By M. Sanford.
There is also hypertrophy and oedema of the fat behind the eye which adds to the exophthalmos discount nexium online gastritis diet 1234. When severe 20mg nexium with mastercard gastritis diet âčęčďĺäč˙, these changes can lead to compression of the optic nerve in the apex of the orbit best buy nexium gastritis x helicobacter pylori. The break in the orbital foor allows herniation of orbital contents into the antrum, which Orbital foor fractures also occur with trauma to the may result in diplopia. A fracture result in a fuid level or complete opacifcation of the of the orbital foor may also be visible. Salivary glands disorders, including masses, diffuse A sialogogue may be used to stimulate secretion of saliva enlargement or symptoms of dry mouth, are all frst inves- to improve visualization. The commonest salivary be performed by injecting contrast into the ducts of the gland tumour of the parotid gland is a benign pleomorphic salivary glands. It confrms the pres- Sialography ence of the mass and differentiates solid from cystic lesions. Note the long duct of even calibre and the fne branching of the ducts within the gland. Direct inspection by laryn- C goscopy reveals a great deal of information about the larynx, particularly in regard to the vocal cords. However, imaging can provide additional information regarding the extent of the tumour and its spread outside the larynx (Fig. The thyroid gland, which is the investigation of abnormal thyroid function and in situated on either side of the trachea, normally enhances patients with known thyroid carcinoma. It is important to note eating the extent of most tumours in the neck because of that iodinated contrast should be avoided in those patients the superior soft tissue contrast. Ultrasound deter- too small to palpate or are in sites not amenable to clinical mines whether a nodule is cystic or solid or a mixture of examination. Ultrasound may Ultrasound is more able to accurately predict the underly- show that the nodule is part of a multinodular goitre by 464 Chapter 16 M (a) (b) Fig. The two lobes of the tumour (T) in the larynx that has destroyed the vocal cords and thyroid (arrows) lie on either side of the trachea (T). The enlarged thyroid almost surrounds the trachea (T) and enhances avidly after intravenous contrast showing many nodules of varying size. Scintigraphy (with 123I or 131I) for metastatic spread at presentation is usually to no avail as the metastases do not take up suffcient radionuclide. Any metastases, recurrent tumour or residual thyroid tissue may subsequently be treated with a therapeutic dose of 131I. Parathyroid imaging Localization of a parathyroid adenoma prior to surgery for hyperparathyroidism is important because about 10% of (b) adenomas are multiple or occur in an ectopic position. Scintigraphy complex malignant thyroid nodule with cystic areas (*) and bright foci that indicate punctate calcifcation (arrow), which is allows functional localization of abnormal parathyroid associated with papillary and medullary thyroid cancer. Normal parathyroid glands are too small to be visu- Ultrasound showing several hyperplastic nodules in the right alized, but even a small adenoma can be detected. This image was acquired during a therapeutic dose of 131I and shows residual uptake in the thyroid bed (*) as well as multiple bone metastases (one of which is shown with an arrow). Orbits, Head and Neck 469 sestamibi) and one that visualizes the parathyroid glands only (123I or 99mTc pertechnetate). The two sets of images are digitally subtracted from one another and residual radio- activity on the subtraction image represents a hyperfunc- tioning parathyroid tissue (Fig. A few minutes compressing the puncture site peutic interventions that involve the arterial and venous with the fngers is enough to stop the bleeding in most system. The advantages of the Seldinger technique are ology in which minimally invasive procedures are carried that it is easy and quick to perform, that the hole in the out under image guidance. Diagnostic vascular angiography Prior to undertaking any intervention, it is important to Magnetic resonance angiography have an accurate assessment of the extent and distribution of disease whether in the venous or, more commonly, the Magnetic resonance angiography is a very useful non- arterial system. In the past this could be obtained with invasive technique, which can demonstrate both arteries a diagnostic angiogram, though increasingly non-invasive and veins. Magnetic resonance angiography is particularly useful Arteriography for showing the aorta and its branches (Fig. Aneurysms and vas- but occasionally carbon dioxide) is injected through the cular malformations can also be detected in the intracranial catheter, which opacifes the target vessel. At the end of the procedure, the catheter injection of contrast, many thin sections can be obtained so Diagnostic Imaging, Seventh Edition. On the subtracted image (a) the bones and soft tissues are barely visible compared to the unsubtracted image (b). The angiogram shows a patent popliteal