Cordarone

Richard Eric Rothman, M.D., Ph.D.

• Vice Chair of Research, Department of Emergency Medicine
• Professor of Emergency Medicine

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0007064/richard-rothman

Dextrocardia (cardiac apex to the right) occurs in mild cases and situs inversus in more severe cases treatment 30th october order 100 mg cordarone with mastercard. In situs inversus hair treatment buy cordarone 200mg low price, the morphologic right atrium is on the left treatment centers for drug addiction cheap cordarone on line, and the morphologic left atrium is on the right medications generic cordarone 100 mg. It is carried out by placing a small amount of saccharin behind the anterior end of the inferior turbinate medications 4 times a day buy cordarone now. In the presence of normal mucociliary action medications hair loss order 100 mg cordarone visa, the sac charin will be swept backward to the nasopharynx and a sweet taste per ceived. Failure of sweetness to be detected within about 20 minutes indicates delayed mucociliary clearance. When dynein is activated, it produces the sliding motion of the microtubules as it walks along the adjacent doublet (answer a). The basal body (answer b) anchors the microtubules and also plays an essential role in converting the sliding of the outer microtubules into the bending of the cilium. Nexin (answer c) links the outer microtubular doublets, creating a strap-like arrangement of paired microtubules around the central microtubule doublet. The radial spokes hold the microtubule doublets in place, and sliding is limited lengthwise. The hemidesmosomes combined with the desmosomes act to distribute tensile forces through the epithelial sheet and the supporting connective tissues. Classification Type Function Interactions Occluding Zonula Prevents passage Intramembranous occludens of luminal sub sealing strands (tight junction) stances; confers occlude the space epithelial tight between cells (# of ness or leakiness; strands directly maintains apical proportional to vs. Specific desmogleins are the target of the autoantibodies in different forms of the disease. The other parts of the junctional complex: zonula occludens (answer b) and gap junctions (answer d) are not affected in pemphigus. The connections to the basal lamina, hemidesmo somes (answer a), as well as the basal lamina itself, are not part of the etiol ogy of pemphigus. Cad herins are also critical molecules in the maintenance of the zonula adherens, but the autoantibodies in pemphigus are specific to the desmogleins. Pemphi gus vulgaris, which is described in the clinical scenario, often begins as oral lesions and subsequently appears cutaneously. The Nikolsky sign is positive (pressure at the edge of a blister causes extension of the bulla into adjacent nor mal skin) in pemphigus, while in bullous pemphigoid the Nikolsky sign is neg ative. For more details on junctional complexes, see the table in the answer for question 83. Cytoplasmic microtubules (answer b) are found in the sin glet form and undergo constant association and dissociation of tubulin at their plus ends and minus ends, respectively. Stereocilia (answer e) are large, mod ified microvilli, found in the epididymis and on hair cells in the organ of Corti, therefore, they are not composed of microtubules. On physical examination it is noted that she has scoliosis, pectus excavatum, ectopia lentis, and myopia. Her musculoskeletal exam reveals long upper and lower extremities, including the fingers and toes, and an overall gangly, lanky appearance. She has very flexible fingers and a narrow face as well as a narrow mouth with overcrowded teeth. Which part of the cardiovascular system would often be adversly affected in this syndrome The extracellular matrix and the cytoskeleton communicate across the cell membrane through which of the following A pregnant 29-year-old woman diagnosed with type I diabetes 2 decades ago, taking Humulin three times per day, is referred to the oph thalmology clinic. Dilated indirect ophthalmoscopy coupled with biomi croscopy and fundus photography detect the presence of proliferative dia betic retinopathy with leaky retinal vessels indicative of increased vascular permeability, growth of new, fragile vessels on the retina and posterior sur face of the vitreous and macular edema. Overexpression of fibronectin is a histological marker of diabetic microangiopathy. Which of the following is the primary function of fibronectin in the basement membrane A 36-year-old man is referred by his family medicine physician to the pulmonary clinic. He complains of shortness of breath following physical activity and a decreased capacity for exercise. He says that strenuous exercise including yard work is impossible without sitting down and resting every few minutes. He is not a smoker and as an office worker he is not exposed to dust, fumes or other irritants at work. In the synthesis of collagen, the hydroxylation of proline and lysine occurs in which of the following The primary function of entactin (also known as nidogen) is to cross link which of the following A 14-year-old boy presents with thin, translucent skin, and a history of easy bruising. Imperfections in dentin formation (dentinogenesis imperfecta) 174 Anatomy, Histology, and Cell Biology 94. The tissue shown in the photomicrograph differs from white adipose tissue in which of the following ways Diseases in which there is a loss of function mutation in integrin expres sion on lymphocytes would most likely result in: a. A 33-year-old homeless woman has been living in an abandoned building eating dried meat, bread from the trash cans outside a bakery. She presents at the free clinic with bleeding under the skin particularly around hair follicles with bruises on her arms and legs. She is irritable, clinically depressed, and fatigued with general muscle weakness. She is afebrile and a glucose finger stick is nor mal and urine dipstick shows no sugar, protein or ketones. Which of the following is a major contributor to the tensile strength of collagen In adherence of epithelia to the basement membrane 176 Anatomy, Histology, and Cell Biology 99. A 40-year-old woman is referred to a dermatologist with more than 100 oval or round red-brown macules on her back. There are an excessive number of the metachromatically stained cells labeled with the arrows and shown in the inset to the lower left in the photomicrograph below. A 46-year-old