Condet

Shaon Sengupta, MBBS, MPH

• Attending Neonatolgist, CHOP & Instructor, Penn
• Research Interests: Circadian underpinnings of lung inflammation

https://www.med.upenn.edu/fitzgeraldlab/personnel.html

Detection of subacute effects spasms causes shallaki 60caps on-line, such as poor reproductive performance and immunosuppression muscle relaxant spray generic shallaki 60caps with mastercard, is also confounded by these same factors muscle relaxant options generic 60caps shallaki otc. Residue levels alone will generally not be sufficient data for making a diagnosis spasms 2 generic 60caps shallaki visa. Bird use of heavily contaminated sites should be prevented to the extent feasible by habitat manipulation, physical barriers, scaring devices, and other appropriate means. Residues in wildlife can only be transferred to humans by consuming contaminated tissues. As with most chlorinated hydrocarbons, the greatest concentrations of residues are in fat tissue, and removing fatty parts of the carcass prior to cooking can significantly reduce potential human exposure. Always wear gloves or use other physical barriers to prevent personal contact with the carcass. Polychlorinated Biphenyls 307 308 Field Manual of Wildlife Diseases: Birds Chapter 42 Oil Synonyms Petroleum Each year, an average of 14 million gallons of oil from more than 10,000 accidental spills flow into fresh and saltwater environments in and around the United States. Most accidental oil spills occur when oil is transported by tankers or barges, but oil is also spilled during highway, rail, and pipeline transport, and by nontransportation-related facilities, such as refinery, bulk storage, and marine and land facilities (Fig. Accidental releases, however, account for only a small percentage of all oil entering the environment; in heavily used urban estuaries, the total petroleum hydrocarbon contributions due to transportation activities may be 10 percent or less. Most oil is introduced to the environment by intentional discharges from normal transport and refining operations, industrial and municipal discharges, used lubricant and other waste oil disposal, urban runoff, river runoff, atmospheric deposition, and natural seeps. Discharges of oil field brines are a major source of the petroleum crude oil that enters estuaries in Texas. Cause Birds that are exposed to spilled or waste petroleum can be affected both externally and internally. Pipelines 12 percent Marine facilities and vessels 29 percent Fixed facilities (refineries, storage) 36 percent Land transport 14 percent Unknown 6 percent Other 3 percent Figure 42. Oiled birds lose the ability to fly, and they frequently die from hypothermia, starvation, exhaustion, or drowning. Birds that are exposed to oil during their reproductive season can also transfer lethal doses of the contaminant to their eggs during incubation. Even small quantities of oil (5­20 microliters) externally applied to eggs can kill embryos. Birds can also ingest, inhale, or absorb oil when exposed to a spill or while preening contaminated plumage. The toxic effects of ingested oil vary, depending on the type of oil and on the species of birds affected. These effects include gastrointestinal irritation and hemorrhaging, anemia, reproductive impairment, depressed growth, and osmoregulatory dysfunction (Table 42. Unfortunately, the effects of petroleum pollution can persist long after the visible spill is cleaned or dispersed. Petroleum persistence in the water column is usually less than 6 months, but it can be much longer (more than 10 years) in other components of the environment. For example, oil from the 1989 Exxon Valdez spill is still se- Photo by Milton Friend Oil 309 Photo by Nancy J. Thomas questered in bivalve communities within the areas of contamination and, thus, is still available to birds and other wildlife that feed on bivalves. Subtle effects on reproduction, such as decreased egg production, reduced fertility and hatchability, and decreased sperm production, as well as reduced immunologic function and impaired disease resistance, may occur as a result of ingesting oil-contaminated food (Table 42. Impact Mechanical Loss of waterproofing and insulation value of feathers Consequences Wetting, chilling, and hypothermia leading to death Exhaustion due to depletion of body stores, inability to feed, and greater expenditure of energy to maintain body heat and stay afloat Altered behavior Drowning Toxicological Pathological changes in tissue Inflammation of gastrointestinal lining Malformations Embryotoxicity Physiologic disruptions Altered endocrine function Liver and kidney disorders Altered blood chemistry Blood disorders including anemia Impaired salt (nasal) gland function resulting in disruption of osmoregulation Reproductive Embryotoxicity Impaired reproduction Other Reduced growth and development Reduced immunologic function Impaired disease resistance 310 Field Manual of Wildlife Diseases: Birds Species Affected A wide variety of birds and other wildlife have been affected by oil. The bird species affected depend on the location of the oil and the behavior of the birds. Species that suffer the greatest losses are gregarious, spend most of their time on the water, often near shipping lanes, and dive into the water to find food or to avoid disturbance. Seabirds, such as auks, guillemots, murres, puffins, sea ducks, and penguins, are particularly susceptible to contamination from oil spills (Fig. In addition, annual losses of marine birds occur due to natural oil seeps along the Santa Barbara Channel of the California coast. High susceptibility Medium susceptiblility Low susceptibility Ducks, geese, and swans Sea and bay ducks Seasonality Species with high reproductive rates may quickly recover from a spill, but for species with low reproductive rates, such as brown pelicans, oil pollution can cause catastrophic losses and it may take decades for populations to return to prespill numbers.

