By W. Bufford. Wright Institute.
They have to attempt in the first place to prevent the occurrence of chronic oral health diseases - caregivers of children could play a major part in keeping children free of obvious dental caries cheap 25mg clomiphene with visa. This by setting up an optimal treatment and by providing best practices for managing oral diseases once they have been diagnosed generic clomiphene 25 mg. Oral health information systems--towards measuring progress in oral health promotion and disease prevention order 50 mg clomiphene mastercard. Are we ready to move from operative to non-operative/preventive treatment of dental caries in clinical practice? Although useful and even essential trusted clomiphene 100 mg, comparisons between countries have many caveats (Kosonen 1994, Kautto & Moisio 2004, Gissler et al. An important condition is comparable units of measurements, and therefore creation and development of indicators is essential (Kosonen 1994). Without reliable indicators a picture of a situation or developments may remain ambiguous. The lack of standardisation both in indicator definitions and methods of measurement has hindered international comparisons (Koponen & Aromaa 2006). It also includes sexual health, the purpose of which is the enhancement of life and personal relationships, and not merely counseling and care related to reproductive and sexually transmitted diseases. For each indicator there is an operational definition, justification for selection, criteria for selection, data sources and (when appropriated) references. A systematic review of factors associated with teenage pregnancy in European Union (Imamura, 2007). Results came from 4444 studies identified and screened, 20 met the inclusion criteria. The well-recognized factors of socioeconomic disadvantage disrupted family structure and low educational level and aspiration appear consistently associated with teenage pregnancy. However, surprisingly for some of us, evidence that access to services in itself is a protective factor remains inconsistent. Although further association with diverse risk-taking behaviours and lifestyle, sexual health knowledge, attitudes and behaviour are reported, the independent effects of these factors too remain unclear. Another conclusion resulting from the systematic review was that included studies varied widely in terms of methods and definitions used. First, we cannot synthesize or generalize key findings as to how all these factors interact with one another and which factors are the most significant. Future research ensuring comparability and generalizability of results related to teenage sexual health outcomes will help gain insight into the international variation in observed pregnancy rates and better inform interventions (Imamura, 2007). Friends, books and magazines were the most important source of information on puberty for every country. School teachers appeared as one of he most important sources of information of sexual and reproductive systems of men and women. In every country the large majority of respondents had already had a boy or girl friend: 76. More than 47% (between 47% in Estonia and 58% in Belgium) respondents had already had heterosexual intercourse. However, some outcomes of this apparently similar sexual and reproductive behaviour of young people is obviously different when considering the same four Member States. Teenage pregnancy is a good example, with rates, 1n 2005, varying between 6% in Portugal and 2 % in Belgium (Estonia with 4 % and Czech Republic 1 %). This seems to be due to either one of the following reason: contraceptive failure (Portugal, for instance, having a huge use of emergency contraception, with sales increasing enormously from 80. This is, of course, a pilot study conducted at high-school, needed to be followed by further and larger studies with a core module of sexual and reproductive health (e. Ideally, the population that, in some countries, already drop-out from school at this age one of the high-risk groups should be included. It is also more difficult to identify evidence based knowledge of eventual different risk factors associated to different age groups. An important issue concerns teenage pregnancy when it results from a wanted decision and not from contraceptive failure. This happens sometimes mostly among ethic minorities and lower class populations and creates a need for specific approach to prevent it, if possible. It should here be understood that for a considerable number of health professionals the huge majority of young teenage pregnancies should be prevented, for health, social and emotional reasons. Portugal and Belgium) the law specifically forbids that national health data can be disaggregated by their ethnical provenance. One understands that this was done in order to prevent eventual racist or chauvinist politics. But under a