woman who has been a type I diabetic for 35 years vis its your family medicine office. You prescribe Beclaperin gel, a prescription drug for the treat ment of diabetic foot ulcers. His physical examination reveals slight right-sided muscular weakness and a pulse of 78/min, regular; blood pressure 140/82 mm Hg. X-ray examina tion of the spine showed two wedged thoracic vertebrae, T7 and T8; no osteolytic lesions are observed. The bone marrow shows an increase in the cells shown in the accompany ing light micrograph. She works as a software developer and lives with her 52-year-old husband and 12-year-old daughter. She is a nonsmoker; and drinks an occasional glass of wine when she and her husband go out to din ner. In this patient, dur ing the period of weight gain which of the following responses would be most expected in the cells shown in the photomicrograph Increased release of norepinephrine from nerve terminals in adipose tissue 180 Anatomy, Histology, and Cell Biology 103. A 65-year-old African-American man who has a history of both uri nary tract infections and urinary stones presents at the urology clinic with hematuria. He has a dietary history high in saturated fats and has been exposed to second-hand smoke both at home (his wife smokes) and at work where many of his coworkers smoke. Decreased elasticity of lung tissue causes an increased tendency toward spontaneous pneu mothorax, also known as a collapsed lung. The aorta is the most affected organ because of the extensive elastin in the wall, and dissecting aortic aneurysms are common in these patients. Marfan malformations include cardiovascular (valve problems as well as aortic aneurysm), skeletal (abnor mal height and severe chest deformities), and ocular systems. The result is the disloca tion of the lens because of loss of elasticity in the suspensory ligament. The receptor structure includes an intracytosolic portion that binds to the actin cytoskeleton through the attachment proteins talin or actinin. Proteoglycans (answer a) are located on the extracellular surface of the plasma membrane and throughout the extracellular matrix. The cadherins (answer c) function as transmembrane glycoproteins involved in the formation of parts of the intercellular junctional complexes. Intermediate filaments and micro tubules (answers d and e) are found intracellularly and constitute the cytoskeleton. It is important for modulation of cell migration in the adult and during development. Neural crest and other cells appear 181 182 Anatomy, Histology, and Cell Biology to be guided along fibronectin-coated pathways in the embryo. Fibronectin is found in three forms: a plasma form that is involved in blood clotting; a cell-surface form, which binds to the cell surface transiently; and a matrix form, which is fibrillar in arrangement. Cell-cell interactions involve both transient and more long-term, stable processes. Cell-cell adhesion is mediated by transmembrane proteins called cell adhesion mol ecules which include the calcium or magnesium-dependent selectins, inte grins, and cadherins (answers c and d) and the non-calcium-dependent immunoglobulin (Ig) superfamily. The stable adhesion junction, known as the zonula adherens, links the cytoskeleton of adjacent cells through cad herins (transmembrane linker proteins) to actin filaments inside the cell [answer e (see feedback for question 199)]. Desmosine and isodesmosine are amino acids unique to elastin and responsible for the covalent binding of elastin fibers to each other. Microfibrils, composed of fibrillin, facilitate for mation of the elastin molecules, but are not directly involved in cross-linking. One third of elastin is composed of the hydrophobic amino acid glycine, which is randomly distributed throughout the elastin molecule. The overall hydrophobicity of elastin molecules allows for their distensibility and facilitates their capacity to slide over one another. Hydroxyproline, which constitutes 10% of collagen, is often used to determine the collagen content of various tis sues. Hydroxylation of proline stabilizes the triple helix through interchain hydrogen bonds, and hydroxylation of lysine is critical for the cross-linking stage of collagen assembly. Procollagen is sub sequently transported in transfer vesicles to the Golgi for packaging into secretory vesicles. Transport of secretory vesicles is an energy and micro tubule-dependent process. Outside of the cell, N-terminal and C-terminal specific procollagen peptidases cleave the nonhelical registration peptides, which results in the formation of tropocollagen. Tropocollagen sponta neously assembles in a staggered array to form collagen fibrils. Lysyl oxi dase (answer a) is an extracellular enzyme responsible for the formation of covalent cross-links between tropocollagen molecules. Fibrils form colla gen fibers under the influence of other extracellular matrix constituents, such as proteoglycans and glycoproteins. Collagenases (answer d) specifi cally cleave tropocollagen in the extracellular matrix. Integrins like laminin receptors (answer b) bind cells to the basal lamina; fibronectin receptors bind cells to the extracellular matrix (answer c). Laminin receptors in the cell mem brane also organize the assembly of the basal lamina. Collagen (answer d) is cross-linked by covalent intramolecular and intermolecular cross-links that form primarily between the nonhelical segments at the ends of the collagen molecules. Lysyl oxidase is a key enzyme in the cross-linking process; it deaminates lysine and hydroxylysine to form aldehyde groups that react with each other to form the covalent bonds. Actin is cross-linked 184 Anatomy, Histology, and Cell Biology (answer e) into bundles by actin-binding proteins such as the bundling protein actinin and the gel-forming protein (fimbrin). This results from a genetic mutation that alters the propeptide sequence in such a way that the molecular orientation and cross-linking are adversely affected. Both types of fat tissue (brown and white) are highly vascularized and function in protection from the cold. Brown fat specifically is involved in heat production, whereas white fat is a true thermal insulator. Brown fat is involved in nonshiver ing thermogenesis and generates heat (answer c), probably as a protective device for developing organs in the fetus and neonate. White adipose tissue is specialized for lipid storage and functions as a thermal insulator (answer b) and shock absorber.

