Sign ¾ single or multiple ¾ Pale order 0.25 mg lanoxin otc hypertension chart, waxy ¾ umblicated nodules ¾ If the nodule is located on the lid margin it may give rise to ipsilateral chronic follicular conjunctivitis and occasionally a superficial keratitis 74 Treatment ¾ Expression ¾ shaving and excision ¾ destruction of the lesion by cauterization buy lanoxin mastercard blood pressure chart for tracking, cryotherapy 3 purchase lanoxin 0.25 mg on line heart attack jack. Squamous Cell Carcinoma - a malignant neoplasm of keratinizing cells of the epidermis. Kaposi’s Sarcoma a malignant vascular tumor that develops on the skin, mucous membrane, lymph node and visceral organs. It appears like flat or raised non tender , purple red -dark reddish lesion over the eye lid or conjunctiva. Cranial nerve palsy If the third, fourth, or sixth nerves are affected, there will be diplopia. These forms are more effective for the front of the eye, the conjunctiva, cornea, anterior chamber and iris. Drops are the most convenient and common way of giving topical treatment to the eye. If high levels of the drug need to be maintained, the drops must be applied frequently. Predispose to infection by reducing local immunity Contra indication of steroids 1. Equipment and supplies - Snellen’s E- chart -Reading chart - Occluder - Pinhole - Torch -2. How to apply eye medication - explain to the patient what is to be done - read the instruction on the eye drop/ointment carefully and sit the patient with the head tilted back. Making and Applying an Eye Pad - Cut the cotton and gauze rolls - Place layers of gauze on the working bench or table - Place a thick cotton layer on top of the gauze - Further place another layer of gauze on top of the cotton - This makes a three layered patch: gauze-cotton wool-gauze - Cut the patch in to smaller patches and trim it with scissor to make it oval. Making and Applying a Protective shield - Trace the edge of a drinking cup or gally pot on card board or x-ray film - Cut a circle of thin card from the card board or used x- ray film from the traced and make a cut to the center of the circle or tip of the fold using one of the radius. We hope that you will find this to be a pleasurable and challenging introduction to diseases of the nervous system. During this phase of your medical school experience, you are expected to become familiar with the vocabulary, basic pathologic concepts and morphologic aspects of neurologic diseases. Traditionally, diseases of the nervous system have been classified or divided etiologically into vascular, metabolic, neoplastic, infectious, degenerative, demyelinative, traumatic and developmental categories. Diseases of the neuromuscular system have been segregated somewhat, but can be divided similarly. This approach is still considered to be the most effective and understandable way to present this myriad of afflictions, but it often seems disjointed to the novice. So, be patient and we believe that things will fall into place by the end of the course. We shall try to emphasize common entities in the lectures, the small groups and images reviews, but prototypes of rare diseases also will be presented to provide you with an overview and perspective. The main purpose of the formal lectures is the presentation of conceptual, nosological, or pathogenetic aspects of neuropathology. In the small groups, we will reinforce material from lectures largely through review of images. Additionally, we will illustrate the application of basic neuropathologic principles to problem solving and analysis in the clinical setting. We will enlist your help in generating differential diagnoses to give you a feel for how we approach neurological diseases. We have included a lecture on Neuroimaging since this area is currently expanding tremendously and a basic appreciation of techniques and the value, and limitations, of those techniques will assist you in many areas of your clinical training. We have intentionally listed somewhat extensive chapters, too much to be used in a short course. This will lead you to the site that contains images for all pathology courses (topic bar will say ‘General Pathology’). A large number of additional websites are available that may enhance your learning, if you wish to investigate them. If you want to review some normal neurohistology, there is an interesting “virtual slide box of histology” at www. Finally, constructive criticism and comments are welcome and should be referred to the course director. Phone and office numbers are given for the preceptors and we encourage you to make use of this resource outside of our formal teaching plan. Introduction to Cellular Neuropathology/Cerebral Edema Cerebrovascular Diseases R eview Weds. Dementia and Degenerative Diseases & M etabolic D iseasesR eview Case 2: Dementia Fri. You will discover that these alterations are common to a variety of neuropathological disorders. Acute ischemic or hypoxic damage produces a shrinkage of the cell body and a hypereosinophilia. The neuron may be involved