Professor, Department of Otolaryngology/Head and Neck Surgery
Chief Otolaryngology/Assistant Chief Surgery, Portland VA Medical Center
Oregon Health and Science University
Portland, Oregon
The classic triad of exophthalmos pulse pressure 64 aceon 4mg otc, goiter blood pressure healthy range purchase 4mg aceon with mastercard, and hyperthyroidism in Graves disease is associated with symptoms of hyperthyroidism heart attack lyrics trey songz generic aceon 8mg online. The endocrine disorders encountered most frequently in gynecologic patients are those related to disturbances in the regular occurrence of ovulation and accompanying menstruation hypertension diagnosis jnc 7 order discount aceon. Other conditions leading to ovulatory dysfunction blood pressure medication uk names buy aceon 8mg with amex, hirsutism pulse pressure 27 cheap aceon 8 mg on line, or virilization arrhythmia causes buy aceon 8 mg amex, and common disorders of the pituitary and thyroid glands associated with reproductive abnormalities blood pressure in children discount aceon 8 mg with visa, are reviewed in this chapter. Hyperandrogenism Hyperandrogenism most often presents as hirsutism, which arises as a result of androgen excess related to abnormalities of function in the ovary or adrenal glands, constitutive increase in expression of androgen effects at the level of the pilosebaceous unit, or a combination of the two. By contrast, virilization is rare and indicates marked elevations in androgen levels. An ovarian or adrenal neoplasm that may be benign or malignant commonly causes virilization. Hirsutism Hirsutism, the most frequent manifestation of androgen excess in women, is defined as excessive growth of terminal hair in a male distribution. This refers particularly to midline hair, side burns, moustache, beard, chest or intermammary hair, and inner thigh and midline lower back hair entering the intergluteal area. The response of the pilosebaceous unit to androgens in these androgen responsive areas transforms vellus hair (fine, nonpigmented, short) that is normally present into terminal hair (coarse, stiff, pigmented, and long). Androgen effects on hair vary in relation to specific regions of the body surface. The hair of the limbs and portions of the trunk exhibits minimal sensitivity to androgens. Pilosebaceous units of the axilla and pubic region are sensitive to low levels of androgens, such that the modest androgenic effects of adult levels of androgens of adrenal origin are sufficient for substantial expression of terminal hair in these areas. Follicles in the distribution associated with male patterns of facial and body hair (midline, facial, inframammary) require higher levels of androgens, as seen with normal testicular function or abnormal ovarian or adrenal androgen production. Scalp hair is inhibited by gonadal androgens, in varying degrees, as determined by age and genetic determination of follicular responsiveness, resulting in the common frontal-parietal balding seen in some males and in virilized females. Hirsutism results from both increased androgen production and skin sensitivity to androgens. Hair demonstrates cyclic activity between growth (anagen), involution (catagen), and resting (telogen) phases. The durations of both the growth and resting phases vary according to region of the body, genetic factors, age, and hormonal effects. The cycles of growth, rest, and shedding are normally asynchronous, but when synchronous entry into telogen phase is triggered by major metabolic or endocrine events, such as pregnancy and delivery, or severe illness, dramatic (although transient) hair loss may occur in the following months (telogen effluvium). What is normal in one setting may be considered abnormal in others; social and clinical reactions to hirsutism can vary significantly, reflecting ethnic variation in skin sensitivity to androgens and cultural ideals. Androgen-dependent hair (excluding pubic and axillary hair) occurs in only 5% of premenopausal white women and is considered abnormal by white women of North America, whereas considerable facial and male pattern hair in other areas may be more common and more often considered acceptable and normal among such groups as the Inuit and women of Mediterranean background. Hypertrichosis and Virilization Two conditions should be distinguished from hirsutism. Hypertrichosis is the term reserved for androgen-independent terminal hair in nonsexual areas, such as the trunk and extremities. This may be the result of an autosomal-dominant congenital disorder, a metabolic disorder (such as anorexia nervosa, hyperthyroidism, porphyria cutanea tarda), or medications. Although hirsutism accompanies virilization, the presence of virilization indicates a high likelihood of more serious conditions than are common with hirsutism alone and should prompt evaluation to exclude ovarian or adrenal neoplasm. Although rare, these diagnoses become likely when onset of androgen effects is rapid or sufficiently pronounced to produce the picture of virilization. The history should focus on the age of onset and rate of progression of hirsutism or virilization. A rapid rate of progression or virilization is associated with a more severe degree of hyperandrogenism and should raise suspicion of ovarian and adrenal neoplasms or Cushing syndrome. This is true whether rapid progression or virilization occurs before, during, or after puberty. Anovulation, manifesting as amenorrhea or oligomenorrhea, increases the probability that there is underlying hyperandrogenism. Hirsutism occurring with regular cycles is more commonly associated with normal androgen levels and thus is attributed to increased genetic sensitivity of the pilosebaceous unit and is termed idiopathic hirsutism. In determining the extent of hirsutism, a sensitive and tactful approach by the physician is mandatory and should include questions regarding the use and frequency of shaving and/or chemical or mechanical depilatories. Most physicians arbitrarily classify the degree of hirsutism as mild, moderate, or severe. Objective assessment is helpful, especially in establishing a baseline from which therapy can be evaluated. It is a scoring scale of androgen-sensitive hair in nine body areas rated on a scale of 0 to 4 (2). Although widely used, this scoring system has limitations, one of which is the fact that the scale does not include the sideburn, buttocks, and perineal areas. Substantial hirsutism may be confined to one or two areas without exceeding the cutoff value in total hirsutism score. Each of the nine body areas most sensitive to androgen is assigned a score from 0 (no hair) to 4 (frankly virile), and these separate scores are summed to provide a hormonal hirsutism score. In addition to drugs that commonly cause hypertrichosis, anabolic steroids and testosterone derivatives may cause hirsutism and even virilization. During the physical examination, attention should be directed to obesity, hypertension, galactorrhea, malepattern baldness, acne (face and back), and hyperpigmentation. With virilization, the presence of an androgen-producing ovarian neoplasm or Cushing syndrome must be considered. A moon-shaped face, upper body obesity, muscle weakness, and the development of a pad of fat between the shoulder blades are particularly notable to both patients and diagnosticians considering the diagnosis of Cushing syndrome. Biosynthesis begins with the rate-limiting conversion of cholesterol to pregnenolone by side-chain cleavage enzyme. In a parallel fashion, progesterone undergoes transformation to androstenedione in the fi-4 steroid pathway. The basis for this action is related to the increase in the zona reticularis and in the increased activity of the 17-hydroxylase and the 17,20-lyase enzymes. Independent of the increase in ovarian androgen secretion accompanying puberty, the increase in adrenal androgens owing to adrenarche can account for significant increases in pubic and axillary hair and sweat production by the axillary pilosebaceous units. The ovaries and adrenal glands contribute almost equally to testosterone production in women. The contribution of the adrenals is achieved primarily through secretion of androstenedione. Therefore, when moderate hyperandrogenism, characteristic of many functional hyperandrogenic states, occurs, elevations in total testosterone levels may remain within the normal range, and only free testosterone levels will reveal the