Consensus Process: Group meetings medicine reminder app order cordarone 100mg fast delivery, conference calls treatment in statistics buy cordarone canada, and e-mail communications enabled consensus symptoms 7 generic cordarone 100mg free shipping. Endocrine Society committees medications 44334 white oblong order cordarone cheap online, members and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines symptoms leukemia purchase cheap cordarone on line. Conclusion: Gender affirmation is multidisciplinary treatment in which endocrinologists play an important role treatment coordinator 100 mg cordarone with amex. Gender-dysphoric/gender-incongruent persons seek and/or are referred to endocrinologists to develop the physical characteristics of the affirmed gender. Hormone treatment is not recommended for prepubertal gender-dysphoric/gender-incongruent persons. We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13. For the care of peripubertal youths and older adolescents, we recommend that an expert multidisciplinary team comprised of medical professionals and mental health professionals manage this treatment. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents. For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient. We suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. When high doses of sex steroids are required to suppress endogenous sex steroids and/or in advanced age, clinicians may consider surgically removing natal gonads along with reducing sex steroid treatment. Clinicians should monitor both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete. Additionally, clinicians should persistently monitor adverse effects of sex steroids. For gender-affirming surgeries in adults, the treating physician must collaborate with and confirm the criteria for treatment used by the referring physician. Clinicians should avoid harming individuals (via hormone treatment) who have conditions other than gender dysphoria/gender incongruence and who may not benefit from the physical changes associated with this treatment. We recommend against puberty blocking and the criteria for the endocrine phase of gender gender-affirming hormone treatment in pre transition before beginning treatment. We recommend that clinicians evaluate and ad (1 EEss) dress medical conditions that can be exacerbated 1. We recommend that clinicians inform and by hormone depletion and treatment with sex counsel all individuals seeking gender-affirming hormones of the affirmed gender before begin medical treatment regarding options for fertility ning treatment. We suggest that clinicians measure hormone pression in adolescents and prior to treating with levels during treatment to ensure that endog hormonal therapy of the affirmed gender in both enous sex steroids are suppressed and admin adolescents and adults. In adolescents who request sex hormone treat 3 months during the first year of hormone ment (given this is a partly irreversible treatment), therapy for transgender males and females and we recommend initiating treatment using a then once or twice yearly. We suggest that clinicians evaluate transgender informed consent, which most adolescents have persons treated with hormones for cardiovas by age 16 years. We recognize that there may be compelling abetes screening, and/or other diagnostic tools. We suggest that transgender females treated parameters every 6 to 12 months during sex with estrogens follow individualized screening hormone treatment. We advise that clinicians approve genital gender children, adolescents, and adults seeking gender affirming surgery only after completion of at least confirming treatment of their options for fertility preser 1 year of consistent and compliant hormone vation. Prior to treatment, clinicians should evaluate the treatment, unless hormone therapy is not desired presence of medical conditions that may be worsened or medically contraindicated. A multidis Practice Statement) ciplinary team, preferably composed of medical and 5. We advise that the clinician responsible for en mental health professionals, should monitor treat docrine treatment and the primary care provider ments. Clinicians evaluating transgender adults for ensure appropriate medical clearance of trans endocrine treatment should confirm the diagnosis of gender individuals for genital gender-affirming persistent gender dysphoria/gender incongruence. We recommend that clinicians refer hormone hormone levels and metabolic parameters, as well as as treated transgender individuals for genital sur sessments of bone density and the impact upon prostate, gery when: (1) the individual has had a satisfactory gonads, and uterus. We also make recommendations for social role change, (2) the individual is satisfied transgender persons who plan genital gender-affirming about the hormonal effects, and (3) the individual surgery. The task force followed the approach recom mended by the Grading of Recommendations, Assessment, dividual. There is insufficient evidence to rec Development, and Evaluation group, an international group ommend a specific age requirement. The task force Changes Since the Previous Guideline used the best available research evidence to develop the rec ommendations. The task force also used consistent language Both the current guideline and the one published in 2009 and graphical descriptions of both the strength of a recom contain similar sections. Cross filled of Youth and Adults (5), Treatment of Adolescents (6), circles indicate the quality of the evidence, such that Esss Hormonal Therapy for Transgender Adults (4), Adverse denotes very low quality evidence; EEss, low quality; Outcomes Prevention and Long-term Care (7), and EEEs, moderate quality; and EEEE, high quality. The task Surgery for Sex Reassignment and Gender Confirmation force has confidence that persons who receive care according to the strong recommendations will derive, on average, more (6). The section on each recommendation is a description of the evidence and the Case: 3:18-cv-00309-wmc Document #: 166-9 Filed: 04/24/19 Page 6 of 36 doi: 10. In some instances, there are remarks in which the summarized the available evidence regarding the effect of task force offers technical suggestions for testing conditions, sex steroids on bone health in transgender individuals dosing, and monitoring. In transgender males, there was best available evidence applied to a typical person being treated. In transgender females, there emphasize the importance of shared decision making, general was a statistically significant increase in lumbar spine