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Factor IX Deficiency

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1201. Septic Arthritis, Pediatrics (Follow-up)

drained. Patients may be treated with antibiotics and repeated joint aspiration in cases of involvement of an easily accessible peripheral joint; a clinical course shorter than 6 days; and no evidence of an associated osteomyelitis, immune deficiency, or other chronic illness. If the patient’s condition fails to improve, open drainage is the next approach. Peripheral joints may be adequately drained with arthroscopy if the technology is available. Open drainage is definitely indicated in the hip (...) ):1083-106, ix. . Yagupsky P, Bar-Ziv Y, Howard CB, Dagan R. Epidemiology, etiology, and clinical features of septic arthritis in children younger than 24 months. Arch Pediatr Adolesc Med . 1995 May. 149(5):537-40. . Mataika R, Carapetis JR, Kado J, Steer AC. Acute rheumatic fever: an important differential diagnosis of septic arthritis. J Trop Pediatr . 2008 Jun. 54(3):205-7. . Peltola H, Kallio MJ, Unkila-Kallio L. Reduced incidence of septic arthritis in children by Haemophilus influenzae type-b

2014 eMedicine Surgery

1202. Skull Base Tumors (Follow-up)

beam or helium, is particularly effective for chordoma or chondrosarcoma of the skull base and, if available, is the technique of choice. Despite aggressive therapy, recurrence is common. Gross total surgical resection correlates with lower recurrence rates and is the strongest factor in patient survival. [ ] Nerve sheath tumors Vestibular schwannoma Treatment aims to cure the tumor and preserve neurological function. Surgery using current microsurgical techniques is highly effective. Facial nerve (...) in some preoperative neurological deficits, cranial neuropathies are frequently irreversible. Skull base locations such as the medial sphenoid wing, the clivus, the cerebellopontine angle, and especially the cavernous sinus often allow only subtotal resection because of the high risk of injury to adjacent structures such as the internal carotid artery or cranial nerves. Operative morbidity rates associated with skull base meningiomas can be as high as 14% and is significantly riskier than

2014 eMedicine Surgery

1203. Peripheral Nerve Injuries (Follow-up)

Lacerations In patients who have neurologic deficits after a laceration, an operative procedure to explore the nerve should be performed as soon after injury as possible. With clean, sharp injuries to the nerve, a direct repair is performed. With more crushing or avulsion injuries, the nerve ends are reapproximated so that motor and sensory topography can be aligned. The definitive reconstruction is done at 3 weeks or when the wound permits. [ , ] Gunshot or blast wounds Typically, blast wounds associated (...) with neurologic deficit have good potential for neurologic recovery. Thus, unless an associated vascular or bony problem is present, patients with a neurologic deficit after a gunshot or blast injury are initially managed nonoperatively and monitored with frequent clinical examinations. If, by 3 months after the injury, no evidence of clinical recovery or electrical recovery is noted on electrodiagnostic testing, surgical exploration is recommended. Closed injuries In patients with closed traction injuries

2014 eMedicine Surgery

1204. Deep Venous Thrombosis (Follow-up)

criteria for outpatient management are as follows: Suspected or proven concomitant PE Significant cardiovascular or pulmonary comorbidity Iliofemoral DVT Contraindications to anticoagulation Familial or inherited disorder of coagulation: antithrombin III (ATIII) deficiency, prothrombin 20210A, protein C or protein S deficiency, or factor V Leiden Familial bleeding disorder Pregnancy Morbid obesity (>150 kg) Renal failure (creatinine >2 mg/dL) Unavailable or unable to arrange close follow-up care Unable (...) /vitamin K antagonist regimen. [ ] Anticoagulant therapy is recommended for 3-12 months depending on site of thrombosis and on the ongoing presence of risk factors. If DVT recurs, if a chronic hypercoagulability is identified, or if PE is life threatening, lifetime anticoagulation therapy may be recommended. This treatment protocol has a cumulative risk of bleeding complications of less than 12%. Most patients with confirmed proximal vein DVT may be safely treated on an outpatient basis. Exclusion