directly or indirectly, through retrograde (via efferents) or anterograde (via afferents) transneuronal or transynaptic degeneration. Chromatolysis may be followed by regrowth of the axon from the point of damage, a phenomenon more often seen in the peripheral than in the central nervous system. In neuronal storage diseases, excessive amounts of lipids, carbohydrates, glycosaminoglycans, or glycoproteins accumulate within neurons, enlarging and distorting the normal geometry of the cell body and proximal processes. These are usually seen in the context of inherited disorders of lipid or glycosaminoglycan catabolism (eg. Some reflect the focal storage of metabolites, some the presence of viral proteins or nucleoproteins, and some the abnormal accumulation of structural proteins (eg. Lipofuscin is an insoluble mix of proteins, lipids, and minerals that accumulates in neurons and astrocytes during the normal aging process. Neuronophagia is the phagocytosis of degenerating neurons, usually by macrophages. This is commonly seen after hypoxic or ischemic insults or during viral infections. Dying back degeneration, a degeneration of the most distal axon, followed by the progressive loss of more and more proximal regions, is often seen in toxic peripheral neuropathies. Demyelination refers to the primary loss of myelin with relative preservation of the axon (eg. Spheroids contain mixtures of lysosomes, mitochondria, neurofilaments, and other cytoplasmic constituents. Slowing or cessation of axoplasmic transport at sites of damage presumably account for spheroids. This is seen in many types of mental retardation, including congenital hypothyroidism (cretinism). Atrophy is a reduction in the volume and surface area of dendritic branches, commonly seen in neurodegenerative diseases. Neuritic plaques are collections of degenerating axons and dendrites, mixed with microglia and astrocytes and associated with the extracellular deposition of amyloid (beta-amyloid, see lecture on Neurodegenerative diseases). Status spongiosis refers to a spongy state of the neuropil, the formation of fine to medium sized vacuoles representing swollen neuronal and astrocytic processes. This change is typical of transmissible spongiform encephalopathies, such as Creutzfeldt- Jacob disease.
Clinical Pharmacology: It evaluate the pharmacological action of drug preferred route of administration and safe dosage range in human by clinical trails best lanoxin 0.25 mg pulse pressure 2013. Drugs are generally given for the diagnosis buy lanoxin 0.25mg lowest price hypertension icd code 9, prevention purchase lanoxin without a prescription blood pressure tool, control or cure of disease. Pharmacy: It is the science of identification, selection, preservation, standardisation, compounding and dispensing of medical substances. Pharmacodynamics: The study of the biological and therapeutic effects of drugs (i. Pharmacotherapeutics: It deals with the proper selection and use of drugs for the prevention and treatment of disease. Poisons are substances that cause harmful, dangerous or fatal symptoms in living substances. Chemotherapy: It’s the effect of drugs upon microorganisms, parasites and neoplastic cells living and multiplying in living organisms. Pharmacopoeia: An official code containing a selected list of the established drugs and medical preparations with descriptions of their physical properties and tests for their identity, purity and potency e. Out of all the above sources, majority of the drugs currently used in therapeutics are from synthetic source. Pharmacodynamics Involves how the drugs act on target cells to alter cellular function. Receptor and non-receptor mechanisms: Most of the drugs act by interacting with a cellular component called receptor. Some drugs act through simple physical or chemical reactions without interacting with any receptor. Many drugs are similar to or have similar chemical groups to the naturally occurring chemical and have the ability to bind onto a receptor where one of two things can happen- either the receptor will respond or it will be blocked. A drug, which is able to fit onto a receptor, is said to have affinity for that receptor. An agonist has both an affinity and efficacy whereas antagonist has affinity but not efficacy or intrinsic activity. When a drug is able to stimulate a receptor, it is known as an agonist and therefore mimics the endogenous transmitter. When the drug blocks a receptor, it is known as antagonist and therefore blocks the action of the endogenous transmitter (i. However, as most drug binding is reversible, there will be competition between the drug and the natural stimulus to the receptor. The forces that attract the drug to its receptor are termed chemical bonds and they are (a) hydrogen bond (b) ionic bond (c) covalent bond (d) Vander waals force. Covalent bond is the strongest bond and the drug-receptor complex is usually irreversible. Dose Response relationship The exact relationship between the dose and the response depends on the biological object under