preventive care measures, and basic principles of the treatment of transgender persons. There was minimal information on fracture ered out of the scope of this guideline. The Endocrine Society maintains a rigorous conflict of interest review process for developing clinical practice guide Introduction lines. All task force members must declare any potential conflicts of interest by completing a conflict of interest form. The 20th century sures for this guideline and resolved or managed all identified marked the emergence of a social awakening for men and conflicts of interest. Magnus Hirschfeld and Harry Benja amount from commercial interests; grants; research support; consulting fees; salary; ownership interests [e. Magnus Hirschfeld (6) and others (4, 7) have described other types of trans phenomena besides transsexualism. These early Commissioned Systematic Review researchers proposed that the gender identity of these the task force commissioned two systematic reviews to people was located somewhere along a unidimensional support this guideline. Yet such a transgender individuals on lipids and cardiovascular classification does not take into account that people may outcomes. The review identified 29 eligible studies at have gender identities outside this continuum. In transgender males (female to stance, some experience themselves as having both a male male), sex steroid therapy was associated with a statis and female gender identity, whereas others completely tically significant increase in serum triglycerides and renounce any gender classification (8, 9). High-density reports of individuals experiencing a continuous and lipoprotein cholesterol levels decreased significantly rapid involuntary alternation between a male and female across all follow-up time periods. In transgender females identity (10) or men who do not experience themselves as (male to female), serum triglycerides were significantly men but do not want to live as women (11, 12). Specific treatment protocols, however, have not yet more frequent in transgender females. Case: 3:18-cv-00309-wmc Document #: 166-9 Filed: 04/24/19 Page 7 of 36 3874 Hembree et al Guidelines on Gender Dysphoric/Gender Incongruent Persons J Clin Endocrinol Metab, November 2017, 102(11):3869 3903 Instead of the term transsexualism, the current studies across countries that use the same diagnostic and classification system of the American Psychiatric As inclusion criteria, medications, assay methods, and re sociation uses the term gender dysphoria in its di sponse assessment tools. However, more effective endocrinology-based gradually during infant life and childhood. This pro treatments became possible with the availability of cess of cognitive and affective learning evolves with testosterone in 1935 and diethylstilbestrol in 1938. Normative psychological literature, surgery appeared in the press during the second half of however, does not address if and when gender identity the 20th century. The Harry Benjamin International becomes crystallized and what factors contribute to Gender Dysphoria Association was founded in Sep the development of a gender identity that is not con tember 1979 and is now called the World Professional gruent with the gender of rearing. Prior to 1975, few peer-reviewed articles were pub With respect to endocrine considerations, studies lished concerning endocrine treatment of transgender have failed to find differences in circulating levels of sex persons. Since then, more than two thousand articles steroids between transgender and nontransgender in about various aspects of transgender care have appeared. Definitions of Terms Used in this Guideline Biological sex, biological male or female: these terms refer to physical aspects of maleness and femaleness. Typically, transgender people seek to make their gender expression align with their gender identity, rather than their designated gender. For transgender people, their gender identity does not match their sex designated at birth. For some people, their gender identity does not fit neatly into one of those two choices. Not all individuals with gender incongruence have gender dysphoria or seek treatment. Gender-reassignment surgery (gender-confirming/gender-affirming surgery): these terms refer only to the surgical part of gender confirming/gender-affirming treatment. Gender role: this refers to behaviors, attitudes, and personality traits that a society (in a given culture and historical period) designates as masculine or feminine and/or that society associates with or considers typical of the social role of men or women. Sex designated at birth: this refers to sex assigned at birth, usually based on genital anatomy. Sex: this refers to attributes that characterize biological maleness or femaleness. The best known attributes include the sex-determining genes, the sex chromosomes, the H-Y antigen, the gonads, sex hormones, internal and external genitalia, and secondary sex characteristics. Irrespective of their gender identity, transgender people may be attracted to women (gynephilic), attracted to men (androphilic), bisexual, asexual, or queer. Transgender: this is an umbrella term for people whose gender identity and/or gender expression differs from what is typically associated with their sex designated at birth. Transgender male (also: trans man, female-to-male, transgender male): this refers to individuals assigned female at birth but who identify and live as men. Transgender woman (also: trans woman, male-to female, transgender female): this refers to individuals assigned male at birth but who identify and live as women. Transition: this refers to the process during which transgender persons change their physical, social, and/or legal characteristics consistent with the affirmed gender identity. Transsexual: this is an older term that originated in the medical and psychological communities to refer to individuals who have permanently transitioned through medical interventions or desired to do so. In particular, a study by Heylens In summary, although there is much that is still et al. Case: 3:18-cv-00309-wmc Document #: 166-9 Filed: 04/24/19 Page 9 of 36 3876 Hembree et al Guidelines on Gender Dysphoric/Gender Incongruent Persons J Clin Endocrinol Metab, November 2017, 102(11):3869 3903 Natural History of Children With this improves their quality of life. Transgender individuals should be encouraged to During assessment, the clinician obtains information from experience living in the new gender role and assess whether the individual seeking gender-affirming treatment.

