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By: John Alexander Bartlett, MD

  • Professor of Medicine
  • Director of the AIDS Research and Treatment Center
  • Research Professor of Global Health
  • Professor in the School of Nursing
  • Affiliate of the Duke Initiative for Science & Society
  • Member of the Duke Cancer Institute


Epidural analgesia decreases the need for inhalation anesthetics during surgery and can provide significant analgesia without sedation in the postoperative period asthma or out of shape generic 100 mcg proventil amex. Decreased costs and length of stay also may be benefits of epidural analgesic approaches asthma exercise buy discount proventil 100mcg online. Adverse effects include nausea and vomiting asthmatic bronchitis treatment in ayurvedic buy proventil 100mcg amex, motor blockade asthma treatment options purchase 100mcg proventil amex, and technical problems requiring catheter removal. At 1 year of age, the number approaches 7%, because some anomalies may not be identifiable until after the neonatal period. The prevalence of congenital malformations is much greater in inpatient pediatric populations; 30% to 50% of hospitalized children have congenital anomalies or genetic disorders. The purine nucleotides, adenine and guanine, cross-link by hydrogen bonds to the pyrimidines, thymine and cytosine. Human cells have 23 pairs of chromosomes, with one copy of each chromosome inherited from each parent. Twenty-two pairs of chromosomes are autosomes; the remaining pair is called the sex chromosomes. In the open reading frame, every three nucleotides represent a single codon, coding for a particular amino acid. In this way, the sequence of bases dictates the sequence of amino acids in the corresponding protein. Some codons, rather than coding for a specific amino acid, act as a "start" signal, whereas others serve as "stop" signals. Between the start and stop codons, genes consist of two major portions: exons, regions containing the code that ultimately corresponds to a sequence of amino acids, and introns (intervening sequence), which do not become part of the amino acid sequence. Through a mechanism called alternative splicing, these 21,000 genes may create more than 100,000 proteins. A point mutation that changes a codon and the resulting amino acid that goes into the protein is referred to as a missense mutation. A nonsense mutation is a point mutation that changes the codon to a "stop" codon so that transcription stops prematurely. Children from a couple are represented below their parents and are the next generation. Affected individuals are indicated by shading, or some other technique, which should be explained in a key. To be useful, pedigrees should include representatives of at least three generations of family members. Some individuals have only mild clinical symptoms, whereas others have more severe disease. Known in some cases to be associated with advanced paternal age (>35 years of age), spontaneous mutations may account for most individuals with some disorders. Molecular testing is available but is usually reserved for cases that are difficult to diagnose or those in which prenatal diagnosis is requested. Prenatal diagnosis is possible by molecular testing, using fetal cells obtained through amniocentesis or chorionic villus sampling. The bony abnormalities lead to short stature, macrocephaly, a flat midface with a prominent forehead, and rhizomelic shortening of the limbs. Hydrocephalus and central apnea may occur because of narrowing of the foramen magnum and compression of the brainstem and may present a life-threatening complication in infancy. Bowing of the legs may occur later in childhood because of unequal growth of the tibia and fibula. Dental malocclusion, obstructive apnea, and hearing loss due to middle ear dysfunction are common in later childhood. During later childhood and adolescence, the psychological effects of the short stature may manifest. Skeletal findings include a tall, thin body habitus (dolichostenomelia), spider-like fingers and toes (arachnodactyly), abnormalities of the sternum (pectus excavatum or carinatum), scoliosis, pes planus, and joint laxity. Eye findings include high myopia, which can lead to vitreoretinal degeneration; an abnormal suspensory ligament of the lens, which can lead to ectopia lentis (dislocation of the lens); and cataracts. The gene is large and complex; more than 600 mutations have been identified in affected individuals.