observation and the drug employed. When a logarithm of dose as abscissa and responses as ordinate are constructed graphically, the “S” shaped or sigmoid type curve is obtained. The lowest concentration of a drug that elicits a response is minimal dose, and the largest concentration after which further increase in concentration will not change the response is the maximal dose. Graded dose effect: As the dose administered to a single subject or tissue increases, the pharmacological response also increases in graded fashion up to ceiling effect. Quantal dose effect: It is all or none response, the sensitive objects give response to small doses of a drug while some will be resistant and need very large doses. The quantal dose- effect curve is often characterized by stating the median effective dose and the median lethal dose. Penicillin has a very high therapeutic index, while it is much smaller for the digitalis preparation. Structural activity relationship The activity of a drug is intimately related to its chemical structure. Knowledge about the chemical structure of a drug is useful for: (i) Synthesis of new compounds with more specific actions and fewer adverse reactions (ii) Synthesis of competitive antagonist and (iii) Understanding the mechanism of drug action. Slight modification of structure of the compound can change the effect completely. Pharmacokinetics Pharmacokinetics deals with the absorption, distribution, metabolism and excretion drugs in the body. Biotransport of drug: It is translocation of a solute from one side of the biological barrier to the other. Structure of biological membrane: The outer surface of the cell covered by a very thin structure known as plasma membrane. The 5 membrane proteins have many functions like (a) contributing structure to the membrane (b) acting as enzyme (c) acting as carrier for transport of substances (d) acting as receptors. The plasma membrane is a semipermeable membrane allowing certain chemical substances to pass freely e. Drug absorption: Absorption is the process by which the drug enters in to the systemic circulation from the site of administration through biological barrier. In case of intravenous or intra-arterial administration the drug bypasses absorption processes and it enters into the circulation directly. Routes of drug administration: a) From the alimentary tract: (i) Buccal cavity: e. Disadvantages of oral route: Onset of drug action is slow, irritant drugs cannot be administered and it is not useful in vomiting and severe diarrhea, gastric acid and digestive enzymes may destroy some drugs, and water soluble drugs are absorbed poorly. Disadvantages: Pain at local site of injection, the volume of injection should not exceed 10 ml. Advantages: It can be given in large volumes, production of desired blood concentration can be obtained with a well designed dose. Disadvantages: Drug effect cannot be halted if once the drug is injected, expertise is needed to give injection. Bioavailability: It is the rate and amount of drug that is absorbed from a given dosage form and reaches the systemic circulation following non-vascular administration. The route of administration largely determines the latent period between administration and onset of action. Drugs given by mouth may be inactive for the following reasons: a) Enzymatic degradation of polypeptides within the lumen of the gastrointestinal tract e. Factors affecting drug absorption and bioavailability: a) Physico-chemical properties of drug b) Nature of the dosage form c) Physiological factors d) Pharmacogenetic factors e) Disease states. However at the cell surface, the lipid soluble drugs penetrate into the cell more rapidly than the water soluble drugs. Unlike inorganic compounds, the organic drugs are not completely ionized in the fluid. Unionized component is predominantly lipid soluble and is absorbed rapidly and an ionized is often water soluble component which is absorbed poorly. T is impermeable to the ionized form of a weak organic acid or a weak organic base. Disintegration time: The rate of break up of the tablet or capsule into the drug granules.
At any rate discount lanoxin 0.25mg free shipping blood pressure grapefruit, it is important to not focus on negative behaviors buy lanoxin 0.25 mg low cost blood pressure norms, because in that case parents know what they are doing wrong but not how to do it better generic 0.25mg lanoxin heart attack lyrics 007. If the teacher does not feel capable of leading a group in this section, collaboration may be requested from professionals at associations of ex-substance consumers, the school psychologist or a professional from outside the center. At the end of the session establish conclusions or take-home messages that focus on the most appropriate behaviors: reinforcing positive behaviors, fluid family communication, absence of corporal punishments, seeking positive solutions, etc. Although at first glance it may seem extremely difficult to carry out this type of session, prepared materials are available which provide