Associate Director of the Cedars-Sinai Heart Institute
Director of Advanced Heart Disease and Director of the
Heart Transplant Program at Cedars-Sinai
DSL/Thomas D. Gordon Chair in Heart Transplantation
Medicine, Clinical Professor of Medicine and Cardiology
at the David Geffen School of Medicine at the University
of California, Los Angeles (UCLA)
Los Angeles, California
The bands were then removed from the plastic barrell of a variceal ligation device muscle relaxant used for cheap tizanidine 2mg fast delivery. This cap was utilized to provide a larger area of forceful suction enabling us to remove the grape from its impacted location spasms throughout body discount tizanidine 2mg with amex. Multiple biopsies were then taken along the length of the esophagus which revealed degranulated eosinophils and greater than 15 eosinophils per high power field confirming the diagnosis of eosinophilic esophagitis spasms hands and feet cheap tizanidine 2 mg amex. Conclusion: Eosinophilic esophagitis is chronic inflammatory disease of the esophagus and while there are many effective treatments spasms feel like baby kicking buy tizanidine 4 mg low price, the optimal therapy has yet to be fully defined spasms hip order tizanidine 2 mg visa. As it is being recognized more frequently spasms hands fingers generic 4 mg tizanidine overnight delivery, different presentations and findings are being documented muscle relaxant non drowsy generic 2 mg tizanidine mastercard. This case is the first muscle relaxant uses cheap tizanidine 2 mg otc, to our knowledge, of eosinophilic esophagitis presenting with a grape as a food-bolus impaction. Another case of a grape causing esophageal obstruction has been described, but the primary pathology was a stricture. This case also demonstrates an alternative use for the barrell on banding devices, which may prove useful with foreign bodies such as in this case. Purpose: To demonstrate the diagnosis and management of necrotizing esophagitis including esophageal stricture Methods: A 50 year-old woman presented to the emergency room with abdominal pain, nausea, and coffee ground emesis. She was admitted to the hospital with systolic blood pressures greater than 200mmHg and upper gastrointestinal bleeding. Her past medical history was significant for cocaine abuse, stroke, diabetes mellitus, poorly-controlled hypertension, and gastroesophageal reflux disease. Repeat upper endoscopy two weeks later showed healing necrotizing esophagitis and a severe distal esophageal stricture that was unable to be passed with the endoscope (Figure 1-top right). Multiple endoscopic therapy sessions including dilation and temporary metal stent placement (Alimaxx Stent) were required (Figure 1-bottom left). On long-term follow-up (13 months) the patient is asymptomatic and has no evidence of residual esophageal stricture. Results: Acute necrotizing esophagitis is rare and severe form of acute esophagitis diagnosed endoscopically by the black appearance of the esophagus. The etiology appears to be multifactorial attributed to ischemic, traumatic, toxic, and infectious causes. She c/o acute onset solid food dysphagia but denied odynophagia, recent trauma and retching. The endoscopists were concerned for the presence of esophageal varices, but were unsure and transferred her to our tertiary care center. We repeated the upper endoscopy on her arrival; at 20cm within the proximal esophagus we encountered a large submucousal mass that extended continuously to 40cm. The lesion was on the posterior wall of the esophagus, was 2cm wide and 20 cm long. It appeared beefy red in color with multiple areas of purple discoloration and ulceration. Conservative management was undertaken with plans for repeat endoscopy as we entertained a diagnosis of esophageal apoplexy. Repeat endoscopy was performed two weeks later with near resolution of the findings thus confirming our suspicion. Esophageal apoplexy, also known as esophageal intramural hematoma is a rare cause of hematemesis. Precipitating events include food bolus impactions, vomiting with recurrent retching, recent esophageal instrumentation including dilation and biopsy. Barium esophagram may show the "double barrel sign" suggesting intramural dissection. Management is generally conservative as the hematoma usually resolves in 1-3 weeks. Prompt recognition is critical as the prognosis is excellent and the need for more invasive investigation and surgery is unnecessary. Purpose: Eosinophilic esophagitis(EoE)is characterized by an eosinophilic infiltration of the esophagus and is increasingly recognized as a cause of dysphagia and heartburn unresponsive to antireflux therapy. We report a case of eosinophilic esophagitis that presented without dysphagia, heartburn or endoscopic abnormalities to alert clinicians to the importance doing of esophageal biopsies in atypical presentations of EoE. Methods: A 19 yo college student presented with a 3 year history of anorexia and dyspepsia. He had several episodes of minor hematemesis that led to an endoscopy at age 16 (by a different physician) showing only a small Mallory-Weiss tear and normal duodenal biopsies. Because of worsening symptoms and weight loss of ten pounds, he was referred for further evaluation. A full panel of celiac antibodies were negative except for an antigiadin IgG of 100. A repeat endoscopy to assess for celiac sprue was normal except for slight gastric retention. The esophagus was endoscopically normal without evidence of esophagitis, rings, or any other abnormalities. The patient was started on fluticasone swallowed twice a day with resolution of all symptoms within a few weeks. Results: EoE is becoming more frequently diagnosed as a cause of dysphagia and heartburn and is predominantly considered in younger patients presenting with symptoms that are unresponsive to antireflux therapy or with endoscopic signs of EoE such as ringed esophagus. Conclusion: this case highlights the importance of esophageal biopsies in the diagnosis of EoE in atypical presentations. The diagnostic work-up revealed failure of the bypass grafts; the patient subsequently required bilateral above the knee amputations. On post-op day 3, the patient had multiple episodes of melena with an acute drop in hemoglobin of 2g without abdominal pain. The remainder of the endoscopy was normal; acute esophageal necrosis was presumed to be the etiology of the bleed. Biopsies revealed necrotic debris with acute inflammatory leukocytic infiltration. The patient was treated conservatively with high dose proton-pump inhibitor therapy and maximization of cardiac output. Acute esophageal necrosis, or black esophagus, is a rare endoscopic finding, with only a handful of cases described in the world literature. The proposed pathophysiology involves ischemia in a majority of cases; massive gastroesophageal reflux, infection, and caustic ingestion have also been implicated. Associated risk factors have included atherosclerotic vascular disease, diabetes, end stage renal disease, and recent surgery ͠all of which were common to the patient presented. Purpose: Varices in the distal esophagus are a commonly seen complication of portal hypertension; these are termed "uphill" varices, based on the direction of flow to the superior vena cava from the portal venous system. Proximal esophageal varices are termed "downhill" varices, referring to flow from above downwards and are usually associated with upper body venous obstruction. We report a case of bleeding downhill esophageal varices as a complication of upper extremity hemodialysis access. Due to failures of upper extremity dialysis fistulae, he underwent repeated placement of dialysis catheters into the central venous system. This resulted in bilateral innominate vein occlusion, and led to balloon angioplasty with the insertion of stents to maintain flow and hemodialysis access. Conclusion: Felson and Lessure in 1964 first coined the term downhill varices because the direction of blood flow is from above downwards. Most downhill varices results from superior venacaval syndrome/occlusion either by intrinsic or extrinsic causes. Although downhill varices are usually limited to the upper esophagus they can present in entire length of esophagus depending on the site of obstruction. If the occlusion appears proximal to the azygous vein, blood will be diverted via collaterals through the internal mammary, vertebral and patent azygous vein and downhill varices will be confined to the proximal esophagus. Sclerotherapy is not recommended as it may cause severe complications such as vertebral infarction and pulmonary embolism. Histopathologic examination of the surgical specimen was significant for diffuse microcystic adenoma of the pancreas. Usually unifocal, they present as single, large, well-demarcated multiloculated cystic tumors. Pancreatic cysts usually do not produce any symptoms and are diagnosed incidentally by abdominal imaging studies. Biliary cast formation is usually associated with biliary strictures and/or hepatic ischemia. Endoscopic techniques