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In highrisk circumstances asthma definition 6 careers cheap proventil 100mcg mastercard, such as neonatal sepsis or bacteremia in immunocompromised persons asthma treatment equipment order 100mcg proventil overnight delivery, empirical therapy includes broad-spectrum antimicrobials (see Chapters 96 and 120) asthma definition naepp buy proventil 100mcg without prescription. Because rabies is one of the deadliest infections asthma treatment qvar order proventil 100mcg with visa, recognition of potential exposure and prophylaxis are crucial. Any healthy-appearing domestic animal responsible for an apparently unprovoked bite should be observed for 10 days for signs of rabies, without immediate treatment of the victim. Prophylaxis should be administered if the animal is rabid or suspected to be rabid, or if the animal develops signs of rabies while under observation. A captured wild animal should be euthanized (by animal control officials) without a period of observation and its brain examined for evidence of rabies. If the biting animal is not captured, particularly if it is a wild animal of a species known to harbor the virus in the region, rabies should be presumed and prophylaxis administered to the victim. Skunks, raccoons, foxes, woodchucks, most other carnivores, and bats are regarded as rabid unless proved negative by testing. Prophylaxis also should be provided following exposure to a bat for persons who might be unaware or unable to relate that a bite or direct contact has occurred, such as a mentally disabled person, a sleeping child, or an unattended infant. All rabies postexposure management begins with immediate thorough cleansing of the bite using soap and water and, if available, irrigation with a virucidal agent such as povidone-iodine. Definitive therapy can additionally minimize drug toxicity, development of resistant microorganisms, and cost. Infections associated with foreign bodies, such as an intravascular catheter, are difficult to eradicate with antimicrobials alone because of organism-produced biofilms that impair phagocytosis. Similarly it is difficult for phagocytic cells to eradicate bacteria amid vegetations of fibrin and platelets on infected heart valves. Prolonged, bactericidal therapy is required with these infections, and outcomes are not always satisfactory. Foreign body devices may have to be removed if sterilization does not occur promptly. Infections in closed spaces with limited perfusion (such as abscesses or chronic osteomyelitis with poorly perfused bone) are difficult to cure without surgical drainage, debridement of the infected tissue, and reestablishment of a good vascular supply. Optimal antimicrobial therapy requires an understanding of both the pharmacokinetics. The bioavailability of orally administered antibiotics varies, depending on the acid stability of the drug; degree of gastric acidity; and whether it is taken with food, antacids, H2 blockers, or other medications. An ileus or profuse diarrhea may alter intestinal transit time and result in unpredictable absorption. Aminoglycosides, active against aerobic organisms only, have significantly reduced activity in abscesses with low pH and oxygen tension. Infections of the central nervous system or the eye necessitate treatment with antimicrobials that penetrate and achieve therapeutic levels in these sites. Limited renal function (as in premature infants or those with renal failure) requires increasing dosing intervals to allow time for excretion of certain drugs. The larger volume of distribution of certain hydrophilic antimicrobials and increased renal clearance. Weight-based dosage regimens may result in overdoses in obese children due to significantly smaller volumes of distribution for hydrophilic drugs. Drug-drug interactions must be considered when multiple antimicrobial agents are used to treat infection. Use of two or more antimicrobial agents may be justified before organism identification or for the benefit of two drugs with different mechanisms of action. The use of a bacteriostatic drug, such as a tetracycline, along with a -lactam agent, effective against growing organisms only, may result in antibiotic antagonism, or less bacterial killing in the presence of both drugs than if either is used alone. There is a normal diurnal variation, with maximum temperature in the late afternoon. Normal body temperature is maintained by a complex regulatory system in the anterior hypothalamus. Development of fever begins with release of endogenous pyrogens into the circulation as the result of infection, inflammatory processes, or malignancy. Microbes and microbial toxins act as exogenous pyrogens by stimulating release of endogenous pyrogens, including cytokines such as interleukin-1, interleukin-6, tumor necrosis factor, and interferons. These cytokines reach the anterior hypothalamus, liberating arachidonic acid, which is metabolized to prostaglandin E2. Elevation of the hypothalamic thermostat occurs via a complex interaction of complement and prostaglandin-E2 production.