Public Health point of view this becomes a serious difficulty to document the need for a specific intervention targeted at those groups. Also, in the youth pilot survey about sexual health, some socio-economic and ethnical inequalities were probably not detected. First, because of the sampling itself: students attending the high-school answering a questionnaire during the classes. Young people (probably, mostly from ethical minorities) that already drop out from the school (in certain cases those with high risk sexual behaviours) were missed. As far as total fertility rate is considered, again the consensual clinical and health policy- makers feeling is that the rate is higher for several ethical minorities and among some of the lowest socio-economic levels. Indeed, it is accepted that fertility rate is often higher among these sub-groups. This indicator should be considered together with the mean maternal age at first childbirth, because usually it is accepted that the first one is one of the consequences of the second one: if a woman has her first childbirth at the end of her twenties, most probably she will not have many children. However, in Poland, an extremely low fertility rate coexists with a relatively young maternal age at the first childbirth (24. Whatever the relationship between these two indicators is, the total fertility rate in the eight countries considered in this study ranged from 1. Under an epidemiologic and Public Health perspective, having the first term pregnancy after 30 years old is a recognized increased risk factor for breast cancer. This indicator by no way necessarily reflects direct contraceptive failure due to both induced abortion and intended pregnancy among some adolescents. But, anyway, the reasons for such a huge discrepancy among different Member States have to carefully be analyzed and critically understood in the context of specific health and cultural contexts and environments of each region, community and country. In certain cases the same disease can affect more than one single recommended indicator. Also, mean age at first intercourse and contraceptive use at first intercourse can be linked with age-specific birth rate in teenagers. Contraceptive failure is obviously related to induced abortion, two important indicators of sexual morbidity, even when the induced abortion is safe, legal and rare. As already mentioned, mothers are increasingly delivering their first child at older ages. Maternal and fetal problems are well known: increased incidence of dystocic deliveries (e. More difficult to evaluate in all its extension is the morbidity linked to an unpleasant sexual life. Sexual and reproductive health is an important measure of the general health and social well being of a population. Moreover, the scope of sexual and reproductive health extends across the life span (from adolescence to the ageing) and across several Public Health domains. In order that sound evidence based politics can be taken on these issues, some more evidence based knowledge and wisdom is needed, overcoming existing ignorance and misconceptions. This can be done with small adaptations and will be a reliable approach to teenagers specific needs and autonomy. Monitoring reproductive health in Europe what are the best indicators of reproductive health? Factors associated with teenage pregnancy in the European Union countries: a systematic review. Special issue of European Journal of Obstetrics & Gynecology and Reproductive Biology 111 Suppl 1:S5- S14, 2003. Gissler M, Dumitrescu A, Addor V: Improving the performance of National Health Information Systems: the 2002-2003 reform in Finland from an international perspective. Monitoring health in Europe: opportunities, challenges, and progress Eur J Public Health 13 (supplement 3): 1-4, 2003. The generic term for such indicators is health expectancies and they are summary measures of population health combining information on survival with the prevalence of a health measure (Robine 2006).
Therefore individual nee- to be infected after establishing immunocompetence be- dles are essential for this procedure and for parenteral cause they have both virus and antibody against the virus injections buy cheap clomiphene 100 mg on-line. However trusted 50mg clomiphene, are more likely to be infective than those that are rela- it must be assumed that milk or colostrum from tively acellular clomiphene 50mg on-line. Respiratory secretions may harbor in- vide some immediate protection against infection order clomiphene 50 mg otc. In- fected cells, but the natural risk of these secretions fected lymphocytes given orally to susceptible newborn spreading infection seems low. Semen presents little risk when articial insemina- milk from birth to 3 days of age and thereafter may not tion is used because highly cellular ejaculates are usually be as commonly infected by this