models for all the activities to be performed during the session and how to conduct each so that they can be implemented by the tutor of a course in which adolescents are enrolled. However, formal education often uses assessment only as way to assign a numerical score to students, which serves to certify whether or not progress is being made in the course. The activities that follow are aimed at assuring that the student continues learning about the topic before us. If at any time you use information that was not given in the course, we ask that you cite and reference the place you extracted the information so as to corroborate the relevance and adaptation of the information source. Separate the following questions into two columns: one relating to family risk factors for substance consumption during adolescence, and the other to protection factors: Limited affective relationship, positive emotional climate, parent-child avoidance of communication about drugs, lax standards, unconventional family structure, a sense of trust, setting limits, family conflictivity, explicitly stating values and healthy lifestyle habits, sharing activities and leisure time, substance use by parents, permissive attitude about the consumption of substances; supervision of: activities, acquaintances, places of leisure; parenting style: authoritarian, authoritative, neglectful, indifferent Solution: Protection Factors Risk Factors Positive emotional climate Limited affective relationship Setting limits Parent-child avoidance of communication about drugs Explicitly stating values and healthy lifestyle habits Lax standards A sense of trust Substance use by parents Supervision of: activities, acquaintances, places Permissive attitude about the consumption of of leisure substances Sharing activities and leisure time Parental Style neglectful and indifferent Parental Style authoritarian and, above all, authoritative. If excessive, family conflictivity becomes a risk factor, but a medium conflictivity associated with a positive emotional climate, promotes in adolescents the need to discuss with their parents the reasons for the conflict, and therefore the internalization of the norms, and a better mutual understanding, and ultimately, a better adjustment of the boy or girl. Make a list of at least five subjects that you would discuss at a work session with parents about adolescence and substance consumption. Demystifying some issues that are taken for granted, such as that cannabis is less harmful than tobacco because it is a type of grass) 24 b) Myths about adolescence (Give a clear idea of what adolescence is, which issues are expected and not expected of an adolescent. Demystify the negative idea of adolescence) c) Individual factors that affect the consumption of substances during adolescence (low self-esteem, sensation seeking, antisocial attitudes and low norm conformity, dissatisfaction with the use of free time, positive attitudes about drugs, distorted information about drugs, deviant group of friends, lack of self-control, stressful or critical life situations poor assertivity) d) Family relationships during adolescence: e) Parental styles: the role of monitoring and affection f) The importance of communication, although it leads to discussion in an affective environment g) Family modeling: parents as examples for their children h) Group of friends (what are they like, what kinds of activities do they do, what influence do they have over the adolescent and to what extent can they exercise it, how are they chosen, etc) i) Leisure and free time j) Where to go for more information (physical locations and websites updated and reliable) 3. It must be designed with sufficient depth, so that any other teammate could carry it out without the need to consult you further. This activity can be varied by asking participants to seek an activity from a program they know and implement it in their center (It is important that it be carried out in a public place within the platform, so that other program participants can see them and thus have more examples of activities)) An example, taken from: Oliva, A. Debunk myths and misconceptions Objectives: Reflect on dialogue as the best tool in the prevention of drug use. Developing the Activity The session coordinator explains to participants that this activity is carried out to find out what we know or think we know about drugs. To do this, a copy of the index card "Myths and Beliefs", on which are a series of statements, is distributed to each attendee. Individually, participants should read the statements and mark the box corresponding to T if one believes the claim is true or, conversely, F if one thinks it is false. After these five minutes have elapsed, the coordinator will start reading the first myth and ask the participants their opinions and arguments about why they believe that the claim is true or false. If an adolescent tries a joint (marijuana cigarette), she/he will be unable 26 to avoid the continuation into taking other drugs. Intoxication occurs when a