have been recently described in the successful removal of biliary casts. Using a basket, the distal aspect of the cast was secured and a 6 cm long cast was successfully removed in a single piece. Liver function tests have subsequently normalized and the patient remains normal with a follow period of 10 months without recurrence. Single operator cholangioscopy provides a safe means of diagnosing and treating patients with Biliary cast syndrome particularly in cases with intrahepatic duct casts where surgery or percutaneous techniques are often required. A 56 years old gentleman with no significant past history presented for evaluation of fatigue and weight loss. Gastroscopy revealed a large fungating mass in lower esophagus, with yellowish colored debris. They were arranged in clumps, columns and vague acinar configuration intercepted by thin vascular channels. Conclusion: Primary tumors of the upper gastrointestinal tract showing hepatoid differentiation are very infrequent. To our knowledge, this is the first case of hepatoid esophageal cancer to be reported from the United States. We report a case of a patient with spinal hemangioblastomas due to Von Hippel Lindau syndrome who was found to have numerous pancreatic cysts on abdominal imaging. Biopsy revealed a diffuse variant of microcystic adenoma of the pancreas which, according to literature review, is extremely rare. The patient was referred to neurosurgery for resection of the cervical hemangioblastomas. Serum lipase peaks at 24 hours, has a half-life between 7-14 hours & may stay elevated for 8-14 days; it is secreted by the biliary ductal system & kidneys. The sensitivity of serum amylase & lipase for the diagnosis of acute pancreatitis ranges from 85-100% in various reports. Results: Diagnostic work-up revealed diabetic ketoacidosis & an acute myocardial infarction. Five days into his admission, the patient was still experiencing vague abdominal pain, persistent fevers and leukocytosis. Repeat amylase and lipase were 86 and 15, respectively; they continued to be persistantly normal throughout hospitalization. An abdominal ultrasound was unremarkable for gallstones or common bile duct dilation. Autopsy revealed diffuse fatty necrosis of the pancreas with extension into the mesentery. Conclusion: the setting of acute pancreatitis associated with a normal serum amylase is rare, but well described. Multiple factors may contribute to the absence of hyperamylasemia on admission, including a return to normal enzyme levels before hospitalization, inability of the inflamed pancreas to produce amylase, or suppressed levels due to hypertriglyceridemia. Despite a thorough literature review, we were unable to find a case report of acute necrotizing pancreatitis with a normal serum lipase. Methods: A 50-year-old Caucasian female is referred to Gastroenterology for evaluation of 3 months of intermittent abdominal pain associated with nausea, vomiting, and acholic stools. Laboratory studies revealed abnormal transaminases and an elevated alkaline phosphatase, convincingly suggestive of biliary disease. Synthetic liver function appeared to be intact and abdominal ultrasonography revealed a dilated common bile duct to 1. Intrahepatic ducts were within normal limits and thus ultrasound was suggestive possibly of an obstructive lesion. Results: Direct visualization with upper endoscopy and endoscopic ultrasonography was initially planned. Endoscopically, a very large, smooth rimmed juxta-ampullary diverticulum was visualized, measuring 3. Using careful dissection and an endoscopic irrigation device the bezoar was broken up and dislodged from the diverticulum. Proteinaceous material was snared and removed to the lumen and the diverticulum was cleared. Follow-up clinical assessment revealed complete resolution of all abdominal symptoms including the intense pain and nausea with vomiting. Conclusion: this case illustrates an unusual etiology for a commonly encountered clinical scenario. Direct endoscopy proved to be the most effective means to evaluate this patient and simultaneously provided the modality for treatment. As in this case, these lesions have an unexpected ability to mimic many other physiologic, pathologic and/or anatomic conditions. The rarity of juxta-ampullary diverticulum may very well contribute to an expensive and at often times, unfocused workup. However, in March 2008, he presented with a productive cough and pleuritic, right-sided chest pain. A chest x-ray revealed a large, rightsided pleural effusion and a thoracentesis revealed bilious, exudative fluid with a neutrophilic predominance. Furthermore, tumor encasement of biliary structures and subsequent increases in retrograde biliary flow may serve to maintain flow into the pleural space. We describe a case of post endoscopic biliary sphinterotomy bleeding in a patient with both duodenal diverticulae and abnormal vascular anatomy. Upon visualization of the ampulla, the anatomy of the ampulla was noted to be altered due to large diverticulae bilaterally. Due to both the inadequacy and inability to extend the sphincterotomy, a 25mm wire sphincterotome was used to further extend the sphincterotomy. The endoscopic field was quickly and completely obscured with blood preventing any endoscopic intervention. The patient was emergently transferred to interventional radiology due to the profuse ongoing bleeding. Post embolization angiogram revealed a small collateral branch off of the hepatic artery in the region of the previously seen bleeding site. Due to the possibility that this was the collateral branch contributing to the bleeding, this was also embolized. While the presence of duodenal diverticulae is a well documented risk factor for post sphinterotomy bleeding, we present a case of severe bleeding in a patient with both duodenal diverticulae and abnormal vascular anatomy. Purpose: A 43 year-old male presented complaining of left upper quadrant pain for one week, and fevers for 3 days. At current presentation, he was febrile to 104ц and diaphoretic, although appeared comfortable. Fine needle aspiration was performed with a 19G needle yielding 6 mL of purulent fluid. The cyst was then accessed with a needleknife and cystduodenostomy was established using a 10mm x 40mm balloon dilator and two 6 Fr double-pigtail stents. A 5 Fr nasocystic catheter was placed into the cyst for irrigation over the next three days. The presence of esophageal candidiasis suggested unrecognized immunosuppression and served as a clue to the diagnosis. Endoscopic ultrasound is often used in the evaluation of pancreatic cystic lesions but infrequently for the diagnosis of pancreatic tuberculosis. We believe this is the first reported case of an endoscopic cystduodenostomy for therapy of a tubercular pancreatic abscess. Endoscopic management of tubercular pancreatic abscesses is feasible and effective. Purpose: When patients present with several symptoms including extraintestinal problems, a unitary diagnosis is occasionally possible. A 28 year-old white female reported one year of diarrhea with more than 10 watery bowel movements daily. There was mild bilateral lower quadrant abdominal pain without associated or alleviating factors. She had been receiving potassium supplements for chronic hypokalemia and had several 282 Poster Abstracts ͠Monday, October 6 episodes of generalized weakness, followed by "paralysis" that had required hospitalization for the treatment of profound hypokalemia. The evaluation included negative results for stool cultures, stool Clostridium difficile toxin, amoeba serology, sedimentation rate, C reactive peptide level, thyroid stimulating hormone level, serum gastrin level, calcitonin level, tissue transglutaminase IgA, serum protein electrophoresis with quantitative immunoglobulins, urine laxative screen, and complete blood cell count. Colonoscopy with terminal ileum intubation showed no mucosal lesions and random biopsies were normal mucosa. She underwent a laparoscopic subtotal pancreatectomy, splenectomy and lymph node resection. Light microscopy of the pancreatic mass demonstrated a well-differentiated pancreatic endocrine neoplasm with no extension through the tumor capsule. This case demonstrates the importance of considering pancreatic neuroendocrine tumors in patients presenting with watery diarrhea and periodic hypokalemia-associated paralysis. It results from a needle tract connection of the hepatic artery, portal vein or both to the biliary tree. Only 30-40% of cases have the Sandblom triad of biliary colic, gastrointestinal bleeding and jaundice. With a rapid rate of bleeding, acute upper gastrointestinal bleeding such as melena or hematemesis can be seen. When the rate of bleeding is slow, a clot can be formed in the biliary tree causing obstruction, acute cholecystitis or cholangitis.
Artemisia Herba-Alba. Tizanidine.
Cough; stomach upset; common cold; measles; diabetes; jaundice; anxiety; irregular heart beat; muscle weakness; and parasitic infections such as roundworms, pinworms, tapeworms, hookworms, and flukes.