As with the other atypical antipsychotics medications information discount 200 mg cordarone with amex, it may be more helpful for Conventional Neuroleptics treating the negative symptoms of schizophrenia (flat affect medicine hat tigers discount 250mg cordarone with mastercard, isolation and withdrawal medications not covered by medicare generic 250 mg cordarone otc, and apathy) than conventional Chlorpromazine antipsychotics medications you cant drink alcohol purchase cordarone 250 mg with mastercard. Anecdotal and case report data support its Haloperidol utility in child and adolescent psychotic disorders medicine for diarrhea buy cordarone 100 mg low cost. Quetia bipolar affective disorder in adults (risperidone and olanza pine is given in 25 to 50-mg increments up to 800 mg for the pine) medicine 751 buy discount cordarone line. They are also used for acute mania and as adjuncts to treatment of psychotic symptoms. It is thought to be a antidepressants in the treatment of psychotic depression weight-neutral medication, and the primary side effect is (with delusions or hallucinations). They may also be useful Risperidone (Risperdal) blocks type 2 dopamine receptors for the body image distortion and irrational fears about food (similarly to haloperidol) and type 2 serotonin receptors. Risperidone has also demonstrated antipsychotics in their receptor specificity and effect on clinical efficacy in the treatment of Tourette syndrome. The introduction of the atypical anti psychotics has significantly changed neuroleptic prescribing E. The atypical antipsychotics have a better side-effect profile for most individuals and comparable efficacy for the Ziprasidone (Geodon) has affinity for multiple serotonin treatment of psychotic symptoms and aggression. The symptom should be carefully considered and reviewed with initial dose is 20 mg, with dose changes in 20-mg increments the parent or guardian. There are no studies of ziprasidone in tonic reactions are tonic muscle spasms, often of the tongue, children and adolescents at this time. Onset is Clozapine (Clozaril) is usually reserved for individuals who usually within days after a dosage change and symptoms may have not responded to multiple other antipsychotics due to occur in up to 25% of children treated with conventional its side effect of agranulocytosis. Some case reports note benefit from clozapine in long-term use of neuroleptic medications. Choreoathetoid child and adolescent schizophrenic patients who were resis movements of the tongue and mouth are most common, but tant to other treatment. It presents count must be obtained biweekly before a 2-week supply of as muscle stiffness, cogwheel rigidity, masklike facial expres the drug is dispensed. If the white count falls below 3000/mL, sion, bradykinesia, drooling, and occasionally pill-rolling clozapine is usually discontinued. Anticholinergic medications or dosage reductions sedation, weight gain, and increased salivation. It presents as an unpleasant feeling of driven motor restlessness that ranges from vague muscular the following adverse effects of antipsychotics apply to both discomfort to a markedly dysphoric agitation with frantic typical and atypical antipsychotics, but are thought to have a pacing. Anticholinergic agents or blockers are sometimes significantly lower incidence with the atypical antipsychotics. Transdermal administration of cloni tem depressant effects or the anticholinergic effects of other dine using a skin patch can be quite effective but may result drugs may occur, as well as increased plasma levels of in skin irritation in 40% of patients. Most antipsy include transient headaches and stomach aches in 25% of chotic treatments seem to be associated with relevant weight patients. Side effects ing of blood pressure, weight gain, abdominal circumference, include fatigability, dizziness associated with hypotension, dietary and exercise habits, and, if indicated, fasting blood increased appetite and weight gain, headache, sleep distur glucose and lipid panels. Guanfacine is less sedating and less hypotensive than should be monitored during withdrawal. The proportion of intrafamilial to extrafamilial cases child syndrome was thought to affect 749 children in the varies with the type of abuse as well as the gender and age of United States in 1960. Each of the following conditions may exist as referrals were made to child protective service agencies separate or concurrent diagnoses. Neglect is the most com involving the alleged maltreatment of approximately 6 monly reported and substantiated form of child maltreat million children. Just under 900,000 of these cases were substantiated by Physical Abuse child protective services in 2005, yielding an abuse victim Physical abuse of children is most often inflicted by a ization rate of 12. This dramatic increase in cases has significant number of unexpected pediatric deaths, particu resulted from increased recognition of the problem by larly in infants and very young children (eg, sudden unex professionals, partly in response to statutory reporting pected infant death), are related to physical abuse. Sub Sexual abuse is defined as the engaging of dependent, devel stance abuse, poverty and economic strains, parental opmentally immature children in sexual activities that they capacity and skills, and domestic violence are cited as the do not fully comprehend and to which they cannot give most common presenting problems in abusive families. It includes all forms of incest, sexual assault or rape, ecological perspective, which recognizes the individual, fam and pedophilia. This includes fondling, oral-genital-anal ily, social, and psychological influences that come together to contact, all forms of intercourse or penetration, exhibition contribute to the problem. Kempe and Helfer termed this ism, voyeurism, exploitation or