous suture displacement. Terbutaline, the most commonly used beta sympathomimetic, stimulates the beta-2 receptors found in the uterus. Potential fetal side effects of beta-2 agonists include elevation in baseline heart rate, rhythm disturbances, septal hypertrophy, and hypoglycemia. Magnesium sulfate affects uterine activity by decreasing the release of acetylcholine and altering the amount of calcium pumped out of myometrial cells. Respiratory and motor depression can occur in the neonate with high maternal magnesium levels. In general, side effects to the fetus and neonate are minimal when compared to beta sympathomimetics. Given the role of prostaglandins in labor, indomethacin would seem a logical choice for a tocolytic agent. Reported fetal side effects include oligohydramnios secondary to decreased fetal urine output, ductal constriction with the potential for subsequent persistent pulmonary hypertension in the neonate, and necrotizing enterocolitis. The use of indomethacin is restricted to pregnancies at <30-32 weeks gestation and for a treatment period of less than 48 hours. Ampicillin and erythromycin have been shown to increase the latency period from the time of rupture of membranes to delivery with significant neonatal benefits (1). The incidence of neonatal mortality and morbidity increases with decreasing gestational age. Although it is outside the scope of this chapter to address the multiple medical, psychosocial, neurodevelopmental and financial problems associated with prematurity, it should be emphasized that the "borderline viable" population of infants (<25 weeks gestational age) remain the greatest challenge. Due to their statistically poor outcomes, the question of whether or not to provide life supportive measures in the delivery room is, ideally, discussed with the prospective parents prior to delivery. The management of these most fragile newborns remains an ongoing area of controversy and debate in neonatal medicine. Preeclampsia is defined as new onset gestational hypertension with proteinuria, with or without edema. It complicates approximately 8% of pregnancies and is a major cause of maternal and perinatal morbidity and mortality. Uteroplacental ischemia mediated by the renin-angiotensin system is one of the most fundamental abnormalities of this disorder, however, the etiology of Page 85 preeclampsia is still unknown. Predisposing factors include primiparity, younger and older age extremes, familial/genetic factors, twin gestation, diabetes, and non-immune hydrops fetalis. Additional and alternative treatment strategies such as antihypertensives and magnesium sulfate for prevention of seizures are commonly employed especially when the degree of fetal immaturity (balanced with maternal status) precludes immediate delivery. The increase in perinatal morbidity and mortality associated with preeclampsia is largely due to prematurity. Uteroplacental insufficiency and abruptio placenta contribute to poor outcomes (3). Fetal intrauterine growth restriction is a frequent and expected by product of uteroplacental ischemia. Interestingly, despite the increase in fetal growth restriction and prematurity, preeclampsia is associated with a decreased risk of cerebral palsy (4). Diabetes mellitus is classified as type 1 (lack of insulin production or pre-gestational), type 2 (adult onset, insulin resistance). An elaborate and more detailed classification system for diabetes in pregnancy was developed by Priscilla White and later modified where type A1 is described as gestational diabetes treated with diet, and type A2 requires insulin therapy. Gestational diabetes is defined as carbohydrate intolerance first recognized during pregnancy. It accounts for the majority (80-90%) of the 3-5% of pregnancies complicated by diabetes and is caused by a 60% decrease in peripheral insulin sensitivity (a normal phenomenon in pregnancy), for which some women cannot compensate. Because this condition is often asymptomatic, screening is indicated between 24 and 28 weeks gestation. Glucose management is strict with the recommendation to maintain levels between 60 and 120 mg/dl. It is well established that tight metabolic control is associated with a marked reduction in the fetal and neonatal complications associated with diabetes in pregnancy listed in the table below: Fetal and Neonatal Complications of Diabetes in Pregnancy: A. Macrosomia occurs in 25%-45% of pregnancies complicated by diabetes which is a direct result of fetal hyperglycemia and hyperinsulinemia. Neonatal management of all infants of diabetic mothers includes a thorough evaluation for birth trauma and congenital defects, screening for and management of hypoglycemia, and close scrutiny of the infant for signs of respiratory distress. This condition presents the greatest clinical challenge to the pediatrician because prevention and treatment strategies are either nonexistent or unsatisfactory. Agent specific neonatal outcomes are frequently confounded