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If the British completed the conquest of San Domingo asthma definition 38th buy 100mcg proventil free shipping, the colonial em pire of revolutionary France was gone; its vast resources would be directed into British pockets asthma treatment youtube buy proventil american express, and Britain would be able to asthmatic bronchitis curable purchase proventil 100mcg fast delivery return to Europe and throw army and navy against the revolution. Sonthonax, Polverel and Laveaux knew this and fought to save San Domingo for the revolution. We shall have no other asylum than cannons, no other food than water and bananas, but we shall live and die free. Laveaux, a nobleman under the old regime, called out Major James Grant who, however, de clined. Traitors let them into an im portant fort on the outskirts, and Sonthonax and Polverel. It was June 4th and the English celebrated the capture of the capital on the birthday of the King. Toussaint, a Spanish officer and therefore ally of the British, saw all his secret hopes being wrecked by the Brit ish victories. Despite the feeling for the slaves in France, the Con vention did nothing for over a year. As long as Brissot and the Girondins remained in power no word would be said about the slaves. They would not check the speculations of the bourgeoiSie with the currency, they would not fix maximum prices for food, they would not tax the rich to pay for the war, they would not pass the legislation necessary to abolish the feudal dues, they would not ratify the seizure of the land by the peasants. Being afraid of Paris they would not hring the whole country under a strong central government, and despite incessant royalist insurrection and plotting they 23 Saintoyant La Colonisation Franaise. They it was, and not Robespierre and the Moun tain, who instituted the revolutionary tribunals aimed, not against the counter-revolution, but against all who pro posed any "agrarian law or any other law subversive of ter ritorial, commercial or industrial prosperity. Dumouriez, the Girondin general commanding in the field, deserted to the counter-revolution. The Paris masses, deserting the Paris Commune, hitherto the real revolution ary centre of Paris, organised an independent centre of their own, the famous Eveche; and on May 31st and June 2nd, with firmness but great moderation, made the Giron din leaders retire from the Convention, placing them only under house arrest, and offering hostages out of their own ranks as guarantees for their safety. In those difficult days Robespierre and the Mountain gave France a strong government. The Convention abol ished the feudal laws at last, put an end to the most crying abuses, and won the confidence of the people. Despite the political intrigues of the leaders, the Government (while hostile to Communism) took the people into its confidence, for it had nobody else to depend upon. A rare exaltation of sacrifice and devotion moved through revolutionary France and Paris. Never until 1917 were masses ever to have such powerful influence-for it And the Pam Masses Complete 139 was no more than influence-upon any government. In these few months of their nearest approach to power they did not forget the blacks. They felt towards them as broth ers, and the old slave-owners, whom they knew to be sup porters of the counter-revolution, they hated as if French men themselves had suffered under the whip. These are the people whom the sons of Mrica and the lovers of humanity will remember with gratitude and affection, not the perorating Liberals in France nor the "philanthropy plus five per cent" 26 hypocrites in th British Houses of Parliament. This was the France to which, in January 1794, three deputies sent by San Domingo to the Convention arrived. The Chairman of the Committee on Decrees addressed the Convention, "Citizens, your Committee on Decrees has verified the credentials of the deputies from San Domingo. A black man, a yellow man, are about to join this Convention in the name of the free citizens of San Domingo. The black face of Bellay and the yellow face of Mills excited long and repeated bursts of applause. Next day, Bellay, the Negro, delivered a long and fiery oration, pledging the blacks to the cause of the revolution and asking the Convention to declare slavery abolished. It was fitting that a Negro and an ex-slave should make the speech which introduced one of the most important legis lative acts ever passed by any political assembly. Instead Levasseur (of Sarthe) moved a motion: "When drawing up the constitution of the French people we paid no attention to the unhappy Negroes. The two deputies of colour appeared on the tribune and em braced while the applause rolled round the hall from mem bers and visitors. Lacroix led the Mulatto and the Negro to the President who gave them the presidential kiss, when the applause started again. Cambon drew the attention of the House to an incident which had taken place among the spectators. I demand that this fact be mentioned in the min- utes, and that this citizeness be admitted to the sitting and receive at least this much recognition of her civic virtues. In conse quence it declares that all men, without distinction of col our, domiciled in the colonies, are French citizens, and enjoy all the rights assured under the Constitution. He had been treated as anyone would be treated who for the Union of South Africa to-day proposed merely social and political equality for educated Africans and relief from the slavery of the pass-laws for the rest. Like Gregoire he would be denounced as a Bolshevik and would be lucky to escape lynching. If a revolution carries high overhead expenses, most of them it inherits from the greed of reactionaries and the cowardice of the so-called moderates. Long before abolition the mis chief had been done in the French colonies and it was not abolition but the refusal to abolish which had done it. At that time slavery had been overturned only in San Domingo of all the French colonies, and the generous spon taneity of the Convention was only a reBection of the over Bowing desire which filled all France to end tyranny and oppression everywhere. But the generosity of the revolu tionary spirit was at the same time the soundest political policy. But that master of revolutionary tactics could not fail to see that the decree, by ratifying the liberty which the blacks had won, 143 was giving them a concrete interest in the struggle against British and Spanish reaction. As soon as the decree was passed the maritime bourgeois sent to the deputies of the Convention an "address on the occa sion of the enfranchisement of the Negroes. This is the cry with which all our places of business resound when,the public press comes each day and bring us details of your great operations. Certainly, we have all the time to read them at leisure since we have no longer any work to do. There is no longer any ship-building in our ports, still less any construction of boats. We can count more than three hundred thousand in our differ ent towns who have no other occupation than, arms folded, to talk about the news of the day, of the Rights of Man, and of the Constitution.
