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By Z. Jesper. California Polytechnic State University, San Luis Obispo.

Cerebral Salt Wasting9 In acute and rarely chronic brain injury an increase in urinary sodium excretion is seen with increased urinary volume buy discount azulfidine 500mg line. Management consists of volume by volume replacement of fluids with normal saline and if needed 3% saline purchase azulfidine visa. Some researchers have successfully used mineralocorticoids to treat this condition although it may not always be effective cheap azulfidine 500 mg with visa. In: Hanley, Belfus (Eds): Frequently overlooked diagnoses in acute care, (1st edn). Any delay in diagnosis and management of these cases may add to the morbidity and mortality. Hence, it is essential to know about the diseases that cause acute abdominal pain a the rational approach to the problem. The common causes of abdominal emergencies in childhood are innumerated in Table 31. Pancreatic pain is in upper abdomen while that due to ovarian torsion in lower abdomen, appendicular pain is in right iliac fossa, Meckel’s diverticulitis and mesenteric adenitis causes periumbilical region pain, and perforation or primary peritonitis causes generalized pain. Inquiry into the location, timing of onset, character, severity, duration, radiation, precipitating or relieving factors pain are all important points but must be viewed in the context of the child’s age. Dark green, bilious vomiting is always due to surgical cause5 and usually suggests intestinal obstruction. Failure to pass flatus or faeces suggests either functional constipation or intestinal obstruction. The classical “red currant-jelly stool” often is seen in patients with intussusception. Urinary frequency, dysuria, urgency, and malodorous urine suggest a urinary tract infection. Presence and site of abdominal guarding is very important clue to know origin of pain. Rectal and pelvic examination should be used when significant information is sought or expected. In shocked or listless child, 100% oxygen via a rebreathing circuit should be given with continuous pulse oximetry. Intravenous or intraosseous access should be obtained if there is shock or dehydration: initial crystalloid infusions should be given as bolus of 20 ml/kg. It not uncommon for children to require more than 40 ml/kg of intravenous fluids: establishing an adequate capillary refill time (less than 2 seconds) should be used as an end point. Liver function tests and serum amylase should be obtained if there are clinical indications of hepatobiliary disorders or pancreatitis. Capillary or arterial blood gases are useful in the assessment of associated acid-base disorders and their response to treatment. Metabolic acidosis is common in hypovolemic shock, but failure of the acidosis to respond to fluid resuscitation and supportive measures may suggest ischemic or infracted bowel especially in the presence of raised levels of lactate in serum. Plain film abdominal radiographs are most useful when intestinal obstruction or perforation of a viscus (gas under diaphragm) in the abdomen is a concern. The most contentious issue in emergency medicine may be the usefulness of ultrasonography and computed tomography in patients with abdominal pain. Initial management Maintenance of airway, breathing and circulation is important first step. Maintenance of intravascular volume by intravenous crystalloids after treating of shock is next step. Virtually all children less than 5 years may have perforated their appendix at presentation. The cardinal symptoms and signs include vomiting, passage of blood and mucus per rectum (‘red current jelly’), abdominal pain, palpable abdominal lump and lethargy. Ultrasonography of the abdomen is the standard noninvasive diagnostic technique and is quite reliable in experienced hands. Vigorous fluid resuscitation, nasogastric suction, and antibiotics is of utmost importance. Contraindication to hydrostatic reduction is evidence of peritonitis, indicating the presence of gangrenous intestine. If reduction fails or is contraindicated, open surgical reduction or resection is needed. Often, it is difficult to differentiate this condition from a mild attack of appendicitis. Management is symptomatic; if the diagnosis is in doubt, surgical exploration is indicated. It presents with midepigastric pain radiating to back and left flank; with associated nausea and vomiting. Elevated amylase in serum and urine with amylase-creatinine clearance ratio above five are of value in diagnosis but not specific. Nil orally, nasogastric suction, parenteral analgesia, parenteral nutrition if required, and sometimes antibiotics are generally required. Surgery (Ladd’s procedure) involves derotation of bowel, placement in the non-rotated arrangement and broadening of mesentry to prevent volvulus. Constipation and Hirschsprung’s Disease Constipation is difficulty in passage of hard or firm stool, while prolonged interval between passages of hard stools is called obstipation. Constipation during neonatal period, with associated distension and vomiting, is never functional, so anatomic or mechanical obstruction must be suspected. During the first year of life, failure to have bowel movement every other day warrants an evaluation. Hirschsprung’s disease should be considered in any child who has history of constipation dating back to newborn period. Constipation, abdominal distension poor feeding, emesis, failure to thrive and explosive passage of stools, is a common presentation. Total colonic aganglionosis may present with intestinal obstruction and perforation. Diversion colostomy proximal to aganglionic segment in neonatal period followed by definitive repair at age of 9 to 12 months was standard treatment. Toilet trained child usually presents with frequency, urgency, dysuria, lower abdominal pain and urinary incontinence. Vesicoureteral reflux and congenital obstructions at pelviureteric junction, ureterovesical junction and posterior urethral valves are the common causes, which present with urinary tract infection with abdominal symptoms. Pediatric appendicitis in “real-time”: the value of sonography in diagnosis and treatment. Effect computed tomography of the appendix on treatment of patients and use of hospital resourses. Ultrasound scans done by surgeons for patient with acute abdominal pain: a prospective study.