by polysubstance abuse, poor nutrition, poor health care and unsatisfactory home environments. In Hawaii, the most commonly abused drugs are alcohol, marijuana, amphetamines, and methamphetamines. Additional substances of abuse include cocaine, heroin, and miscellaneous other agents. As a general rule, the severity and frequency of fetal/neonatal side effects associated with maternal substance abuse is related to timing, dose, and duration of use. Heroin has been one of the best studied and well characterized due to its prolonged existence as an illicit drug. Complications of heroin addiction in pregnancy include an increased incidence of stillbirth, preterm birth, and the delivery of infants who are small for gestational age. Neonatal abstinence syndrome (symptoms of withdrawal) occur in 50%-75% of infants and usually begin within 48 hours after birth and consists of a combination of irritability, jitteriness, coarse tremors, high pitched cry, sneezing, yawning, tachypnea, poor feeding, vomiting, diarrhea, sweating, temperature instability, hyperreflexia, and, occasionally, seizures. A scoring system has been devised using the above symptoms to assist with the management of these infants. Pharmacotherapy for severe withdrawal symptoms include tincture of opium, phenobarbital, and methadone. The use of naloxone is strictly contraindicated as it can lead to acute, severe withdrawal and seizures. Methadone withdrawal seen in infants of mothers under treatment for heroin addiction has many similar characteristics to heroin abstinence syndrome. Methadone is associated with both delayed onset and increased severity of withdrawal symptoms, including seizures. Exposure during pregnancy may result in a spectrum of symptoms secondary to varying degrees of insult to the central nervous system. Microcephaly, mild to moderate mental retardation, subtle cognitive and behavioral deficits have all been well described. No consistent or specific complications have been associated with the use of marijuana in pregnancy. Adverse pregnancy outcomes associated with cocaine abuse include higher incidence of stillbirth, asphyxia, prematurity, and babies with low birth weight and smaller heads. Breastfeeding is contraindicated as cocaine intoxication has been demonstrated in breast fed infants. Abuse of either amphetamine or methamphetamine during pregnancy is associated with a higher incidence of perinatal mortality, prematurity, and growth deficits. Abnormal central nervous system findings including cystic encephalomalacia and hemorrhage have also been described (6). Selective drug screening of mothers and newborns takes place routinely at most perinatal centers. Decisions regarding who to screen is often related to other perinatal risk factors such as inadequate prenatal care, previous history of substance abuse, high risk clinical signs in the mother (inappropriate or unusual behavior), history of prostitution, history of preterm labor, and presence of sexually transmitted disease(s). Documentation of fetal drug exposure by newborn urine or meconium toxicology screening typically results in referral to child protective services. All too often, these infants are placed in foster care pending rehabilitation of the mother or correction of the potentially harmful home situation. Page 86 In summary, there are many high risk conditions of pregnancy that can result in adverse neonatal outcomes, especially prematurity. It is important for the pediatrician to be fully aware of maternal risk factors so that he/she may be fully prepared to receive the newborn in the delivery room and provide ongoing care. Timely recognition of certain high-risk conditions during pregnancy often results in the transfer of the mother and fetus to a facility equipped to provide subspecialty care. An effective and safe measure for treating preterm labor and delaying preterm delivery is: a. Detection of uterine contractions through the use of home uterine activity monitoring d. True/False: Naloxone is the treatment of choice for drug withdrawal in methadone addicted newborns. The mother was hospitalized at 27 weeks gestation due to cervical changes and received 2 doses of betamethasone two weeks prior to delivery. Apgar scores were 6 and 6 at one and five minutes, respectively due to poor respiratory effort, decreased tone and decreased response to stimulation. He has a normal precordium and a grade 2/6 holosystolic murmur at the upper left sternal border. He has decreased tone but he responds well to stimulation and he has normal age appropriate reflexes A chest x-ray demonstrates a normal heart size, lungs expanded to 9 ribs, and clear lung fields. Because of a persistent heart murmur, an echocardiogram is performed which reveals a moderate to large patent ductus arteriosus with normal cardiac anatomy and function. He is not treated for this initially since he is not exhibiting signs of congestive heart failure.

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