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Bowel loops seen in the chest with mediastinal shift to asthma kitty purchase discount proventil opposite side on chest radiograph asthma treatment hyderabad proventil 100mcg cheap. This congenital malformation consists of herniation of abdominal organs into the hemithorax (usually left-sided) through a posterolateral defect in the diaphragm asthma bronchial purchase proventil 100mcg with amex. It presents in the delivery room as severe respiratory distress in an infant with poor breath sounds and scaphoid abdomen. Omphalocele Omphalocele is a membrane-covered herniation of abdominal contents into the base of the umbilical cord. At delivery, the omphalocele is covered with a sterile dressing soaked with warm saline to prevent fluid loss. If the contents of the omphalocele will fit into the abdomen and can be covered with skin, muscle, or both, primary surgical closure is done. Barium radiography is helpful to rule out anatomic abnormalities but is not diagnostic of pathologic reflux. Initial steps in treatment include thickened feeds (rice cereal, 1 tbsp/oz of formula) for those with frequent regurgitation and poor weight gain. Prokinetic agents such as metoclopramide are of little benefit and have significant side effects. Affected infants are prone to development of pneumothorax during attempts at ventilation of the hypoplastic lungs. Use of a gentle ventilation style and permissive hypercarbia is recommended to avoid barotrauma and further lung injury. Old blood ("coffee-grounds" material) in the stomach of the newborn may be either swallowed maternal blood or infant blood from gastritis or stress ulcer. Bright red blood from the stomach is most likely from acute bleeding, again due to gastritis. If the volume of bleeding is large, intensive monitoring, fluid and blood replacement, and endoscopy are indicated. An abdominal radiograph should be obtained to rule out pneumatosis intestinalis or other abnormalities in gas pattern suggesting inflammation, infection, or obstruction. If the radiograph is negative and the examination is benign, a protein hydrolysate or predigested formula (eg, Nutramigen or Pregestimil) should be tried. Susceptibility of the newborn infant to infection is related to immaturity of both the cellular and humoral immune systems at birth. Passive protection against some organisms is provided by transfer of IgG across the placenta during the third trimester of pregnancy. Treatment A high index of suspicion is important in diagnosis and treatment of neonatal infection. If rupture of the membranes occurs more than 24 hours prior to delivery, the infection rate increases to 1 in 100 live births. If early rupture of membranes with chorioamnionitis occurs, the infection rate increases further to 1 in 10 live births. Regardless of membrane rupture, infection rates are five times higher in preterm than in full-term infants. Clinical Findings Early-onset bacterial infections appear most commonly on day 1 of life, and the majority appear at less than 12 hours. Other features include unexplained low Apgar scores without fetal distress, poor perfusion, and hypotension. Late-onset bacterial infection (> 5 days of age) presents in a more subtle manner, with poor feeding, lethargy, hypotonia, temperature instability, altered perfusion, new or increased oxygen requirement, and apnea. Late-onset bacterial sepsis is more often associated with meningitis or other localized infections. Low total white count, absolute neutropenia (< 1000/mL), and elevated ratio of immature to mature neutrophils all suggest neonatal bacterial infection. Other laboratory signs are hypoglycemia or hyperglycemia with no change in glucose administration, unexplained metabolic acidosis, and elevated C-reactive protein. In early-onset bacterial infection, pneumonia is invariably present; chest radiography shows infiltrates, but these infiltrates cannot be distinguished from those resulting from other causes of neonatal lung disease. Guidelines for evaluation of neonatal bacterial infection in the full-term infant. Initial broadspectrum coverage should also include a third-generation cephalosporin (cefotaxime or ceftazidime, 100 mg/kg/d divided q12h, when Pseudomonas aeruginosa is strongly suspected). To prevent the development of vancomycin-resistant organisms, vancomycin should be stopped as soon as cultures and sensitivities indicate that it is not needed. The incidence is low in infants with early-onset sepsis and much higher in infants with late-onset infection. The mortality rate of neonatal meningitis is approximately 10%, with significant neurologic morbidity present in one third of the survivors. Pneumonia the respiratory system can be infected in utero or on passage through the birth canal. Pneumonia should also be suspected in older neonates with a recent onset of tachypnea, retractions, and cyanosis. In infants already receiving respiratory support, an increase in the requirement for oxygen or ventilator support may indicate pneumonia. When signs of sepsis are present, a lumber puncture, if feasible, should be perfomed. If laboratory results and clinical course do not indicate bacterial infection, duration may be as short as 48 hours. If any one of these conditions is not met, the infant should be observed in the hospital for at least 48 hours and until criteria for discharge are achieved.
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Although healthy live births are accepted as the usual outcomes resulting from successful application of these procedures asthma definition qi discount 100 mcg proventil fast delivery, questions about the risks of adverse effects on development are beginning to asthma 2015 rotten tomatoes purchase proventil cheap be raised asthma symptoms questionnaire generic 100 mcg proventil amex. Increased rates of twinning, both monozygotic and dizygotic, are well recognized while the possibility of increased rates of birth defects remains controversial. Evidence supports increased prevalence of Beckwith-Wiedemann and Angelman syndromes among offspring of in vitro pregnancies. Prenatal diagnosis introduces options for management including termination of abnormal pregnancies, preparation for specialized perinatal care, and, in some cases, fetal therapies. Maternal Anticonvulsant Effects Anticonvulsant exposure during pregnancy is associated with adverse outcomes in approximately 10% of children born to women treated with these agents. A syndrome characterized by small head circumference, anteverted nares, cleft lip and palate (occasionally), and distal digital hypoplasia was first described in association with maternal use of phenytoin but also occurs with other anticonvulsants including carbamazepine. Risks for spina bifida are increased, especially in pregnancies exposed to valproic acid. Maternal Blood Analysis Elevated levels of maternal serum -fetoprotein correlate with open neural tube defects but low levels are associated with Down syndrome and other chromosomal abnormalities. In addition, chromosomal abnormalities detected by this technique may be confined to the placenta (confined placental mosaicism). Fetal Blood and Tissue Fetal blood can be sampled directly in late gestation through ultrasound-guided percutaneous umbilical blood sampling. A wide range of diagnostic tests ranging from biochemical to cytogenetic can be applied. Fetal urine sampled from the bladder or dilated proximal structures can provide important information about fetal renal function. It is occasionally necessary to obtain biopsy specimens of fetal tissues such as liver or muscle for accurate prenatal diagnosis; however, these procedures are available in only a few perinatal centers. In the second trimester maternal -fetoprotein, human chorionic gonadotropin, unconjugated estradiol, and inhibin combine to estimate risks for trisomies 21 and 18. Low estradiol levels can also predict cases of Smith-Lemli-Opitz syndrome, a devastating autosomal recessive disorder discussed earlier. Fetal cells, including lymphocytes, trophoblasts, and nucleated red blood cells, circulate at low frequency in maternal blood and may eventually provide access to direct information about the conceptus. Ultrasonography has joined maternal blood sampling as a screening technique for common chromosomal aneuploidies, neural tube defects, and other structural anomalies. Amniocentesis Whereas maternal blood levels are screened for fetal abnormalities, genetic amniocentesis is applied to make specific diagnoses. This procedure samples