No queremos robar protagonismo ni competir con la voraz innovaciecnola muscle relaxant benzodiazepine buy cheap tizanidine 4 mg line, solo demandamos que la informaciea veraz y sencilla al entendimiento del consumidor muscle relaxant pakistan buy generic tizanidine 2 mg line. Que los comensales puedan elegir y que tengan acceso a lo mejor al precio correcto muscle relaxer 7767 cheap tizanidine 2 mg otc. No estamos de acuerdo con la tecnologal servicio del mercantilismo de los alimentos muscle relaxer sleep aid buy cheap tizanidine 2 mg on-line, somos productores de alimentos y nuestro principal objetivo es promover la produccie alimentos saludables y perfectos para nuestros ambientes muscle relaxant pharmacology discount tizanidine 4 mg line. Donde nutrimos a nuestro pueblo que nos elige por sus caractericas geogr⧩cas y culturales muscle relaxants for tmj cheap tizanidine 4mg visa, no somos una tendencia de la moda estamos y hemos existido siempre muscle relaxants yahoo answers tizanidine 4mg free shipping, somos el origen y all𨡵scamos las respuestas spasms spinal cord injury safe tizanidine 4 mg. Nos ignoran, les son indiferentes las pr⤴icas ganaderas indnas y criollas que sostuvieron naciones y sostienen pueblos enteros evitando la pobreza urbana, la malnutricila desidia, la violencia, el hambre. El Pastoralismo/ Sistemas Pastoriles basados en la movilidad, es un sector que no estᡳuficientemente visibilizado en nuestras sociedades y en los niveles de decisiolca, nacional y global. Se lo incluye en otros sistemas en manos de campesinos o indnas pero en realidad los pastoralistas tenemos muchas especificidades en nuestra forma de vida y producciue deben ser tenidos en cuenta. Hablamos de formas de tenencia de tierras, de las necesidades especiales en polcas de desarrollo rural, de infraestructura, en servicios de salud, educacinecesidades especiales en t곭inos de conectividad, de asistencia t꤮ica, entre los puntos mⳠrelevantes. No queremos un discurso coherente a nuestro orgullo ganadero, queremos acciones y conceptos firmes que avalen nuestra permanencia y sostenibilidad, que garanticen nuestra paz social y econa. Fundamentos que garanticen la nuestra permanencia en nuestros territorios, respeto a nuestros ambientes, integridad y dignidad de nuestras familias, herramientas claras y legitimas que nos permitan el acceso a la construcciolectiva y enda de las polcas pcas de nuestros gobiernos. Normalmente los organismos pcos y multilaterales se refieren al "sector productivo o privado" solamente para los sistemas empresariales y de gran escala. Nosotros somos un sector de la sociedad, privado, pero sobre todo productores de bienes y servicios para nuestras sociedades; producimos alimentos sanos y al alcance de los sectores populares y de los mercados urbanos mⳠfavorecidos. No identificarnos en esa categor usualmente nos ubica como sujetos de polcas sociales. Somos sujetos de desarrollo y exigimos polcas pcas para el desarrollo del aporte enorme que hacemos a la sociedad. La ganaderextensiva responde a las necesidades de los territorios donde se forjaron culturas milenarias y nuevas que se han sostenido mediante las pr⤴icas ganaderas en las grandes extensiones donde ninguna otra pr⤴ica de produccie alimento prospero. Somos los mejores amigos de nuestros ambientes no destrozamos no cambiamos pasajes no desplazamos a nuestros pros para beneficios individuales, convivimos y nos adaptamos a los cambios. Mediante constantes y pequeinversiones que responden a las demandas de nuestros territorios, donde predomina un profundo respeto por los recursos naturales, nuestros animales son gen굩ca local, mestizos, adaptados, no producen impactos agresivos a nuestros ambientes. Por eso existimos, por ello no nos extinguimos, por ello somos capaces de proveer siempre de alimentos sanos. Reconocer la diversidad de sistemas ganaderos que existen y analizarlos segsa diversidad, contextualiz⯤olos segas circunstancias de los lugares donde se desarrollan. Reconocer que los pequeganaderos y pastores son "productores" creadores de riqueza en los pas y proveedores de alimentos sanos, casi siempre en los sitios mⳠimpredecibles y vulnerables climcamente. Derechos de acceso a la tierra asegurados y sistemas de tenencia adecuada a sistemas ganaderos variados, especialmente los sistemas mes. Apoyo a planes de sanidad animal integrales, combinar saberes tradicionales y la tecnologconvencional. Incorporar productos de sistemas ganaderos en los planes alimentarios gubernamentales. Acceso al financiamiento apropiado a los diferentes sistemas y realidades, especialmente considerando que los pastores acumulan en general capital231 en forma de animales y no en forma de tierras. Programas de Desarrollo (no de asistencia social) destinados a los sistemas ganaderos de pequescala, mes, trashumantes, etc. Informaciportuna sobre riesgo de eventos extremos (sequ, inundaciones, problemas erosivos. Formacie profesionales capaces de entender y asistir los diversos sistemas ganaderos desde perspectivas holicas. Rescate y sistematizacie buenas pr⤴icas ganaderas en las diversas regiones, investigaciara mejores pr⤴icas. Fomento de sistemas ganaderos mixtos, agro-silvo pastoriles, tanto pequey medianos como grandes productores para zonas con bosques nativos; turismo rural y otras actividades de diversificaci Tecnolog de la Informaciisponibles para sistemas ganaderos en regiones aisladas. Comentarios t꤮icos Page 8: A paragraph is missing explaining the nutritional benefits of livestock production for population in arid lands, where horticulture is not possible. Page 9: On issues, a real danger in these areas is posed by milk commercialization strategies without designing further market strategies to substitute these micronutrients in milk by equivalent ones from horticulture. A further 231 La palabra "capital" proviene del lat"caput", cabeza, ya que los mayores capitales reunidos histamente siempre lo han sido en forma de cabezas de ganado. Es muy triste que el origen mismo del capitalismo no sea admitido ahora como una garantpara financiamiento en la mayorde sociedades modernas, contribuyendo al empobrecimiento de los ganaderos. In the whole section that starts at page 17, no mention to the intrinsic sustainability of extensive livestock production in areas of marginal crop production, as well as the challenges to improve an already very efficient system, is done (cf. This is a pity given the opportunities for poverty reduction that price increases bring, especially when it involves production of high added value, highquality products that do not yield big quantities. This is especially relevant as it is the most marginalized livestock keeping communities (extensive livestock keepers including pastoralists) who would benefit more from this price increase if the adequate measures to facilitate their access to markets are taken into account ͠and of course taking into account the nutritional challenges that may appear as I have mentioned above. Page 27 start: All what we have mentioned is not taken into account either in the comment on the Livestock Revolution. There seems to be a unique vision on future of the livestock systems as for increasing yield, and not quality or access to other tools for adding value to the production. This vision automatically ignores the most marginalized but most sustainable livestock producers ͠extensive livestock keepers including pastoralists. Page 28-29 Box 4: the Mediterranean diet traditionally includes low quantities of high-quality animal products with very good nutritional characteristics such as the Iberian ham (Jimꯥz Colmenero et al 2010234,but similar evidence is available for cattle and sheep products). Page 32: the poor quality of data on pastoralism and pastoralists should be noted. To begin with, estimates on the area grazed by domestic herbivores (most of which includes both pastoralists and commercial ranchers, but with the overwhelming majority of it likely being 232 Hoffmann I. Ecosystem services provided by livestock species and breeds, with special consideration to the contributions of small-scale livestock keepers and pastoralists. Regarding the estimate of how many pastoralists there are in the world the situation is even more dramatic. What proportion of their livelihoods coming from extensive livestock should be the cutting line to consider or not to consider them as such? It should be noted that many of the challenges experienced by pastoralists are also experienced by commercial ranchers (p. Page 32-33: Regarding the Smallholder mixed farming systems, it would be good to see further reference in the report on the sustainability of their systems as waste recyclers and users of marginal food sources that do not compete with human food (similar to extensive livestock). The border between these systems and Smallholder systems where animals represent less than 10 percent of the total farm output in value terms is not sharp at all ͠backyard livestock production takes place in both as a continuum. Considerations on these systems are very important also regarding future change (p 34) because of the increase urbanization of world population. A section on social elements should also consider the opportunities for rural development associated with livestock production, or the displaced livestock keepers due to the disruption of traditional production systems associated with mobility (and the consequent loss of production) Page 43-44 Section 2. Pages 47-51: all sections can be enriched based on the comments provided above Page 52 Section 3. Pastoralists have protested against these claims as, even if the raw data may be accurate, the following automatic policy implication of restricting extensive livestock to combat climate change makes no sense. The case study on pork production in China (Box 5 at page 36) illustrates very well how traditional systems were designed to preclude these kinds of issues. There are loads of evidences on this in a livelihood that makes the most out of climate variability and production heterogeneity. Page 59 Box 8: a fundamental missing constraint is the lack of service provision that allows the endogenous development of pastoralist communities. Education, when provided, is done through boarding schools, which drives to drop-outs from the pastoralist livelihoods and makes that there will never be pastoralist and mobile doctors, lawyers, teachers, engineers. No access to energy means no way to diversify production or to process the foods in origin so to add value. Finance services are not provided except for new developments with mobile money, but it is still impossible for a pastoralist that may owe assets worth a lot of money but no land (because of the very sustainable communal land tenure systems) to get a loan! Even for mobile phones, which have caused a revolution by modernizing pastoralist livelihoods, getting network coverage is more than challenging. This error has a direct consequence in terms of sustainability and of food security. An upcoming paper on that is to be published next year, although the draft is not ready yet but it can be shared in the near future. Further sections from there on would be extensively revised if the arguments we have listed here were to be considered. Benjamin Schraven, German Development Institute (on behalf of the reseach project: "Promoting food security in rural Sub-Saharan Africa: the role of agricultural intensification, social security and results-oriented approaches"), Germany 240 Teillard, F. On the other hand there are many repetitions and some issues are overly relativized - in particular with regard to basic positions, dilemmata and conflicts. Furthermore, there are also some contradictions when it comes to time pressure (from "very urgent" to "we need more data, research. Are there not some recommendations that could definitively be regarded as adequate ("no regret")? One could structure the recommendations on a scale from "no regret und urgent" to "very sensitive, more info needed, and can wait a bit longer". Answer: One of the challenges that the report could further elaborate on is the danger that restrictive and scientifically unjustified private standards pose on the regulatory authority if States. It is important not to undermine state capacity to regulate in a transparent, sciencebased and undiscriminatory manner. Increase efforts in animal disease surveillance and