By L. Orknarok. Oakland University.

May get severe obstruction Adenoid and tonsillar hypertrophy: reaches peak at 8 10 years cheap renagel 800 mg line, but relatively largest at 5 6 buy 400mg renagel amex. Generally resolve Pneumo-mediastinum angel wing appearance as air lifts up thymus Chylothorax: lymph surrounding lung in the newborn ? Also safe renagel 800mg, pre-term babies less likely to pass meconium when stressed Respiratory Tract Infections in Children Reference: Mainly from Prof Grimwoods extensive infectious diseases handout Epidemiology: Common: During the first 3 years of life, a child may have up to 6 episodes of otitis media, 2 episodes of gastro-enteritis and 6 respiratory infections per year. May take out adenoids at same time eustachian tube function (Paediatricians say adenoidectomy is treatment of choice). Treatment: get rid of infection then surgical repair Pharyngitis See Acute Pharyngitis, page 63 Almost 100% given broad-spectrum antibiotics. Air-fluid levels, opacification, mucosal thickening > 4 mm Maxillary and ethmoid sinuses present at birth (although small). Varies hour to hour (ie dont send them home just yet) Lasts 3 4 days then changes to sound productive. Few side effects (< 5% with local reactions) Notifiable disease Pertussis Bordetella Pertussis = Whooping Cough Epidemiology: Highly contagious. If severe may need suction In between paroxysms looks well, is afebrile and has no chest signs Median length: 6 weeks. Can be up to 12 weeks Infectious for 2 3 weeks of paroxysmal phase Persistent cough for 3 4 months (convalescent phase bacteria cleared) Treatment: if < 4 weeks duration: erythromycin. Doesnt impact illness after paroxysmal phase is established, but will infectivity Admit if under 6 months and/or cyanosis or apnoea in paroxysms Complications: Anoxic seizures in 1 3% Encephalopathy in 0. Rate of severe neurological complications of immunisation negligible compared with the risk of encephalitis from whooping cough Vaccine: Whole cell vaccine effective in 60 90%, has higher efficacy for more severe outcomes, local reactions or fever in 50%. Cyanosis is a late sign Feeding a good indicator of respiratory distress (and one which parents can monitor at home) Recurrence common (? Evidence of poor efficacy Nedocromil (Tilade + spacer) Inhaled steroids: if it makes no difference then stop Persistent Asthma Male: female = 4:1 Preventative. Collapsible airways Can become an unhappy wheezer when they get a cold, in which case treat as for bronchiolitis Bronchiolitis: See 610 Uncommon: Inhalation: If convincing episode of inhaling a foreign body (stridor, went blue, etc) should be bronchoscoped even if they you think they brought it all back up. Only consider if lots of serious illnesses th th 614 4 and 5 Year Notes Cilia dyskinesia: usually starts with ears (middle ear has respiratory epithelium with cilia), then lungs and sinuses. Associated with dextrocardia Hypogammaglobulinaema Can confuse wheezing with soft stridor: eg laryngomalacia. Eventually Cor Pulmonale Pancreas: fibrosis around ducts, dilated ducts, islets cells relatively preserved. White spots on cheery-red buccal mucosa for 24 hours before rash (Kopliks Spots) pathognomonic nd Treatment: Supportive, antibiotics for 2 ary infection Complications: Otitis media (10%) Pneumonia (1 5%) Encephalitis (0. Used to be 3 4 year epidemics, now longer Presentation: Incubation 2 3 weeks 70% develop fever and swelling and tenderness of salivary glands 15% have aseptic meningitis 0. Scattered vesicular lesions in the mouth with similar lesions surrounded by erythematous areolae on the hands and feet. Serology difficult Paediatrics 617 Human Herpes 6 and 7 (Roseola Infantum) Acute febrile illness of young children for several days with occipital adenopathy, then reduced fever and appearance of a fine red maculo-papular rash over the trunk and arms for 1 2 days (confused with antibiotic rash) 70% of 2 year olds are sero-positive. With cleft lip, the lesion runs from the lip to the nostril, can be bilateral Incidence: 0. Coves a spectrum from instability through subluxation to dislocation Commoner on the left. Fix the pelvis with one hand and try and press the head and neck of the femur backwards out of the acetabulum Investigations. Later: open reduction Prognosis: The earlier the treatment the better the outcome. Associated with other abnormalities (eg myelomeningocele) Aetiology: multifactorial inheritance Treatment: early diagnosis, stretching and strapping then serial casting from 10 days. Surgery at 12 weeks if not right yet to release tight tissues (eg tendons) on inner side of foot. Follow-up: prone to relapse Calcaneo-Valgus Foot: Dorsiflexed and heal in valgus Tarsal Conditions = Peroneal Spastic Flat Foot (old term) An abnormal union between one or other of the bones of the hind foot Autosomal dominant failure of segmentation or maturation of the mesenchyme Incidence 1% Diagnosis: flat foot as child with increasing stiffness of the hind foot. Osteotomy if deformity is severe and does not correct Scoliosis Lateral spine curvature Types: Non-structural or postural curves, eg due to limb length inequality (curve disappears on bending forward) Paediatrics 619 Structural curves: has lateral deviation and rotation of the vertebra. When child bends forward there is a hump to one side and curve is still present/exaggerated eg congential, neuromuscular, miscellaneous Idiopathic types often present during adolescent growth phase Causes pain, deformity and impaired lung function Usually progressive. Type 3: Completely displaced Complications: nerve palsy (usually resolves after 6 - 8 weeks), vascular injury (esp brachial artery), compartment syndrome Treatment: closed reduction and percutaneous pin fixation. Non-displaced fractures without collapse of the medial or lateral columns can be treated by immobilisation. Open reduction if unsatisfactory closed reduction, open fracture or if vascular compromise Medial Epicondyle Fractures Often accompanied by dislocation.