hyperandrogenism. Severe hyperandrogenism, as occurs in virilization and that results from neoplastic production of testosterone, is reliably detected by measures of total testosterone. Therefore, in practical clinical evaluation of the hyperandrogenic patient, determination of the total testosterone level in concert with clinical assessment is frequently sufficient for diagnosis and management. When more precise delineation of the degree of hyperandrogenism is desired, measurement or estimation of free testosterone levels can be undertaken and will more reliably reflect increases in testosterone production. These measurements are not necessary in evaluating the majority of patients, but they are common in clinical research studies and may be useful in some clinical settings. Because many practitioners measure some form of testosterone level, they should understand the methods used and their accuracy. Although equilibrium dialysis is the gold standard for measuring free testosterone, it is expensive, complex, and usually limited to research settings. In many cases of hirsutism, albumin levels are within a narrow physiologic range and thus do not significantly affect the free testosterone concentration. In individuals with normal albumin levels, this method has reliable results compared with those of equilibrium dialysis. Bioactive testosterone determined in this manner provides a superior estimate of the effective androgen effect derived from testosterone (5). Derived estimates of free testosterone, as opposed to direct measure by equilibrium dialysis, are therefore inaccurate during pregnancy. Testosterone measurements in pregnancy are primarily of interest when autonomous secretion by tumor or luteoma is in question, and for these, total testosterone determinations provide sufficient information for diagnosis. Two isozymes of 5 fi-reductase exist: type 1, which predominates in the skin, and type 2, or acidic 5fi-reductase, which is found in the liver, prostate, seminal vesicles, and genital skin. Both type 1 and 2 deficiencies in males result in ambiguous genitalia, and both isozymes may play a role in androgen effects on hair growth. Dihydrotestosterone is more potent than testosterone, primarily because of its higher affinity and slower dissociation from the androgen receptor. Although postmenopausal ovarian steroidogenesis contributes to testosterone production, testosterone levels retain diurnal variation, reflecting an ongoing and important adrenal contribution. Peripheral aromatization of androgens to estrogens increases with age, but because small fractions (2% to 10%) of androgens are metabolized in this fashion, such conversion is rarely of clinical significance. These guidelines suggest against testing for elevated androgen levels in women with isolated mild hirsutism because the likelihood of identifying a medical disorder that would change management or outcome is extremely low (Fig. In clinical situations requiring a testosterone evaluation, the addition of 17-hydroxyprogesterone will screen for adult onset adrenal hyperplasia, when indicated (Table 31. In cases of suspected Cushing syndrome, patients should undergo screening with a 24-hour urinary cortisol (most sensitive and specific) assessment or an overnight dexamethasone suppression test. Cortisol levels of 2 fig/dL or higher after overnight dexamethasone suppression require a further workup for evaluation of Cushing syndrome. Precocious pubarche precedes the diagnosis of adult onset congenital adrenal hyperplasia in 5% to 20% of cases. Because increased testosterone production is not reliably reflected by total testosterone levels, the clinician may choose to rely on typical male pattern hirsutism as confirmation of its presence, or may elect measures that reflect levels of free or unbound testosterone (bioavailable or calculated free testosterone levels). Total testosterone does serve as a reliable marker for testosterone-producing neoplasms. Total testosterone levels greater than 200 ng/dL should prompt a workup for ovarian or adrenal tumors. Routine determination of androgen conjugates to assess hirsute patients is not recommended, because hirsutism itself is an excellent bioassay of free testosterone action on the hair follicle and because these androgen conjugates arise from adrenal precursors and are likely markers of adrenal and not ovarian steroid production (8). When hirsutism is moderate (>9) or severe or if mild hirsutism is accompanied by features that suggest an underlying disorder, elevated androgen levels should be ruled out. Plasma testosterone is best assessed in the early morning on day 4 to 10 in regularly cycling women. A 17-hydroxyprogesterone is also indicated when symptoms warrant a bioavailable testosterone measurement. The mild form presents with vitalization or precocious puberty without hypertension. Calculated values for free and bioavailable testosterone compare well with equilibrium dialysis methods of measuring unbound testosterone when albumin levels are normal. Bioavailable testosterone is the most accurate assessment of bioactive testosterone in the serum without performing equilibrium dialysis. A random sample is sufficient because the level of variation is minimized as a result of the long halflife characteristic of sulfated steroids. In the study, the demographics and the prevalence of hirsutism, acne, oligomenorrhea and amenorrhea were not different in each group. When clinical signs of androgen excess reach the point of virilization or the free testosterone level is above 6. Careful consideration of the sensitivity and specificity, diurnal variation, and agerelated variation of potentially measureable androgens will aid in choosing the most useful measurements (Table 31. It is characterized by a combination of hyperandrogenism (either clinical or biochemical), chronic anovulation, and polycystic ovaries. It is the most common cause of hyperandrogenism, hirsutism, and anovulatory infertility in developed countries (15,16). The association of amenorrhea with bilateral polycystic ovaries and obesity was first described in 1935 by Stein and Leventhal (17). Their diagnostic criteria recommended clinical and/or biochemical evidence of hyperandrogenism, chronic anovulation, and exclusion of other known disorders. Clinical and/or biochemical signs of hyperandrogenism and exclusion of other etiologies. Clinical hyperandrogenism includes hirsutism, male pattern alopecia, and acne (19). A likely explanation for this discrepancy is the genetically determined differences in skin 5fi-reductase activity (22,23). It is important to measure the basal follicular phase 17-hydroxyprogesterone level in all women presenting with hirsutism to exclude the presence of nonclassic congenital adrenal hyperplasia, regardless of the presence of polycystic ovaries or metabolic dysfunction (24). Classically, the disorder is lifelong, characterized by abnormal menses from puberty with acne and hirsutism arising in the teens. It may arise in adulthood, concomitant with the emergence of obesity, presumably because this is accompanied by increasing hyperinsulinemia (26). The body fat is usually deposited centrally (android obesity), and a higher waist-to-hip ratio is associated with insulin resistance indicating an increased risk of diabetes mellitus and cardiovascular disease (30). Insulin resistance may eventually lead to the development of hyperglycemia and type 2 diabetes mellitus (32). A cross-section of the surface of the ovary discloses a white, thickened cortex with multiple cysts that are typically less than a centimeter in diameter. Microscopically, the superficial cortex is fibrotic and hypocellular and may contain prominent blood vessels. In addition to smaller atretic follicles, there is an increase in the number of follicles with luteinized theca interna. Insulin resistance, in concert with genetic factors, may also lead to hyperglycemia and an adverse profile of cardiovascular risk factors. The serum total testosterone levels are usually no more than twice the upper normal range (20 to 80 ng/dL). The presence and activity of 5fi-reductase in the skin largely determines the presence or absence of hirsutism (22,23). Aromatase and 17fi-hydroxysteroid dehydrogenase activities are increased in fat cells and peripheral aromatization is increased with increased body weight (51,52). With obesity the metabolism of estrogens, by way of reduced 2-hydroxylation and 17fi-oxidation, is