treatment, both to improve livestock sector productivity and to reduce dangers associated with the spread of pests and outbreaks of animal diseases and zoonoses. Give higher priority to establishing and enforcing agreed standards of animal care developed for different livestock production systems and species, especially in intensive systems, without creating a disguised restriction on international trade or unjustifiable discrimination between countries where the same conditions prevail: include financial and technical support for improved animal care in agricultural development funding initiatives. Though higher prices might have a marginal effect on the demand of food and feed (inelasticity of the demand), they do encourage investment. Given that agriculture is crucial for developing countries, such dynamic should be positive for food security. Moreover, low food and feed prices discourage food and feed investment therefore causing further drop in the future price. The report does a good job at acknowledging the importance of the multilateral trade system. Still, it fails to address the negative effects that the agricultural protectionism has inflicted on developing countries. Namely market access restrictions, domestic support measures (included the unlimited amounts of green box), export subsidies and arbitrary non-tariff trade barriers. In this respect, the report should make a call for the swift conclusion of the Doha Developing Round in accordance to its mandate. The disclaimer used for signaling that the conclusions of the paper are subject to the result fo the 10th In addition, we suggest the following changes with regard to specific provisions in the text: 1. Page 8, line 51: "Climate change is already impacting on the agriculture sector, which will have to continue to adapt as well as to reduce its contribution to greenhouse gas emissions, always taking into consideration the principle of common but differentiated responsibilities, respective capabilities and social and economic conditions of countries, as expressed in the United Nations Framework Convention on Climate Change. The solution is not to slow agricultural development ͠it is to seek more sustainable production systems. There are important implications here, in maintaining equilibrium between different farming systems and between local production and international trade. We would suggest that the whole paragraph be removed, or at least the reference to "environmental footprint". Page 21, line 17: "biodiversity in agro-ecosystems, including the animal component, performs important ecological services beyond food production, and conditioning such as recycling of nutrients, pollination, pest control, regulation of microclimate and local hydrological processes, detoxification of noxious chemicals, control of greenhouse gas emissions, risk reduction under unpredictable environmental conditions and the conservation of surrounding natural ecosystems. Page 45, line 29: "The priority environmental challenges are: reducing the intensity of greenhouse gas emissionsproduction; reversing land degradation and biodiversity loss; reducing water pollution; and adapting to climate change" - Rationale: We believe that with regard to food production and distribution, the focus should be on the reduction of emissions intensity and on increased efficiency, as opposed to total emissions reductions, as this would negatively affect food security. In both Asia and the Americas emissions grew at a slower pace (1ͱ:2% yr1), while they decreased in Europe (1:7% yr1). In addition, the figures in the referenced document which do distinguish between developed and developing countries refer only to emissions in 2010, and not a particular upward or downward trend. Given this, we believe this text should be removed from the document, as it depicts a situation in which developing countries have a greater responsibility to act to reduce emissions, when this could adversely affect food security, in a context in which the overarching priority of developing countries is to eradicate poverty and hunger. Page 54, line 12: "The water footprint of livestock products is much higher than for crop products in terms of calories produced (although when biological value of protein is compared, no plant protein is significantly more efficient at using water than protein produced from eggs, and only soybean is more water-efficient than milk and goat and chicken meat (Mekonnen and Hoekstra, 2012; Shlink et al. Animal products from industrial, feed-based systems are generally more water intensive and generally consume and pollute more ground- and surface-water resources than animal products from grazing or mixed systems. Page 62, line 20: "The livestock sector has a large potential to reduce the intensity (ghg/kg of product) of greenhouse gas emissions, although it is much less likely for total emissions given the projected increase in livestock production in the context of population growth and the need to safeguard food security. Many technical options to reduce emissions exist, including feed supplements and feed management, grazing land and manure management, health management, improvements in genetics and animal husbandry practices. In more intensive systems, progress could be made by introducing technological innovations to increase efficiencies in production and shift towards monogastric species. Soil carbon sequestration is also an important option that shows potential for mitigating net emissions from grazing livestock. For instance, restoring degraded soils, better adjusting stocking density and using legumes has a significant potential worldwide for mitigation in the livestock sector" - Rationale: We believe that there are no "one-size fits-all" solutions which can be applied globally, and that the mention of specific measures necessarily leaves out others which could be more appropriate and effective given specific national circumstances and capabilities, as well as economic, social and environmental priorities. Given this, we believe that there should be no mention in the text of specific options for measures that might be implemented. Furthermore, we believe that with regard to food production and distribution, the focus should be on the reduction of emissions intensity and on increased efficiency, as opposed to total emissions reductions, as this would negatively affect food security. Page 64, line 50: "However, when the impacts of farm practices are not taken into account by farmers and livestock keepers, because there is no financial remuneration for the provision of public goods (such as carbon sequestration in soils or habitats for wildlife), or penalties for polluting water courses or harming biodiversity for example, or the social consequences are not factored in to producer decisions, then sustainability is compromised. Page 66, line 13: "Set payments for using and for providing environmental services that are not remunerated through the market" Page 84, line 35: "Incorporate wherever possible incentives (to reward public goods provision). Atento a ello, esto no significa que no apoyemos las iniciativas en materia de cooperaciintercambio de tecnologe investigaciue puedan ser lanzadas a nivel internacional, siempre y cuando no impliquen asumir compromisos cuantitativos de reduccie emisiones en agricultura. Sin embargo, nuestro padecidirᡤe acuerdo con sus capacidades, condiciones, necesidades y prioridades, en qu顳ectores mitigarᮍ Particularmente, entendemos que no serapropiado adoptar compromisos en mitigacin el sector agropecuario dado que: (a) reducir en t곭inos absolutos las emisiones en el sector agropecuario implicarproducir menos alimentos, lo cual no resulta compatible con el objetivo de salvaguardar la seguridad alimentaria en un contexto de poblaciundial creciente; (b) el sector agropecuario es fundamental para el desarrollo social, econo y rural de nuestro pay (c) el sector es el principal damnificado por el cambio climco (y no su principal causante) por lo que los esfuerzos deben centrarse en adaptaci Es importante resaltar el cumplimiento de las obligaciones multilaterales en la materia a fin de evitar que, con el pretexto de salvaguardar la salud humana o animal se adopten barreras no arancelarias que no tengan otro fin que proteger injustificadamente los mercados nacionales de la competencia extranjera. Atento a ello, se ha acordado que la resistencia a los antimicrobianos solo puede abordarse trabajando conjuntamente entre veterinarios, agricultores, productores de piensos y alimentos, y profesionales de la inocuidad alimentaria, a fin de apoyar las mejores pr⤴icas de sanidad y produccinimal que respalden una utilizaciazonable de las sustancias antimicrobianas. We have noted a number of areas where the report would benefit from a more balanced approach. We also urge the authors to make a stronger case for the centrality of food security and nutrition in sustainable food systems. Food systems are not truly sustainable unless they meet the nutritional needs of populations. Specific comments: pg 9 line 37: Please supply reference for the statement that expected food demand can be met with existing technologies. The three key questions beginning with line 47 seem to better reflect the objectives of the paper. In addition, the other side of this position should be presented: trade and markets can expand diversity and resilience of diets. For example pg 12, line21 for example "Compared with the less diversified diets of rural communities, city dwellers have a varied diet. Pg 12: For balance, the three paragraphs listing the disadvantages of longer supply chains should be balanced by at least one pointing out that larger market networks can expand the diversity and resilience of food supplies. For example, see the conclusion of the section starting on page 50: "Trade and trade liberalization is often a key element in achieving food security and nutrition" and "The experience over many years and many countries demonstrates that the benefits of trade liberalization and globalization clearly outweigh the risks" (pg 51 line 37). Page 18 ͠Footnote: It is odd that the report puts dietary guidance in such a negative light. Footnote #9 is particularly loaded: "In 2015, the American Dietary Guidelines Advisory Committee abandoned previous restrictions on cholesterol and fat and recommended that artificial sweeteners should not be promoted for weight loss. Other studies have created ambiguity over appropriate recommendations on reducing salt, alcohol, coffee and increasing breastfeeding. The exploratory and normative scenarios are a more appropriate fit in section 3, Challenges to Achieving Sustainable Agricultural Development. In addition, the level of detail is not enough to understand the models supporting the scenarios. And, if the authors are proposing the pathways listed on page 25 as the only pathways, they need to supply better justification. What about the possible pathway of technological change to improve yields and the sustainability of natural resource use (and environmental externalities)? The summary paragraph at the top of page 26 seems to acknowledge this possibility. In addition, the wording of the paragraph seems to suggest that local foods have all the benefits listed in the paragraph. Needs balance (or deletion): Should include discussion on the value to consumers of lower priced and varied diets achieved through longer supply chains There is a huge variety of choice in large supermarkets and groceries, including a huge variety of fresh and minimally processed produce. It is incorrect to suggest that consumers in Western countries only have access to foods high in salt, fat and sugar. While empirical evidence finds that strong local food systems in a community can increase employment and income in that community, life-cycle assessments suggest that localization can but does not necessarily reduce energy use or greenhouse gas emissions (or food loss and waste). Pg 41 footnote 14: Over a similar time period, the percentage of fat in pork and beef has dropped. Pg 43 line 25: Should note possibility that livestock intensification can result from diversification, as described on page 34 line 25. How does the definition of sustainable food systems presented earlier fit into this discussion? The para starting on line 35 states that the challenges are discussed in the context of the farming typologies.