Favourable outcomes using alternative instruments and meth- ods of transection have been described by neurosurgeons [15 generic 500mg azulfidine,16] order azulfidine 500mg with mastercard. Operative procedure Patients are given preoperative antibiotics and ofen steroids and are positioned so that the surgical site is at the highest point in the Outcome operative feld cheap 500mg azulfidine with amex. However, Anaesthesia is accomplished with intravenous methohexital and as has been reported by other centres, there is a late reoccurrence local anaesthesia. Re- tion hook is introduced into the grey matter layer and advanced to duction in seizures by 50% or more was seen in 79% of patients. If the 4-mm tip is excellent outcome (greater than 95% reduction in seizure frequen- introduced just below the pia, it should remain in the grey matter cy) in 87% of patients who had generalized seizures and 68% of layer, leaving the white matter undisturbed. Ten to 44 months postsurgery three pa- tients remained seizure free and the remaining four had only rare seizures. During this pro- cedure, longitudinal hippocampal circuits are cut and disrupted by transection of the pyramidal cortical layer while the transverse lam- inar confguration of the hippocampus, which serves memory func- tion, is preserved. Similar fndings have been described in mouse models of mesial temporal lobe epilepsy where a selective transec- tion of the dentate gyrus and hilus signifcantly reduced the occur- rence of paroxysmal epileptic discharges and abolished the spread (d) over the longitudinal axis of the hippocampus, suggesting that lon- gitudinal projections are critical for the generation and spread of Figure 72. Of the 21 patients, 17 were as to select the next transection site 5 mm from the frst. Fourteen patients (82%) became sei- until the identifed epileptogenic zone is transected. Eight patients underwent procedure is to abolish synchronized epileptic activity and preserve the a full postoperative battery of neuropsychological testing of verbal functional status of the transected cortex by sectioning the intracortical memory. Verbal memory was completely spared in seven, with one horizontal fbres at 5-mm intervals while preserving the columnar patient having a transient worsening that cleared over 6 months organization of the cortex. The authors were encouraged with the above results; however, a longer follow-up and greater numbers of patients are required be- fore transection of hippocampus is confrmed to be efcacious and sparing of verbal memory function. This usually included afected cortex extending 5–7 cm from the Multiple subpial transection 919 temporal tip. The postoperative results were excellent with Multiple subpial transection with cortical resection has been used 94. Repeat neuropsy- in patients with multifocal multilobar epilepsy, clinical seizures and chological testing at 3–6 months postoperatively was available in developmental regression. Verbal memory improved in seven of nine improvement in language, social and behavioural function with a patients and in the remainder it remained stable. Good The patients who underwent right-sided surgery showed improve- success rates, even in groups of patients with catastrophic types of ment in verbal memory only, while the patients who underwent epilepsy, have been reported, without signifcant cognitive or func- lef-sided surgery had no signifcant memory change in relation to tional decline [41]. In a series of sev- patients with non-lesional dominant mesial temporal lobe epilepsy. The mortality of this condition is high and achieving seizure and immunotherapy is used to control seizures and behaviour- control to prevent further neurological and systemic damage is im- al changes, but the cognitive defcits associated with the disease perative. All intractable infantile spasm with some improvement in seizures and had continuous spike and wave in slow-wave sleep from a unilat- developmental delay [45]. The variability of reported short and long-term out- ment of language