route. Colostrum con- infections causing increased numbers of infective cells taining virus and antibodies against the virus seems to in the ejaculate could spread infection to susceptible be associated with limited, immediate infection. Physical cow interactions and man- Calves fed milk from infected cows up to weaning agement procedures (e. Lymphocytes in milk represent a potential occurrence is difcult to determine based on conicting source of virus and certainly represent a signicant se- experimental results. Herds with an extremely high incidence of infected milk that reaches a pH of less than 4. Estimates in some Lymphosarcoma may occur in peripheral lymph southern states reach 50% or greater positive dairy cattle. This is an impor- and epidural region of the central nervous system (see tant statistic because veterinarians sometimes diagnose gures of lymphosarcoma in other chapters). Any or all lymphosarcoma erroneously when faced with vague ill- of the aforementioned tissues may become neoplastic. However, lymphosarcoma cattle with one predomi- Persistent lymphocytosis is the result of benign poly- nant lesion, such as epidural spinal cord compression, clonal B-lymphocyte proliferation. Further genetic relationships regard- enough, they might have neoplasms in many target areas. Internal lymph nodes such as cattle are asymptomatic, immune-competent, and can the sublumbars, mesenteric or others may be found to be as productive as their seronegative herdmates. Although several classic clinical presentations Bloat occurs as a result of failure of, or interference with, occur in lymphosarcoma cattle as a result of specic eructation associated with pharyngeal or mediastinal target organ involvement, the majority require careful lymph node neoplasia. Similarly, compressive neoplas- differentiation from a multitude of other diseases. Lym- tic lymph nodes may interfere with effective air move- phosarcoma can masquerade as a myriad of other in- ment that usually occurs in the pharyngeal or laryngeal ammatory or debilitating diseases of cattle. Clinical signs of lymphosarcoma seldom develop The intestinal tract is a common site for lymphosar- before 2 years of age and are most common in cattle coma tumors. Lymphosarcoma occur- monly affected area of the gastrointestinal tract, the ring in cattle less than 2 years of age is rarely caused by forestomach and intestine can also have lesions. When a major lymphosar- or upper airway inltrates, lymph node enlargements, or coma tumor involves the pylorus, abdominal distention tumor masses in the upper airway. Dyspnea of lower typical of vagus indigestion results from interference with airway origin may reect pleural effusions, pulmonary abomasal outow. Bleeding from ulcerative neoplasms involvement, mediastinal masses, or congestive heart or mucosal ulcers resulting from lymphosarcoma inl- failure. Affected cattle also may grind their teeth the retrobulbar area as a common target location. Although the retrobulbar masses or inltrate usu- bloat, or signs of vagus indigestion. Such tumors are ally progresses over several weeks, the subsequent ap- difcult to diagnose unless either abdominal uid cy- pearance of the eye associated with pathologic exoph- tology or exploratory laparotomy is performed. Focal or thalmus can appear to be acute as the eyelids lose the diffuse lymphosarcoma masses or inltrates may rarely ability to completely protect the protruding globe involve the small or large intestine. Corneal exposure damage, desiccation, The uterus and reproductive tract constitute another and profound chemosis generally develop quickly. Neo- though the rate of progression may vary in retrobulbar plasms may be focal, multifocal, or diffuse. Classical areas, cattle usually are affected bilaterally if they survive uterine lymphosarcoma lesions consist of multifocal long enough. Palpation of such masses can be compared the spinal cord cause progressive paresis and eventual with palpation of caruncles and feel nodular or like paralysis consistent with the anatomic location of the raised umbilicated lesions with a central depression. Posterior paresis and paralysis are most common Such lesions may be present in one or both uterine because of the frequency of tumors in the thoracolum- horns. Large focal or diffuse tumors may completely nial thoracic lesions are possible such that tetraparesis involve the uterus or the entire caudal reproductive may be observed. Reproductive tract neoplasms are much easier to again be focal, multifocal, or diffuse. Lymphosarcoma of identify in nongravid tracts than in heavily pregnant the brain also has been observed but is much less com- cows, in which placentomes and the fetus frequently mon than spinal cord compressive neoplasms and is obscure the masses. Although not a rm rule, compres- uncover reproductive tract lymphosarcoma before de- sive lymphosarcoma