certain amount of a drug is taken and the body is unable to eliminate or transform it. T – F Below is the script the coordinator can use to analyze the extent to which each of these myths corresponds with reality. Drugs can also be taken out of passiveness and to escape (to pass time and flee from problems), to adapt to established social norms (to study, out of habit, to facilitate social contact), to calm the nerves and to experience new pleasurable sensations. If an adolescent tries a joint (marijuana cigarette), she/he will be unable to avoid the continuation into taking other drugs. Smoking a joint does not necessarily mean that the adolescent will continue taking the drug nor, eventually have to try other drugs. There are certain phases in the consumption of substances that imply that if the boy or girl is using a particular type of drug, he or she has already used others previously. However, it does not necessarily imply that the adolescent has to continue using other substances considered "more dangerous. All drugs are harmful to people, although some are more dangerous than others and have less visible short-term effects on health. Continual and abusive consumption can cause disease in all the organs, especially in the digestive and circulatory systems, and severe psychological disorders. Intoxication occurs when a certain amount of a drug is taken and the body is unable to eliminate or transform it. When a certain amount of a drug is taken and the body is unable to eliminate or transform it, intoxication occurs. It will have different symptoms depending on the type of substance consumed and will remain until transformed or eliminated by the body. Depending on the amount consumed, the characteristics of the organism at the time and the characteristics of the substance, intoxication can present very serious symptoms, even inducing coma or requiring emergency medical intervention. Regular consumption of cannabis can lead to dependence, such that its abrupt discontinuation can lead to nervousness, insomnia, irritability and depression. The consumption of legal drugs, especially tranquilizers and tobacco, is more common among girls (in the case of tobacco with major differences), while alcohol and all the illegal drugs are consumed more by boys. Dependence is the set of behaviors and reactions including the impulse and need to take the substance on a continuous or regular basis, be it to feel its effects or to avoid the discomfort that the deprivation of the substance produces. This state may or may not be accompanied by tolerance, which would be the progressive adaptation of the body to consumed substances, such that to feel the same effects, it is necessary to increase the intake amount. Activity Summary To end the activity, the session coordinator will conduct a theoretical exposition with the theoretical content presented on the subject. Therefore, parents must know the different types of drugs and their effects in order to give their children clear, reliable, accurate and objective information about them. This information can and should be obtained and updated and contextualized in each country where the program is implemented, so do not add it here. Parental Mediators of Associations between Perceived Authoritative Parenting and Early Adolescent Substance Use. What parents know, how they know it, and several forms of adolescent adjustment: Further evidence for a reinterpretation of monitoring. Patterns of competence and adjustment among adolescents from authoritative, authoritarian, indulgent, and neglectful families. Consumo de sustancias durante la adolescencia: trayectorias evolutivas y consecuencias para el ajuste psicológico. Outcome, attrition and family/couples treatment for drug abuse: A meta-analysis and review of the controlled and comparative studies. Patterns of Competence and Adjustment Among Adolescents from Authoritative, Authoritarian, Indulgent, and Neglectful Homes: A Replication in a Sample of Serious Juvenile Offenders. Impact of parenting practices on adolescent achievement: Authoritative parenting, school involvement, and encouragement to succeed. Drug consumption, its causes and consequences, is a multifaceted phenomenon that can only be understood if viewed from different perspectives.
Other prognostic factors include: - Invasive and metastatic potential - Histological grade of tumor - Estrogen receptor status - Patient age and menopausal status are some of the factors Treatment of Breast Cancer: Treatment of breast cancer is a multi disciplinary approach 0.25 mg lanoxin visa blood pressure chart in europe. It largely depends on clinical stage and other tumor characteristics described previously buy lanoxin 0.25mg lowest price heart attack and blood pressure. Modes of treatment include: • surgery • radiotherapy and • Medical therapy (including chemotherapy and hormonal therapy discount 0.25mg lanoxin free shipping arrhythmia flashcards. A-20 year old female patient presents with a solitary painless lump in the breast. A thirty-five year-old nulliparous