artery (thin arrow) with a short segment occlusion proximal to the trifurcation (curved arrow). Computed tomography angiography is particularly useful for visualizing the aorta and its branches for sus- pected aneurysms (Fig. Ultrasound of the arterial system Ultrasound has an important role to play in diagnosing Fig. A normal internal vessels, and is commonly the primary imaging modality carotid artery is seen on the left (arrowhead). The common, internal and external carotid arteries can be readily visualized in the neck. The location or size of any atheromatous plaques and the sever- Ultrasound venography ity of any luminal narrowing can be determined. With colour Doppler imaging, a stenosis in the artery can be Duplex ultrasound has now largely replaced contrast visualized and an occlusion will show as an absence of venography for the detection of venous thrombosis. Because a stenosis disrupts the normal fow pattern, a venous thrombosis, intraluminal echogenic material is analysis of the fowâvelocity waveform can give further visible and the veins lose their normal compressibility; information regarding the degree of stenosis. Imaging of thrombus-free veins should be compressible by direct pres- the iliac vessels may be diffcult due to overlying bowel sure using the ultrasound transducer. Colour Doppler gas, but evaluation of the abdominal aorta is invariably scanning shows that there is a lack of spontaneous fow successful and can easily be performed during an outpa- in the affected veins. In practice, this is often not clinically signifcant as of contrast medium is injected into a vein on the arm or calf vein (i. The contrast is forced into the deep venous system of the upper limb by means of a tourniquet. Thrombi may be seen as flling defects in the opacifed veins, and Contrast venography any stenosis or occlusion in the central veins is well Contrast venography is routinely used for the evaluation demonstrated. Vascular and Interventional Radiology 475 under local anaesthesia, causing only relatively minor dis- comfort to the patient, allowing many procedures to be performed as âday casesâ. Only the basic principles of the interventional techniques in widespread use will be described here. Angioplasty and stents Arterial stenoses and even occlusions may be traversed with a guidewire.
Adult autopsy studies report the presence of noncaseating granulomas in the epicardium or myocardium (especially the left ventricular free wall) in 27% of sarcoidosis patients discount 20 mg nexium overnight delivery gastritis y sintomas. However buy 40 mg nexium otc gastritis clear liquid diet, only âź5% of adult patients have clinical cardiac symptoms (63 40 mg nexium with amex gastritis symptoms nhs direct,65,145,146,147,148,153,175,176,313,316,317). Cardiac symptoms or signs are more of a concern in patients with more extensive systemic sarcoidosis. Manifestations may include conduction defects, atrial or ventricular arrhythmias, sudden death, cardiomyopathy, and heart failure (62,73,109,138,152,313,314,317). Cardiac involvement in adult patients is an ominous sign with myocardial involvement in the United States accounting for as many as 13% to 25% of deaths from sarcoidosis (32,70,81,136,137,139,151,309,310,313). In Japan, where cardiac involvement accounts for 85% of the deaths due to sarcoid, the Japanese Ministry of Health and Welfare has published a protocol for diagnosing cardiac sarcoidosis (53,72,73,76,318,319). The diagnosis is based on either histologic findings on biopsy (although sensitivity is low) or clinically using a set of electrocardiographic, echocardiographic, nuclear medicine, and catheter-based criteria (69,79,317,318). Portable Holter monitoring can be helpful when there is a clinical suspicion for arrhythmia. Magnetic resonance imaging can provide a more sensitive assessment of the myocardium than echocardiography. Treatment Steroids are first-line treatment for cardiac symptoms thought to be attributable to sarcoidosis regardless of the clinical presentation (140,153,317). Therapy with immunolytic and immunomodulation agents may provide effective treatment and spares patients some corticosteroid exposure. Antiarrhythmics may be necessary, and there are sometimes indications for placement of a pacemaker or implantable cardiac defibrillator (314). The hallmark of this vasculitis is the development of microaneurysms, and a fluctuating disease course with flares, remissions, and relapses. Vasculitis is typically patchy in nature and is characterized by endothelial proliferation, fibrinoid necrosis, and microthrombi resulting in vessel damage and microaneurysm formation. Rupture or thrombosis of these microaneurysms can lead to organ ischemia and damage, intraperitoneal bleeds, and perirenal hematoma (330,331). In advanced lesions, vascular remodeling leads to the development of intimal hyperplasia and diffuse fibrotic changes within the vessel wall (330,331,332). Vessels with acute necrotizing lesions typically coexist with others with fibrotic or healing changes, representing different stages of the inflammatory process (330,331,332). Systemic inflammation with evidence of necrotizing vasculitis or angiographic abnormalities of medium- or small- sized arteries is required for the diagnosis, plus one of the following related to vascular insufficiency: Skin involvement (livedo reticularis, nodules, infarcts) Myalgias Hypertension Peripheral neuropathy Renal involvement (proteinuria, hematuria, or impaired function) In a small pediatric study by Gunal et al. An autopsy study including both children and adults showed primary coronary vasculitis in over 50%. Coronary arteritis requires aggressive immunosuppression with steroids and/or agents such as cyclophosphamide (339). In life-threatening or organ-threatening situations, plasmapheresis may be indicated (322). Surgery may be necessary for disease complications such as ischemia, hemorrhage, perforation, or rupture (338). The relapse rate was 35% in a pediatric series of 69 children at a single center, and the mortality rate was 4% (326). Polyarticular juvenile idiopathic arthritis - epidemiology and management approaches. Stent placement for treatment of long segment (âĽ80 mm) carotid artery stenosis in patients with Takayasu disease. International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: second revision, Edmonton, 2001. Ongoing disease activity and changing categories in a long-term nordic cohort study of juvenile idiopathic arthritis. Cardiac tamponade in juvenile chronic arthritis: report of two cases and review of publications. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. The â174G allele of the interleukin-6 gene confers susceptibility to systemic arthritis in children: a multicenter study using simplex and multiplex juvenile idiopathic arthritis families. Clinical features, treatment, and outcome of macrophage activation syndrome complicating systemic juvenile idiopathic arthritis: a multinational, multicenter study of 362 patients. Association between duration of symptoms and severity of disease at first presentation to paediatric rheumatology: results from the Childhood Arthritis Prospective Study. Epidemiology of juvenile idiopathic arthritis in a multiethnic cohort: ethnicity as a risk factor. Epidemiology of juvenile rheumatoid arthritis in Manitoba, Canada, 1975â92: cycles in incidence. Early predictors of longterm outcome in patients with juvenile rheumatoid arthritis: subset-specific correlations. Diagnosis and assessment of disease activity in takayasu arteritis: a childhood case illustrating the challenge. Assessment of cardiac and pulmonary function in children with juvenile idiopathic arthritis. Prevalence of pericardial effusion by echocardiography in juvenile rheumatoid arthritis. Recurrent cardiac tamponade in a child with newly diagnosed systemic-onset juvenile idiopathic arthritis. Assessment of left ventricular systolic and diastolic function in juvenile rheumatoid arthritis. Complete heart block in an adult with systemic lupus erythematosus and recent onset of hydroxychloroquine therapy. A patient diagnosed with pauciarticular juvenile rheumatoid arthritis after a mechanical prosthetic valve replacement due to aortic regurgitation. Cardiac operations for North American children with rheumatic diseases: 1985â2005. Cardiovascular autonomic function assessed by autonomic function tests and serum autonomic neuropeptides in Egyptian children and adolescents with rheumatic diseases. Excess of adiposity in female children and adolescents with juvenile idiopathic arthritis. Influence of age at disease onset in the outcome of paediatric systemic lupus erythematosus. An antibody profile of systemic lupus erythematosus detected by antigen microarray. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus.
Testis is commonly located in scrotum 40mg nexium overnight delivery gastritis diet ulcer, ovary in the abdomen purchase nexium us gastritis english, and ovotestis can be present anywhere along the route of testicular descent from abdomen to labio- scrotal fold cheap 20mg nexium overnight delivery gastritis high fiber diet. The term ovotestis denotes the presence of ovarian follicles and seminiferous tubules within the same gonad. He had history of surgery for gynecomastia at the age of 15 years and multiple surgeries for hypospadias. The index patient had immature facies, poor facial hair, and feminine voice suggestive of hypogonadism. Genital examination revealed Tanner pubic hair stage P4, bilateral scrotal testes (size 15 ml bilateral), microphallus (stretched penile length 7 cm), penile hypospadias (despite multiple correc- tive surgeries), and redundant skin folds (after corrective surgery). The dif- ferential diagnosis in this individual with genital ambiguity, bilateral palpable gonads, and gynecomastia includes partial androgen insensitivity and androgen biosynthetic defects. The differentiating features among these disorders are summarized in the table given below. A 20 - year - old individual who was reared as male presented with poor facial hair and genital ambiguity. The index patient had immature facies and poor facial hair suggestive of hypo- gonadism. Genital