neoplasms affecting the spinal cord velopment of overt systemic signs, but palpable uterine frequently cause neurologic signs before the patient s masses discovered per rectum must rst be differenti- ated from other uterine tumors, as well as uterine and periuterine abscesses and hematomas. Focal, mul- tifocal, or diffuse neoplasia is possible, thereby explain- ing the plethora of potential clinical consequences. Lymphosarcoma in the left retrobulbar region causing Respiratory signs associated with lymphosarcoma pathologic exophthalmos and exposure damage to the masses include inspiratory stridor resulting from nasal globe. Diffuse splenic lymphosarcoma with lymphosarcoma masses compressing the spinal may result in splenic capsular rupture, subsequent fatal cord usually progress from paresis to paralysis within 2 intraabdominal hemorrhage, and acute death. During this time, they may be noticed to have sion is observed as the cause of fatal exsanguination difculty rising, require manual assistance (lifting them approximately once yearly by the Necropsy Service at by the tail) to rise, or make repeated attempts before be- the Cornell University Veterinary College. Loss of tail hemorrhage causing acute death is not rare in adult and anal tone and perineal desensitization may also be dairy cattle; most have no proven etiology; and only a seen with caudal lymphosarcoma lesions involving the few are caused by lymphosarcoma. Symptom- Lymphosarcoma masses are possible in virtually atic treatment with corticosteroids may result in tempo- any tissue, and cattle with lymphosarcoma tumors in rary clinical improvement. Diffuse lymphosarcoma in weeks to a few months, and almost all succumb one or both ureters may cause hydronephrosis, hematu- within 6 months. Extradural spinal cord compressive neoplasms af- liatively in terms of reaching parturition. However, the fecting sacral segments also may cause bladder dysfunc- prognosis beyond palliative treatment for more than a tion. It is possible to see some suc- colic, renal azotemia (bilateral), hematuria, or other cess with the use of nonabortifacient corticosteroids signs. Tumors affecting the urinary system frequently in late pregnancy, typically prednisone (1 mg/kg daily) are palpable on rectal or vaginal examinations. Enlarge- or isoupredone acetate in the treatment of cattle ment of the left kidney may be appreciated on routine with retrobulbar, thoracic, or abdominal visceral tu- rectal examination, and this should prompt ultrasono- mors. It should be remembered that dexamethasone graphic evaluation of both kidneys transrectally and/or is highly unlikely to cause abortion in the rst transabdominally. Signicant differentials for renal 150 days of gestation, so this may be an option for lymphosarcoma include other nonpainful, rm masses open cows with lymphosarcoma, for which the only such as those encountered with renal carcinomas and goal is to retrieve embryos for preservation of genetic renal amyloidosis. Denitive diagnosis phosarcoma that are limped through to parturition may be reached by biopsy. These calves are also commonly mary gland or mammary lymph nodes may be occult or infected in utero and bull calves would therefore be of overt. Such calves have high perinatal mortality clinically affected than the mammary glands, and rates and can be challenging to save. Diffuse inltration or focal lymphosarcoma such as vincristine, L-asparaginase, and cyclophospha- tumors are possible in one or more mammary glands mide in the treatment of individual cows with lym- and are best detected by palpation of the glands. Such tumors are rm and either nodular or ited in animals whose milk or meat is intended for plaquelike. Skin tumors are usually 5 to 20 cm in diam- human consumption, and the use of such large doses eter. Palliative treatment of most apparent in the region of the paralumbar fossa, is a late pregnant cow with pericardial lymphosarcoma rarely associated with lymphosarcoma in dairy cattle. Tumor cells pression, pleural effusion, and pulmonary edema contrib- of sporadic lymphomas represent immature lineages of T ute to signs of dyspnea. The protooncogene c-Myb is within the thorax or thoracic inlet also may cause jugular expressed in most sporadic lymphomas but not enzootic vein distention as a result of reduced venous return and lymphomas. Younger racic mass may be suspected based on mufed heart cattle are generally affected by the B-cell calf form.