prostitution, and the the abusive pattern, in which the child, the crisis, and the involvement of children in the production of pornography. For most pediatric health care professionals, downward trend in total reports of sexual abuse cases, however, their involvement will be limited to individual exploitation and enticement of children and adolescents via cases. This chapter focuses on the knowledge necessary for the Internet remains a growing trend. Emotional or psychological abuse has been defined as the rejection, ignoring, criticizing, isolation, or terrorizing of chil Discrepant, evolving, or absent history dren, all of which have the effect of eroding their self-esteem. A common manifestation of emotional Unrealistic expectations of caregiver for the child neglect in infancy is nutritional (nonorganic) failure to thrive. Raising the possibility that a child has been abused is clothing, and shelter and a safe environment in which not the same as accusing the caregiver of being the abuser. History Medical Care Neglect In all cases of abuse and neglect, a detailed psychosocial Medical care neglect is failure to provide the needed treat history is important. This should include information on who ment to infants or children with life-threatening illness or lives in the home, other caregivers, domestic violence, sub other serious or chronic medical conditions. Inquiring about any previous involvement with social Munchausen Syndrome by Proxy services or law enforcement can help to determine risk. Munchausen syndrome by proxy is a relatively unusual disor der in which a caregiver, usually the mother, either simulates or creates the symptoms or signs of illness in a child. The child can present with a long list of medical problems or General or direct statements about sexual abuse often bizarre, recurrent complaints. Persistent doctor shop Sexualized knowledge, play, or behavior in developmentally imma ping and enforced invalidism (eg, not accepting that the child ture children is healthy and reinforcing that the child is somehow ill) are Sexual abuse of other children by the victim also described in the original definition of Munchausen Behavioral changes syndrome by proxy. Obvious signs Hysterical or conversion reactions of injury, sexual abuse, or neglect may be present. Classic Suicidal, runaway threats or behavior radiographic and laboratory findings are discussed later in Excessive masturbation this chapter. Psychosocial factors may indicate risk for or Medical conditions confirm child maltreatment. The approach to Sexually transmitted infections the family should be supportive, nonaccusatory, and empa Pregnancy thetic. The individual who brings the child in for care may not Promiscuity or prostitution, sexual dysfunction, fear of intimacy have any involvement in the abuse. Approximately one third of School problems or truancy Substance abuse child abuse incidents occur in extrafamilial settings. Emotional abuse can occur in the medical diagnosis of physical abuse is based on the the home or day care, school, sports team, or other settings. Neglect partial, changing over time, or simply illogical or improba Even though in 2005 there were three times as many reports ble. The presence of a discrepant history should prompt a of neglect of children as of physical abuse, neglect is not request for consultation with a multidisciplinary child pro easily documented on history. This agency is mandated by state law to investigate present even after adequate social services have been pro reports of suspected child abuse and neglect. Emotionally neglectful parents social services and possibly law enforcement officers, as well appear to have an inability to recognize the physical or as a home visit, may be required to sort out the circum emotional states of their children. Failure to Thrive caregiver, suspecting that the child may have been sexually the history offered in cases of growth failure (failure to abused, may bring the child to the health care provider and thrive) is often discrepant with the physical findings. Medical closure of sexual abuse by the child or an allegation of abuse conditions causing poor growth in infancy and early child by a parent or third party. The presentations listed (eg, substance abuse, violence, poverty, or psychiatric ill should arouse suspicion of the possibility of sexual abuse ness). Ask of the severely malnourished patient is sometimes required, ing the child nonleading, age-appropriate questions is but most cases are managed on an outpatient basis. Community agency Physical Findings protocols may exist for child advocacy centers that help in the investigation of these reports. Physical Abuse sexual abuse in the context of divorce and custody disputes the findings on examination of physically abused children should be handled in the same manner, with the same may include abrasions, alopecia, bites, bruises, burns, dental objective, nonjudgmental documentation. Injuries Academy of Pediatrics has published guidelines for the may be in multiple stages of healing. Bruises in physically evaluation of child sexual abuse as well as other guidelines abused children are sometimes patterned (eg, belt marks, relating to child maltreatment. Emotional Abuse children typically sustain accidental bruises over bony promi Emotional abuse may cause nonspecific symptoms in chil nences such as shins and elbows. Loss of self-esteem or self-confidence, sleep distur developmentally mobile should be viewed with concern. Neisse unusual patterns, burns to the genitalia, and any unexplained burn ria gonorrhoeae infection or syphilis beyond the perinatal injury period is diagnostic of sexual abuse. In the case of human papillomavirus, an initial appearance of venereal warts beyond the toddler age should prompt a terns include stocking or glove distribution; immersion burns discussion