examination revealed Tanner pubic hair stage P ,4 bilateral scrotal testes (size 6 ml each), microphallus (stretched penile length 5 cm), ventralâurethral groove, and penile hypospadias. Therefore, genetic analysis is required for a deďŹnitive diagnosis in the index patient (Fig. The acquisition of aromatase activity by placenta is important to prevent viril- ization of the female fetus by androgens secreted from fetal adrenal gland. The severity of virilization of fetus varies from isolated clitoromegaly to Prader stage 4. During peripubertal period, affected females present with primary amenorrhea, poor breast development, hirsut- ism, virilization, hypergonadotropic hypogonadism, and tall stature. Affected males have persistent linear growth, eunuchoidal body proportions, genu val- gum, and impaired fertility. On evaluation , he was well virilized and had normal proportions (upper seg- ment to lower segment ratio 0. Semen analysis showed azoospermia and ďŹne needle aspiration cytology was consistent with Sertoli cell - only syndrome. Psychosexual development (âbehavioural sexâ) of an individual comprises of gender identity, gender role, and gender orientation. A condition associated with marked psychosexual distress due to discrepancy between an individualâs perception of his/her own gender and the assigned sex of rearing is termed as âgender dysphoria. What are the factors that guide gender assignment in patients with genital ambiguity? The patient underwent bilateral testicular prosthesis implantation after corrective surgery 9 Disorders of Sex Development 333 c Fig. She underwent bilateral gonadectomy and phallic resection during prepubertal period and is on estrogen replacement. This is because gender identity of an indi- vidual is established by 2â3 years of life, and, therefore, early genital surgery is associated with better psychosocial and emotional outcome. Further, surgery during this period has favorable outcome because of pliability of genital tissues, reduced pro-inďŹammatory cytokine response, and lesser surgical complica- tions. However, it is controversial whether to perform gonadectomy during childhood or after puberty. Patients with Turner syndrome having Y-cell line are at inter- mediate risk for development of malignant germ cell tumors; hence, gonadectomy is recommended at diagnosis. Ahmed S, Achermann J, Arlt W, Balen A, Conway G, Edwards Z, Elford S, Hughes I, Izatt L, Krone N, Miles H, OâToole S, Perry L, Sanders C, Simmonds M, Wallace A, Watt A, Willis D. State of the art review in gonadal dysgenesis: challenges in diagnosis and management. Surgical options in dis- orders of sex development (dsd) with ambiguous genitalia. She was a product of non-consanguineous mar- riage and was delivered by induced labor at 33 weeks of gestation due to maternal complications (pregnancy-induced hypertension). She was investigated and found to have hyponatre- mia and hyperkalemia (Na+ 119 mEq/L, K+ 8. With this treat- ment, her symptoms subsided but she failed to thrive and progressively became darker; however, serum electrolyte abnormalities were resolved. This therapy resulted in weight gain and decrease in pigmentation, and patient became more active. Her height was 81 cm (10 percentile, target height 158 cm), weight 12 Kg (25 percen-th th tile), and she had a Tanner staging of A , P- 1, B1. Examination of the external genitalia showed posterior labial fusion, hyperpigmented labioscrotal folds, isolated clitoromegaly, and the gonads were not palpable. The annual follow-up of the patient with clinical and biochemical parameters is depicted in the table given below. Between the age of 3â5 years, her growth velocity was appro- priate for her age, and there was no progression of Tanner staging, but she had cushingoid facies. However, in the next 6 months, patient did not have progression of pubertal events. With this therapy, her growth velocity was approximately 6 cm/year, and there was no progression of breast development till the age of 12 years. At the age of 12 years, leuprolide was discontinued, and after 3 months, she had menarche and her Tanner staging was A+, P5, B4. Six months later, she presented with worsening of hyperpigmentation, secondary amenorrhea, and deepening of voice. Ultrasonography of pelvis showed uterine size 4 Ă 3 cm, endometrial thickness 5 mm, and ovarian volume 3. Hydrocortisone was added at a daily dose of 10 mg (in three divided doses) along with dexamethasone and fludro- cortisone (Fig. The dif- ferential diagnosis of recurrent episodes of vomiting in a neonate raises a suspicion of neonatal sepsis, gastroenteritis, and hypertrophic pyloric stenosis. This occurs because of transplacental 338 10 Congenital Adrenal Hyperplasia passage of maternal progesterone which exerts partial mineralocorticoid agonistic activity in the presence of aldosterone deďŹciency, which progressively wanes there- after, as circulating progesterone is metabolized by second week of life. The index patient was assigned female gender possibly because she had mild genital virilization (clitoromegaly with posterior labial