The most commonly assessed efficacy outcomes in these trials were penile rigidity (using RigiScan) and the quality of erections achieved at home buy renagel 400 mg with visa. The trials did not report information on the methods used for randomization renagel 400mg for sale, blinding purchase 400 mg renagel fast delivery, and allocation concealment. Many study results may have been biased in favor of active treatment, because the analyzed samples predominantly included responders and excluded many randomized participants from their efficacy analyses. In general, the reporting of harms was less consistent and detailed than that of efficacy outcomes. For example, the occurrence of any or serious adverse events was not reported in many trials. Some trials reported only most frequently encountered or treatment-related adverse events, the ascertainment of which may be prone to subjective judgment. In some instances, it was not explicitly defined whether the number and percentage referred to the actual number of adverse events or to the number of patients with at least one adverse event. In open label trials, patients or investigators may have over- or under-reported the incidence of adverse events because of their knowledge of the assigned treatment. In many cases, the statistical test results for between-group differences in adverse events were not reported, thereby limiting the interpretability of the data. The long-term safety data obtained from retrospective observational studies is not as conclusive as that obtained from well-conducted long-term large randomized trials, which have fewer methodological limitations. The reviewed evidence consisted of randomized trials using either parallel-arm or crossover design. Although crossover trials are efficient in terms of resources and study power, they require additional caution and careful interpretation of results. For example, one problem inherent in all crossover trials is a potential for a carryover effect, which could be minimized by employing an adequate washout period between alternative treatment 387 periods. The total, free and calculated testosterone levels were used as primary measures inconsistently, limiting the ability to meaningfully pool data across studies. The effect of age on the prevalence rates of hypogonadism may not be readily determined. For example, the descriptive analysis did not reveal the patients age to be an important factor in explaining the observed variation in the prevalence rates of hypogonadism across studies. In contrast, within-study age-stratified results reported for three trials demonstrated that the prevalence rates of hypogonadism (i. Similarly, there was a wide variation in the prevalence rates of hyperprolactinemia (1. The wide variation in the prevalence rates of hypogonadism and hyperprolactinemia could be explained by between-study differences in age distribution, types of tests (e. Results from these trials indicated greater improvements in erectile outcomes based on International Index of Erectile FunctionErectile Function domain scores (i. For example, one of these trials used an open-label design and had low quality methodology and reporting (total Jadad score of 1), thereby limiting the interpretability of the results. Clinical Practice Evidence regarding accurate identification of men who would benefit from testosterone replacement therapy is scarce. Thus, there is no universally accepted method of identifying men with clinically relevant hypogonadism affecting erectile function and the implications of 389 androgen status for erectile dysfunction and its treatments remains controversial. Given the current gaps in knowledge, the most adequate and cost-effective laboratory test for hormonal 14,39 evaluation is unclear. Optimal approaches from a clinical and resource-allocation standpoint remain to be determined. Compared with placebo, the use of either sildenafil or vardenafil was associated with an increased risk of either headache or flushing. The observed dose- response trends in efficacy were less obvious for tadalafil trials, in which the degree of improvement in erectile function was numerically similar in patients who received three doses of tadalafil (20 mg, 10 mg, and 5 mg). The difference for the corresponding proportions between 50 mg and 100 mg groups favored the higher 100 mg dose but was not statistically significant. The incidence of any all-cause adverse events in sildenafil (25 mg versus 50 mg versus 100 mg) and vardenafil (5 mg versus 10 mg versus 20 mg) trials had a numerical pattern of dose-dependence, indicating that adverse events occurred more frequently at the higher doses. The dose-response pattern for the effect of tadalafil (10 mg versus 20 mg) was not obvious. The meta-analyses conducted on vardenafil trials showed an increased risk of any adverse events in patients treated with the 20 mg versus the 10 mg dose. The difference for the proportion of patients with serious adverse events between the two doses of vardenafil was not statistically significant. Neither the rate of withdrawal resulting from adverse events nor specific adverse events (i.