regarding concerns of sexual abuse. The absence of splash typing is rarely indicated and often of limited availability. Symptoms can ment of risk of transmission and consultation with an be subtle and may mimic other conditions such as gastroen infectious disease expert. Neglect and Nonorganic Failure to Thrive well as the normal developmental changes and variations in Infants and children with nonorganic failure to thrive have a prepubertal female hymens, have been described in journal relative absence of subcutaneous fat in the cheeks, buttocks, articles and visual diagnosis guides. Other conditions associated with poor comfort and routine for the patient, the genital examination nutrient and vitamin intake may be present. Older children who have been chronically lum examination is rarely necessary unless there is suspicion emotionally neglected may also have short stature (ie, depri of internal injury; the external female genital structures can vation dwarfism). The head circumference is usually normal be well visualized using labial separation and traction with in cases of nonorganic failure to thrive. The signify a prenatal condition, congenital disease, or chronic majority of victims of sexual abuse exhibit no physical nutritional deprivation and increases the likelihood of more findings. The reasons for this include delay in disclosure by serious and possibly permanent developmental delay.

Clozapine (Clozaril) Requires psychiatrist Requires psychiatrist involvement involvement b medications blood thinners cheap cordarone amex. Reduced growth Lamotrigine (Lamictal) Requires psychiatrist ++ involvement velocity occurs only during active administration symptoms of a stranger 200 mg cordarone for sale. Treatment Tricyclic antidepres + ++ with stimulant medications does not predispose to future sants substance abuse symptoms melanoma order cordarone on line. Assess for abnormal movements such as and decreased impulsivity when given stimulant medica motor tics at each visit medicine to stop vomiting order cordarone master card. A sustained-release preparation may individuals with a personal or family history of motor tics or have clinical effects for up to 8 hours medications beginning with z generic 250 mg cordarone visa. There is also an Tourette syndrome treatment vitiligo order cordarone australia, as these medications may cause or extended-release form. The Treatment of Adolescent Depression Study found that cognitive-behavioral therapy combined with fluoxetine led to 3. Selective Serotonin Reuptake Inhibitors expected blood levels of other drugs, including antidepres Citalopram, escitalopram (Celexa, Lexapro) sants, antiarrhythmics, antipsychotics, blockers, opioids, Fluvoxamine (Luvox) and antihistamines. A potentially fatal interaction that Sertraline (Zoloft) clinically resembles neuroleptic malignant syndrome may 1. The starting dose for a child younger than 12 years therapeutic effects in adolescents with major depressive old is generally half the starting dose for an adolescent. One in ten individuals may experience sedation and prefer to take the medication at bedtime. Venlafaxine must be discontinued slowly to certain behavioral, emotional, and functional conditions. It is also available in syndromes, migraines, headache, depression, anxiety, enure an extended-release form. Mirtazapine the treatment of major depression in adults and for enuresis Mirtazapine is an 2-antagonist that enhances central nor for children age 6 years and older. Studies have not supported efficacy in major combination with monoamine oxidase inhibitors. Other screening procedures include serum electro depression, generalized anxiety disorder, and diabetic lytes and blood urea nitrogen in patients who have eating peripheral neuropathic pain in adults. Increased plasma levels appear to be weakly associated with an increased risk of cardiac conduction abnormalities. Upper limits of cardiovascular been the drugs of choice for mood stabilization in bipolar parameters with tricyclic antidepressants. New research also finds that the atypical antipsychotic medications are also effective. Medications that are effective as mood stabilizers may be helpful also in the treatment of severe aggressive symptoms. Moderate to Atypical Antipsychotics severe symptoms of lithium toxicity are associated with blood levels above 2 mEq/L. Ibuprofen should Reportedly, it does not have the worrisome side effects of be avoided by individuals who take lithium due to combined bone marrow suppression and liver enzyme induction. Precautions against dehydration are required Blood levels cannot be monitored, and the dose range is in hot weather and during vigorous exercise. Doses may be increased Valproate is more effective than lithium in patients with weekly until there is effective symptom control. Increased appetite and weight gain can be trou lute neutrophil counts below 1000/mL call for discontinua blesome for children and adolescents. Lamotrigine hepatitis, pancreatitis, thrombocytopenia, and agranulocyto Lamotrigine is approved for the treatment of bipolar depres sis occur only rarely. Gabapentin the target symptoms of mood instability, irritability, or behavioral dyscontrol. Because of their increased use 1800 mg/d in three divided doses and may need to be over conventional antipsychotics, this section focuses pri adjusted downward in individuals with renal impairment. Although its use among adolescents and even children is increasing, gabapentin is not approved for this indication, A. Olanzapine Risperidone (Risperdal) (Zyprexa) has greater affinity for type 2 serotonin receptors Quetiapine (Seroquel) than dopamine-2 receptors and also has an effect on musca Ziprasidone (Geodon) rinic, histaminic, and adrenergic receptors. Munchausen Syndrome by Proxy graphic photography), or rapid healing of minor injuries such as