coming within the frst 6 months postoperatively. The main one is probably the experience of tive improvement on receptive and expressive tasks, which further the neurophysiology and neurosurgical team performing the pro- improved as they were followed over a longer period of time afer cedure. The frequency of disconnection over the transected area result in better postoper- of seizures and behavioural disorders signifcantly improved in ative seizure outcome. This might be related to the duration of epilepsy prior seems to result in better outcome. Finally, the diversity and limitations of recent hospital series describes similar trends. Ten children ages 5 the design of the reported studies also plays an important role in 920 Chapter 72 Table 72. Tese included foot tapping test showed a much broader and bilateral cortical activation drop in 2%, language defcit in 2% and a parietal sensory loss in 1%. Available data sup- subpial transection for control of epileptic seizures: efectiveness and safety. Evaluation of the combination of multi- ple subpial transection and other techniques for treatment of intractable epilepsy. Additional experimental and clinical studies are needed before Chin Med J 2003; 116: 1004–1007. Multiple subpial transection for intractable mamentarium at all major epilepsy centres. Neuronal disconnection for the surgical treatment of pedi- curve should be expected whenever these procedures are newly im- atric epilepsy. Malignant rolandic-sylvian epilepsy in chil- Acknowledgment dren: diagnosis, treatment, and outcomes. Dentate gyrus and hilus transection blocks seizure propagation and granule cell dispersion in a mouse model for mesial tem- References poral lobe epilepsy. Transsylvian hippocampal transection for mesial bellar nuclei to the motor cortex in the cat. Modality and topographic properties of single neurons of cat’s transection for lef temporal lobe epilepsy without hippocampal atrophy. The penicillin focus: a study of feld characteristics using cross-correla- with subpial intracortical transection. Epilepticus During Slow Sleep Acquired Epileptic Aphasia and Related Conditions, 40. Magnetoencephalography in presurgical evaluation of children with review of available therapies and a clinical treatment protocol. Relation between extent of resection of mesial structures and postsur- ry partial status epilepticus with multiple subpial transection: case report. Surgical Treat- al transection on patients with uncontrolled atypical infantile spasms. The signifcance of parahippocampal with refractory epilepsy treated using a modifed multiple subpial transection high gamma activity for memory preservation in surgical treatment of atypical technique. J Neurol Neurosurg Psychiatry 1995; 58: ization following multiple subpial transection in human brain - a study with posi- 344–349. Horsley’s experimental studies of cortical stimulation functions postoperatively [3]. In patients undergoing dominant hemisphere sur- the years that followed, Otfrid Foerster’s operations for epilepsy gery, the traditional approach has utilized awake surgery with intra- under local anaesthesia, along with Jasper and Gibbs’ pioneering operative functional brain mapping to preserve ‘eloquent’ language electroencephalographic studies, inspired Wilder Penfeld to spend functions and even memory functions during surgery [8]. Using this technique, parsimonious ‘eloquent’ Advances in anaesthetic and surgical techniques have made cortical patches are defned, and if resections are 1 cm distant [9] awake surgery for intractable epilepsy much safer than was the from them (‘1 cm rule’), the presumption is that gross language case in previous decades. In fact, the utility of awake surgery in the defcits (expressive/receptive) can be avoided postoperatively. This context of brain tumour resections has resulted in the widespread technique, however, is not universally efective at avoiding postop- adoption of this technique in neuro-oncological neurosurgery erative defcits as has been documented in many studies.