Patients may be dys- tation has been used in patients with end-stage liver pnoeic generic 800 mg renagel with mastercard, clubbed and cyanosed buy renagel 800mg without prescription. Coarse crackles and sometimes wheeze (due to airow Prognosis limitation) are heard over affected areas 400mg renagel amex. Median age of survival is 31 years but is expected to rise with improving therapies. Bronchiectasis Denition Microscopy Bronchiectasis is a condition characterised by purulent Chronic inammation in the wall of the abnormal sputum production with cystic dilation of the bronchi. In developed countries, cystic brosis is the most com- mon cause, tuberculosis and post-childhood infections Complications are also common. Pathophysiology Impairment of the mucociliary transport mechanism Management leads to recurrent infections, which leads to further ac- The aim is to prevent chronic sepsis and reduce acute cumulation of mucus. Patients are Unknown but there is strong evidence for an im- taught to tip and hold themselves in the correct posi- munopathological basis: tions several times a day. Around half present with respiratory symptoms or are diagnosed following an incidental nding of bilateral hilar lymphadenopathy or lung inltrates on chest X- Granulomatous/vasculitic ray. Other presentations include arthralgias, non- specic symptoms of weight loss, fatigue and fever. Pulmonary manifestations: Sarcoidosis r Bilateral hilar lymphadenopathy with or without pul- Denition monary inltration. Extra pulmonary manifestations: Incidence Anyorgan of the body can be affected, most com- 19 per 100,000 in United Kingdom. Viola- ceous plaques on the nose, cheeks, ears and ngers Sex known as lupus pernio or skin nodules may occur. Geography r Arthralgia and joint swelling with associated bone Affects American Afro Caribbeans more than Cau- cysts. Microscopy Non-caseating granulomas consisting of focal accumu- Prognosis lation of epithelioid cells, macrophages, (mainly T) lym- Once on steroids, many patients require long-term phocytes and giant cells. Arare form of necrotising small vessel vasculitis of the r Tuberculin test: 80% show anergy, but this is not help- upper and lower respiratory tract and the kidneys asso- ful diagnostically. It affects the kidneys in 90% of cases, manifesting as ChurgStrauss syndrome oliguria, haematuria and uraemia. Macroscopy/microscopy An inammatory small vessel arteritis with predom- Pleural effusion, pneumothorax, inantly mononuclear inltrates. Pleural effusion Investigations Denition 1 Full blood count: anaemia of chronic disease, neu- A pleural effusion is dened as an accumulation of uid trophilia. Decreased Hypoalbuminaemia, 8 Renal biopsy to assess the pattern and severity of oncotic e. Miscellaneous Hypothyroidism Meigs syndrome Management (usually a Cyclophosphamide and high-dose steroids to induce re- right-sided effusion and a benign mission. Inpulmonaryhaemorrhageorsevere Exudate (>30 g/L Infections Bacterial including acute renal failure, plasma exchange may be used. Initially the pleural space is lled with a thin watery uid Signsofaneffusion are only present when >500 mL of containing pus cells (purulent effusion). There is then uid is present and include reduced chest expansion on laying down of brin between the parietal and visceral the affected side, stony dull percussion note, reduced or pleura, which may become organised to form a thick absent breath sounds and vocal resonance. Investigations Clinical features 1 Chest X-ray: visible when there is >300 mL, ranges Patients present with similar features to a pleural effu- from blunting of the costophrenic angles to dense ho- sion: dullness to percussion, absence of breath sounds. Medi- They often appear generally unwell with tachycardia, astinal shift occurs with massive effusion. Needle r Microbiology if the aspirate is turbid and to search aspiration is used to obtain uid for microscopy, culture for an infective course. Management r Cytology to detect neoplastic cells, and distinguish The aim of therapy is to drain the uid and expand the acute from chronic inammation on the basis of lungs whilst treating the infection with appropriate em- the cellular inltrate. Antibiotics are tailored ac- 3 Pleural biopsy if needed: particularly for suspected cording to microbiology results from the uid. Is aimed at the underlying cause thus identication is of r In some patients, videoscopic assisted thorascopic primary importance. Recurrent malignant effusions can be treated with chemical or surgical pleuradhesis. Pneumothorax Empyema Denition Dened as air in the pleural space which may be trau- Denition matic or spontaneous. Themostcommoncauseofempyemaispneumoniawith spread of infection to an associated effusion. Exogenous Clinical features infection may be from a penetrating injury or be iatro- Sudden onset of unilateral pleuritic pain and/or increas- genic, e.