The relationships among patient position muscle relaxant metabolism order tizanidine 4mg online, film location spasms temporal area generic tizanidine 2mg on-line, and beam direction vary depending on the specific radiographic information desired spasms of the stomach cheap tizanidine 2 mg with visa. The standard technique for making several extraoral radiographs is discussed in Chapter 12 spasms pregnant belly cheap tizanidine 2mg with amex. Only the panoramic radiograph is described here because it has common use as a radiographic examination for general dental patients xanax muscle relaxant dose order tizanidine 4 mg on-line. We think that it is appropriate to expose patients only when it benefits their health care muscle relaxant and pain reliever buy cheap tizanidine 4mg online. Use of Guidelines to Order Dental Radiographs At any time muscle relaxant you mean whiskey proven 2mg tizanidine, patients generally have a combination of diseases that the clinician must consider spasms stomach quality 4mg tizanidine. Therefore guidelines specify not only which examinations to order but also which specific patient factors influence the number and type of x-ray films to order. The panel addressed the topic of appropriate radiographs for an adequate evaluation of a new or recall asymptomatic patient seeking general dental care. The guidelines were updated in 2004 to reflect changes in technology and to address situations not considered in the first document (Table 15-2). However, there was no change in philosophy between the original and current guidelines. The guidelines describe circumstances (patient age, medical and dental history, and physical signs) that suggest the need for radiographs. The guidelines also suggest the types of radiographic examinations most likely to benefit the patient in terms of yielding diagnostic information. They recommend that radiographs not be made unless some expectation exists that they will provide evidence of diseases that will affect the treatment plan. Central to the guidelines is the idea that dentists should expose patients to radiation only when they reasonably expect that the resulting radiograph will benefit patient care. Accordingly, two situations mandate a radiograph: some clinical evidence of an abnormality that requires further evaluation for a complete assessment or a high probability of disease that warrants a screening examination. Selection criteria for radiographs are those signs or symptoms found in the patient history or clinical examination that suggest that a radiographic examination will yield clinically useful information. A key concept in the use of selection criteria is recognition of the need to consider each patient individually. The guidelines include a description of clinical situations in which radiographs are likely to contribute to the diagnosis, treatment, or prognosis. Two examples highlight the differences between ordering radiographs for dental diseases with clinical signs and symptoms and dental diseases with no clinical indicators but high prevalences. In the first case, a patient has a hard swelling in the premolar region of the mandible with expansion of the buccal and lingual cortical plates. The clinical sign of swelling alerts the dentist to the need for a radiograph to determine the nature of the abnormality causing the swelling. An example of the second situation is the patient who comes seeking general dental care after having not seen a dentist for many years. Even without clinical evidence of caries, bitewings are indicated because of the prevalence of dental caries in the population. Because this patient has not had interproximal radiographs for many years, it is reasonable to assume that the patient may benefit from the radiograph by the detection of interproximal caries. Although no clinical signs exist that predict the presence of early caries, the dentist relies on clinical knowledge of the prevalence of caries to decide that this radiograph has a reasonable probability of finding disease. Without some specific indication, it is inappropriate to expose the patient "just to see if there is something there. The probability of finding occult disease in a patient with all permanent teeth erupted and no clinical or historical evidence of abnormality or risk factors is so low that making a periapical or panoramic radiographic survey just to look for such disease is not indicated. Accordingly, the first step is a careful examination of the patient, including transillumination of the anterior teeth to evaluate for interproximal decay. The clinical examination provides indications as to the nature and extent of the radiographic examination appropriate to the situation. This testing of the use of selection criteria demonstrated that a small but significant number of radiographic findings was not 100% covered in the anterior region if only posterior interproximal and selected periapical radiographs were used. The testing suggested that anterior interproximal radiographs or anterior periapicals are also indicated to detect interproximal caries and periodontal disease in the anterior region, specifically for patients with high levels of dental disease. A panoramic radiograph could be made in place of the periapical radiographs to supplement the posterior bitewings if the totality of the disease expected indicates a broad area of coverage and fine detail is not required. A footnote to Table 15-2 also outlines some other clinical findings that indicate when radiographs are likely to contribute to a complete description of the asymptomatic patient. Applying these guidelines to the specific circumstances with each patient requires clinical judgment and an amalgamation of knowledge, experience, and concern. Clinical judgment is also required to recognize situations that are not described by the guidelines but in which patients will need radiographs nonetheless. Initial Visit the guidelines recommend that a child with primary dentition who is cooperative and has closed posterior contacts have only interproximal radiographs to examine for caries. Additional periapical/occlusal views are recommended only in the case of clinically evident diseases or specific historic or clinical indications such as those listed at the footnote of Table 15-2. If the molar contacts are not closed, interproximal radiographs are not necessary because the proximal surfaces may be examined directly. The guidelines group adolescents and dentate adults together to identify the kind and extent of appropriate radiographic examination. The guidelines recommend that these patients receive an individualized examination consisting of interproximal views and panoramic or periapical views selected on the basis of specific historical or clinical indications. The presence of generalized dental disease often indicates the need for a full-mouth examination. Alternatively, the presence of only a few localized abnormalities or diseases suggests that a more limited examination consisting of interproximal and selected periapical views may suffice. In circumstances with no evidence of current or past dental disease, only interproximal views may be necessary for caries examination. For the edentulous patient presenting for prosthetic treatment, an individualized examination that is based on clinical signs and symptoms should be performed. This may include a panoramic radiograph or selected periapical/occlusal views, with some type of crosssectional examination if dental implants are being considered. Recall Visit Patients who are returning after initial care require careful examination before determining the need for radiographs. As at the initial examination, selected periapical views should be obtained if any of the historical or clinical signs or symptoms listed in the footnote to Table 15-2 are present and need further evaluation. The guidelines recommend interproximal radiographs for recall patients to detect interproximal caries. The optimal frequency for these views depends on the age of the patient and the probability of finding this disease. If the patient has clinically demonstrable caries or the presence of high-risk factors for caries (poor diet, poor oral hygiene, and those listed in the footnote to Table 15-2), then bitewings are exposed at fairly frequent intervals (6 to 12 months for children and adolescents and 6 to 18 months for adults) until no carious lesions are clinically evident. The recommended intervals are longer for individuals not at high risk for caries: 12 to 24 months for the child, 18 to 36 months for the adolescent, and 24 to 36 months for the adult. Note that individuals can change risk category, going from high to low risk or the reverse. Clinical judgment about need for and type of radiographic examination should be used for other circumstances, such as evaluating the status of periodontal disease, monitoring growth and development, and endodontic or restorative considerations. A radiographic examination may be required in a number of other situations, such as for patients contemplating orthodontic or implant treatment or patients with intraosseous lesions. The dentist should determine specifically what type of information is needed and the most appropriate technique for obtaining it. An example of a clinical algorithm for ordering radiographs before orthodontic treatment is shown in Figure 15-1, using guidelines endorsed by the American Academy of Orthodontics. Because guidelines for ordering radiographs for other situations are not as well developed, the dentist must rely on clinical judgment. The x-ray beam is largely confined to the head and neck region in dental x-ray examinations; thus, fetal exposure is only about 1 microgray (Gy) for a full-mouth examination. This exposure is quite small compared with that received normally from natural background sources. Because the use of radiographs in all patients is predicated on there being a diagnostic need for them, the guidelines apply to patients who are pregnant as well as those who are not. Radiation Therapy Patients with a malignancy in the oral cavity or perioral region often receive radiation therapy for their disease. Although such patients are often apprehensive about receiving additional exposure, dental exposure is insignificant compared with what they have already