Examples include corneal or epithelial disease (eg back spasms 38 weeks pregnant buy generic shallaki 60caps, dry eye) muscle relaxant gi tract shallaki 60 caps with amex, superficial corneal injury or ocular injuries (eg spasms after eating cheap shallaki 60 caps on-line, those due to foreign bodies) muscle relaxant adverse effects buy shallaki 60 caps amex, and contact lens wear (eg, daily disposable soft lenses, extended-wear soft lenses, gas-permeable lenses, hard polymethylmethacrylate lenses). Spontaneous corneal abrasions may be associated with map-dot-fingerprint dystrophy or recurrent corneal erosion syndrome. Definitive cause for tonsillectomy: A-retro pharyngeal abscess B-sleep apnea C-alloplasia D-non symptomatic enlargement Answer: B Explanation: Absolute Indications of tonsillectomy: · Most common indication: sleep-disordered breathing · 2nd most common indication: recurrent throat infections · Tonsillar hypertrophy causing upper airway obstruction, obstructive sleep apnea, severe dysphagia, or cardiopulmonary complications such as cor pulmonale · Suspicion of malignancy. Old age 80 dull pain with bilateral renal hydroneohrosis no urinary symptoms dx A- Prostate enlargement B- Bladder cancer Answer: incomplete Q. Deltoid lig tear Answer: a Median never Answer: a Explanation: the median nerve then passes between the superficial (humeral) head and deep (ulnar) head of the pronator teres in the proximal third of the forearm. Purulent Mucopurulent Answer: A Explanation: In neonates, in whom bilateral conjunctivitis (ophthalmia neonatorum) often follows vaginal delivery from an untreated mother with a gonococcal infection, symptoms of gonococcal conjunctivitis include the following: Eye pain Redness Purulent discharge Reference: emedicine. Explanation: Etomidate and Benzodiazepines (midazolam) have the lowest doses> Reference: Toronto notes 2017/ page A16 Anesthesia 173. A- Fentanyl Answer: A Explanation: Transdermal fentanyl isapproximately 80 times as potent as morphine. Case of rheumatoid arthritis with swelling in the 2nd to 5th fingers bilaterally, what are these? A- Bouchard nodules B- Heberden nodules C- Synovial swilling (my answer) D- Subcutaneous nodules 175. Answer: Levothyroxin Explanation: the mainstay in the treatment of congenital hypothyroidism is early diagnosis and thyroid hormone replacement. Optimal care may includes diagnosis before age 10-13 days and normalization of thyroid hormone blood levels by age 3 weeks. Antidiuretic Hormone secreted part in pituitary gland is: A- Pars tuberalis B- Infundibulum C- Pars intermedia D- Neurohypophysis Answer: D Explanation: Posterior pituitary = neurohypophysis. Which allergy if you have it you are contraindicated to flu vaccine A- Egg Answer: Flu and Yellow fever vaccines contain egg. Embryological origin of Rt Atrium A- Right horn of sinus venousus Answer: Depends on which part of right atrium. Microbiology pathogen description of pseudomonas, Gram-negative lactose nonferments greenish producing discharge. Ask what is the organism Answer: pseudomonas Explanation: Aerobic, motile, gram rod. Explanation: the injury happens iatrogenically during intramuscular injection to upper medial gluteal region. Clear case of gout, what enzyme should inhibited by a medication used in acute attack A: Xanthene oxidase Answer: Cyclooxygenase. Explanation: Acute gout Rx: Indomethacin (Cyclooxygenase inhibitor), Phenylbutazone (Cyclooxygenase inhibitor), and Colchicine (inhibit microtubule polymerization). Chronic gout Rx: Allopurinol (xanthine oxidase inhibitor), Febuxostat (xanthine oxidase inhibitor), Pegloticase ( catalyzes metabolism of uric acid to allantoin), Probenecid (Inhibits reabsorption of uric acid in proximal convoluted tubule). C terminal single Answer: not sure, but most likely C Explanation: Proteins to be degraded need to enter the small channel in the 20S core formed by the subunits. However, the entrance is usually blocked by the N-termini of the -subunits, which together form a gate to control entry and prevent indiscriminate protein degradation. Pleurisy pain radiate to right shoulder which part of pleura affected: a- visceral b- mediastina l c- anterior Answer: B Explanation: the visceral pleura does not contain any noci-ceptors or pain receptors. The parietal pleura is innervated by somatic nerves that sense pain when the parietal pleura is inflamed. The parietal pleura subdivided according to the part of the body that it is contact with: Mediastinal pleura (central), Cervical pleura, Costal pleura, and Diaphragmatic pleura. The phrenic nerve supplies innervations to the central part of each hemidiaphragm; when these fibers are activated, the sensation of pain is referred to the ipsilateral neck or shoulder Intercostal nerves supply outer rib cage and lateral aspect of each hemidiaphragm: when these fibers are activated, the sensation of pain is referred to thoraco-abdominal wall. Atypical hyperplasia -What is most common serious chronic infection found in expatriates coming to Saudi Arabia? Aurine catacholamins Bdexamethasone stress test **I think pheochromocytoma -twisted ankle What is the most common ligament Anterior talofibular ligament ** in inversion sprain. A Sickle cell anemia B Thalassmia C Spherocitosi s D B12 **Functional hyposplenism is a condition accompanying many diseases such as 1-sickle celiac disease 2-alcoholic liver disease 3-hepatic cirrhosis 4-lymphomas 5-autoimmune disorders.