2014 eMedicine Surgery

1205. Closed Head Trauma (Follow-up)

months. Previous Next: Transfer Once the patient's acute issues have been addressed, seek long-term placement (eg, long-term acute care, skilled nursing facility, inpatient cognitive rehabilitation center) if the patient continues to require significant medical attention or assistance (eg, because of ventilation, need for significant nursing care). Previous Next: Complications See Secondary injuries. Previous Next: Prognosis The prognosis is affected by many factors, including (1) the type of injury (...) (penetrating vs blunt), (2) severity of the injury and accompanying neurological deficit, (3) the age of the patient, (4) comorbid conditions, and (5) secondary injuries. The (GCS) has been reported to be the most predictive of neurological outcome at 1 year after severe head injury, while the 24-hour GCS score is the strongest predictor of cognitive recovery at 2 years after injury in patients with moderate-to-severe head injury. [ , ] In a study of mortality in 44 elderly patients (≥75 years) who

2014 eMedicine Surgery

1206. Acquired Flatfoot (Follow-up)

is subject to wear and tear. These changes result in marked disruption of collagen bundle orientation and structure and likely predispose to rupture. Epidemiologic studies have not established a clear link between a specific factor and tendon dysfunction. [ ] In one study, 60% of patients were obese or had diabetes mellitus, hypertension, previous surgery or trauma to the medial foot, or treatment with steroids. Myerson described two subsets of patients with PTT dysfunction. [ ] One patient group (...) was younger and had associated enthesopathies at multiple sites, a higher incidence of HLA-B27 positivity, and a significant family history for inflammatory disease and psoriasis; these factors suggested a seronegative spondyloarthropathy. The other patient group was older and had isolated dysfunction; these factors suggested a purely mechanical degenerative cause. Previous Next: Epidemiology Although PTT dysfunction is a common clinical entity, its true incidence or frequency is difficult to ascertain

2014 eMedicine Surgery

1207. Abdominal Trauma, Penetrating (Follow-up)

=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMjAzNjg1OS10cmVhdG1lbnQ= processing > Penetrating Abdominal Trauma Treatment & Management Updated: Jan 13, 2017 Author: Patrick Offner, MD, MPH; Chief Editor: John Geibel, MD, DSc, MSc, AGAF Share Email Print Feedback Close Sections Sections Penetrating Abdominal Trauma Treatment Approach Considerations The management of abdominal trauma varies according to the following factors: Mechanism and location of injury Hemodynamic and neurologic status of the patient Associated injuries Institutional resources Management (...) on a cardiac monitor, pulse oximeter, and 100% nonrebreather oxygen mask. Airway protection and ventilatory support are followed by circulatory resuscitation with fluid infusion. Antibiotics should be administered to patients undergoing exploration. Airway Patients with severe shock or loss of ability to control their airway should be intubated to ensure appropriate oxygenation or ventilation. In general, occult cervical spine injury in penetrating trauma is highly unlikely. Unless there are clear deficits

2014 eMedicine Surgery

1208. Acute Mesenteric Ischemia (Follow-up)

North Am . 1998 Dec. 27(4):783-825, vi. . Boley SJ, Brandt LJ, Sammartano RJ. History of mesenteric ischemia. The evolution of a diagnosis and management. Surg Clin North Am . 1997 Apr. 77(2):275-88. . Liu JJ, Ardolf JC. Sumatriptan-associated mesenteric ischemia. Ann Intern Med . 2000 Apr 4. 132(7):597. . Abu-Daff S, Abu-Daff N, Al-Shahed M. Mesenteric venous thrombosis and factors associated with mortality: a statistical analysis with five-year follow-up. J Gastrointest Surg . 2009 Jul. 13(7):1245 (...) outcome with early diagnosis and prompt anticoagulation therapy. Int J Surg . 2009 Jun. 7(3):210-3. . Ji M, Yoon SN, Lee W, Jang S, Park SH, Kim DY, et al. Protein S deficiency with a PROS1 gene mutation in a patient presenting with mesenteric venous thrombosis following total colectomy. Blood Coagul Fibrinolysis . 2011 Oct. 22(7):619-21. . Kumar S, Sarr MG, Kamath PS. Mesenteric venous thrombosis. N Engl J Med . 2001 Dec 6. 345(23):1683-8. . Abdu RA, Zakhour BJ, Dallis DJ. Mesenteric venous