For example: Interviewer: "Have you ever gotten into trouble because you stayed out at night more than two hours past the time you were supposed to asthma symptoms in teens order 100 mcg proventil fast delivery be home? In such cases asthma treatment ppt buy proventil 100 mcg free shipping, you should always read all or part of the question again asthma symptoms due to allergies 100 mcg proventil overnight delivery, emphasizing the frequency term asthma levels purchase proventil 100mcg with amex. Gives a Vague or Unclear Answer In some cases, the respondent may appear to have understood the question, but gives a vague or unclear response, such as "It depends" or "Oh, Lordy! The interviewer must still read the question exactly as written and, if asked, acknowledge that some questions may be repeated. Note: Never assume or imply an answer, even if it was volunteered earlier in the interview. More often than not, these types of answers are subtle, and the interviewer must be alert in noticing them. For example: Interviewer: "Does he often not listen when people are speaking to him? The correct response to this is to repeat the question, emphasizing the last part. If the subject continues to give a nonresponsive answer, however, you must accept it and continue with the rest of the questions. Misunderstands the Time Frame of the Question If the respondent provides a response that makes you think that he or she is not focusing on the correct time period for the question, reread the key part of the question or the entire question, emphasizing the time period. Use the timeline/whole-life chart, pointing to the relevant time period on the chart. This can be beneficial in getting the respondent to focus on the time period concerned. The interviewer must include these phrases whenever they appear as part of the question. Has Difficulty Recalling the Age of Onset of the Disorder If the respondent cannot remember what age some sets of symptoms started, the interviewer should refer to the whole-life chart for a grade equivalent. Certain questions will give the option to enter "66 = Whole Life," should respondents say that they "have always been like that"; this should be accepted after minimal attempts to pin down whether it was prior to kindergarten/first grade. For example (Eating Disorders Q12D): Interviewer: "In the last year has there been a time when you had an eating binge at least twice a week? In such cases, repeat all or part of the question, emphasizing the frequency term. Misunderstands the Intensity of the Question Sometimes the interviewer will need to probe because the respondent does not understand or ignores the intensity or severity that is asked about in the question. In such cases, the interviewer should repeat part or all of the question, emphasizing the word (usually in bold or underlined) that indicates the intensity. If there is still no response, say, "Let me read the question again" and repeat the question, emphasizing key words. Bear in mind that, often, failing to provide a response can be an indication that the respondent finds the question very personal, and so the situation should be dealt with carefully. Reluctance to Continue With the Interview the offer of a quick five-minute break may help the respondent to be more inclined to continue the interview. In such cases, the interviewer should wait silently and expectantly for an answer. It might also help 32 for the interviewer to tell the caretaker to take their time in answering. He or she actually does not know the answer to the question or is unsure of the best answer. In such cases, it might help to ask the caretaker to answer to the best of his or her knowledge. If you believe that this is the case, try and obtain a response by informing the youth that a "yes" or "no" answer is needed or by repeating the question. Correct typing of information that will be inserted later in certain questions. Knowing how to cope with non-standardized answers and to utilize proper probing techniques. Social-Phobia Challenges (a) determining attachment figure (b) some questions sound "babyish" to adolescents (c) reading the "co-occurrence" question.

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Gives a Response that Appears to labile asthma definition purchase proventil 100 mcg without prescription Contradict What They Intended If you think the additional information might contradict the "yes" or "no" answer asthma action plan age 6 discount proventil 100mcg mastercard, repeat all or part of the question asthma symptoms pdf generic 100 mcg proventil visa. In this instance asthma symptoms test generic proventil 100 mcg visa, you should repeat the question using a slightly different emphasis, making the respondent aware that it is the fear in the last year, not the onset of the fear that is the focus of inquiry. Further probing depends upon which of the two following categories the misunderstanding falls into. For example: Interviewer: "In the last year, have you gone out someplace without him? For example: Interviewer: "In the last year, has he counted certain things over and over again. Answers "Sometimes" or "Somewhat" With answers like these or something similar ("sorta", "a little, I guess," or "some of the time, but not all of the time") to a question with a response category of "sometimes/somewhat". If there is not a response category for "sometimes/somewhat," the interviewer must decide what to do. In some instances, a "sometimes/somewhat" response is an obvious "yes," and so this should be entered without further probing. Specific Phobia (SpPh) Essential feature is marked and persistent fear of a specific object or situation. Examples of Situations (a) animals (particularly dogs, birds, snakes) (b) natural environment (dark, storms, heights, water) (c) blood, injection, injury (d) situations (bridges, tunnels, etc. Specific-Phobia Challenges (a) identification of "worst" fear (b) repetition of questions with second worst fear, if not meeting criteria for first worst fear 4. Essential feature of a panic attack is discrete period of intense fear or discomfort that is accompanied by a number of somatic or cognitive symptoms (four symptoms). The attack has a sudden onset and builds to a peak rapidly (in ten minutes or less) and is often accompanied by a sense of impending doom and urge to escape. Panic-Disorder Challenges (a) reading the introductory questions with correct emphasis (b) read-backs of "grouping" questions defining the attack. Examples of Situations (a) going out alone (b) being in a crowd (c) traveling on public transportation (d) being on bridges Agoraphobia Challenges (a) if all situations are endorsed, some of the later questions can be rather long 6. These youth worry about things they have no reason to worry about or worry much more than they need to and find it difficult to keep from worrying. Examples of Worries (a) anxiety about tests (b) worrying about doing things well (c) anxiety about health Disturbance must be present on most days for six months and cause distress or impairment. Selective Mutism (SeMu) the essential feature is a persistent failure to speak in specific social situations when speaking is expected. Disturbance must last for at least one month (not limited to the first month of school). It cannot result solely from speech disorder or lack of comfort with a particular language. Obsessions Persistent thoughts, ideas, impulses, or images that are experienced as being intrusive and inappropriate and cause marked distress or anxiety. Worry about being contaminated, having doubts, and aggressive or horrific images 36 Compulsions Repetitive behaviors. Obsessive-Compulsive Disorder Challenges (a) Reading the long introductory parts 9. Examples of Symptoms (a) persistent "reexperiencing" of trauma (feels like "re-living" it, nightmares, intrusive recollections, distress when reminded of it) (b) avoidance of reminders (c) inability to recall event completely (d) numbing of responsiveness (e) increased arousal, irritability, jumpiness, etc. Disturbance must last at least a month and cause distress or impairment Post-Traumatic-Stress-Disorder Challenges (a) Questions 9 and 10 - determining "traumatic event" (b) wording for referring to the traumatic event in different questions 10. Bulimia Nervosa Individual has eating binges, uses compensatory methods to prevent weight gain, and his/her feelings about himself/herself are influenced by body shape/weight. Eating-Disorder Challenges (a) assessment of height and weight (b) parallel onset questions for anorexia and bulimia 11. Elimination-Disorder Challenges (a) respondent and/or interviewer embarrassment (b) onset questions are slightly different due to primary/secondary distinction 12.