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No part of this text may be reproduced spasms film discount shallaki 60caps on line, transmitted spasms under breastbone order 60 caps shallaki with amex, downloaded muscle relaxant vs analgesic buy 60 caps shallaki otc, or stored in or introduced into any information storage or retrieval system muscle relaxant in renal failure cheap shallaki 60caps on-line, in any form or by any means, whether electronic or mechanical, now known or hereinafter invented, without the written permission of the Guilford Press. The more you know about the diagnostic process, the greater power you have to ensure that your child receives the most accurate diagnosis possible. In fact, boys are at greater risk than girls for virtually all developmental, behavioral, and learning disorders. With such protective factors present, the risk for developing disorders is lower in girls than boys and may require the presence of more of these causative factors. Practice explaining the process of screening to families and describe the limitations of screening tools. Discuss with your preceptor where you would refer a child with a positive screen in your area (for example: audiology, Early Intervention, a developmental pediatrician). Your first patient for the afternoon is a baby you have been following since birth. You first met the family in the newborn nursery and have enjoyed seeing little Matthew learn to roll over, sit, cruise, and walk. Matthew is now 18 months old and is coming in for a routine health care maintenance visit. You spend a few more moments engaging Matthew in play before going back to the conference room to present to the attending. Although Matthew is a quiet and sweet boy, you remain concerned about his language and variable eye contact. Your next patient is Claudia, a 2-year-old girl who has just moved to the area from another state. You attempt to engage Claudia with toys, but Claudia appears more interested in the buttons on her sweater. You provide ideas for engaging Matthew in creative play, as well as facilitating speech and language development, and provide ideas for engaging Matthew in creative play, as well as facilitating speech and language development, and you make another health care-maintenance appointment for Matthew during which you will continue to follow his you make another health care-maintenance appointment for Matthew during which you will continue to follow his development progress. For instance, Claudia takes interest in children, but typically does not respond to the presence of others. She does not instance, Claudia takes interest in children, but typically does not respond to the presence of others. She does not engage in pretend play and does not play properly with toys, preferring to bang them on the floor. Although she uses engage in pretend play and does not play properly with toys, preferring to bang them on the floor. Although she uses her finger to point, she cries and whines when she wants something and does not use gestures or pointing in order her finger to point, she cries and whines when she wants something and does not use gestures or pointing in order to work to gain attention from others. She occasionally responds to her name, but does not respond when she is focused on a preferred activity. She also has been noted to stare at nothing and but does not respond when she is focused on a preferred activity. You with the concerns, but also wonder how these results are accurate based on such a short time for observation. You refer Claudia for a hearing evaluation and an assessment by an early intervention specialist. You also refer her for a refer Claudia for a hearing evaluation and an assessment by an early intervention specialist. You schedule a follow-up visit with Claudia and her parents in two months to continue to follow her progress and to You schedule a follow-up visit with Claudia and her parents in two months to continue to follow her progress and to ensure that assessments and services are underway. These programs often provide evaluations and other services even before a medical evaluation is complete. The child should be scheduled for a follow-up visit and will then re-enter the algorithm at 1b. All communication between the referral sources and the pediatrician should be coordinated.