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This could 1200 mg/day have been shown to be efective and well tolerated suggest a rebound phenomenon but more likely refects the slower [38 cheap azulfidine master card,39 buy azulfidine 500mg low price,40 cheap 500 mg azulfidine amex,41]. The initial target dose for adults, recommended for all elimination of phenytoin [97]. For smaller adults and older per- sons, a target dose of 900 mg/day may be considered [86]. Tere were Current place in therapy surprisingly few drop-outs because of side-efects (only 3 of 51) in The efcacy of oxcarbazepine has been established thoroughly with the inpatient trial in which a 2400-mg dose was reached on the sec- many well-controlled clinical trials. However, outpatients are less likely to tol- treatment of focal seizures and for generalized onset or secondar- erate high doses, especially as adjunctive therapy. Nearly two-thirds ily generalized tonic–clonic seizures, when used as either mono- of patients in the 2400 mg/day arm discontinued the drug in an therapy or adjunctive therapy. Withdrawals because of adverse efects in the controlled trial of phenytoin and valproate, but it may be better tolerated than carba- the extended-release formulation at 2400 mg was 30. It should be noted, however, controlled studies of similar design, although direct comparisons in that the most common baseline drug in most adjunctive-therapy this setting are not available. One might expect typical junctive drug is usually good for children treated with 30–45 mg/ sodium-channel blocker side-efects, such as dizziness and diplopia, kg/day [98] and for adults treated with 600–1200 mg/day, but toler- to be additive with such a combination, and indeed there are data ability is considerably worse for adults treated with 1800–2400 mg/ indicating that at an oxcarbazepine dose of 2400 mg/day, discontin- day [46]. The rate for An average dose for children, based on a childhood new-on- both minor and serious skin rashes is low, and is apparently low- set monotherapy study [40], is 20 mg/kg/day. Mood dis- duction in seizures is achieved, even without clinical toxicity, at orders are uncommon, as are behavioural disorders such as irrita- 1800 mg/day in adults or 45 mg/kg/day in children, then further in- bility or hostility. Cognitive complaints and fatigue can occur, but creases are unlikely to be very productive. However, there is no clear population ad- be weighed against the probable beneft of trying a diferent drug. Oxcarbazepine is more likely than carbamazepine suggests that three daily doses of the immediate-release tablets to produce hyponatraemia, nausea and vomiting, and is ofen more would be optimal, but most of the clinical trials utilized two daily expensive. It is not completely free of drug interactions, was found in a study comparing twice daily with three times dai- and can reduce the efficacy of birth control pills. However, in another study that focused on patients ing pregnancy has not been established, and pregnancy may reduce receiving high doses of oxcarbazepine, tolerability could be im- the serum levels of its active metabolite monohydroxycarbazepine. Occa- Why would oxcarbazepine be chosen as a frst drug for new-on- sional patients tolerate three daily doses better than two because set focal seizures over other drugs? Levetiracetam is widely used in this ence and better adherence than to pharmacokinetic advantages. Topiramate may be chosen if migraine The manufacturer states that measurement of serum sodium levels prophylaxis is needed, but is more likely to produce cognitive ef- should be considered, particularly for susceptible patients (e. Lamotrigine is ofen chosen for women of childbearing age taking diuretics), or if symptoms possibly indicating hyponatrae- and is relatively free of cognitive side-efects, but establishing a mia develop, such as nausea, malaise, headache, lethargy, confusion therapeutic dose takes at least 6 weeks. Antiepileptic drug pharmacokinetics and interactions: zures, with or without secondary generalization, for both children impact on the treatment of epilepsy. Oxcarbazepine: pharmacokinetic interactions and tolerability with other drugs for focal epilepsy. Infuence of oxcarbazepine and methsuximide include a need to establish an efective dose quickly, to minimize on lamotrigine concentrations in epileptic patients with and without valproic acid comedication: results of a retrospective study. A double-blind, placebo-controlled inter- fects, and absence of a comorbid condition better addressed with a action study between oxcabazepine and carbamazepine, sodium valproate and diferent drug. Eslicarbazepine and the enhancement of slow strel metabolism by oxcarbazepine in healthy women. Oxcarbazepine: an update on its efcacy in the manage- droxy-carbazepine concentrations and adverse efects in patients with epilepsy on ment of epilepsy. Changes in the disposition of oxcarbaze- and their clinical significance: comparison with