woman comes with history of swelling in the breast of 2-months duration. In association with this, the patient has moderate fever, decreased appetite and weight loss. List the most important laboratory investigations which help you confirm the diagnosis. On Physical examination, the tumor measured 4cm, its non-mobile and rough surfaced. Introduction Acute upper airway obstruction is a surgical emergency with no time to lose. Infants are vulnerable more than adults due to small diameter of the airway, longer soft palate, more posterior pharyngeal soft tissues, compliant epiglottis, etc. Generally, in any patient with thoracic problem, chest physiotherapy, that is incentive spirometry if available or inflating a glove or intravenous fluid bag with deep inspiration and expiration and early movement is of paramount importance for smooth recovery of the patient. It is usually characterized by stridor (noisy breathing); suprasternal retraction; tachycardia and cyanosis develop as obstruction becomes complete. If a foreign body aspiration is suspected, tilt the patient’s head down and slap the patient sharply across the back. Then, explore the pharynx and mouth by finger and if possible, urgent laryngoscopy should be done. If indicated, intubate the airway immediately, otherwise do emergency cricothyroidotomy (insert wide bore needle to the cricothyroid membrane) and give 100% oxygen until intubation or proper tracheostomy is done. It is indicated to by- pass upper airway obstruction, for drainage of the respiratory tract and to provide assisted ventilatory support. Tracheostomy should be performed in operating room under general anaesthesia with intubation, if possible, especially in case of children. But if very urgent situation is encountered, do cricothyroidotomy while preparing for tracheostomy. Make incision over fourth tracheal ring transversely or vertically in case of emergency. Dissect strictly in midline to separate the strap muscles and pre tracheal fascia to expose the trachea. Open the trachea by midline incision through three adjacent tracheal rings, usually rd th th 3 , 4 and 5 , after holding upper end of cricoid cartilage using fine cricoid hook. Hold open cut edge by tracheal dilator and insert a tube which comfortably fits the trachea while the anaesthesiologist withdraws the endotracheal tube. Aspirate tracheal secretion soon after initial incision on the trachea and repeat after the tube in place. Humidify inhaled gas as near to body temperature as can be achieved by frequent application of saline soaked gauze over the tube. Tracheostomy toilet from 10 minutes to as long as two hours as needed and if there is inner tube take it out every four hours and wash it. The terrible death toll related to chest injuries is avoidable by simple measures. It results in hemothorax in more than 80% and pneumothorax 146 in nearly all cases. It should be considered as thoracoabdominal if penetration is below fourth intercostal space. Tightly dress any sucking wound and look for signs of tension pneumothorax (distended neck veins, shift of the trachea, hyper resonance with decreased air entry), cardiac tamponade (hypotension, distended neck vein and distant heart sounds), massive hemothorax and flail chest all of which can compromise ventilation despite patent airway and adequate oxygenation. Control extreme hemorrhage and restore circulation: Insert wide bore cannula for fluid and blood transfusion. B: If one suspects tension pneumothorax, massive hemothorax or cardiac tamponade, the management should be dealt as part of resuscitation and patients should not be sent for confirmatory investigations. Besides, in case of suspected cardiac tamponade, simple insertion of a needle through xiphoid angle pointing towards the left shoulder tip can help enter the pericardium and aspirate accumulated blood. Major chest wall injuries: Flail chest: paradoxical movement of a segment of chest wall as a result of fracture of four or more ribs at two points or bilateral costochondral junction separation. Diagnosis: Usually clinical, by closely observing paradoxical chest motion, chest x-ray shows multiple segmental fractures. Fracture of first, second rib and the sternum: These are considered to be major injuries since a considerable force, which usually causes associated injury to underlying structures like vessels or nerves, is required. Diagnosis: Chest x-ray (parenchymal opacity immediately after injury and increasing in the next 24-48 hours). Injury to mediastinal structure: Injury to trachea, bronchus, major vessel and heart are fortunately rare. But if they occur, they are usually fatal and patient often does not reach health facility. Diaphragmatic rupture: Mostly occurs on the left side and diagnosis needs high index of suspicion. Symptoms and signs are usually due to herniation of intra abdominal organ like stomach or colon in to the chest. Tension: This is a surgical emergency associated with development of pressure which compromise breathing as well as circulation. B: In most cases