Several early intensive behavioral and developmental intervention paradigms change measures over the course of very lengthy treatments spasms liver cheap 60 caps shallaki free shipping, but such outcomes usually have not been assessed beyond treatment windows iphone 5 spasms buy shallaki 60caps otc. One family of studies140 muscle relaxant m 751 60 caps shallaki otc, 141 muscle spasms 37 weeks pregnant cheap shallaki 60 caps, 148, 149 attempted to follow young children receiving early joint attention intervention until they were school aged, but this study failed to include adequate followup of control conditions. It also involved children were receiving many hours of uncontrolled interventions during the course of study. Generalization of Treatment Effects Few studies included in this review explicitly measured generalization of treatment effects to different conditions or locations. Presumably, changes measured on these instruments document important skills with potential impact in other areas. However, some caution is warranted: In some instances, the interventions themselves may actually target component skills of these assessments, particularly in the case of cognitive and language assessments. The majority of the social skills and behavioral intervention studies targeting associated conditions attempted to index outcomes based on parent, self, teacher, and peer report of targeted symptoms. While such ratings outside of the clinical setting may be suggestive of generalization in that they improve outcomes in the daily context/life of the child, in most cases, these outcomes are parent reported and not confirmed with direct observation. Behavioral intervention studies rarely measured outcomes beyond the intervention period, and therefore we cannot assume that effects are maintained over time. Treatment Components That Drive Outcomes We again did not identify any studies meeting our inclusion criteria that addressed this question. None of the fair or good quality studies compared treatment groups to a no treatment control group. One poor quality study found positive differential effects of treatment,97 but the level of intervention intensity varied significantly between groups, making it difficult to differentiate the effects of treatment intensity vs. Findings in Relation to What Is Already Known Other reviewers have also synthesized the impact of early intensive behavioral interventions. Specifically, other reviews have demonstrated consistent impact on cognitive and language skills with fairly large effect sizes across these somewhat overlapping syntheses. These same investigations have also noted much less consistent changes in adaptive behavior skills. Further, these reviews have highlighted similar methodological concerns as 95 noted in our current review: relatively small sample sizes, inclusion of nonrandomized studies, lack of standardized control groups, errors in interpretation of studies, and wide variations in the early intervention approaches assessed. The investigators rated all studies as having high risk of bias (low overall quality) and found positive effects for early intervention on all outcomes. Tests of heterogeneity and small sample sizes precluded assessment of moderators of effects. Results restricted to studies with control groups were consistent with results for all studies across outcomes. Across outcomes, effect sizes were generally slightly better for clinic-based approaches vs. Receptive and expressive language scores for the early intervention group compared with control each improved by more than 13 points, while improvements on Vineland subscales scores ranged from 4. A sequential or cumulative meta-analysis compiled data from 15 studies rated as adequate or high quality in five previously published meta-analyses (Eldevik 2009, Makrygianni 2010, Peters-Scheffer 2011, Reichow 2009, Spreckley 2009). The sequential meta-analysis found a medium treatment benefit for early intervention vs. The magnitude of treatment benefit varied for outcomes when assessing pre- to postdifferences in the early intervention group. Between group effect sizes for adaptive behavior and language were also considered medium (0. The authors note that meta-analyses for pre to post differences in adaptive behavior and language were underpowered. An overview of four of the same meta-analyses noted above plus one additional (ViruesOrtega 2010) described methodologic limitations across the meta-analyses. Four of the five meta-analyses concluded that early intervention was an effective approach.

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