fluid surrounding the fetus; the cells obtained are cultured for cytogenetic, molecular, or metabolic analyses. This is a safe procedure 1018 36 Allergic disorders are among the most common problems seen by pediatricians and primary care physicians, affecting over 25% of the population in developed countries. In the most recent National Health and Nutrition Examination Survey conducted in the United States between 1988 and 1994, 54% of the population had positive test responses to one or more allergens. In children, the increased prevalence of asthma, allergic rhinitis, and atopic dermatitis has been accompanied by significant morbidity and school absenteeism, with adverse consequences for school performance and quality of life, as well as economic burden measured in billions of dollars. Understanding the language of allergy and the basic mechanisms involved may help physicians when treating these disorders. In this chapter, atopy refers to a genetically determined predisposition to develop IgE antibodies found in patients with asthma, allergic rhinitis, and atopic dermatitis. General Considerations Asthma is the most common chronic disease of childhood, affecting over 6 million children in the United States, and almost two of every three children affected have had at least one attack due to asthma in the past year. Despite advances in the understanding of asthma, associated morbidity and mortality rates are still historically high. Recent data suggest that death rates appear to have stabilized, yet the rate has not declined for black children. Although asthma prevalence in children increases with age, health care utilization is most marked among the very young. The prevalence, morbidity, and mortality rates for asthma are higher among minority and inner city populations. The reasons for this are unclear but may be related to a combination of more severe disease, poor access to health care, lack of asthma education, delay in prescribing appropriate controller therapy, and environmental factors (eg, irritants including smoke and air pollutants, and perennial allergen exposure). Exposure to tobacco smoke, especially from the mother, is also a risk factor for asthma. About 40% of infants and young children who have wheezing with viral infections in the first few years of life will have continuing asthma through childhood. Sensitization to inhalant allergens increases over time and is found in the majority of children with asthma. The principal allergens associated with asthma are perennial aeroallergens such as dust mite, animal dander, cockroach, and Alternaria (a soil mold). Other triggers include exercise, cold air, cigarette smoke, pollutants, strong chemical odors, and rapid changes in barometric pressure. Psychological factors may precipitate asthma exacerbations and place the patient at high risk from the disease. Pathologic features of asthma include shedding of airway epithelium, edema, mucus plug formation, mast cell activation, and collagen deposition beneath the basement membrane. The inflammatory cell infiltrate includes eosinophils, lymphocytes, and neutrophils, especially in fatal asthma exacerbations. Airway inflammation contributes to airway hyperresponsiveness, airflow limitation, and disease chronicity. Persistent airway inflammation can lead to airway wall remodeling and irreversible changes. Symptoms and Signs Wheezing is the most characteristic sign of asthma, although some children may have recurrent cough and shortness of breath. Complaints may include "chest congestion," prolonged cough, exercise intolerance, dyspnea, and recurrent bronchitis or pneumonia. If symptoms are absent or mild, chest auscultation during forced expiration may reveal prolongation of the expiratory phase and wheezing. As the obstruction becomes more severe, wheezes become more high-pitched and breath sounds diminished. Flaring of nostrils, intercostal and suprasternal retractions, and use of accessory muscles of respiration are signs of severe obstruction. Laboratory Findings Airway hyperresponsiveness to nonspecific stimuli is a hallmark of asthma. These include inhaled pharmacologic agents such as histamine and methacholine as well as physical stimuli such as exercise and cold air. Airways may exhibit hyperresponsiveness or twitchiness even when pulmonary function tests are normal.
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Persistent pain is the most common symptom asthma symptoms and rapid heartbeat buy discount proventil 100 mcg on line, and the patient may present with limp or limitation of motion asthmatic bronchitis with hyperpyrexia cheap 100 mcg proventil otc. Laboratory Findings Laboratory findings asthma symptoms in children age 5 buy 100 mcg proventil mastercard, including studies of joint aspirates, are normal. Imaging Radiographic findings correlate with the progression of the process and the extent of necrosis. The early finding is effusion of the joint associated with slight widening of the joint space and periarticular swelling. The necrotic ossification center appears denser than the surrounding viable structures, and the femoral head is collapsed or narrowed. As replacement of the necrotic ossification center occurs, rarefaction of the bone occurs in a patchwork fashion, producing alternating areas of rarefaction and relative density, referred to as "fragmentation" of the epiphysis. In the hip, widening of the femoral head may occur associated with flattening, or coxa plana. If infarction has extended across the growth plate, a radiolucent lesion will be evident within the metaphysis. If the growth center of the femoral head has been damaged so that normal growth is arrested, shortening of the femoral neck results. The fragment of bone may be broken off from the host bone and displaced into the joint as a loose body. If it remains attached, the necrotic fragment may be completely replaced by creeping substitution. The pathologic process is the same as that described previously for avascular necrosing lesions of ossification centers. Because these lesions are adjacent to articular cartilage, however, joint damage may occur. The most common sites of these lesions are the knee (medial femoral condyle), the elbow joint (capitellum), and the talus (superior lateral dome). However, local swelling or locking may be present, particularly if a fragment is free in the joint. Early closure of the sac is the rule, although there has been some hesitancy to provide treatment to all of these patients because of the extremely poor prognosis associated with congenital hydrocephalus, high levels of paralysis, and associated congenital anomalies. A high percentage of these children have hydrocephalus, which may be evident at birth or shortly thereafter, requiring shunting. Associated musculoskeletal problems may include clubfoot, congenital dislocation of the hip, arthrogryposis-type changes of the lower extremities, and congenital scoliosis. Foot deformities may be in any direction and are complicated by the fact that sensation is generally absent. Spinal deformities develop in a high percentage of these children, with scoliosis present in approximately 40%. Careful urologic follow-up must be obtained to prevent complications from bladder dysfunction. In children who have a reasonable likelihood of walking, operative treatment consists of reduction of the hip and alignment of the feet in the weight-bearing position as well as stabilization of the scoliosis. In children who lack active quadriceps function and extensor power of the knee, the likelihood of ambulation is greatly decreased. In such patients, aggressive surgery in the hip region may result in stiffening of the joints, thus preventing sitting. The overall treatment of the child with spina bifida should be coordinated in a multidisciplinary clinic where various medical specialists work with therapists, social workers, and teachers to provide the best possible care. If large areas of a weight-bearing joint are involved, secondary degenerative arthritis may result. The greatest gains from this therapy are obtained during the first few years of life, and therapy should not be continued when no improvement is apparent. Bracing and splinting are of questionable benefit, although night splints may be useful in preventing equinus deformity of the feet or adduction contractures of the hips. Orthopedic surgery is useful for treating joint contractures that interfere with function. In general, muscle transfers are unpredictable in cerebral palsy, and most orthopedic procedures are directed at