carbamazepine. Comparison of oxcarbazepine and zepine acetate and oxcarbazepine at steady state in healthy volunteers. A double-blind controlled clinical bazepine and 10,11-dihydro-10-hydroxycarbamazepine. Neurosci Lett 2005; 390: trial of oxcarbazepine versus phenytoin in children and adolescents with epilepsy. Oxcarbazepine (Trileptal) drug concentration rela- omized, placebo-controlled, monotherapy trial for partial seizures. Safety and efficacy of oxcarbazepine macokinetics of oxcarbazepine and its 10-hydroxy metabolite. Antiepileptic Drugs, 5th partial onset seizures: a multicenter, double-blind, clinical trial. Phenytoin, carbamazepine, sulthiame, lamotrigine, ing trial in refractory partial epilepsy. Oxcarbazepine-induced toxic epidermal necrolysis: a tory partial-onset seizures: a randomized controlled trial. The regulation of serum sodium carbazepine monotherapy: a prospective study in adult and elderly patients with afer replacing carbamazepine with oxcarbazepine. Oxcarbazepine reduces seizure frequency in a high pro- in epilepsy patients taking carbamazepine or oxcarbazepine. Epilepsia 2006; 47: portion of patients with both newly diagnosed and refractory partial seizures in 510–515. A multicenter trial of oxcarbazepine oral sus- proate therapies on growth in children with epilepsy. Endocr Res 2012; 37: 163– pension in children newly diagnosed with partial seizures: a clinical and cognitive 171. Oxcarbazepine in children with nocturnal concentrations in children with epilepsy treated with oxcarbazepine monothera- frontal-lobe epilepsy. The evaluation of thyroid functions, monotherapy in an unselected population of adult epileptics. Seizure 2005; 14: thyroid antibodies, and thyroid volumes in children with epilepsy during short- 72–74. Oxcarbazepine in painful diabetic neuropa- in children and adolescents with intellectual disability. Safety of the new antiepileptic drug oxcarbazepine during pregnan- double-blind randomized trial. A double-blind, randomized, place- partial seizures afer conversion to oxcarbazepine monotherapy. Epilepsy Behav bo-controlled trial of oxcarbazepine in the treatment of bipolar disorder in chil- 2006; 9: 457–463. Neuroprotective efects of anticonvulsants in rat hippocampal slice tions for oxcarbazepine. Cognitive efects of oxcarbazepine and and phenytoin withdrawal seizures during epilepsy monitoring. Epilepsy Res 2008; phenytoin monotherapy in newly diagnosed epilepsy: one year follow up.

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George’s Respiratory Questionnaire order generic azulfidine, mean di erence Questionnaire—dyspnea 500 mg azulfidine overnight delivery, fatigue generic 500 mg azulfidine visa, emotional function, and –3. In addition, when compared tation improved both maximal and functional exertional with patients who were referred to pulmonary rehabilita- capacity. At least two controlled trials have evaluated the e ects of exercise training in patients with asthma. A er 3 months, the training group expe- • Use of inhaled corticosteroids for at least 4 weeks rienced improvements in physical limitations, symptom frequency, psychological score, and anxiety and depres- Prophylactic treatments sion levels, and had more days with no asthma symptoms. Turner and coworkers103 evaluated 35 mast cell stabilizers > anticholinergics individuals with xed-airway obstructive asthma who were Preventative measures randomized to either supervised-exercise training or usual • Thorough pre-exercise warm-up care for 6 weeks. Continuous treatment with both short- and long-acting β2-agonist bron- or nocturnal oxygen therapy in hypoxemic chronic chodilators e ectively and safely prevents exercise-induced obstructive lung disease: A clinical trial. Exertional desatura- Additionally, asthma self-management education var- tion in patients with chronic obstructive pulmonary ies with the age of asthma onset. Effect of been taught what to do during an asthma attack, but only long-term oxygen therapy on survival in patients with 28. Patient-reported asthma chronic obstructive pulmonary disease with moderate self-management education declines as the age of asthma hypoxaemia. Characteristics exchange function is well preserved maintaining nor- and survival of patients prescribed long-term oxy- mal oxygenation. However, during asthma exacerbations, gen therapy outside of prescription guidelines. Training with supplemental oxygen in gen therapy in hypoxic chronic bronchitis (abstract). Summary of a report of the royal triggered thermal burns in the presence college of physicians. Home Domiciliary oxygen cylinders: Indications, prescription oxygen therapy: Adjunct or risk factor. A pragmatic assessment of the diagnosis and management of asthma— the placement of oxygen when given for exercise Summary report 2007. Effects of breathing supplemental oxygen driven β2-agonists nebulization for children and before progressive exercise in patients with adults with acute asthma: A systematic review chronic obstructive pulmonary