decreased and metabolism via estrogen active 16-hydroxyestrogens (estriol) is increased (53). A chronic hyperestrogenic state, with reversal of the E1-to-E2 ratio, results and is unopposed by progesterone. Polycystic ovary syndrome is a complex multigenetic disorder that results from the interaction between multiple genetic and environmental factors. Oophorectomy in patients with hyperthecosis accompanied by hyperinsulinemia and hyperandrogenemia does not change insulin resistance, despite a decrease in androgen levels (70,71). This thickened, pigmented, velvety skin lesion is most often found in the vulva and may be present on the axilla, over the nape of the neck, below the breast, and on the inner thigh (72). Multiple other testing or screening schema were proposed to assess the presence of hyperinsulinemia and insulin resistance. In one, the fasting glucose-to-insulin ratio is determined, and values less than 4. When compared to the gold standard measure for insulin resistance, the hyperinsulemic-euglycemic clamp, it shows that the glucose-toinsulin ratio does not always accurately portray insulin resistance. This deficient insulin secretion exacerbates the effects of insulin resistance and renders inaccurate the use of hyperinsulinemia as an index of insulin resistance. Interventions Two-Hour Glucose Tolerance Test Normal Glucose Ranges (World Health Organization criteria, after 75-gm glucose load) Fasting 64 to 128 mg/dL One hour 120 to 170 mg/dL Two hour 70 to 140 mg/dL Two-Hour Glucose Values for Impaired Glucose Tolerance and Type 2 Diabetes (World Health Organization criteria, after 75-gm glucose load) Normal (2-hour) <140 mg/dL Impaired (2-hour) = 140 to 199 mg/dL Type 2 diabetes mellitus (2-hour) fi200 mg/dL Abnormal glucose metabolism may be significantly improved with weight reduction, which may reduce hyperandrogenism and restore ovulatory function (74). In obese, insulin-resistant women, caloric restriction that results in weight reduction will reduce the severity of insulin resistance (a 40% decrease in insulin level with a 10-kg weight loss) (75). This decrease in insulin levels should result in a marked decrease in androgen production (a 35% decrease in testosterone levels with a 10-kg weight loss) (76). In addition to addressing the increased risk for diabetes, the clinician should recognize insulin resistance or hyperinsulinemia as a cluster syndrome called metabolic syndrome or dysmetabolic syndrome X. Recognition of the importance of insulin resistance or hyperinsulinemia as a risk factor for cardiovascular disease led to diagnostic criteria for the dysmetabolic syndrome. The more dysmetabolic syndrome X criteria are present, the higher the level of insulin resistance and its downstream consequences. The presence of three of the following five criteria confirm the diagnosis, and an insulinlowering agent and/or other interventions may be warranted (19). Dietary management of obesity should focus on reducing body weight, maintaining a lower long-term body weight, and preventing weight gain. Metabolic improvements in fasting insulin, glucose, glucose tolerance, total cholesterol, triglycerides, plasminogen activator inhibitor-1, and free fatty acids are reported. The incorporation of structured exercise, behavior modification, and stress management strategies as fundamental components of lifestyle management increases the success of the weight loss strategy (Table 31. Alternative approaches to the treatment of obesity include the use of pharmacologic agents, such as orlistat, sibutramine, and rimonabant, or bariatric surgery (31).
Some nosocomial transmission can be prevented by good infection control procedures hypertension medication drugs order aceon with american express, including handwashing; procedures such as ultraviolet irradiation heart attack feat thea austin eye of the tiger cheap aceon 4mg free shipping, aerosols and dust control have not proven useful blood pressure how to read purchase cheap aceon. They are transmitted by ixodid (hard) ticks blood pressure chart neonates purchase generic aceon from india, which are widely distributed throughout the world; tick species differ markedly by geographical area blood pressure medication interactions buy aceon 2 mg mastercard. For all of these rickettsial fevers 01 heart attackm4a demi effective 4 mg aceon, control measures are similar blood pressure medication diuretic effective 8 mg aceon, and doxycycline is the reference treatment pulse pressure units aceon 2 mg without prescription. A petechial exanthem occurs in 40% to 60% of patients, generally on or after the 6th day. Risk factors associated with more severe disease and death include delayed antibiotherapy and patient age over 40. The rickettsiae can be transmitted to dogs, various rodents and other animals; animal infections are usually subclinical, but disease in rodents and dogs has been observed. Chloramphenicol may also be used, but only when there is an absolute contraindication for using tetracyclines. In more temperate areas, the highest incidence is during warmer months when ticks are numerous; in tropical areas, disease occurs throughout the year. Clinically similar to Boutonneuse fever (see above), but fever less common, rash noticed in only half the cases and may be vesicular. Outbreaks of disease may occur when groups of travellers (such as persons on safari in Africa) are bitten by ticks. The disease, caused by Rickettsia akari, a member of the spotted fever group of rickettsiae, is transmitted to humans from mice (Mus musculus) by a mite (Liponyssoides sanguineus). Clinically, this is usually indistinguishable from febrile rash illness due to measles, dengue, parvovirus B19, human herpesvirus 6, Coxsackie virus, Echovirus, adenovirus or scarlet fever. Encephalitis is a more common complication than generally appreciated, and occurs with a higher frequency in adults. Laboratory diagnosis of rubella is required, since clinical diagnosis is often inaccurate. An epidemiologically confirmed rubella case is a patient with suspected rubella with an epidemiological link to a laboratoryconfirmed case. In countries where rubella vaccine has not been introduced, rubella remains endemic. Consequently, it is essential that childhood rubella vaccination programs achieve and maintain high levels of coverage (above 80%) on a long-term basis. Following the introduction of large-scale rubella vaccination, coverage should be measured periodically by age and locality. Rubella vaccine should be avoided in pregnancy because of the theoretical, but never demonstrated, teratogenic risk. If pregnancy is being planned, then an interval of one month should be observed after rubella immunization. It is sometimes given in huge doses (20 ml) to a susceptible pregnant woman exposed to the disease who would not be in a position to consider abortion, but the value of this has not been established. Early reporting of suspected cases will permit early establishment of control measures. Infection may begin as acute enterocolitis and develop into septicemia or focal infection. In cases of septicemia, Salmonella may be isolated on enteric media from feces and blood during acute stages of illness. In cases of enterocolitis, fecal excretion usually persists for several days or weeks beyond the acute phase; administration of antibiotics may not decrease this duration. Epidemiologically, Salmonella gastroenteritis may occur in small outbreaks in the general population. This includes contaminated raw and undercooked eggs/egg products, raw milk/milk products, contaminated water, meat/meat products, poultry/poultry products. With several serotypes, a few organisms ingested in vehicles that buffer gastric acid can suffice to cause infection, but over 100 to 1000 organisms are usually required. Epidemics may also be traced to foods such as meat and poultry products processed or prepared with contaminated utensils or on work surfaces contaminated in previous use. The organisms can multiply in a variety of foods, especially milk, to attain a very high infective dose; temperature abuse of food during its preparation and cross-contamination during food handling are the most important risk factors. Maternity units with infected (at times asymptomatic) infants are sources of further spread. In recent years, geographically widespread outbreaks due to ingestion of tomatoes or melons from single suppliers have been recognized. A temporary carrier