of traumatic pneumothorax, there will be associated bleeding which may not be apparent. Look for decreased chest expansion, tracheal shift, hyper resonant percussion note and decreased air entry. In case of tension pneumothorax, insertion of needle at second intercostal space over the mid clavicular line of the same side relives the tension until chest tube insertion. Massive Hemothorax is a bleeding of more than 1500ml in to pleural cavity and rarely occurs in blunt trauma. Signs of fluid collection in the pleural cavity (decreased air entry, dull percussion note) are found on physical examination. Chest x-ray: Erect chest film reveals costophrenic angle obliteration if more than 500 ml blood exists. The purpose is to maintain the negative intrapleural pressure and allow complete re-expansion of underlying lung. This is achieved by connecting the tube to underwater seal drainage bottle with or without suction. B: Remove the chest tube while patient is in full inspiration and tightly close the insertion site by gauze soaked with a lubricant. Staphylococcus aureus, Streptococcus pneumonia and Streptococcus pyogens most common causes in healthy adult. Immunocompromised patients are prone to Aerobic gram negative bacilli and fungal infection.
To date 0.25mg lanoxin sale blood pressure risks, this has been repeatedly shown to be false (American Academy of Pediatrics buy 0.25 mg lanoxin with mastercard blood pressure jump, 2001 buy 0.25mg lanoxin fast delivery hypertension classification jnc 7; Duhaime et al. In a minority of cases, external injuries including bruises or scalp swelling may signal the presence of abuse to health care providers (Duhaime et al. These non-specific symptoms can be mistakenly diagnosed as viral infections, gastroenteritis, or infant colic, especially when a truthful account of the circumstances surrounding the injuries is withheld (American Academy of Pediatrics, 1993; Blumenthal, 2002). Sadly, studies have revealed that 30 to 60% of infants diagnosed with shaken baby syndrome have been victims of repeated, prior shaking abuse (American Academy of Pediatrics, 2001; Dias, Backstrom, Falk, & Li, 1998; Jenny, Hymel, Ritzen, Reinert, & Hay, 1999; Kemp & Coles, 2003; King, MacKay, & Sirnick et al. A multidisciplinary team of emergency room physicians, pediatric ophthalmologists, community pediatricians, pediatric neurosurgeons, pediatric radiologists, nurses, social workers, psychologists, and law enforcement officers are essential for the optimal provision of medical, legal, and community services. Shaken baby syndrome permeates all socio-economic and educational classes in society (American Academy of Ophthalmology, 2002; Dias & Barthauer, 2001; Health Canada, 2001; Lancon et al. Biological fathers and stepfathers are the most common perpetrators (56% of cases), followed by boyfriends (16%), biological mothers (15%), and babysitters (14%) (Newton & Vandeven, 2005). In all, parents and paramours comprise approximately three-quarters of all perpetrators (Lazoritz & Palusci, 2001). Race has not been found to correlate with the incidence of shaken baby syndrome (Sinal & Petree, 2000). Factors such as unemployment, poverty, young parental age, substance abuse, and behavioural problems in the parent or child do contribute to the incidence of shaken baby syndrome (Fulton, 2000; Kemp & Coles, 2003; Starling et al. Parent education level and single parent status may also be important (Goldstein, Kelly, Bruton, & Cox, 1993). Parents that harbor unrealistic expectations for the child to fulfill the parents’ personal needs, or to behave beyond their age, are also at a higher risk of harming their children (Fulton, 2000; Showers, 1989). Because the prevalence of shaken baby syndrome is relatively low in the population, the predictive value of social characteristics is limited (Kemp & Coles, 2003). Studies have shown that shaken baby syndrome is more likely to be missed in families where the parents are married, Caucasian, and of higher socioeconomic status, due to health care provider bias (Ricci, Giantris, Merriam, Hodge, & Doyle, 2003; Sanders, Cobley, Coles, & Kemp, 2003). It is therefore prudent for health care workers to maintain a uniform index of suspicion in all cases of infants with traumatic brain injury. This is significant for the prevention of shaken baby syndrome, since 15 to 25% of healthy infants spend up to 50% of their waking hours crying inconsolably (Papousek & von Hofacker, 1998). Perpetrators classically describe, in hindsight, how an infant’s relentless, inconsolable crying, compounded by various life stressors, caused them to violently and impulsively shake an infant in their care (American Academy of Ophthalmology, 2002; Fulton, 2000; Levin, 1998). Infant colic is defined in the medical literature as persistent, excessive crying in an otherwise healthy infant, and is relatively poorly understood (Deshpande, 2005). Various theories as to the cause of colic have included gastrointestinal discomfort from lactose intolerance, difficulty adjusting to a