received. The average skin dose from a dental radiograph is approximately 3 milligrays (mGy), less if faster film or digital imaging is used. Furthermore, patients who have received radiation therapy may have radiation-induced xerostomia and thus are at a high risk for development of radiation caries, which may produce serious consequences if extractions are needed in the future. Accordingly, patients who have had radiation therapy to the oral cavity should be carefully followed up because they are at special risk for dental disease. A careful clinical examination reveals that the patient is cooperative and that the posterior teeth are in contact. Radiographs for the detection of development abnormalities are not in order at this age because a complete appraisal cannot be made at age 5 years. Even if it could be made, it is too early to initiate treatment for such abnormalities. No caries is evident on interproximal radiographs made 6 months ago; currently no clinical signs suggest caries, nor does the patient have high-risk factors for caries. No evidence exists of periodontal disease or other remarkable signs or symptoms in general or associated with the recently fractured tooth. Food and Drug Administration Guidelines for Prescribing Dental Radiographs* the recommendations in this table are subject to clinical judgment and may not apply to every patient. Because every precaution should be taken to minimize radiation exposure, protective thyroid collars and aprons should be used whenever possible. This practice is strongly recommended for children, women of childbearing age and pregnant women. Department of Health and Human Services, Public Health Service, Food and Drug Administration; and American Dental Association, Council on Dental Benefit Programs, Council on Scientific Affairs. Clinical situations for which radiographs may be indicated, but are not limited to , include the following: Positive historical findings: Previous periodontal or endodontic treatment, history of pain or trauma, familial history of dental anomalies, postoperative evaluation of healing, remineralization monitoring, presence of implants or evaluation for implant placement. Positive clinical signs/symptoms: clinical evidence of periodontal disease, large or deep restorations, deep carious lesions, malposed or clinically impacted teeth, swelling, evidence of dental/facial trauma, mobility of teeth, sinus tract ("fistula"), clinically suspected sinus pathology, growth abnormalities, oral involvement in known or suspected systemic disease, positive neurologic findings in the head and neck, evidence of foreign objects, pain and/or dysfunction of the temporomandibular joint, facial asymmetry, abutment teeth for fixed or removable partial prosthesis, unexplained bleeding, unexplained sensitivity of teeth, unusual eruption, spacing or migration of teeth, unusual tooth morphology, calcification or color, missing teeth with unknown reason, clinical erosion. At his last visit you placed two mesial, occlusal, distal amalgam restorations on premolars and performed root canal therapy on number 30. The patient has a 5-mm pocket in the buccal furcation of number 3 but no other evidence of periodontal disease. The guidelines recommend that this patient receive interproximal radiographs to see whether he still has active caries and periapical views of numbers 3 and 30 to evaluate the extent of the periodontal disease and periapical disease, respectively. A history exists of root canal therapy in two teeth, although the patient is not aware which teeth were treated. Clinical examination reveals multiple carious teeth, multiple missing teeth, and pockets of more than 3 mm involving most of the remaining teeth. The guidelines recommend a full-mouth examination, including interproximal radiographs, for this patient because of the high probability of finding caries, periodontal disease, and periapical disease. Department of Health and Human Services, Public Health Service, Food 8 1 and Drug Administration, and American Dental Association, Council on Dental Benefit Programs, Council on Scientific Affairs: the selection of patients for dental radiographic examinations, revised ed (2004): Backer Dirks O: Posteruptive changes in dental enamel, J Dent Res 1 2 45(Suppl):503-511, 1966. American Dental Association Council on Scientific Affairs: the use of dental 2 radiographs: update and recommendations, J Am Dent Assoc 137:13041312, 2006. Bruks A, Enberg K, Nordqvist I et al: Radiographic examinations as an aid to 8 orthodontic diagnosis and treatment planning, Swed Dent J 23:77-85, 1999. European Commission: Radiation protection 136, European guidelines on radiation protection in dental radiology: the safe use of radiographs in dental practice, 2004: ec. Hollender L: Decision making in radiographic imaging, J Dent Educ 56:8340 1 843, 1992. Molander B: Panoramic radiography in dental diagnostics, Swed Dent J 3 1 119(Suppl):1-26, 1996. However, reading this chapter, by itself, will not instantly bestow the ability to interpret radiographic films correctly; rather, it will equip the reader with a systematic method of image analysis. T Clinical Examination Radiographs are prescribed when the dentist thinks that they are likely to offer useful diagnostic information that will influence the treatment plan. This clinical information should be used first to select the type of radiographs and later to aid in their interpretation. Because the general practitioner often is responsible both for prescribing and interpreting radiographs, inadequate films should be recognized and supplemental images obtained before proceeding with the analysis. Quality of the Diagnostic Image Before the analysis is started, the quality of the images is examined. For instance, if the image is elongated, greater error occurs in measuring the length of a root canal. Because of the inherent frequency of image distortion in panoramic films, this factor must always be taken into consideration. For example, a region of image magnification involving the mandibular condyle may be diagnosed erroneously as condylar hyperplasia. For this reason, a thorough knowledge of all possible image distortions is a prerequisite for analysis of panoramic images. The practitioner also should check to see whether the density or contrast of the image has been degraded by exposure or developing errors. It may be impossible, for example, to diagnose osteoporosis in an overexposed image, or detail may be obscured in an underexposed film. If the images are of poor quality, it might be prudent to obtain better quality images before proceeding to the analysis. Number and Type of Available Images Initially the clinical examination indicates the number and types of films required (see Chapter 14). The interpretation of these films in turn may suggest the need for additional imaging. Caution should be 256 exercised in attempting to make an interpretation on the basis of a single film, especially if the only film is a panoramic view. Also, a bitewing or periapical projection often can be supplemented by another view produced by altering the horizontal or vertical angulation of the x-ray beam. For example, detection of recurrent caries around a heavily restored dentition may benefit from an additional view taken by altering the angle of the x-ray beam. One of the benefits of a full-mouth series of intraoral films is that it provides a second view of most areas at a slightly different angle. Conventional dental radiography produces images in only two dimensions, usually in the mesiodistal direction. In some cases a view at right angles to the plane of the original film is beneficial. For instance, if a condylar neck fracture is suspected, a lateral view of the condylar region. In a similar fashion, occlusal projections of the jaws can provide a supplementary right-angle view for the periapical film. Use of a vertex occlusal view follows this principle in establishing the location of impacted maxillary cuspids. In some cases an investigation requires other images in addition to intraoral radiography or panoramic images. Techniques such as tomography, sialography, nuclear imaging, cone-beam computed tomography, conventional computed tomography, and magnetic resonance imaging may be required (see Chapter 15). These techniques are available through consultation with an oral and maxillofacial radiologist. Diagnostic imaging should be completed before a biopsy procedure or treatment is provided. Diagnostic imaging can aid in the selection of the most appropriate site for a biopsy procedure to obtain the most representative tissue sample. Also, the biopsy procedure may alter the tissue by inducing inflammatory changes, which in turn alter the imaging characteristics of the tissue. This compromises the diagnostic information that can be obtained, such as determining the extent of a disease. Viewing Conditions Ideally, viewing conditions should include the following characteristics: נAmbient light in the viewing room should be reduced. If the viewing area is larger than the film, an opaque mask should be used to eliminate all light from around the periphery of the film. This mask can be fabricated from a sheet of opaque material cut to fit the entire viewbox, leaving an opening for one film. When images in a digital format are viewed, both room lighting and quality of the monitor are important. Image Analysis When the quality and number of films are satisfactory, analysis of the image begins. A profound knowledge of the variation of normal appearance is required to be able to recognize an abnormal appearance. Because no textbook can display all possible variations, the best learning method is to identify normal anatomy in every film analyzed. In this way the observer can build up a large mental database of the spectrum of normal anatomic appearances. An additional benefit of this procedure is that it forces the observer to examine the entire film. Practitioners should avoid limiting their attention to one particular region of the film; rather, all aspects of each image should be examined systematically. For instance, a bitewing radiograph made to detect caries and alveolar bone loss also may reveal just the edge of an unsuspected intraosseous lesion that will be seen only if the dentist examines the radiograph thoroughly.