state occasionally continues for months, especially in infants. Severity of the disease is related to serotype, number of organisms ingested and host factors. Septicaemia in people with sicklecell disease increases the risk of focal systemic infection. Exclude symptomatic individuals from food handling and from direct care of infants, elderly, immunocompromised and institutionalized patients. In communities with adequate sewage disposal systems, feces can be discharged directly into sewers without preliminary disinfection. Trimethoprim-sulfamethoxazole and chloramphenicol are alternatives when antimicrobial resistant strains are involved. In infants, the head, neck, palms and soles may be involved; these areas are usually spared in older individuals. Itching is intense, especially at night, but complications are limited to lesions secondarily infected by scratching. Diagnosis may be established by recovering the mite from its burrow and identifying it microscopically. Care should be taken to choose lesions for scraping or biopsy that have not been excoriated by repeated scratching. Past epidemics were attributed to poverty, poor sanitation and crowding due to war, movement of refugees and economic crises. For hospitalized patients, contact isolation for 24 hours after start of effective treatment. Treat prophylactically those who have had skin-toskin contact with infested people (including family members and sexual contacts). On the following day, a cleansing bath is taken and a change made to fresh clothing and bedclothes. Eggs produce minute granulomata and scars in organs where they lodge or are deposited. Eggs can be deposited at ectopic sites, including the brain, spinal cord, skin, pelvis and vulvovaginal areas. Such infections may be prevalent among bathers in lakes in many parts of the world. Definitive diagnosis of schistosomiasis depends on demonstration of eggs in biopsy specimens, or in the stool by direct smear or on a Kato thick smear, or in urine by the examination of a urine sediment or Nuclepore filtration. People, dogs, cats, pigs, cattle, water buffalo and wild rodents are potential hosts of S. The eggs hatch in water and the liberated larvae (miracidia) penetrate into suitable freshwater snail hosts. After several weeks, the cercariae emerge from the snail and penetrate human skin, usually while the person is working, swimming or wading in water; they enter the bloodstream, are carried to blood vessels of the lungs, migrate to the liver, develop to maturity and then migrate to veins of the abdominal cavity. Eggs are deposited in venules and escape into the lumen of the bowel or urinary bladder or end up lodging in other organs, including the liver and the lungs. Preventive measures: 1) Treat patients in endemic areas with praziquantel to relieve suffering and prevent disease progression. To minimize cercarial penetration after brief or accidental water exposure, vigorously and completely towel dry skin surfaces that are wet with suspected water. Epidemic measures: Examine for schistosomiasis and treat all who are infected, but especially those with disease and/or moderate to heavy intensity of infection; pay particular attention to children. The disease spread to more than 20 additional sites throughout the world, following major airline routes. The major part of the spread occurred in hospitals and among families and contacts of hospital workers. Symptoms may worsen for several days coinciding with maximum viraemia at 10 days after onset. Sensitivity can be increased if multiple specimens/multiple body sites are tested. An antibody rise between acute and convalescent phase sera tested in parallel is highly specific. The surveillance case definitions are based on available clinical and epidemiological data and are supplemented by laboratory tests. Case definitions continue to be reviewed as diagnostic tests currently used in research settings become more widely available. A case initially classified as suspect or probable for whom an alternative diagnosis can fully explain the illness should be excluded after considering the possibility of co-infection. Current understanding, based on limited numbers of patients, suggests that the case fatality is less than 1% in persons aged 24 years or younger, 6% in persons aged 25 to 44 years, 15% in persons aged 45 to 64 years, and above 50% in persons aged 65 years or more. The virus is known to have been transported by infected humans to over 20 additional sites in Africa, the Americas, Asia, Australia, Europe, the Middle East and the Pacific. Initial studies suggest that transmission does not occur before onset of clinical signs and symptoms, and that maximum period of communicability is less than 21 days. Because of the small numbers of cases reported among children, it has not been possible to assess the infiuence of age. Soiled gloves, stethoscopes and other equipment must be treated with care as they have potential to spread infection. If an independent air supply is not feasible, air conditioning should be turned off and windows opened (if away from public places) for good ventilation. Particular attention should be paid to interventions such as use of nebulizers, chest physiotherapy, bronchoscopy or gastroscopy and other interventions that may disrupt the respiratory tract or place the healthcare worker in close proximity to the patient and to potentially infected secretions. From current epidemiological evidence, a contact is a person who cared for, lived with, or had direct contact with the respiratory secretions, body fiuids and/or excretion. Ribavirin with or without use of steroids has been used in several patients, but its effectiveness has not been proven and there has been a high incidence of severe adverse reactions. It has been proposed that a coordinated multi-centered approach to establishing the effectiveness of ribavirin therapy and other proposed interventions be examined. Place under active surveillance for 10 days and recommend voluntary isolation at home and record temperature daily, stressing to the contact that the most consistent first symptom that is likely to appear is fever. Severity and case-fatality rate vary with the host (age and pre-existing nutritional state) and the serotype. Isolation of Shigella from feces or rectal swabs provides the bacteriological diagnosis. Outside the human body Shigella remains viable only for a short period, which is why stool specimens must be processed rapidly after collection. A specific virulence plasmid is necessary for the epithelial cell invasiveness manifested by Shigellae. More than one serotype is commonly present in a community; mixed infections with other intestinal pathogens also occur. Infection may occur after the ingestion of contaminated food or water as well as from person to person. Individuals primarily responsible for transmission include those who fail to clean hands and under fingernails thoroughly after defecation. They may spread infection to others directly by physical contact or indirectly by contaminating food. General measures to improve hygiene are important but often difficult to implement because of their cost. Common-source foodborne or waterborne outbreaks require prompt investigation and intervention whatever the infecting species. Institutional outbreaks may require special measures, including separate housing for cases and new admissions, a vigorous program of supervised handwashing, and repeated cultures of patients and attendants. The most difficult outbreaks to control are those that involve groups of young children (not yet toilet-trained) or the mentally deficient, and those where there is an inadequate supply of water. Preventive measures: Same as those listed under typhoid fever, 9A1-9A10, except that no commercial vaccine is available. Because of the small infective dose, patients with known Shigella infections should not be employed to handle food or to provide child or patient care until 2 successive fecal samples or rectal swabs (collected 24 or more hours apart, but not sooner than 48 hours after discontinuance of antimicrobials) are found to be Shigella-free. Multidrug resistance to most of the low-cost antibiotics (ampicillin, trimethoprim-sufamethoxazole) is common and the choice of specific agents will depend on the antibiogram of the isolated strain or on local antimicrobial susceptibility patterns. In many areas, the high prevalence of Shigella resistance to