Aortic and pulmonary valves open soon after S1; however generic 50 mg clomiphene with visa, this is usually inaudible in the normal heart purchase 100mg clomiphene mastercard. Flow across the aortic and pulmonary valves follows purchase clomiphene 100 mg fast delivery, which is again usually inaudible in the normal heart cheap 25mg clomiphene amex. The aortic valve closes first, followed by the pulmonary valve; the delay in closure of the pulmonary valve gives the splitting character of the second heart sound. Diastole, similar to systole is quiet; during diastole, blood flows through the tricuspid and mitral valves into the right and left ventricles. In atrial septal defect, increased blood flow across the pulmonary valve causes a systolic ejection murmur along the left upper sternal border. Severe anemia with increase in blood volume to compensate for decreased oxygen carrying capacity causes turbulence of blood flow and consequently a murmur across both aortic and pulmonary valves. These mur- murs are distinguished from those caused by stenosis of the pulmonary or aortic valves by lack of a systolic ejection click heard just before the systolic murmurs. These murmurs are loudest over the right upper sternal borders in aortic stenosis and the left upper sternal border in pulmonary stenosis. The systolic ejection click is caused by the snap sound of opening of abnormal pulmonary or aortic valves. Backward flow of blood into the right or left ventricles due to valve regurgitation will cause an early diastolic murmur. Pulmonary regurgitation is typically inaudible due to low pressures in the right heart and if heard may indicate pulmonary hypertension. Excessive blood flow across the tricuspid valve, such as with atrial septal defect, or across the mitral valve such as with patent ductus arteriosus will cause a mid-diastolic murmur heard over the left lower sternal border in patients with atrial septal defect and at the apex in patients with patent ductus arteriosus Pathologic murmurs can be at any intensity level, though louder murmurs (>grade 2) are more likely to be pathologic. Holo (or pan) systolic murmurs and mid to late systolic regurgitation murmurs are pathologic, and usually indicate either ventricular septal defects or mitral or tricuspid valve regurgitation. Harsh quality (wide frequency 1 Cardiac History and Physical Examination 11 Table 1. Early diastolic decrescendo murmurs are indicative or aortic or pulmonary insuffi- ciency and are usually best heard at the mid to upper sternal border, especially with the patient sitting and leaning forward. Mitral stenosis usually results in a low frequency mid to late diastolic murmur, often with crescendo at end diastole, best heard at the apex with the patient in the left lateral decubitus position. The presence of an abnormal additional finding, such as an abnormal S2 or a click, makes a murmur much more likely to be pathologic than innocent. Heart Disease Presenting in Infancy Most serious congenital heart defects are present in the neonatal period. Often a syndromic appearance may raise suspicion of specific heart defects (trisomy 21 and A V canal defect, trisomy 18 and ventricular septal defect, Noonan s syndrome and 12 W. Tachypnea and poor feeding are the most common symptoms, and result from metabolic acidosis and pulmonary venous hypertension. Prior to ductal closure a difference in pulse oximetry between the upper (higher saturation) and lower (lower saturation) maybe the only clue to the diagnosis of critical coarctation or interrupted aortic arch and may be difficult or impossible to distinguish from persistent pulmonary hypertension of the newborn without echocardiography. After 1 Cardiac History and Physical Examination 13 ductal closure, the pulse oximetry differential is replaced by a difference in pulse intensity and blood pressure between the upper (higher systolic pressure) and lower (lower pressure) extremities. A systolic pressure differential greater than 10 mmHg, often with upper extremity hypertension, is a sign of aortic arch obstruction. Critical aortic stenosis presents with a harsh systolic ejection murmur noted immediately after birth, followed by low systemic output upon ductal closure. Hypoplastic left heart syndrome may be undetected until there is systemic collapse, with a pale, gray appearance indicating both cyanosis and shock. Cyanotic Heart Disease Cyanotic heart disease is due to inadequate effective pulmonary blood flow, resulting from either obstruction of flow to the lungs (tetralogy of Fallot) or from the lungs (obstructed total anomalous pulmonary venous return), or parallel (instead of in-series) circulations (transposition of the great arteries). With severe pulmonary stenosis, a harsh systolic ejection murmur is usually heard immediately after birth. If a to fro murmur is heard (systolic ejection murmur with early diastolic decrescendo murmur), the diagnosis is usually tetralogy of Fallot with dysplastic pulmonary valve, especially if the infant appears to be in respiratory distress from airway extrinsic compression (due to enlarged pulmonary arteries). Other rare causes of to fro murmurs in the neonate include truncus arteriosus and aorta to left ven- tricular fistula. Transposition of the great arteries usually has a single second heart