2014 eMedicine Surgery

1209. Transfusion and Autotransfusion (Diagnosis)

to at least 4 units of FFP to effect a therapeutic response. Efficacy is monitored by laboratory tests of coagulation function, including prothrombin time (PT), activated partial thromboplastin time (aPTT), and the international normalized ratio (INR). Platelets Platelet transfusion may be beneficial in patients with platelet deficiency or dysfunction. Prophylactic platelet transfusion is indicated in patients with bone marrow failure, no other associated risk factors for bleeding, and platelet counts (...) cause of the hemorrhage is being addressed. Common etiologies to be corrected include, but are not limited to, large volume hemorrhage control failure (solid organ or vascular conduit), hypothermia, acidosis, traumatic brain injury, individual factor deficiencies, and acquired inhibitors of coagulation. The optimal time to measure the effect of platelet transfusion is 1 hour after the completion of the infusion. This timeframe allows one to discern an appropriate increase from ongoing consumption

2014 eMedicine Surgery

1210. Transfusion and Autotransfusion (Follow-up)

to at least 4 units of FFP to effect a therapeutic response. Efficacy is monitored by laboratory tests of coagulation function, including prothrombin time (PT), activated partial thromboplastin time (aPTT), and the international normalized ratio (INR). Platelets Platelet transfusion may be beneficial in patients with platelet deficiency or dysfunction. Prophylactic platelet transfusion is indicated in patients with bone marrow failure, no other associated risk factors for bleeding, and platelet counts (...) cause of the hemorrhage is being addressed. Common etiologies to be corrected include, but are not limited to, large volume hemorrhage control failure (solid organ or vascular conduit), hypothermia, acidosis, traumatic brain injury, individual factor deficiencies, and acquired inhibitors of coagulation. The optimal time to measure the effect of platelet transfusion is 1 hour after the completion of the infusion. This timeframe allows one to discern an appropriate increase from ongoing consumption

2014 eMedicine Surgery

1211. Pes Planus (Overview)

is subject to wear and tear. These changes result in marked disruption of collagen bundle orientation and structure and likely predispose to rupture. Epidemiologic studies have not established a clear link between a specific factor and tendon dysfunction. [ ] In one study, 60% of patients were obese or had diabetes mellitus, hypertension, previous surgery or trauma to the medial foot, or treatment with steroids. Myerson described two subsets of patients with PTT dysfunction. [ ] One patient group (...) was younger and had associated enthesopathies at multiple sites, a higher incidence of HLA-B27 positivity, and a significant family history for inflammatory disease and psoriasis; these factors suggested a seronegative spondyloarthropathy. The other patient group was older and had isolated dysfunction; these factors suggested a purely mechanical degenerative cause. Previous Next: Epidemiology Although PTT dysfunction is a common clinical entity, its true incidence or frequency is difficult to ascertain

2014 eMedicine Surgery

1212. Abdominal Trauma, Penetrating (Overview)

depends on various factors, including the type of penetrating weapon or object, the range from which the injury occurred, which organs may be injured, and the location and number of wounds. Close-range injuries transfer more kinetic energy than those sustained at a distance, although range is often difficult to ascertain when assessing gunshot wounds. A gunshot wound is caused by a missile propelled by combustion of powder. These wounds involve high-energy transfer and, consequently, can involve (...) includes assessment of the following: Airway, breathing, circulation (ABCs): Includes vital signs level of consciousness (D, disability): To detect neurologic deficits Location(s) of the wound(s) (E, exposure): Inspect all body surfaces, and document all penetrating wounds Type of penetrating weapon or object Amount of blood loss The secondary survey is a complete head-to-toe physical examination in hemodynamically stable patients and includes external inspection with respect to anatomic landmarks