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It will also later be inserted into the symptom questions that inquire about that time period asthmatic bronchitis during pregnancy order proventil 100mcg with amex. Caution must be observed in typing these events accurately asthma headache order proventil 100 mcg overnight delivery, so that they flow in a grammatically correct format following the word "since asthma symptoms for adults order proventil 100 mcg free shipping," and refer to asthma symptoms 3-4 purchase proventil 100mcg mastercard the subject rather than the interviewer. If you make a mistake, you will be reminded of your error many times during the remainder of the interview, so it is wise to take care with typing. On screen instructions advise the interviewer of how the event description should be entered. In the first example, one might say, "since [you] were in the hospital" (assuming the child went to the hospital), and in the second, "since [you] were attacked. This happens regardless of whether they are within the time parameters asked about in the diagnostic questions. A summary of such events and when they occurred is presented to the subject before starting the timeline probes. Instead the questions will refer to the appropriate month, rather than the event. This allows the interviewer to refer to the hard copy of the timeline during the interview, rather than using the timeline on-screen. The interviewer will also need to insert events into the structure of the diagnostic questions when necessary. In order to save time during administration, the interviewer should write in the months of the last year on the timeline before beginning the interview. Early on in the interview, you should point to the timeline whenever you introduce a switch in time period, until the subject is well aware of the connection between the time frame and the relevant event marker. Throughout the interview, make sure that you and the subject are focusing on the same time period as outlined in the questions. You can always add a new time reminder to the paper copy of the timeline, if the subject seems to need one. This can be represented by writing on the lines of the chart, rather than within the boxes. Early in the interview, interviewers should obtain and make note of information about ages for starting school, repeated grades, and moves. At one point in the introduction, the interviewer is instructed that if the whole-life chart is "sparse" (generally, periods of more than three years without an event), the interviewer can use his/her own questions to fill in details. However, being a self-administered interview, the subject will need to type in the events when asked. During the diagnostic sections, the event entered will appear on screen in parenthesis at the appropriate place to serve as a time marker. The event will not be read aloud by the computer, and the subject is informed of this during the Demographic section. The timeline automatically pops up on screen when the diagnostic questions refer to a different time period, or the subjects can pull it up themselves if needed. The age of onset questions are still asked, but instructions in the Introductory section alert the subject that at times they will need to think back to their entire life. These describe the essential aspects of a symptom in broad terms, are designed to be overly sensitive, and yield many false positives. That is, most people who have the symptom will endorse it, but most will not turn out to have the symptom. Contingent Questions There are approximately 1,300 "contingent" questions that are asked if a stem or previous contingent question has been answered positively. Therefore, these questions function to reduce the number of false-positive responses to the stem. Age of Onset Questions Following the symptom questions, there are questions assessing the age of onset and impairment. These are only asked if a "clinically significant" number of symptoms have already been endorsed - usually, half or more of those required for the diagnosis. Onset asks for the age at which the endorsed symptoms first started, followed by a series of questions to assess earlier discontinuous episodes. They inquire as to whether the symptoms present during the last year have resulted in any degree of impairment in six different social domains: · · · · · · getting along with parents/caretakers participating in family activities participating in peer activities academic/occupational functioning relationships with teachers/boss distress attributable to symptoms.

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