diet of breast milk, self-regulatory dysfunction of behavioural-emotional states, and an immature infant sleep-wake organization (Papousek & von Hofacker, 1998). Barr, a pediatrician with a research interest in shaken baby syndrome, has identified a ‘crying curve’ that represents a universal pattern of infant crying. Barr contends that all infants follow this pattern, and that infants with ‘colic’ are merely at the end of a spectrum of normal crying behaviour (Barr, 1990). In a German study examining the link between persistent infant crying and the mother-infant relationship, Papousek and von Hofacker found that mothers of persistent criers scored markedly higher on scales for depressed mood, exhaustion, frustration/anger, and anxious overprotection (Papousek & von Hofacker, 1998). As well, Stifter and Bono found that mothers of colicky babies reported feeling less competent as mothers (Stifter & Bono, 1998). Clearly, incessant infant crying takes its toll on caregivers and predisposes infants to the risk of violent shaking. Accurate assessment of the true incidence of shaken baby syndrome presents an exceedingly difficult challenge. Some infants may not be brought to medical attention at the time of injury but later manifest unexplained developmental delays, neurological impairments, and learning difficulties (American Academy of Pediatrics, 2001; Duhaime et al. Consequently, experts suspect that documented cases of shaken baby syndrome represent a mere fraction of the total number of shaken infants per year. It is estimated that one of every 2,600 infants will be violently shaken before reaching one year of age (Lithco, 2004). In a prospective, population-based study of the incidence of shaken baby syndrome, Barlow found a rate of 24. Thirteen to 30% of shaken infants succumb to fatal injuries (American Academy of Ophthalmology, 2002; American 10 11 Academy of Pediatrics, 2001; Dias et al. Half of the remaining infants experience blindness and various global neurological impairments, including seizures, spasticity, paralysis, and developmental delays (A. Shaken baby syndrome is an ominous form of child abuse with devastatingly high rates of morbidity and mortality. Any physician suspecting an infant has been abused is legally obligated to report the case to state or province-specific child welfare agencies. Efforts to educate health care providers about the characteristic features of shaken baby syndrome will serve to increase the detection and reporting of new cases, and hopefully increase the conviction rate of identified perpetrators. Caffey first described the combination of subdural hemorrhages, retinal hemorrhages and long bone fractures in infants without external signs of injury; he named the phenomenon ‘whiplash shaken baby syndrome’ (Caffey, 1972). In his landmark article in 1972, he called for the implementation of a nation-wide prevention campaign. Unfortunately, clinical 11 12 and research efforts remained focused on intervention rather than prevention for several reasons. First, the perceived importance of educating the public about shaken baby syndrome differed among professionals. Some felt it was common knowledge that shaking an infant was dangerous, while others routinely gave advice to shake apneic infants. Second, it was believed that the impulsive act of infant shaking was not amenable to primary prevention through public education. Third, the risk factors associated with shaken baby syndrome were unclear, eliminating the possibility of targeted secondary prevention initiatives (Barron, 2003). Prevention-based research finally began in the United States in the mid 1980’s and has been steadily gaining momentum world-wide. After a 1989 survey by Showers demonstrated that 25 to 50% of adults and adolescents were unaware of the dangers of violent infant shaking, prevention efforts in the form of media campaigns, public education initiatives, male-targeted parenting classes, baby-sitting training courses, and hospital-based programs began to appear. Unfortunately, the impact these programs had on the incidence of shaken baby syndrome remained unknown because the programs were sporadic, fragmented, and unevaluated. In the long term, the total cost of comprehensive medical 12 13 care for a single shaken infant can exceed $1 million (Showers, 1998). These figures do not even begin to capture the hidden costs of shaken baby syndrome, when one considers each victim’s loss of societal productivity and occupational revenue, the cost of prosecuting and incarcerating perpetrators, the cost of foster care and child welfare agency involvement, and the on-going mental, physical, and educational therapy that each victim requires (Dias & Barthauer, 2001, August). Financial costs aside, shaken baby syndrome has devastating effects on the personal lives and emotional health of victims and affected families. Clearly, the hidden costs of treating victims of shaken baby syndrome far exceed the costs of implementing a prevention program.
By J. Barrack. Eastern Mennonite University.