Diseases
Vernal keratoconjunctivitis
Chorioretinopathy dominant form microcephaly
Polyarthritis, systemic
Bronchiolitis obliterans with obstructive pulmonary disease
Congenital adrenal hyperplasia due to 11?-hydroxylase deficiency
Branchial arch syndrome X linked
Tsukahara Azuno Kajii syndrome
Fibromuscular dysplasia
Achenbach S spasms just below rib cage buy discount tizanidine 4 mg, Moshage W muscle relaxant anxiety buy generic tizanidine 4 mg online, Ropers D spasms rectum discount tizanidine 4mg otc, et al: Value of electron-beam computed tomography for the noninvasive detection of high-grade coronary-artery stenoses and occlusions muscle relaxant walgreens order 4mg tizanidine otc. The most common imaging approaches are the spin-echo (black blood) and gradient-echo (bright blood with areas of turbulence depicted as regions of low signal intensity) techniques quercetin muscle relaxant order tizanidine 4mg line. Spin-echo imaging is commonly used to assess cardiac anatomy spasms top of stomach purchase tizanidine 2 mg amex, whereas gradient-echo imaging is more commonly used for cine-imaging spasms after gall bladder removal tizanidine 4mg online. Exogenous intravenous contrast (gadolinium-diethylenetriamine pentaacetic acid) may be helpful in some situations but is generally not needed for most current cardiac applications muscle relaxer jokes buy generic tizanidine 4 mg. The "sine qua non" of aortic dissection (see Chapter 66) is the identification of an intimal "flap" separating the true and false lumens. Cine gradient-echo imaging is often obtained to define flap mobility and blood flow in both lumens. Eccentric aortic wall thickening may also be seen and possibly represents an early dissection or intramural hematoma. Diagnosis and serial evaluation of thoracic aorta Aneurysm Dissection Hematoma Coarctation 2. Assessment of simple and complex congenital heart disease Spatial relationships of aorta, pulmonary arteries, cardiac chambers, venous system Identification of anomalous coronary arteries Quantitation of intracardiac shunt 3. Quantitation of ventricular volumes, ejection fraction, mass Quantitative left and right ventricle volumes, ejection fraction, mass Regional and global systolic function 4. Primary or secondary cardiac tumors Especially tumors that involve extracardiac structures 5. Pericardial disease Constriction Pericardial effusions-especially loculated effusions 6. Assessment of specific cardiomyopathies Hypertrophic cardiomyopathy-distribution of hypertrophy Sarcoidosis Hemochromatosis Right ventricular dysplasia 7. Future Coronary artery integrity Atherosclerotic plaque Myocardial perfusion 203 Figure 45-1 Ascending aortic dissection: coronal orientation, gradient-echo sequence. Note that the dissection flap (black arrows) begins immediately superior to the aortic valve leaflet. Signal void (turbulence) is seen in the left ventricular cavity immediately below the aortic valve and is caused by associated aortic insufficiency (curved white arrow). While uncommon, with a prevalence of only 1 to 2%, an anomalous vessel that courses between the aorta and pulmonary artery is associated with an increased Figure 45-2 Anomalous left coronary artery: transverse image, gradient-echo sequence. Semiautomated methods allow for delineation of the endocardial and epicardial borders with very high accuracy/reproducibility and for determination of ventricular volumes, stroke volume, and ejection fraction. With spin-echo imaging, depressed myocardial signal intensity correlates with systolic function, as well as the severity of iron deposition. In contrast, focal signal enhancement may be found with other diseases such as sarcoidosis or myocarditis. The right ventricular free wall (arrows) is thin with enhanced/bright signal within the wall consistent with fatty replacement. Similarly, sternotomy wires and thoracic vascular clips are not a contraindication to imaging, but localized artifacts are common. Faxon Cardiac catheterization and angiography provide the detailed assessment of both anatomy and physiology of the heart and vasculature and are the gold standard for assessment of cardiac disease. The technique was first applied to humans by Werner Forssmann in 1929, but it was expanded into a diagnostic tool by Andre Cournard and Dickinson Richards; in 1956, all three shared the Nobel Prize for their discovery. Selective coronary angiography was introduced by Mason Sones in 1963 and further modified by Melvin Judkins. Cardiac catheterization is now the second most common operative procedure in the United States, with nearly 2 million procedures performed per year. Cardiac catheterization is most commonly performed to determine the nature and extent of a suspected cardiac problem in a symptomatic patient in whom surgical or interventional therapy is anticipated (Table 46-1) (Table Not Available). Because coronary angiography is the only technique capable of accurately defining the severity and extent of coronary disease, it is essential in the assessment of patients being considered for revascularization. If coronary disease is unlikely and non-invasive testing can accurately define the cardiac abnormality, then cardiac catheterization may not be necessary in young adults or children with simple congenital anomalies, such as atrial septal defect, or young adults with valvular heart disease, such as aortic stenosis or mitral stenosis. Even then, valuable prognostic information often can be gathered from the hemodynamic measurements at the time of cardiac catheterization. These risks, however, are increased substantially in certain subsets of patients, such as those patients undergoing an emergency procedure, patients having an acute myocardial infarction, and patients who are hemodynamically unstable. In patients who require catheterization as a prelude to a potentially lifesaving intervention, there are no absolute contraindications, but relative contraindications include acute renal failure, pulmonary edema, bacteremia, acute stroke, active gastrointestinal bleeding, and documented anaphylactic reaction to contrast dye. Of all the potential complications, contrast medium-induced allergic 205 reactions and contrast medium-induced renal failure are particularly important because they are common, even in relatively healthy patients, and precautions can reduce these risks. For example, the frequency of allergic reactions is 5% and life-threatening anaphylactic reactions occur in 0. Pretreatment of patients with prior allergic reactions with corticosteroids, antihistamines, and H2 antagonists can substantially reduce the risk of a subsequent reaction. Contrast medium-induced renal failure occurs in 3 to 7% of all patients but is most common in patients with diabetes and/or pre-existing renal failure, in whom the incidence is 12 to 30%. Diabetics on metformin should have the drug withdrawn 48 hours before the procedure to reduce the risk of contrast medium-induced lactic acidosis. Oral anticoagulation should be stopped before the procedure, but emergent cardiac catheterization can be performed on full anticoagulation or even after the recent administration of thrombolytic agents. The vast majority of procedures are performed percutaneously through the femoral artery and vein. A brachial (or radial or, rarely, axillary) approach is used when peripheral vascular disease precludes access from the lower extremity or when early ambulation after the procedure is critical. After the femoral approach, 4 to 6 hours of local compression and bed rest is desirable before the patient ambulates and is discharged. The most commonly used catheter is a balloon flotation catheter that is introduced into the femoral, brachial, subclavian, or internal jugular vein and then passed with or without fluoroscopic guidance into the right atrium, right ventricle, and pulmonary artery. If necessary, hemodynamic measurement of oxygen saturations can be obtained as the catheter is passed into the pulmonary artery. Once in the pulmonary artery, inflation of the balloon at the tip of the catheter occludes the smaller pulmonary arteries and allows for measurement of the pulmonary capillary wedge pressure, which is nearly always an accurate reflection of left atrial pressure. With a thermistor-tipped balloon, thermal dilution cardiac output can also be obtained. The left-sided cardiac structures can be accessed from the femoral, brachial, radial, or axillary artery. The catheters are passed retrograde under fluoroscopic guidance into the ascending aorta. Because embolization of a clot from a catheter in the arterial circulation could lead to a stroke, heparin is frequently used. Occasionally, left-sided heart catheterization can be accomplished by a needle-tipped catheter that punctures the atrial septum from the right atrial side to enter the left atrium; the needle is withdrawn, and the catheter is advanced to the left ventricle. This technique is reserved for situations in which the left ventricle cannot be accessed by the retrograde approach, such as in patients who have aortic valve prostheses, or when mitral valvuloplasty or invasive electrophysiology studies are being done. The measurement of intracardiac pressure is an essential component of cardiac catheterization and is performed through fluid-filled catheters that are attached to an external pressure transducer (Table 46-2). The shape and magnitude of the waveforms provide important diagnostic information. For example, an elevated mean right atrial pressure associated with a rapid y descent and an early rise (square root sign), with equalization of right atrial, right ventricular diastolic, left atrial, and left ventricular diastolic pressures is characteristic of constrictive pericarditis. Cardiac tamponade (see Chapter 65), on the other hand, results in equalization of diastolic chamber pressures but without a prominent y descent. A large v wave (two times greater than the mean pressure) in the right atrium or left atrium suggests severe tricuspid or mitral regurgitation, respectively. Simultaneous recording of pressures in the proximal and distal cardiac chambers can allow for assessment of valvular stenosis. For instance, a pressure gradient in diastole between the pulmonary capillary wedge or left atrial pressure and the left ventricle is found in patients with mitral stenosis. A gradient between the aorta and left ventricular systolic pressure is present when aortic stenosis (see Chapter 63) occurs. Simultaneous measurement of blood flow is important in assessment of valvular disease. When a premature ventricular contraction induces a large pressure gradient between the aorta and left ventricle as well as a reduction in pulse pressure in the aorta (Brockenbrough effect), hypertrophic obstructive cardiomyopathy (see Chapter 64) is suggested. Severe aortic regurgitation (see Chapter 63) causes an elevation in aortic systolic pressure, a fall in aortic diastolic pressure, and equalization of the end-diastolic pressures in the ventricle and aorta. The Fick method is the most accurate in low cardiac output states, whereas the indicator dilution method is most accurate in high output conditions. The Fick principle states that the amount of a substance taken up or released by an organ is the product of its blood flow and the arterial-venous difference in the concentration of the substance. Because oxygen can be reliably measured, the