trimethoprim-sufamethoxazole, ampicillin and tetracycline has resulted in a reliance on fiuoroquinolones such as ciprofioxacin as first line treatment, but resistance to these has also occurred. If administered in an attempt to alleviate the severe cramps that often accompany shigellosis, antimotility agents should be limited to 1 or at most 2 doses and never be given without concomitant antimicrobial therapy. Disaster implications: A potential problem where personal hygiene and environmental sanitation are deficient (see Typhoid fever). Fewer than 3% of variola major cases experienced a fulminant course, characterized by a severe prodrome, prostration, and bleeding into the skin and mucous membranes; such hemorrhagic cases were rapidly fatal. The chickenpox rash is more abundant on covered than on exposed parts of the body; the rash is centripetal rather than centrifugal. Smallpox was indicated by a clear-cut prodromal illness; by the more or less simultaneous appearance of all lesions when the fever broke; by the similarity of appearance of all lesions in a given area rather than successive crops; and by more deep-seated lesions, often involving sebaceous glands and scarring of the pitted lesions (chickenpox lesions are superficial and chickenpox rash is usually pruritic). Although the rash was like that in ordinary smallpox, patients generally experienced less severe systemic reactions, and hemorrhagic cases were virtually unknown. Electron microscopy or immunodiffusion technique often permitted a rapid provisional diagnosis.
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Samples should be obtained from any sites of contact (vagina prehypertension need medication order aceon online pills, rectum hypertension level 2 order 8mg aceon overnight delivery, or mouth) and tested for gonorrhea and chlamydia blood pressure korotkoff sounds cheapest aceon. Urine and blood samples should be collected to screen for the presence of any date rape drugs arrhythmia babys heartbeat buy online aceon. Evidence must be properly collected for legal purposes according to the following procedures: Examination of the patient with a Wood light may help identify semen hypertension vitamins order 4 mg aceon mastercard, which will fluoresce blue-green to orange arrhythmia episode order aceon 8 mg with visa. Areas of fluorescence should be swabbed with a cotton-tipped applicator moistened with sterile water blood pressure chart for dogs buy 4 mg aceon with amex, then air dried and submitted as evidence zopiclone arrhythmia order aceon without a prescription. Swabs of the skin, vagina, mouth, breasts, and rectum may be obtained to test for the presence of sperm or semen. In general, use a dry swab to obtain evidence from wet areas, and a wet swab to obtain evidence from dry areas. A sample of the vaginal secretions should be obtained for examination for motile sperm, semen, or pathogens. Nonmotile sperm can be found in the cervical mucus for as long as 1 week after ejaculation. If ejaculation occurred in the mouth, seminal fluid may be rapidly destroyed by salivary enzymes (142). If the survivor reports an anal assault, specimens can be obtained by washing the rectal vault with 10 mL of normal saline injected with a red rubber catheter. Allow the saline to stand for several minutes, then aspirate the rectal fluid and submit as evidence. Saliva should be collected from the survivor to document whether she is a secretor of major blood group antigens (80% of the population are secretors). If the patient is not a secretor and blood group antigens are found in vaginal washings, the antigens are probably from the semen of the assailant (151). Respiratory spray from where the assailant placed his face and breathed on the survivor may be collected from her breasts, shoulders, face, or neck. All sexual assault survivors of reproductive age should be offered emergency contraception (157). If the survivor desires emergency contraception, a preexisting pregnancy can usually be ruled out by performing a sensitive human chorionic gonadotropin assay. Levonorgestrel is available by prescription for women younger than 17 years, and available over the counter for women 17 years and older. Levonorgestrel is more effective than any other emergency contraception method and has the fewest side effects (160) Immediate administration of two tablets of a combination oral contraceptive (each containing 50 fig of ethinyl estradiol and 0. Emergency contraception failure poses little teratogenic risk if the pregnancy continues (163). Some patients experience nausea and vomiting when given emergency contraception containing estrogen, which can be controlled with an antiemetic agent such as promethazine (12. Emergency contraception should be repeated if vomiting occurs within 2 hours of taking the initial dose. Most women who take emergency contraception usually experience their next menstrual period within 3 days of the expected date. Women using mifepristone for emergency contraception may experience delayed onset of the subsequent menstrual period (161). Emergency contraception may delay but not prevent ovulation; for this reason, patients receiving emergency contraception should be encouraged to use contraception if further coital episodes occur during the cycle. The risk is estimated as follows: gonorrhea, 6% to 12%; trichomonas, 12%; chlamydia, 2% to 12%; syphilis, 5%. This is especially important because most sexual assault patients do not return for follow-up appointments (151). Subsequent doses are provided 1 month and 6 months after the first dose is administered. About 33% of survivors who elect to take antiviral medication discontinue therapy prematurely (168). Bite wounds can be treated with amoxicillin/clavulanate (Augmentin) 875 mg twice a day for 3 days. Ongoing supportive counseling for the patient should be arranged, and the patient should be referred to a sexual assault center or a therapist who specializes in the treatment of sexual assault survivors. A number of excellent resources are available for providers caring for women who were sexually assaulted (170). These include a policy statement on treatment of sexual assault survivors from the American Academy of Family Physicians and a national protocol for sexual assault medical forensic evaluations from the U. Assessing female sexual dysfunction in epidemiological studies: why is it necessary to measure both low sexual function and sexually related distressfi The sexual excitation/sexual inhibition inventory for women: psychometric properties. Progestin receptors: neuronal integrators of hormonal and environmental stimulation. The effects of experimentally-induced sad and happy mood on sexual arousal in sexually healthy women. Sexual desire in women: an integrative approach regarding psychological, medical and relationship dimensions. Female sexual desire disorders: subtypes, classification, personality factors, a new direction for treatment. Effect of estradiol versus estradiol and testosterone on brain activation patterns in postmenopausal women. Genital vascular responsive and sexual feelings in midlife women: psychophysiologic, brain and genital imaging studies. Functional evidence for nitrergic neurotransmission in human clitoral corpus cavernosum: a case study. Agreement of self-reported and genital measures of sexual arousal in men and women: a meta-analysis. Response of the internal reproductive organs to clitoral stimulation: the clitorouterine reflex. Men versus women on sexual brain function: prominent differences during tactile genital stimulation but not during orgasm. Evaluating a two-dimensional model of the orgasmic experience across genders and sexual contexts. The relationship between self-reported sexual satisfaction and general wellbeing in women. Qualities midlife women desire in their sexual relationship and their changing sexual response. The impairment of sexual function is less distressing for menopausal than for premenopausal women. Variability in the difficulties experienced by women undergoing infertility treatments. Metformin treatment of polycystic ovary syndrome improves health-related quality-of-life, emotional distress and sexuality. Quality of life in long-term, disease-free survivors of breast cancer: a follow-up study. Effect of endocrine treatment on sexuality in premenopausal breast cancer patient: a prospective randomized study. Randomized controlled trial of total compared with subtotal hysterectomy