tendon lengthening or bony stabilization by osteotomy or arthrodesis. Flexion and adduction of the hip due to hyperactivity of the adductors and flexors may produce a progressive paralytic dislocation of the hip, which can lead to pain and dysfunction. The principal preventive measure is abduction bracing, but this must often be supplemented by release of the adductors and hip flexors in order to prevent dislocation. In severe cases, osteotomy of the femur may also be necessary to correct the bony deformities of femoral anteversion and coxa valga that are invariably present. Patients with a predominantly athetotic pattern are poor candidates for any surgical procedure or bracing. Because it is difficult to predict the outcome of surgical procedures in cerebral palsy, the surgeon must examine patients on several occasions before any operative procedure is undertaken. Follow-up care by a physical therapist to maximize the anticipated long-term gains should be arranged before the operation. Accurate diagnosis depends on correlation of the clinical, radiographic, and microscopic findings. Complaints about the knee should be investigated for tumor, although the usual causes of knee pain are traumatic, infectious, or developmental in origin. When present, pain is caused by adventitious bursitis or tendinitis due to irritation by the tumor. On radiograph, the tumors tend to be in the metaphysial region of long bones and may be pedunculated or sessile. An osteochondroma should be excised if it interferes with function, is frequently traumatized, or is large enough to be deforming. Bottner F et al: Surgical treatment of symptomatic osteochondroma: A three- to eight-year follow-up study. No treatment is needed because these lesions heal as they ossify with maturation of the bone and growth. A triangle may be adjacent to the tumor produced by elevated periosteum and subsequent tumor ossification. Surgical excision (limb salvage) or amputation is indicated based on the extent of the tumor. On radiograph, the lesion is a radiolucent nidus surrounded by dense osteosclerosis that may obscure the nidus. Surgical incision or radiofrequency ablation of the nidus is curative and may be done using computed tomography imaging and minimally invasive technique. The prognosis is excellent, with no known cases of malignant transformation, although the lesion has a tendency to recur. The classic lesion looks as though someone dragged his or her fingernails through clay, making streaks in the bones.
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A single intraoperative dose of cefoxitin or cefotetan is recommended for all patients to asthma icd-9 code order proventil in india prevent postoperative infection asthma symptoms 8 year old purchase proventil no prescription. The mortality rate is less than 1% during childhood asthmatic bronchitis benzonatate purchase 100 mcg proventil with visa, despite the high incidence of perforation. In uncomplicated nonruptured appendicitis, a laparoscopic approach is associated with a shortened hospital stay. The mucosa of the dilated colonic segment may become thin and inflamed, causing diarrhea, bleeding, and protein loss (enterocolitis). A familial pattern has been described, particularly in total colonic aganglionosis. The other common locations of duplication are the duodenum, rectum, and esophagus. Duplications usually contain fluid and sometimes blood if necrosis has taken place. They generally do not communicate with the intestinal lumen but share a common muscular coat. The epithelial lining of the duplication is usually of the same type as the bowel from which it originates. Some duplications (neuroenteric cysts) are attached to the spinal cord and are associated with hemivertebrae and anterior or posterior spina bifida. Symptoms of vomiting, abdominal distention, colicky pain, rectal bleeding, partial or total intestinal obstruction, or an abdominal mass may start in infancy. Diarrhea and malabsorption may result from bacterial overgrowth in communicating duplications. Symptoms and Signs Failure of the newborn to pass meconium, followed by vomiting, abdominal distention, and reluctance to feed, suggest the diagnosis of Hirschsprung disease. Enterocolitis manifested by fever, explosive diarrhea, and prostration, is reported in approximately 50% of affected newborns. Enterocolitis may lead to inflammatory and ischemic changes in the colon, with perforation and sepsis. In some patients, especially those with short segments involved, symptoms are not obvious at birth. Intermittent bouts of intestinal obstruction, hypochromic anemia, hypoproteinemia, and failure to thrive are common. On digital rectal examination, the anal canal and rectum are devoid of fecal material despite obvious retained stool on abdominal examination or radiographs. If the aganglionic segment is short, there may be a gush of flatus and stool as the finger is withdrawn. Infants of diabetic mothers may have similar symptoms and, in this setting, small left colon syndrome should be suspected. Meglumine diatrizoate (Gastrografin) enema is both diagnostic and therapeutic in small left colon syndrome as it reveals a meconium plug in the left colon, which is often passed during the diagnostic radiograph. In a small proportion of patients with small left colon, Hirschsprung disease may later be found. Neural crest cells fail to migrate into the mesodermal layers of the gut during gestation, possibly secondary to abnormal endorgan cell surface receptors or local deficiency of nitric oxide synthesis. The absence of ganglion cells results in failure of the colonic muscles to relax in front of an advancing bolus. Laboratory Findings Ganglion cells are absent in both the submucosal and muscular layers of involved bowel. Special stains may show nerve trunk hypertrophy and increased acetylcholinesterase activity. Ganglionated bowel above the aganglionic segment is sometimes found to contain more than normal numbers of ganglion cells in abnormal locations (neuronal dysplasia). This finding is sometimes associated with persistent motor dysfunction of the remnant colon. Retention of feces in the rectum results in encopresis (involuntary fecal leakage) in 60% of children with constipation. Most constipation in childhood is a result of voluntary or involuntary retentive behavior (chronic retentive constipation). Plain abdominal radiographs may reveal dilated proximal colon and absence of gas in the pelvic colon. Barium enema using a catheter without a balloon and with the tip inserted barely beyond the anal sphincter usually demonstrates a narrow distal segment with a sharp transition to the proximal dilated (normal) colon. The transition zone may not be seen in neonates since the normal proximal bowel has not had time to become dilated. Special Examinations Rectal manometric testing reveals failure of reflex relaxation of the internal anal sphincter after distention of the rectum in all patients with Hirschsprung disease, regardless of the length of the aganglionic segment. In occasional patients, a nonrelaxing internal anal sphincter is the only abnormality. Failure to appreciate this normal developmental pattern may lead to the unwise use of laxatives or enemas. Infants and children may, however, develop the ability to ignore the sensation of rectal fullness and retain stool. Many factors reinforce this behavior, which results in impaction of the rectum and overflow incontinence or encopresis. The dilated rectum gradually becomes less sensitive to fullness, thus perpetuating the problem. In childhood, Hirschsprung disease must be differentiated from retentive constipation. In older infants and children it can also be confused with celiac disease because of the striking abdominal distention and failure to thrive. Diverting colostomy (or ileostomy) is performed proximal to the aganglionic segment. At the time of definitive surgery, the transition zone between ganglionated and nonganglionated bowel is identified. Aganglionic bowel is resected, and a pull-through of ganglionated bowel to the preanal rectal remnant is made. In children with ultrashort segment disease, an internal anal sphincter myotomy or botulinum toxin injection of the internal anal sphincter may control symptoms. Complications after surgery include fecal retention, fecal incontinence, anastomotic breakdown, or anastomotic stricture. Postoperative obstruction may result from inadvertent retention of a distal aganglionic colon segment or postoperative destruction of ganglion cells secondary to vascular impairment.