labial, hymenal, or anal abrasions, contusions, or Children with Munchausen syndrome by proxy may present lacerations. If the history indicates that the child may have had are reported to be ill and have a normal clinical appearance. This should occur in an emergency department or mental status, fever, gastrointestinal bleeding, and seizures. Physical Abuse or discharge), the child should be examined for signs of Certain radiologic findings are strong indicators of physical trauma. Skeletal surveys in children aged 3 years or younger should be performed when a suspicious fracture is diag C. Abdominal computed tomography is blood cell count, urinalysis, electrolyte panel, and thyroid the preferred test in suspected abdominal trauma. Newborn or very young child with suspected abuse-related head or screening should be documented as usual. Other tests should abdominal trauma should be evaluated immediately by an be guided by any aspect of the clinical history that points to emergency physician or trauma surgeon. A skeletal survey and Coagulation studies and a complete blood cell count with head computed tomography scan may be helpful if concur platelets are useful in children who present with multiple or rent physical abuse is suspected. Coagulopathy however, is placement in a setting in which the child can be conditions may confuse the diagnostic picture but can be fed and monitored. Hospital or foster care placement may be excluded with a careful history, examination, laboratory required. Weight gain may not occur for several days to a screens, and hematologic consultation if necessary. The differential diagnosis of all forms of physical abuse can be considered in the context of a detailed trauma history, D. Munchausen Syndrome by Proxy family medical history, radiographic findings, and laboratory Recurrent polymicrobial sepsis (especially in children with testing. The diagnosis of osteogenesis imperfecta or other indwelling catheters), recurrent apnea, chronic dehydration collagen disorders, for example, may be considered in the of unknown cause, or other highly unusual unexplained child with skin and joint findings or multiple fractures with laboratory findings should raise the suspicion of Mun or without the classic radiographic presentation and is best chausen syndrome by proxy. Children with failure to mia type 1); chronic or previous central nervous system thrive related to emotional and physical neglect need to be infection; birth trauma; or congenital central nervous system placed in a setting in which they can be fed and cared for. It should be recognized, however, that children with In the United States, clinicians and many other profes these rare disorders can also be victims of abuse or neglect. Sexual Abuse must be made to the local or state agency designated to the forensic evaluation of sexually abused children should investigate such matters. In most cases, this will be the child be performed in a setting that prevents further emotional protective services agency. Knowing the parentsown backlash against physicians in Great Britain involved in history of any victimization is important, as the ability to high-profile child abuse cases should not deter anyone in the engage in this anticipatory guidance discussion with a United States from following the state-specific child abuse provider and their child may be affected by that history. Many hospitals and communities make child Promoting Internet safety and limiting exposure to sexual protection teams or consultants available when there are ized materials and media should be part of this anticipatory questions about the diagnosis and management in a child guidance. A listing of pediatric consultants in child abuse is parents can be found in the parenting and health sections available from the American Academy of Pediatrics. Except in extreme cases, the reporting of emotional abuse Efforts to prevent emotional abuse of children have been is not likely to generate an immediate response from child undertaken through extensive media campaigns. This should not deter reporting, espe available to assess the effectiveness of this approach. The cially if there is also concern for domestic violence or other primary care physician can promote positive, nurturing, and forms of abuse or neglect. Screening for programs (eg, Healthy Families America or Parents Anony domestic violence during anticipatory guidance discussions mous) or to seek mental health consultation. Support for the on discipline, home, and safety can be effective in identifying child may also include mental health counseling or age parents and children at risk. J Pediatr Adolesc Gynecol 2007;20:163 Physical abuse is preventable in many cases. These services can Examiners: Distinguishing sudden infant death syndrome be provided by public health nurses or trained paraprofes from child abuse fatalities. The availability of these services Abuse and Neglect: When is lack of supervision neglect American Academy of Pediatrics, 2008 Prevention of abusive injuries perpetrated by nonparent (forthcoming). Contemp Pediatr 2005; mothers about safe child care arrangements and advocating 22:43. Child Maltreatment: Training Mod anticipatory guidance to encourage parents to consider this ules and Visuals. McCann J et al: Healing of hymenal injuries in prepubertal and Thompson S: Accidental or inflicted It is often helpful to ask what problems the and adolescents with preventive health care and acute and parents specifically wish to address in order to determine what chronic care management services and consultations. Some visits are occasioned by chapter, special attention is given to the pediatric history and problems at school, such as low grades or troublesome peer physical examination, normal developmental stages, office relationships.

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