with 1-year follow-up results. Hysterectomy and sexual well being: prospective observational study of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy. Alteration of sexual function after classic intrafascial supracervical hysterectomy and total hysterectomy. Comparison of total laparoscopic hysterectomy and laparoscopically assisted vaginal hysterectomy. Vaginal blood flow after radical hysterectomy with and without nerve sparing: a preliminary report. Sexual function after hysterectomy early-stage cervical cancer: Is there a difference between laparoscopy and laparotomyfi The effect of the mode of delivery on the quality of life, sexual function, and sexual satisfaction in primeparous women and their husbands. Problems with sexual function and people attending London general practitioners: Cross-sectional study. The prevalence of hypoactive sexual desire disorder in surgically menopausal women: an epidemiological study of women in four European countries. Safety and efficacy of a testosterone patch for the treatment of hypoactive sexual disorder in surgically menopausal women: a randomized, placebo-controlled trial. Testosterone patch for low sexual desire in surgically menopausal women: a randomized trial. Efficacy and safety of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a randomized, placebo controlled trial. Randomized controlled trial to evaluate transdermal testosterone in female cancer survivors with decreased libido: North Central Cancer Treatment Group Protocol N02C3. Safety and efficacy of a testosterone metered-dose transdermal spray for treatment of decreased sexual satisfaction in premenopausal women: a placebo-controlled randomized, dose ranging study. A randomized comparative study of the effects of oral and topical estrogen therapy on the vaginal vascularization and sexual function in hysterectomized postmenopausal women. Effect on intravaginal dehydroepiandrosterone (Prasterone) on libido and sexual dysfunction in postmenopausal women. The consequences of female circumcision for health and sexuality: an update on the evidence. Intimate partner assault against women: frequency, health consequences, and treatment outcomes. Clinical characteristics of women with a history of childhood abuse: unhealed wounds. Comparative effects of sexual assault on sexual functioning of child sexual abuse survivors and others. Prevalence of sexual assault history among women with common gynecologic symptoms. Comparative analysis of adult versus adolescent sexual assault: epidemiology and patterns of anogenital injury. Sexual assault forensic medical examination: is evidence related to successful prosecutionfi Significance of toluidine blue positive findings after speculum examination for sexual assault. A randomized trial of mifepristone (10 mg) and levonorgestrel for emergency contraception. Extending the time limit for starting the Yuzpe regimen of emergency contraception to 120 hours. Prevalence of sexually transmitted infections and mental health needs of female child and adolescent survivors of rape and sexual assault attending a specialist clinic. Postexposure prophylaxis against human immunodeficiency virus infections after sexual assault. Appropriate referral to mental health specialists must be made in a sensitive manner. However, menopausal hormone levels are not correlated with depression, and premenstrual syndrome should not be diagnosed without 2 months of prospective daily ratings. Personality disorders and somatizing disorders rarely can be cured, but informed management can greatly decrease the suffering of the patient Withdrawal of successful psychotropic treatment is very likely to lead to relapse. Psychiatric problems are a central or complicating factor for many patients who seek care on an outpatient basis (1,2). Psychiatric diagnoses are extremely common and account for considerable morbidity and mortality in the general population (3). More than half of the patients who commit suicide have seen a nonpsychiatric physician during the previous 3 months (12). Belief that individuals with psychiatric disorders are weak, unmotivated, manipulative, or defective. Belief that the criteria for psychiatric diagnoses are intuitive rather than empirical. Belief that psychiatric treatments are ineffective and unsupported by medical evidence. Fear that patients with psychiatric problems will demand and consume inordinate and limitless time from a medical practice. Precipitation in others, including doctors, of feelings that are complementary to the strong and unpleasant emotions experienced by patients with psychiatric disorders. Failure to acknowledge psychiatric problems as legitimate grounds for medical attention. Psychiatry in the Gynecology Office Many gynecologists feel uncomfortable diagnosing and treating psychiatric illnesses. The practice of gynecology is demanding, and patients with psychological problems can evoke a variety of negative reactions in physicians (Table 12. Some physicians, and some members of the public, have the misconception that psychiatric diagnoses are vague and ill-defined. Current diagnostic criteria and categories of psychiatric disorders are supported by empirical evidence that is as reliable and valid as those used in most medical treatment. Physicians are naturally reluctant to uncover problems for which there seems to be no solutions. There are effective treatments for psychiatric disorders, and they are straightforward to use in clinical practice. Although the newly enacted parity laws forbid discrimination by insurers against mental health care, gynecologists and their patients may have difficulty accessing mental health services. It is sometimes necessary for the physician and family to advocate strongly for necessary care. By incorporating the management strategies in this chapter into their practice, gynecologists can reduce clinical frustration and play a major role in improving the health and well-being of their patients. This volume is organized by initial signs and symptoms rather than psychiatric categories and uses algorithms and decision trees to facilitate the diagnostic process (9). Accurate diagnosis is absolutely critical to successful management, whether care is provided by a gynecologist or through referral to a mental health expert. Approach to the Patient Although diagnostic criteria list signs and symptoms, the interaction with a patient should not be reduced to a series of rapid-fire questions and answers. A patient who is encouraged to speak for several minutes before being asked to respond to specific questions will reveal information that is useful, even vital, to her care: a thought disorder, a predominant mood, abnormally high anxiety, a personality style or disorder, and attitudes toward her diagnosis and treatment. Such information may emerge only much later, or not at all, in a question-and-answer format (15,16). It is critical that the gynecologist neither jumps to diagnostic conclusions nor proceeds directly to therapeutic interventions. One study revealed that many primary care physicians, feeling that they have too little time or training to assess psychological symptoms, tend to minimize verbal interactions with patients and to rely on the prescription of psychotropic medications (17). Allowing a few moments for openended discussion does not mean that the physician and the other patients awaiting care are to be held hostage by an overly talkative patient. The clinician can tell the patient with multiple, detailed symptoms how much time is available for the current appointment, invite her to focus on her most pressing problem, and offer a future appointment to continue the account. Psychiatric Referral Many gynecologists consider referral to a mental health professional, particularly a psychiatrist, to be a delicate matter. Most mild psychiatric disorders are treated by nonpsychiatric physicians, who often prescribe antidepressants and anxiolytic medications (18). Psychiatric disorders often are overlooked, misdiagnosed, or mistreated in primary care practice. The primary provider should refer patients for psychiatric evaluation when the diagnosis is not clear or when the patient fails to respond to initial treatment. The gynecologist can resume responsibility for ongoing care of many patients after their initial or periodic assessment by a psychiatrist. How to Refer Some clinicians fear that patients will be insulted or alarmed by a psychiatric referral.