sound and no murmur. Increased Pulmonary Blood Flow Heart defects resulting in increased pulmonary blood flow (e. The cardiac examination is almost always abnormal, usually with a pathologic systolic murmur and possible diastolic rumble. Ventricular septal defects cause holosystolic, regurgitant murmurs, usually at the left mid to lower sternal border or at the apex, depending on the location of the defect. The diastolic rumble is produced by the large flow volume crossing the mitral valve. Patent ductus arteriosus and aortopul- monary window have continuous flow from the aorta into the pulmonary artery, resulting in a murmur that has late systolic accentuation, then crosses S2 into early diastole. Often, multiple systolic clicks like the sound of water moving over a water-wheel can be heard, probably due to increased flow in the dilated pulmonary artery or ascending aorta. Heart Disease Presenting in Childhood or Adolescence Since most serious congenital defects present in infancy, heart disease presenting later is typically either asymptomatic or difficult to detect, progressive in severity leading to later presentation, or acquired. Occult Congenital Defects Atrial septal defects often go undetected for several years, as they rarely cause symptoms in infancy but may result in decreased exercise tolerance in the adoles- cent. The classic findings on cardiac examination are a fixed and widely split S2, best heard at the mid to upper sternal border. There may be a grades 1 2/6 systolic ejection murmur at the left upper sternal border of increased flow across the pulmonary valve ( relative pulmonary stenosis ) and a diastolic low-pitched rumble at the left lower sternal border of increased flow across the tricuspid valve. Obstructive lesions such as aortic stenosis or coarctation that present later, are nonductal dependent, progressive lesions that rarely cause symptoms until severe. The murmur of aortic stenosis is a harsh, throat-clearing systolic ejection murmur, best heard at the right upper sternal border. Coarctation of the aorta results in systolic hypertension in the upper extremities, decreased pulses and blood pressure in the lower extrem- ities, and a systolic ejection murmur best heard over the left back or left axilla. The patient should be placed in the left lateral decubitus position to detect this murmur. Cardiomyopathy Familial hypertrophic cardiomyopathy often presents in the 14 18-year-old age range, when it is also most likely to result in sudden death in the athlete, accounting for approximately 40 50% of sudden cardiac death in the teenaged athlete in the United States. Symptoms include shortness of breath, chest pain, dizziness, or syncope with exercise. Family history of heart disease or sudden death prior to age 40 should raise index of suspicion. In 25% of patients, there is dynamic left ventricular mid cavity obstruction that results in a systolic ejec- tion murmur that increases in intensity in the standing position. Cardiac auscultation may reveal an S3 4 summation gallop, best heard with the bell at the left lower sternal border or apex. Myocarditis Myocarditis should be suspected in any child with signs of heart failure who was previous well, especially with a preceding history of a viral illness. On cardiac exam there is often unexplained tachycardia and the heart sounds are usually muffled. The presence of ventricular arrhythmias indicates fulminant presentation and should prompt immediate transfer to the intensive care unit for potential cardiopulmonary support. Mehrotra Many newborn children appear to have cardiomegaly when in fact the thymus is contributing to the cardio-thymic shadow giving the appearance of an enlarged heart. Introduction Chest X-ray is an important tool in evaluating heart disease in children. Luxenberg diagnostic procedures is significant making their routine use difficult. History of present illness coupled with physical examination provides the treating physician with a reasonable list of differential diagnoses which can be further focused with the aid of chest X-ray and electrocardiography making it possible to select a management plan or make a decision to refer the child for further evalua- tion and treatment by a specialist. Approach to Chest X-Ray Interpretation Unlike echocardiography, chest X-ray does not provide details of intracardiac structures. Instead the heart appears as a silhouette of overlapping cardiovascular chambers and vessels. The size and shape of the heart as well as the pulmonary vascular markings, pleura and parenchymal lung markings provide helpful information regarding the heart/lung pathology. It is easy to be overwhelmed with a prominent pathology on a chest X-ray thus overlooking more subtle changes; therefore, it is imperative to conduct interpretation of chest X-ray carefully and systematically considering the fol- lowing issues.