fusion, Prader stage 2), and further this would not have been well evident at birth in a premature child. The index child was initiated with only ďŹudrocortisone that resulted in resolution of symptoms and correction of electrolyte abnormalities; however, she failed to grow and continued to become dark. Later, replacement with dexamethasone was initiated which resulted in clinical improvement but led to decrease in height to 10 percen-th tile. Hence, in the index case, at 2 years of age, dexamethasone was substituted with hydrocortisone. In addition, monitoring of serum androstenedi- one and testosterone (in female) may also be useful to guide the therapy. The growth spurt preceded the onset of thelarche, and it is a usual phenomenon during pubertal development in a growing girl child which was observed in the index patient.
In the neonate with critical Neural crest coarctation 40 mg nexium sale gastritis diet ˙íäĺő, smooth muscle contraction results in both ductal (primordium of closure as well as aortic obstruction immediately proximal dorsal ganglion) to the ductus purchase 40 mg nexium gastritis hiv symptom. If the child is able to survive order 40 mg nexium overnight delivery diet while having gastritis, either because the aortic Neural tube obstruction is not extremely severe or because of rapid for- (c) mation of compensatory collaterals, there is a secondary phase of fbrosis that occurs over the frst 2â3 months of life. By tum arteriosum, a thick fbrous shelf forms within the lumen tracking these cells, it has become apparent that they play a critical of the aorta. Frequently, the external appearance of the aorta role in the development of the semilunar valves, the conotruncal suggests only a mild degree of stenosis, while internally septum and the pharyngeal arches, which include precursors of the the thick intimal shelf opposite the ligamentum arteriosum components of the aortic arch. Bicuspid Aortic Valve The âblood fow theoryâ suggests that a coarctation results Simple coarctation of the aorta is thought to be associated from consequent reduced fetal blood fow through the aor- with a bicuspid aortic valve in approximately 50% of patients. In a study of 183 patients with interrupted aortic of simple coarctation to warrant surgical intervention. Subaortic stenosis was considerably less patients undergoing balloon angioplasty for native coarcta- common in patients with coarctation of the aorta. In a sep- tion had a pre-angioplasty aortic isthmus z-value of less than arate study by the Congenital Heart Surgeons Society,8 the â2 by echocardiographic assessment. The embryological and genetic relationship and left subclavian artery appears to have an incidence of between coarctation, bicuspid aortic valve and subaortic ste- hypoplasia intermediate between the proximal arch and the isthmus. Defnitions Bovine Trunk have included qualitative assessment of hypoplasia, function- A not uncommon form of arch hypoplasia is seen in associa- ally important stenosis determined by pressure gradient and tion with a âbovine trunkâ where the innominate artery and echocardiography-derived indices. One useful rule of thumb left common carotid artery arise as a single trunk from the is that the proximal arch should be greater than 60% of the ascending aorta. The distal arch emerges as a direct leftward diameter of the ascending aorta, the distal arch greater than lateral branch and may be quite long as well as hypoplas- 50%, and the isthmus greater than 40% (Fig. If the distal arch is particularly long, it may most useful is a Z score for arch diameter of less than â2 be necessary to modify the choice of surgical technique for calculated by relating the specifc segment of the aortic dealing with the arch hypoplasia. In addition, there is an internal coarctation of the diameter of the ascending aorta or the aortic isthmus beyond shelf opposite the ductus arteriosus. A review of 326 patients with coarctation by more than the left ventricle, there is often underdevelop- the Congenital Heart Surgeons Society found that 48% of ment of the left ventricle. The defect is almost always large, for example tricuspid atresia with transposed great arter- approximating the size of the aortic annulus. There is often associated hypoplasia of the aortic annu- be given in the patient with a single ventricle and coarctation lus. Generally in the neonatal period and early infancy, there to undertaking a Norwood or DamusâKayeâStansel-type is minimal fbrosis of the left ventricular outfow tract which procedure to avoid the pressure load resulting from systemic is rarely tunnel-like at this age. Coarctation of the aorta is present in at least 80% of patients with hypoplastic left heart syndrome. As described above under Embryology, it is closure of the ductus that frequently pre- cipitates presentation of the neonate with critical coarctation. This results striction of the aorta which results in profound circulatory in an elevated left atrial pressure which can result in âstretch- collapse in the frst month of life. This latter lower Complex assoCiated heart disease body