Antibiotic prophylaxis for transurethral prostatic resection in men with preoperative urine containing less than 100 prehypertension not overweight cheap aceon 2mg online,000 bacteria per ml: a systematic review arteria circumflexa scapulae buy cheap aceon 8mg online. Antibiotic prophylaxis in percutaneous nephrolithotomy: prospective study in 81 patients blood pressure chart during exercise aceon 2mg on line. Antibiotic prophylaxis with cefotaxime in endoscopic extraction of upper urinary tract stones: a randomized study blood pressure quick reduction discount 8 mg aceon with amex. Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy: a prospective clinical study blood pressure chart during exercise purchase aceon 2mg with visa. Percutaneous nephrolithotomy with ultrasonography-guided renal access: experience from over 300 cases arrhythmia in dogs order 2 mg aceon. Prediction of septicemia following endourological manipulation for stones in the upper urinary tract heart attack las vegas cheap aceon 4mg overnight delivery. Perioperative prophylaxis for percutaneous nephrolithotomy: randomized study concerning the drug and dosage blood pressure reducers buy aceon 4 mg on-line. The value of antibiotic prophylaxis during extracorporeal shock wave lithotripsy in the prevention of urinary tract infections in patients with urine proven sterile prior to treatment. Amoxycillin/clavulanate prophylaxis for extracorporeal shock wave lithotripsy-a comparative study. The necessity of prophylactic antibiotics during extracorporeal shock wave lithotripsy. Are prophylactic antibiotics necessary during extracorporeal shockwave lithotripsyfi Antibiotic prophylaxis for shock wave lithotripsy in patients with sterile urine before treatment may be unnecessary: a systematic review and meta-analysis. Antimicrobial prophylaxis prior to shock wave lithotripsy in patients with sterile urine before treatment: a meta-analysis and cost-effectiveness analysis. A population based assessment of complications following outpatient hydrocelectomy and spermatocelectomy. Prospective comparative study of single dose versus 3-day administration of antimicrobial prophylaxis in minimum incision endoscopic radical prostatectomy. Single-dose orally administered quinolone appears to be sufficient antibiotic prophylaxis for radical retropubic prostatectomy. Comparison of 1-day, 2-day, and 3-day administration of antimicrobial prophylaxis in radical prostatectomy. Perioperative antibiotics in radical cystectomy with ileal conduit urinary diversion: efficacy and risk of antimicrobial prophylaxis on the operation day alone. Experience in 100 patients with an ileal low pressure bladder substitute combined with an afferent tubular isoperistaltic segment. Incidence of and risk factors for surgical site infection in patients with radical cystectomy with urinary diversion. Recommendations for empiric parenteral initial therapy of bacterial infections in adults. This information is publically accessible through the European Association of Urology website. Clinical, immunological, and radiological findings of noncompressive myelopathies are reviewed, as are how these findings can be used to distinguish between demyelinating, infectious, other infiammatory, vascular, neoplastic, and paraneoplastic etiologies. In tory myelitis, is one of the causes of acute transverse the following sections, clinical presentations of myelomyelopathy. The predictors of relapses in pathic transverse myelitis; infections such as herpes demyelinating myelopathies are included, followed by an zoster and herpes simplex virus; and other infiammatory algorithm on diagnosis and treatment. However, whether the cause of the there may be instances where our personal clinical acute myelopathy is infiammatory or not is not selfpractice and experience have infiuenced our opinions evident; therefore, the clinical and diagnostic workup for and approach. Copyright # 2008 by Thieme Address for correspondence and reprint requests: Brian G. Table 1 summarizes the clinical matory disorders, vascular, and neoplastic and paraneopresentation of acute spinal cord disorders. The first three are considered infiammatory Myelopathies with selective tract involvement are disorders. Among these, demyelinating disorders are characteristic of metabolic or degenerative myelopathies the most common. The initial task of the clinician is (which are usually chronic) rather than infiammatory or to determine which of these is most likely. Table 2 provides the differential diagnoses of the five groups of disorders that present as acute demyelinating myelopathies and their clinical-radiomyelopathy are: demyelination, infections, other infiamlogical features. In a prospective study, the risk of developing present in more than 90% of patients, and a raised recurrent myelitis or new onset optic neuritis in immunoglobulin (Ig)G index is seen in more than patients with an isolated longitudinally extensive 60%. Subclinical optic nerve involvement may be evident transverse myelitis was more than 50% among those on visually evoked response testing. The lesions in the cord are typically long Table 3 Diagnostic Criteria for Neuromyelitis Optica (> 3 vertebral segments) (Fig. Such Assessment for Recurrence Risk in cases may refiect chance occurrences of idiopathic transDemyelinating Myelopathies verse myelitis in patients who incidentally have had a After management of acute myelitis with steroids and/or vaccination. Incomplete transverse myelitis usually has 15,16 the most common cause of acute myelitis. Criteria asymmetric findings that may involve a limited number 17 have been proposed for this entity (Table 4). However, of tracts and does not typically result in loss of all motor, the idiopathic nature is a diagnosis of exclusion. In general, complete bimodal peaks in onset ages are 10 to 19 years and 30 to transverse myelitis is associated with a long spinal cord 39 years. The lesion lesion, typically one to two segments in length and length varies from less than one segment to the entire peripheral. Louis encephalitis virus Human herpes viruses 6 and 7 Tick-borne encephalitis virusy Epstein-Barr virus36* West Nile virusy Orthomyxoviruses Infiuenza A virus Paramyxoviruses Measles virus Mumps virus Picornaviruses Coxsackieviruses A and By Echoviruses Enterovirus-70 and 71y Hepatitis A, C37 Poliovirus types 1, 2, and 3y Bacterial Spinal cord abscess due to hematogenous spread of systemic infection Mycoplasma, Borrelia burgdorferi (Lyme), Treponema pallidum (syphilis) Mycobacterium tuberculosis Fungal Actinomyces, Blastomyces dermatitidis, Coccidioides, Aspergillus Parasites Neurocysticercosis, Schistosoma, Gnathostoma, angiostrongylosis (eosinophilic myelitis) *Common causes. Some experts advocate prophylactic 6 the seronegative patients experienced recurrence. This is in contrast to established criteria for these disorders should be satisfied parainfectious or idiopathic infiammatory myelitis before the myelitis is attributed to these disorders. The significance of an autoanticause, Table 6 lists the infectious agents, and Table 7 body. However, in most cases of without consistent systemic clinical features is suspect. However, it is rare for myelitis to be the presenting Vascular Disorders the arterial supply of the spinal cord consists