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Pointing out positive areas helps parents focus attention on the unique and special qualities of their child asthma treatment guidelines order generic proventil canada. Parents state they appreciate learning more about their newborn from health care professionals asthma symptoms relief order proventil 100mcg visa. Discharge Planning Nurse Assess whether parents have made plans for hospital discharge asthma bronchitis association of india buy proventil 100mcg line. This assessment may be the responsibility of the delivering physician, nurse practitioner, nurse-midwife, pediatrician, or nurse. This health assessment is done quickly, to prevent overexposing the newborn, yet not so swiftly that important findings are overlooked. Height and Weight Assuming newborns are breathing well, they are weighed nude and without a blanket immediately after birth in the birthing room. Measurements such as body length and head, chest, and abdominal circumferences can be obtained in a newborn or transitional nursery. Performing these measurements while an infant is still damp only exposes the newborn unnecessarily to chilling. Newborn weight helps to determine maturity and establishes a baseline against which other weights can be compared. An infant is weighed nude once a day, at approximately the same time every day, during a hospital or birthing center stay. Compare the weight obtained each day with that of the preceding day to be certain an infant is not losing more than the normal physiologic amount (5% to 10% of birthweight). Abnormal loss of weight may be the first indication that a newborn has an inborn error of metabolism, such as adrenogenital syndrome (salt-dumping type), or is becoming dehydrated. Failure to pass nasogastric tube through nares on either side establishes choanal atresia. With excess of 20 mL of fluid, or yellow fluid, duodenal or ileal atresia is suspected. The presence of one artery suggests possible congenital urinary or cardiac anomalies or chromosomal trisomy (if other portions of examination are consistent). Laboratory Studies After the first hour of undisturbed rest, depending on health agency policy, newborns may have heel-stick tests for hematocrit, hemoglobin, and hypoglycemia determinations. Heel-sticks require a minimum of blood, and, although not pain free, they cause minimal trauma to a baby. In some settings, these tests are not routine but are reserved only for newborns with symptoms of anemia, polycythemia, or hypoglycemia. Hematocrit and hemoglobin determinations are done to detect newborn anemia, because it is difficult to appreciate that anemia is present by clinical observation alone. Anemia can be caused by hypovolemia due to bleeding from placenta previa or abruptio placentae or by a cesarean birth that involved incision into the placenta. Another condition as dangerous as anemia is the presence of an excess of red blood cells (polycythemia), probably caused by excessive flow of blood into an infant from the umbilical cord. A heel-stick hematocrit reveals both of these con- ditions, and treatment then can be instituted. Hypoglycemia may also produce few symptoms, so it is determined by a heel-stick glucose measurement. If a blood glucose heel-stick reading is less than 40 mg/100 mL of blood (30 mg/100 mL in the first 3 days of life), hypoglycemia is present (Fischback, 2004). To correct this condition, the infant is prescribed oral glucose or infant formula to be given immediately. It is important to treat hypoglycemia quickly because, if brain cells become completely depleted of glucose, brain damage can result. If a newborn exhibits symptoms of hypoglycemia (jitteriness, lethargy, seizures) in addition to the low laboratory test results, intravenous glucose probably will be prescribed. A continuous intravenous infusion of glucose may be necessary if the newborn is unable to maintain glucose levels higher than 40 mg/100 mL. As early as 1966, Usher and colleagues (1966) proposed five criteria to evaluate gestational maturity (Table 24. Dubowitz Maturity Scale Dubowitz and colleagues (1970) devised a gestational rating scale that uses more extensive criteria. Although completing a Dubowitz assessment takes practice, it can yield important results; it can help determine whether a newborn needs immediate high-risk nursery intervention. During the 1970s and again in the 1990s, Ballard modified the Dubowitz scale (Ballard et al. The assessment consists of two portions: physical maturity and neuromuscular maturity. The first is a series of observations about skin texture, color, lanugo, foot creases, genitalia, ear, and breast maturity. Each designated body part is inspected and given a score of 0 to 5, as described in Figure 24. This observational scoring should be done as soon as possible after birth, because skin assessment becomes much less reliable after 24 hours. Illustrations of mature and immature body features for Ballard scale use are shown in Chapter 26 as part of the discussion of the preterm infant. To complete the second half of the gestational examination, observe or position a newborn as shown in Figure 24. Using such a standard method to rate maturity is helpful in detecting infants who are small for gestational age (they are light in weight, but the neuromuscular and physical observation scales are adequate for their weeks in utero) and differentiating them from newborns who are immature because of a miscalculated due date. Assessment of Behavioral Capacity Term newborns are physically active and emotionally prepared to interact with the people around them. Six major categories of behavior-habituation, orientation, motor maturity, variation, self-quieting ability, and social behavior-are assessed. To perform an assessment using the scale requires training to ensure that it is used consistently from one individual to another. Unlike many assessment scales, the infant is scored on best performance rather than on average performance. It is useful for comparing different groups of infants, such as those exposed or not exposed to cocaine in utero (Myers et al. The information supplied by this scale has provided concrete evidence that newborns are not passive, nonhearing, unseeing, unresponsive, or even all alike. An important finding from the scale is that newborns are able to quiet themselves after crying. Posture: With infant supine and quiet, score as follows: arms and legs extended = 0; slight or moderate flexion of hips and knees = 2; legs flexed and abducted, arms slightly flexed = 3; full flexion of arms and legs = 4. The angle between hypothenar eminence and anterior aspect of forearm is measured and scored. Arm Recoil: With infant supine, fully flex forearm for 5 sec, then fully extend by pulling the hands and release. Score as follows: remain extended or random movements = 0; incomplete or partial flexion = 2; brisk return to full flexion = 4.