perfusion is dependent on high pulmonary resistance TaussigâBing Double-Outlet Right Ventricle and and continuing patency of the ductus arteriosus. Following Transposition with Ventricular Septal Defect birth, however, if a severe coarctation is present, closure of the ductus will restrict blood fow to the lower body. The child will appear pale, listless, and In anomalies of this type, as well as true transposition with poorly perfused. Chest X-ray reveals congested lung felds and of the conal septum relative to the ventricular septum, i. When there is greater than corrected, the child will develop signs of secondary organ 50% diameter loss, surgery is indicated even though there damage including renal failure, hepatic failure, necrotizing may be only a mild blood pressure gradient of perhaps less enterocolitis, seizures, and ultimately death. The most common symptoms ally large and invests the aortic arch resulting in high qual- are tachypnea and failure to thrive. Depending on the rapid- becomes invested more by the lung than thymus, it becomes ity of collateral development and aggressiveness of medical increasingly diffcult to assess the degree of severity of coarc- therapy, it may be possible to manage the child without surgi- tation. Blunting or âdragâ of the pressure wave in the descending aorta is characteristic of an older Child aNd adult important coarctation. It is not uncommon for a mild or moderate coarctation to remain undiagnosed beyond infancy. The child or adult may Angiography present with a history of exercise intolerance, occasionally Although cardiac catheterization with a pressure pullback with a specifc description of fatigue of the lower extremi- and aortography are the traditional gold standards for assess- ties. When collateral development is excellent, it is not at all ment of a coarctation, it should rarely be necessary to assess uncommon for even a severe coarctation to be completely a coarctation by this invasive technique today. Careful physical examination, however, will advantage in collecting directly measured hemodynamic reveal elevation of blood pressure in the upper extremities information because of the inability to assess the hemody- beyond two standard deviations above the mean for the childâs namic impact of collaterals. In addition, there will be a diminished pulse pressure and delay of the femoral pulses. Chest X-ray in the older child and adult fre- child and adult than any other noninvasive technique. They found that alterations in aor- A fundamental problem in assessing the severity of coarc- tic fow were not limited to the specifc region of repair, but tation is the variable development of an arterial collateral could be found in the entire aorta. Thus, be a useful method in adults who are being followed after assessment of coarctation severity by either blood pressure stent implantation and who are now known to have a risk of cuff measurement or even direct measurement by catheter is late aneurysm formation. Even when there is an associated medical prob- lem, such as intraventricular hemorrhage, it is doubtful that balloon angioplasty is indicated. It is essential to achieve secure intravenous 22 Interventional Study Consortium described 302 patients access and delivery of prostaglandin E1. It is important to who underwent stent implantation for coarctation between optimize the ratio of pulmonary to systemic resistance. Only 21% completed long-term follow-up is usually achieved by reducing FiO2 to 21% and maintain- (>18â60 months). Generally, intubation of the child guarded, âThis study documented acute, intermediate, and is advisable because of possible apneic episodes precipitated long-term outcome data comparable or superior with other by prostaglandin E1. However, even with success- also facilitate achieving the desired level of hypercarbia. It ful initial stent therapy, patients continue to require long-term is often useful to optimize cardiac output with dopamine at follow-up and have associated long-term morbidity, relating 5 Îźg/kg/min. Medical therapy should be maintained until to aortic wall complications, systemic hypertension, recur- the child has achieved normal acid base status and a normal rent obstruction, as well as need for repeat intervention. Enteral feeding should be avoided and a careful It will clearly be many years before the true long-term out- watch should be kept for signs of necrotizing enterocolitis, comes for interventional catheter management of coarctation such as abdominal distention or heme-positive stools. In contrast, surgical management has been avail- able for more than 65 years and is the benchmark against CoNgestive heart Failure BeyoNd the NeoNatal period which alternative methods must be measured. Nevertheless, Congestive heart failure beyond the neonatal period can be many centers presently apply varying strategies according to the patientâs age as outlined by FrĂźh et al. Balloon dilation without outset, Lock cautioned strongly that the technique should be stenting should be limited to a rescue procedure or in recur- rent aortic coarctation in neonates.