of a single Table 7 Cerebrospinal Fluid Evaluation in Suspected anterior spinal artery and two posterior spinal arteries Infectious Myelitis (that course vertically over the surface of the cord) and 27 Stains and cultures their penetrating branches. Neurologic disorder: (a) seizures or (b) psychosis (both not due to drugs or metabolic abnormalities) 9. Objective evidence of dry eyes (at least one present): Schirmer test, Rose-Bengal, lacrimal gland biopsy 4. Objective evidence of salivary-gland involvement (at least one present): Salivary-gland scintigraphy, parotid sialography, unstimulated whole sialometry (1. Skin lesions (erythema nodosum, acneiform nodules, pseudofolliculitis, and papular lesions) 4. Neoplasia and Myelopathy Intramedullary metastatic disease and intradural extramedullary compressive tumors (neurofibromas and meningiomas) are common causes of acute or acuteon-chronic myelopathy. Primary intramedullary cord tumors (ependymomas, astrocytomas, hemangioblastomas) or metastatic intramedullary tumors usually present over weeks. Intramedullary cord lymphomas may respond symptomatically and radiologically to corticosteroids, which can further confuse the diagnosis. Axial T2 sections through the cord of a 69-year-old woman with melanoma and high titres of amphiphysin-immunoglobulin (Ig)G. The short arrow points to the specific lesion, usually symmetrically involving both vertebral changes in the field of radiation. Epidural lipomatosis Dynamic compression on fiexion extension only46,47 Is it really a myelopathyfi Parasagittal meningioma Cerebral venous thrombosis Anterior cerebral artery thrombosis Normal pressure hydrocephalus Hydrocephalus Small vessel disease (vascular lower limb predominant parkinsonism) Other extrapyramidal disorders Is it an acute presentation of an underlying B12, folate, copper deficiency chronic metabolic, degenerative, Nitrous oxide inhalation or infective myelopathyfi Once a demyelinating diagnostic criteria and nosology of acute transverse myelitis. Most patients with multiple sclerosis or a clinically isolated demyelinating imaging techniques, and microbiological tests capable of syndrome should be treated at the time of diagnosis. Acute transverse myelitis following coexist and predict cancer, not neurological syndrome. Early-onset acute transverse myelitis following nuclear autoantibody type 2: paraneoplastic accompaniments. Glutamic acid American Rheumatism Association Diagnostic and Therdecarboxylase autoimmunity with brainstem, extrapyramidal, apeutic Criteria Committee. Severe recurrent clinical and magnetic resonance imaging findings and short myelitis in patients with hepatitis C virus infection. Cervical cord European criteria proposed by the American-European compression caused by a pillow in a postlaminectomy patient Consensus Group. Pathophysiology and Excerpta Medica; 1987 treatment for cervical fiexion myelopathy. The Innocenti Digests are produced by the Centre to provide reliable and accessible information on specific rights issues. This issue of the Innocenti Digest has been principally researched and written by Michael Miller and Francesca Moneti with additional research contributions by Camilla Landini. The Communication and Partnership Unit are thanked for moving this document through the production process. Special thanks to Samira Ahmed, Farida Ali, Daniela Colombo, Maria Gabriella De Vita, Malik Diagne, Neil Ford, Gerry Mackie, Molly Melching, Rada Noeva, Cristiana Scoppa, Mamadou Wane and Stan Yoder for their expert contribution, support and counsel throughout. These include Zewdie Abegaz, Heli Bathija, Nafissatou Diop, Amna Hassan, Khady Koita, Edilberto Loaiza, Diye Ndiaye, Eiman Sharief and Nadra Zaki. The views expressed are those of the authors and are published by the Centre in order to stimulate further dialogue on child rights. The Centre invites comments on the content and layout of the Digest and suggestions on how it could be improved as an information tool. Annunziata, 12 50122 Florence, Italy Tel: (+39) 055 20 330 Fax: (+39) 055 20 33 220 Email general: florence@unicef. Greater understanding of human rights them of their physical and mental integrity, their right provides communities with the tools to direct their to freedom from violence and discrimination, and in own social transformation. Not only is it practiced among communities in Africa and the Middle East, but also in this Innocenti Digest is a contribution to a growimmigrant communities throughout the world. The one of the most persistent, pervasive and silently 1979 Convention on the Elimination of All Forms of endured human rights violations. Moreover, not conforming to the received consistent attention from the Committee on practice stigmatizes and isolates girls and their famithe Rights of the Child and from other treaty bodies lies, resulting in the loss of their social status. The Millennium Development Goals because they want the best for their children and establish measurable targets and indicators of develbecause of social pressure within their community. This procedure may involve the use of unsterto provide the global community with a greater underilised, makeshift or rudimentary tools. This harmful practice is a deeply entrenched social convention: when it is the terminology applied to this procedure has practiced, girls and their families acquire social status undergone a number of important evolutions. In the case of practical tool to bring about positive change for girls girls and women, the phenomenon is a manifestaand women. Girls and women may not always be certain of which procedure was performed on them. Moreover, there may be significant variation in the extent of cutting, because the procedure is commonly carried out without anaesthetic in poorly lit conditions, and girls often struggle to resist. Of these, nearly half most current data from these sources, summarized in are from two countries: Egypt and Ethiopia. The practice has also been however, when interpreting these figures, since they reported among certain populations in India, Indonerepresent national averages and do not reflect the sia, and Malaysia. Of these, more * Sample consisted of ever-married women than one third are of Somali origin. About 90 in rural areas than in urban areas, although in certain per cent of girls in Egypt are cut between the ages of cases the difference is very small. In two cases 5 and 14 years,15 while in Ethiopia, Mali and Maurita(Ethiopia and Guinea), urban and rural rates were nia, 60 per cent or more of girls surveyed underwent both found to be identical or near identical, while in the procedure before their fifth birthday. There are, by the very small proportion of women in this counhowever, certain challenges in obtaining these data, try with secondary schooling or above. Only in Burkithe practice, but alone it is not sufficient to lead to its na Faso was the more extensive procedure, involving abandonment. Innocenti Digest Magnitude, Assessment and Measurement 7 Standardizing indicators the Global Consultation also sought to extend the collection of data on prevalence to girls aged 5 to for situation analysis 14. It may be possible to obtain these data through and monitoring progress local surveys, although these do not yield prevalence data at national levels.