- Beta-thalassemia (gene promoter involvement)
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- Leukemia subleukemic
- Aortic dissection
- Cartilaginous neoplasms
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A team approach is often necessary when providing care to asthma fef25 75 best 100 mcg proventil complex and chronically ill children asthmatic bronchitis treatment guifasen buy proventil 100mcg with mastercard. Family members may need outside help in dealing with their grief through supportive counseling services or peer-support groups asthma treatment cannabis buy proventil 100 mcg low price. Most parents and siblings are able to return to work and school within a month, although their emotional state and thoughts may continue to be dominated by the loss for some time. The discussion with parents and the child about terminal illness is one of the most difficult tasks for a physician working with children and adolescents. Although parents want and need to know the truth, they are best told in stepwise fashion beginning with temporizing phrases such as "The news is not good" and "This is a life-threatening illness. The physician must also attempt to gauge how much of the information the parents are able to comprehend during the initial discussion and consider involvement of appropriate support services. Some parents may dissociate during the sharing of frightening and overwhelming news, and crucial information may need to be addressed again when the parents are in a less-traumatized and more receptive state. These responses vary in their expression, intensity, and duration for each member of the family. Even when the illness is cured, some parents may continue to suffer from post-traumatic stress symptoms related to the diagnosis and treatment. Although most children do not fully understand the permanency of death until about age 8, most ill children experience a sense of danger and doom that is associated with death before that age. Even so, the question of whether to tell a child about the fatal nature of a disease should in most cases be answered in the affirmative unless the parents object. When the parents object, this should alert the physician to involve the unit social worker, who can work with the family to ensure their decision is in the best interest of the child. Refusal of the adults to tell the child, especially when the adults themselves are very sad, leads to a conspiracy of silence that increases fear of the unknown in the child and leads to feelings of loneliness and isolation at the time of greatest need. In fact, children who are able to discuss their illness with family members are less depressed, have fewer behavior problems, have higher self-esteem, feel closer to their families, and adapt better to the challenges of their disease and its treatment. They may feel neglected and deprived because of the time their parents must spend with the sick child. Anger and jealousy may then give rise to feelings of guilt over having such feelings about their sick sibling. Awareness of the emotional responses, coping abilities, and available Long-Term Coping the process of coping with a chronic or terminal illness is complex and varies with the dynamics of each individual child and family. Each change in the illness course and each new developmental stage present different challenges for the child and family. Educate the Patient and Family Children and their families should be given information about the illness, including its course and treatment, at frequent intervals. The explanation should be comprehensible to all, and time should be set aside for questions and answers. Prepare the Child for Changes and Procedures the physician should explain, in an age-appropriate manner, what is expected with a new turn in the illness or with upcoming medical procedures. This explanation enables the child to anticipate and in turn to master the new development and promotes trust between the patient and the health care providers. Encourage Normal Activities the child should attend school and play with peers as much as the illness allows. Individual education plans should be requested from the school if accommodation beyond the regular classroom is necessary. At the same time, parents should be encouraged to apply the same rules of discipline and behavior to the ill child as to the siblings. Protect dignity of patient Adapted, with permission, from Lewis M: Clinical Aspects of Child Development, 2nd ed. Need for aftercare of survivors; autopsy request tactful; accurate information regarding disposal of body; delay billing 1. Promote Self-Reliance Children often feel helpless when others must do things for them, or assist with their daily needs. The health care provider should guide and encourage parents in helping ill children assume responsibility for some aspects of their medical care and continue to experience age-appropriate independence and skills whenever possible. Parents should be encouraged to stay in touch with people in their support system, and to encourage their children in such efforts as well. Feelings of fear, guilt, anger, and grief should be monitored and discussed as normal reactions to difficult circumstances. Many hospitals have such groups, and hospital social workers can facilitate participation for the patient and family. Browning D: To show our humanness-Relational and communicative competence in pediatric palliative care. Christian B: Growing up with chronic illness: Psychosocial adjustment of children and adolescents with cystic fibrosis. Freeman K et al: Childhood brain tumors: Parental concerns and stressors by phase of illness. Laws T: Fathers struggling for relevance in the care of their terminally ill child. Van Riper M: the sibling experience of living with childhood chronic illness and disability. Psychiatric disorders have their origins in neurobiologic, genetic, psychological (life experience), or environmental sources. The neurobiology of childhood disorders is one of the most active areas of investigation in child and adolescent psychiatry. Categories of the major environmental factors that may affect a child, ranging from economic issues to family violence, are described and given V codes. Specific behavioral manifestations are listed under broad groupings and include complaints, definitions, symptoms, differential diagnosis, developmental variation, and etiology. Pediatricians should find this manual to be a valuable tool in the care of children and their families. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision.