disease. Bodies in motion: helium-oxygen mixture in adult patients presenting Monitoring daily activity and exercise with motion with exacerbations of asthma and chronic obstructive sensors in people with chronic pulmonary disease. Semin Respir detect brisk walking in patients with chronic obstruc- Crit Care Med. Optimizing rehabilitation for chronic obstructive pulmonary pulmonary rehabilitation in chronic obstructive disease. An official with mild symptoms: A systematic review with meta- European respiratory society statement on physical analyses. Int J Chron Obstruct Physical activity, exercise, and physical fitness: Pulmon Dis. Veterans factors and asthma quality of life: A population based with chronic obstructive pulmonary disease study. Physiologic mortality in chronic obstructive pulmonary dis- and nonphysiologic determinants of aerobic tness ease: A population-based cohort study. Effects community-based pulmonary rehabilitation for of aerobic training on psychosocial morbidity and individuals with chronic obstructive pulmonary symptoms in patients with asthma: A randomized disease: A systematic review and meta-analysis. Impact of ing in older adults with moderate/severe persistent asthma control on sleep, attendance at work, normal asthma. Age at Evidence for prescribing exercise as therapy in 26 asthma onset and asthma self-management educa- different chronic diseases. For patients unwilling to make a quit attempt at this time: provide interventions designed to increase motivation for future quit attempts. For patients unwilling to make a quit attempt at this time: address tobacco dependence and willingness to quit at next clinic visit. For For patients who endorse a willingness to quit smoking at those who endorse current cigarette smoking, they then need this time, providers should then provide practical assis- to advise the patient to quit smoking in a clear, strong, and tance for quitting. Current smoking cessation guidelines personalized manner and assess the patient’s willingness to highlight two primary approaches for smoking cessation: counseling and pharmacotherapy. It ers about the quit date and soliciting social support; (3) says here that you are a cigarette smoker. As your clinician, I need you ing patients identify their triggers for smoking and help- to know that one of the most important ing them develop strategies to manage these triggers. For things you can do for your current and certain triggers, such as alcohol, avoiding them altogether future health is to quit smoking. For other triggers, patients can try to smoking can make your medications for alter the situation slightly (e. Provider: Yes, a lot of people believe that smoking helps you deal with stress, but research Table 20. Enlist social support by informing family, friends, and at risk of developing an anxiety disorder. Identify smoking triggers and create a plan to deal your physical health, but your emotional with them. I Provider: I’m glad you are ready to take this important can’t smoke at work, so I usually smoke a lot step toward improving your health. The Provider: Smoking and driving seem to go hand- frst step is to set a quit date, ideally some- in-hand for a lot of people. Something that has worked for peo- you will want to make sure you remove all ple in the past is to change the route they cigarettes, lighters, ashtrays, and any other drive to work, maybe fnd one that doesn’t smoking materials from your house and go by many places where you could buy car. Another trick that works well for emergency cigarettes you have hidden people is to substitute another behavior for around. So instead of smoking you could their remaining cigarettes in half, get them chew a piece of sugar-free gum, have a wet, and then throw them away. That way piece of hard candy, or drink a glass of cold you won’t be tempted later when you have a water. That’s how I started lot more confdent about quitting smoking smoking again after I quit the last time— now. So defnitely try to as well as some referrals for local quitlines go through old bags, purses, clothes, and and smoking-cessation programs before things like that before Monday. The last thing we need to you’ve set your quit date, the next step is talk about is medications that can help you to let your family and other important peo- quit smoking. Who do you think you should Although brief interventions are e ective, research indi- tell? In the past when counseling includes problem solving and skills training I’ve tried to quit, I’ve been really cranky, and (e. Nicotine lozenge Use 4 mg for patients who smoke their rst cigarette within 30 minutes of waking, and 2 mg for those who smoke their rst cigarette more than 30 minutes after waking. Use 1 lozenge every 1–2 hours for the rst 6 weeks, using a minimum of 9 lozenges per day, but no more than 20. Decrease lozenge use to 1 every 2–4 hours during weeks 7–9 and then to 1 every 4–8 hours during weeks 10–12.

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