Fick method determines oxygen consumption by measuring inhaled and exhaled oxygen content and the arterial and venous blood oxygen content. The formula for calculating Fick cardiac output is: where the arterial-venous oxygen difference = 1. The indicator dilution method is based on the Stewart-Hamilton equation, in which cardiac output is determined by the following formula: where I = amount of indicator injected, 60 = sec/min, cm = mean indicator concentration (mg/L), and t = total indicator circulatory time in seconds. The indicator dilution method involves injection of a substance that can be measured in blood. Because the completeness of the mixing of the indicator is critical, injection and sampling are optimally done in cardiac chambers that are not adjacent to each other, for example, injection into the right atrium and sampling in the pulmonary artery. Thermodilution techniques are most common: temperature is the indicator, and the mean change in temperature is the indicator concentration that is sampled distally. Because cardiac output varies with body size, it is customary to calculate the cardiac index (L/min/m2) by dividing cardiac output by body surface area. The resistance through the systemic circulation is calculated as the mean aortic pressure minus the mean right atrial pressure, divided by cardiac output, multiplied by 80 to convert to dynes-seconds-cm-5. Likewise, pulmonary vascular resistance is calculated as mean pulmonary artery pressure minus mean pulmonary capillary wedge pressure multiplied by 80 divided by cardiac output. The most commonly used formula for calculation of valve stenosis is the Gorlin formula, where K is the constant (44. Severe aortic stenosis is considered to be present when the mean valvular gradient is greater than 50 mm Hg and the aortic valve area is less than or equal to 0. Patients with known or suspected congenital heart disease (see Chapter 57) should have hemodynamic assessment and estimation of the location and degree of cardiac shunting if present. Estimation of the shunt can be made by changes in oxygen saturation, as well as by angiography. Measurement of oxygen saturation in each of the cardiac chambers and vessels can detect a "step up" in oxygen content in the right side of the heart when a left-to-right shunt is present or a "step down" in the oxygen content in the left side of the heart when a right-to-left shunt is present. Systemic blood flow can be calculated by the Fick principle by obtaining oxygen saturations from the aorta and both venae cavae. Pulmonary blood flow is calculated using oxygen saturations from the pulmonary artery and left atrium. The shunt ratio (pulmonary blood flow:systemic blood flow) measures the severity of a shunt; for an atrial or ventricular septal defect, a shunt ratio of greater than 1. Angiography is almost always performed during cardiac catheterization by injecting an iodine-containing radiopaque contrast agent. These agents are highly viscous and can cause cardiac arrhythmias and adverse hemodynamic changes due to ionic changes, volume expansion, and negative inotropic effects. Use of more expensive, low osmolar, non-ionic agents reduces these adverse effects. Aortography allows for the assessment of the aortic size and the extent of aortic regurgitation. Left ventriculography is frequently performed with coronary angiography, because it allows for assessment of left ventricular size and function as well as the presence and extent of mitral regurgitation. Left ventricular volume in end-diastole and end-systole can be calculated by the area-length method (normal = 70 Ѡ20 mL and 25 Ѡ10 mL, respectively). Cardiac output is calculated by multiplying the stroke volume times the heart rate. The ventricular contour is seen in diastole in the left panel and in systole in the right panel. The major arteries are the left main, left anterior descending, circumflex, and right coronary arteries. Wall motion abnormalities, which are usually indicative of coronary artery disease, can also be assessed during angiography and classified as hypokinetic (reduced motion), akinetic (no motion), or dyskinetic (paradoxical motion). Estimation of Figure 46-4 An example of a significant stenosis in the left anterior descending coronary artery. Usually 3 to 4+ mitral regurgitation is considered to be of hemodynamic significance and a relative indication for mitral valve surgery. Coronary angiography defines the coronary anatomy, the degree of obstruction of the coronary arteries, and the states of any coronary artery bypass grafts by means of injection of a contrast agent selectively in the ostium of the right or left coronary artery or bypass conduit. The degree of obstruction is expressed as the percent stenosis, which is the ratio of the most severely narrowed segment in any view compared with the "normal" proximal and/or distal segment. Visual assessments can overestimate the severity of the stenosis, but quantitative techniques reduce the variability of the measurement. The normal coronary vasculature can be highly variable but generally includes three major vessels: left anterior descending, left circumflex, and right coronary artery, with the first two emanating from the left main artery. A right dominant circulation occurs when the posterior wall of the left ventricle is served by the right coronary artery, and a left dominant circulation when it is served by the left circumflex artery; it is co-dominant when served by both. Because atherosclerosis is a diffuse process, angiography can underestimate the severity of the disease and does not provide direct assessment of the physiologic significance of a stenosis. Intravascular ultrasound uses a small, flexible catheter with a 20- to 30-mHz transducer at its tip that can be passed over an angioplasty guidewire into the coronary artery. Accurate assessment of the degree of atherosclerosis and the percent stenosis can be obtained by this technique. Intracoronary Doppler flow measurements use a Doppler probe mounted on a small angioplasty-type guidewire. Measurement of the change in flow velocity before and after coronary vasodilation with agents such as adenosine can provide an estimate of coronary flow reserve and help assess the severity of the stenosis. A significant reduction in coronary flow reserve is present when the ratio of flow at rest to flow after vasodilation is less than 2:1. Measurement of blood flow velocity and coronary artery diameter before and after administration of acetylcholine can assess the possibility that coronary vasospasm or abnormalities in coronary endothelial function are present. Both intravascular ultrasound and Doppler flow studies are most commonly used in conjunction with interventional procedures. The most up-to-date review of coronary angiography and indications for the procedure. Heart failure is a heterogeneous syndrome in which an abnormality of cardiac function is responsible for the 208 inability of the heart to pump blood at an output sufficient to meet the requirements of metabolizing tissues and/or to do so only at abnormally elevated diastolic pressures or volumes. The heart failure syndrome is characterized by (1) signs and symptoms of intravascular and interstitial volume overload, including shortness of breath, rales, and edema; and/or (2) manifestations of inadequate tissue perfusion, such as impaired exercise tolerance, fatigue, and renal dysfunction. Heart failure may occur as a result of impaired myocardial contractility (systolic dysfunction, characterized as reduced left ventricular ejection fraction), increased ventricular stiffness or impaired myocardial relaxation (diastolic dysfunction, which is often associated with a preserved left ventricular ejection fraction), a variety of other cardiac abnormalities (including obstructive or regurgitant valvular disease, intracardiac shunting, or disorders of heart rate or rhythm), or states in which the heart is unable to compensate for increased peripheral blood flow or metabolic requirements. In adults, left ventricular involvement is almost always present even if the manifestations are primarily those of right ventricular dysfunction (fluid retention without dyspnea or rales). The focus in this chapter is on the syndrome of chronic heart failure, because the common causes, such as myocardial infarction (see Chapter 60), valvular disease (see Chapter 63), and myocarditis (see Chapter 64) as well as cardiogenic shock (see Chapter 95) are discussed elsewhere. Heart failure is growing in incidence and prevalence and is associated with rising mortality rates. Although these trends primarily reflect the strong association between heart failure and advancing age, they also are influenced by the rising prevalence of precursors such as hypertension, dyslipidemia, and diabetes in industrialized societies and the improved long-term survival of patients with ischemic and other forms of heart disease. The annual incidence of new cases of heart failure rises from less than 1/1000 patient-years below age 45, to 10/1000 above age 65, and as high as 30/1000 (3%) in individuals older than 85 years. Although the relative incidence and prevalence of heart failure are somewhat lower in women than men, women constitute at least half of the cases because of their longer life expectancy. The prognosis of patients with heart failure remains poor despite advances in therapy. Of patients who survive the acute onset of heart failure, only 35% of men and 50% of women are alive after 5 years. Mortality rates are higher in older patients, men, and those with reduced ejection fractions and underlying coronary heart disease. In the United States, nearly 1 million hospitalizations each year with a primary diagnosis of heart failure account for 6 million hospital days. The estimated cost of heart failure management ranges from $15 to 40 billion annually, depending on the formula used. Any condition that causes myocardial necrosis or produces chronic pressure or volume overload can induce myocardial dysfunction and heart failure. In developed countries, the causes of heart failure have changed greatly over the past several decades. Valvular heart disease, with the exception of calcific aortic stenosis, has declined markedly, whereas coronary heart disease has become the predominant cause in both men and women, being responsible for 60 to 75% of cases. Hypertension, although less frequently the primary cause of heart failure than in the past, continues to be a factor in 75%, including the majority of those with coronary disease. Treatment of hypertension, with a focus on the systolic pressure, reduces the incidence of heart failure by 50%. Importantly, this intervention remains effective even in patients older than 75 years of age (see Chapter 55). Heart failure is a syndrome that may result from many cardiac and systemic disorders (Table 47-1). Some of these disorders do not, at least initially, involve the heart, and therefore the term heart failure may be confusing. However, even the high output states may present as the classic findings of exertional dyspnea and edema-so-called high-output heart failure-that resolve if the underlying disorder is eliminated. If persistent, these conditions may secondarily impair myocardial performance as a result of chronic volume overload or direct deleterious effects on the myocardium.
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