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Drug therapy is often unnecessary and may complicate the clinical course of a drug-related panic reaction asthma classification chart generic 100mcg proventil. Although phenothiazines have been commonly used to asthma definition racism generic 100mcg proventil fast delivery treat bad trips asthma symptoms of proventil 100 mcg on line, they should be avoided if the specific drug is unknown, because they may enhance toxicity or produce unwanted side effects. For treatment of life-threatening drug abuse, consult the section on the specific drug elsewhere in this chapter and the section on general management at the beginning of the chapter. After the acute episode, the physician must decide whether psychiatric referral is indicated; in general, patients who have made suicidal gestures or attempts and adolescents who are not communicating with their families should be referred. Nevertheless, serious intoxication still occurs and must be regarded as an emergency. Salicylates uncouple oxidative phosphorylation, leading to increased heat production, excessive sweating, and dehydration. They also interfere with glucose metabolism and may cause hypoglycemia or hyperglycemia. Patients usually have signs of hyperventilation, sweating, dehydration, and fever. The severity of acute intoxication can, in some measure, be judged by serum salicylate levels. High levels are always dangerous irrespective of clinical signs, and low levels may be misleading in chronic cases. Other laboratory values usually indicate metabolic acidosis despite hyperventilation, low serum K+ values, and often abnormal serum glucose levels. In mild and moderate poisoning, stimulation of the respiratory center produces respiratory alkalosis. In severe intoxication (occurring in severe acute ingestion with high salicylate levels and in chronic toxicity with lower levels), respiratory response is unable to overcome the metabolic overdose. Once the urine becomes acidic, progressively smaller amounts of salicylate are excreted. Until this process is reversed, the half-life will remain prolonged, because metabolism contributes little to the removal of salicylate. Chronic severe poisoning may occur as early as 3 days after a regimen of salicylate is begun. Treatment Charcoal binds salicylates well and should be given for acute ingestions. Mild poisoning may require only the administration of oral fluids and confirmation that the salicylate level is falling. Once the patient is rehydrated, the solution can contain more free water and approximately 40 mEq/L of K+. Symptoms may be confused with those of Reye syndrome, encephalopathy, and metabolic acidosis. Once this has been accomplished, hypokalemia must be corrected and sodium bicarbonate given. Despite this treatment some patients will develop the paradoxical aciduria of salicylism. This is due to hypokalemia and the saving of K+ and excretion of H+ in the renal tubule. Correction of K+ will allow the urine to become alkaline and ionize the salicylate, resulting in excretion rather than reabsorption of nonionized salicylate in acid urine. Hemodialysis should be used in all patients with altered mental status or deteriorating clinical status. Laboratory measurements of the drugs are not of benefit other than to establish their presence. Adults and older adolescents have been treated with 12 mg initially followed by 2 mg every 2 hours to a maximum of 32 mg/d. Scorpion venom is more toxic than most snake venoms, but only minute amounts are injected. The most common scorpions in the United States are Vejovis, Hadrurus, Androctonus, and Centruroides species. Stings by Centruroides (the Bark scorpion) cause tingling or burning paresthesias that begin at the site of the sting; other findings include hypersalivation, restlessness, muscular fasciculation, abdominal cramps, opisthotonos, convulsions, urinary incontinence, and respiratory failure. The outcome depends on the size of the child, the site of the bite, the degree of envenomation, the type of snake, and the effectiveness of treatment. Nearly all poisonous snakebites in the United States are caused by pit vipers (rattlesnakes, water moccasins, and copperheads). A few are caused by elapids (coral snakes), and occasional bites occur from cobras and other nonindigenous exotic snakes kept as pets. Snake venom is a complex mixture of enzymes, peptides, and proteins that may have predominantly cytotoxic, neurotoxic, hemotoxic, or cardiotoxic effects but other effects as well. Pit viper venom causes predominantly local injury with pain, discoloration, edema, and hemorrhage. Swelling and pain occur soon after rattlesnake bite and are a certain indication that envenomation has occurred. During the first few hours, swelling and ecchymosis extend proximally from the bite. Hematemesis, melena, hemoptysis, and other manifestations of coagulopathy develop in severe cases. Coral snake envenomation causes little local pain, swelling, or necrosis; and systemic reactions are often delayed. In severe cases, the airway may become compromised by secretions and weakness of respiratory muscles. LoVecchio F et al: Incidence of immediate and delayed hypersensitivity to Centruroides antivenom. Adverse effects in therapeutic dosing include suicidal thoughts, aggressive behavior, extrapyramidal effects, and cardiac dysrhythmias, and in overdose may include vomiting, lethargy, seizures, hypertension, tachycardia, hyperthermia, and abdominal pain. Ingestion of soap bars may cause vomiting and diarrhea, but they have a low toxicity. Emergency (First-Aid) Treatment the most important first-aid measure is transportation to a medical facility.
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The last pair is the sex chromosomes; females have two X chromosomes (Figure 2A) asthma definition nih proven proventil 100mcg, while males have one X and one Y chromosome (Figure 2B) asthma definition in kannada order proventil 100 mcg on-line. Females receive an X chromosome from both their mother and father asthma treatment flow chart discount proventil 100mcg visa, while males receive an X chromosome from their mother and a Y chromosome from their father. A mutation anywhere in the gene "book" can cause it to function in an improper manner. As it turns out, many different mutations within the same gene are usually found among different families, all of which cause the same genetic condition. However, the same mutation will always be found in individuals within the same family. A mutation that affects only a single base (one letter) is called a point mutation. Proteins are the building blocks for various tissues, and there are more than eight proteins that are combined to make myelin in the peripheral nervous system. In a dominant condition, a person needs to have a mutation in only one copy of the gene pair for the condition to be physically expressed. A parent who has an autosomal dominant gene has a 1 in 2, or 50 percent, chance of passing the gene on to her or his children, regardless of gender. Although this type of inheritance is called dominant, affected females may have very mild symptoms that can go undetected. Some of this variability is likely due to the phenomenon of random X inactivation in females. This occurs early on in development when one member of each X chromosome pair is randomly "turned off. Females pass one or the other of their X chromosomes to their daughters and one or the other to their sons (Figure 4A). Males pass their X chromosome only to their daughters and their Y chromosome only to their sons (Figure 4B). The daughters may or may not have significant symptoms but could pass it to their children. This means that two nonfunctioning copies of a gene are needed to cause the disorder; one gene mutation must come from each parent. A parent who has one normal gene and one gene with a mutation is called a carrier. Two carrier parents have a 1 in 4, or 25 percent, chance with each pregnancy to have a child affected with an autosomal recessive condition. Sometimes genetic testing helps to determine or confirm a specific diagnosis; at other times, it helps to answer questions for other family members. Ideally, tests should be performed first on a family member who is clearly affected. In addition, a genetic diagnosis in one family member can provide answers to questions other family members may have. Questions arise about who will have access to genetic information and how it will be used. Some people have been denied health insurance, others have lost jobs, and some have been turned down for adoptions-all due to results of genetic tests. This is most disconcerting for people who find out they have the gene for a specific genetic condition but have not yet developed symptoms. Unlike other medical tests, the results of a genetic test may imply a serious diagnosis in other family members who may or may not want to be aware of their diagnosis. The decision to have genetic tests is a personal one that can only be made if one has a full understanding of the pros and cons. For this reason, genetic counseling fulfills an important role in the genetic testing process. When a research laboratory identifies a gene of interest, they usually seek out families who are potential candidates for having mutations within the gene. These laboratories can be selective about which families they agree to test or study. There is usually no fee for these tests, but there is no guarantee how long it will take for results, given that these laboratories often depend on outside funding and their interest and ability to pursue various projects may change over time. When a test is done in a commercial laboratory, there is usually an established turnaround time for results. This means that the laboratory had to pass certain standards to ensure the accuracy and reliability of its results. Since research laboratories do not have to meet the same standards as commercial laboratories, it is usually recommended that all results that come from a research laboratory should be confirmed eventually in a commercial laboratory after the testing becomes commercially available. Because treatment or cure of an affected fetus is not yet possible, the current options involve selecting affected embryos or altering the course of a pregnancy based on the disease status of the fetus. However, patients should be aware of the options that are available to them, and they should be encouraged to make those decisions that are best for them and their families. Patients who are interested in any of the available procedures should be highly encouraged to seek genetic counseling prior to becoming pregnant because the availability of these options can change. A genetic counselor can discuss the details of the currently available options with the patient. Making arrangements for some tests can also take time, which, if a patient is already pregnant, can further complicate the process. This test is generally only available to families for whom the specific type and/or mutation has been identified. If test results show that the developing baby is carrying the condition, the parents have the option to terminate the pregnancy. The cells from the placenta are grown and analyzed for the presence or absence of the mutation. This procedure involves a low risk of miscarriage but should be performed by an experienced doctor. The other option is a procedure called amniocentesis, which involves removing a small amount of the amniotic fluid or water from the uterus surrounding the developing fetus. The cells in the amniotic fluid that have been shed from the skin of the developing baby are tested and analyzed for the mutation. This procedure involves a low risk of miscarriage and should be performed by an experienced doctor. The exact procedures vary somewhat depending on the laboratory where they are performed. The number of eggs produced and retrieved and the number of embryos that form are dependent on several factors, including the age of the woman. Some people choose to have children without having tests, while others make the decision to remain childless. Why are some people in a specific family severely affected while others only have mild symptoms The possibility also exists that environmental factors such as exercise and diet play a role. When only one person in the family is affected, there can be several explanations: 1.
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Neuropsychological testing may be required to asthma symptoms pediatric proventil 100mcg discount define cognitive and behavioral deficits and plan strategies to asthma definition medscape purchase generic proventil from india deal with them in the educational environment asthma symptoms just before giving 100 mcg proventil for sale. Attention deficit, irritability, and fatigue associated with brain injury may be amenable to treatment with stimulants such as methylphenidate and modafinil. Dopaminergic agents such as amantadine, levodopa, and bromocriptine can be useful in improving cognition, processing speed, and agitation. Antidepressants such as selective serotonin reuptake inhibitors can be helpful in treating depression and mood lability. Anticonvulsants can be useful as mood stabilizers and in treating agitation and aggression. Attention and arousal can also be successfully addressed by utilizing behavioral techniques to reinforce desired Treatment the primary goal of rehabilitation after childhood brain injury is to maximize functional independence. Rehabilitative care can be divided into three phases: acute, subacute, and long term. Gains made in the behavioral realm often have a positive impact on therapies designed to address physical issues. An increased number of intracranial lesions and increased depth and duration of coma are also associated with poor functional recovery. Functional outcome assessment is important for judging the efficacy of rehabilitation therapy. Global multidomain measures are used to provide a functional "snapshot in time" of select functions-motor function and mobility, self-care, cognition, socialization, and communication. A small percentage will develop persistent problems such as chronic headache, poor focusing ability, altered memory, and vestibular abnormalities. In children, recovery may not be fully achieved for many months or years after the initial injury. The impact of the injury on developmental processes, and its future consequences, are difficult to predict. The role of anti-seizure prophylaxis following severe pediatric traumatic brain injury. Tenovuo O: Pharmacological enhancement of cognitive and behavioral deficits after traumatic brain injury. Children from birth to 2 years tend to have high-level injuries to the cervical spine because of the anatomical features of the spine in this age group. The facets tend to be shallower and oriented horizontally, and the boney spine is more flexible than the spinal cord. This classification evaluates motor and sensory function, defines the neurologic level of the injury, and assesses the completeness of the deficit. Central cord syndrome-Injury is to the central part of the cord and results in greater weakness in the arms than the legs. Anterior cord syndrome-Disruption of the anterior spinal artery causes motor deficits and loss of pain and temperature sensation. Conus medullaris syndrome-Injury or tumor of the conus causes minimal motor impairment but significant sensory and bowel and bladder abnormalities. Cauda equina syndrome-Injury to the nerve roots produces flaccid bilateral weakness in the legs, sensory abnormalities in the perineum, and lower motor neuron bowel and bladder dysfunction. Initial studies should include radiographs of the entire spine (including cervical spine) and special studies for boney structures. The approach used to stabilize the spine is determined by the type of injury, location of injury, and underlying condition of the spinal cord. Autonomic hyperreflexia or dysreflexia-This condition occurs in spinal injuries above the level of T6. Noxious stimuli in the injured patient cause sympathetic vasoconstriction below the level of injury. Vasoconstriction produces hypertension and then a compensatory, vagally mediated bradycardia. Bowel, bladder, and skin problems are the most common noxious stimuli causing this syndrome. The patient should be placed in an upright position and antihypertensive medication used if conservative measures fail. Hypercalcemia-Hypercalcemia often occurs in male adolescents within the first 2 months of becoming paraplegic or tetraplegic. Initial treatment is focused on hydration and forced diuresis using fluids and furosemide to increase urinary excretion of calcium. In severe cases, especially in older children, calcitonin and etidronate may be required. Thermoregulation problems-These problems are most common and most severe in higher level injuries and usually result in a poikilothermic state. Deep vein thrombosis should be suspected in children with any unilateral extremity swelling, palpable cords in the calf muscles, fevers, erythema, or leg pain. Heterotopic ossification-This complication occurs in both spinal cord and traumatic brain injuries. Ectopic calcium deposits usually appear around joints in the first 6 months after injury. They may cause swelling, decreased range of motion, pain with motion, palpable firm masses, fever, elevated sedimentation rate, and abnormal triple phase bone scan. Surgical removal of ectopic deposits is controversial and usually performed only in cases of extreme loss of motion, pressure sores, or severe pain. The upper trunk (C5 and C6) is the most commonly injured, resulting in a symptom complex called Erb palsy. Clinical Findings Erb palsy is characterized by shoulder weakness with internal rotation and adduction of the upper arm. Klumpke palsy is characterized by good shoulder function but decreased or absent hand function. Brachial plexus injury may also cause Horner syndrome (unilateral miosis, ptosis and facial anhydrosis) due to disruption of cervical sympathetic nerves. The physical examination should include inspection of the humerus and clavicle for fractures. The diagnosis of a brachial plexus lesion should be based on the history and clinical examination. Secondary procedures to maximize function include muscle transfers and orthopedic interventions.