2014 eMedicine Surgery

1213. Acute Mesenteric Ischemia (Overview)

with atherosclerosis, [ ] AMI is commonly considered a disease of the older population, with the typical age of onset being older than 60 years. Nevertheless, younger people who have atrial fibrillation or risk factors for MVT, such as oral contraceptive use or hypercoagulable states (eg, those caused by protein C or S deficiency), may present with AMI. No overall sex preference exists for AMI. Men might be at higher risk for occlusive arterial disease because they have a higher incidence of atherosclerosis (...) predisposing factors, clinical pictures, and prognoses. A secondary clinical entity of mesenteric ischemia occurs as a consequence of mechanical obstruction (eg, from internal hernia with strangulation, volvulus, or intussusception). Tumor compression, aortic dissection and postangiography thrombosis [ ] are other reported causes. Occasionally, blunt trauma may cause isolated dissection of the superior mesenteric artery (SMA) and lead to intestinal infarction. Because the four types of AMI share

2014 eMedicine Surgery

1214. Acquired Flatfoot (Overview)

is subject to wear and tear. These changes result in marked disruption of collagen bundle orientation and structure and likely predispose to rupture. Epidemiologic studies have not established a clear link between a specific factor and tendon dysfunction. [ ] In one study, 60% of patients were obese or had diabetes mellitus, hypertension, previous surgery or trauma to the medial foot, or treatment with steroids. Myerson described two subsets of patients with PTT dysfunction. [ ] One patient group (...) was younger and had associated enthesopathies at multiple sites, a higher incidence of HLA-B27 positivity, and a significant family history for inflammatory disease and psoriasis; these factors suggested a seronegative spondyloarthropathy. The other patient group was older and had isolated dysfunction; these factors suggested a purely mechanical degenerative cause. Previous Next: Epidemiology Although PTT dysfunction is a common clinical entity, its true incidence or frequency is difficult to ascertain

2014 eMedicine Surgery

1215. Pes Planus (Follow-up)

the need for prolonged below-knee immobilization, chemoprophylaxis for venous thromboembolism (VTE) typically is not necessary unless three or more VTE risk factors are present. [ ] Weightbearing is permitted if the patient is able to ambulate without pain. If improvement is noted, the patient may be placed in custom full-length semirigid orthotics. He or she may then be referred to physical therapy for stretching of the Achilles tendon and strengthening of the PTT. Steroid injection into the PTT (...) or through the calcaneocuboid joint achieves arch correction, but it requires an iliac crest tricortical graft and risks nonunion or overcorrection. In large or obese patients, subtalar or talonavicular fusion may be needed to achieve long-term correction, though these procedures limit hindfoot motion significantly. The most biomechanically sound surgical treatments may be those that use tendon transfer to substitute for the deficient PTT, with LCL to restore alignment of the subtalar and talonavicular

2014 eMedicine Surgery

1216. Mesenteric Venous Thrombosis (Follow-up)

with atherosclerosis, [ ] AMI is commonly considered a disease of the older population, with the typical age of onset being older than 60 years. Nevertheless, younger people who have atrial fibrillation or risk factors for MVT, such as oral contraceptive use or hypercoagulable states (eg, those caused by protein C or S deficiency), may present with AMI. No overall sex preference exists for AMI. Men might be at higher risk for occlusive arterial disease because they have a higher incidence of atherosclerosis (...) predisposing factors, clinical pictures, and prognoses. A secondary clinical entity of mesenteric ischemia occurs as a consequence of mechanical obstruction (eg, from internal hernia with strangulation, volvulus, or intussusception). Tumor compression, aortic dissection and postangiography thrombosis [ ] are other reported causes. Occasionally, blunt trauma may cause isolated dissection of the superior mesenteric artery (SMA) and lead to intestinal infarction. Because the four types of AMI share

2014 eMedicine Surgery

1217. Mesenteric Artery Thrombosis (Follow-up)

with atherosclerosis, [ ] AMI is commonly considered a disease of the older population, with the typical age of onset being older than 60 years. Nevertheless, younger people who have atrial fibrillation or risk factors for MVT, such as oral contraceptive use or hypercoagulable states (eg, those caused by protein C or S deficiency), may present with AMI. No overall sex preference exists for AMI. Men might be at higher risk for occlusive arterial disease because they have a higher incidence of atherosclerosis (...) predisposing factors, clinical pictures, and prognoses. A secondary clinical entity of mesenteric ischemia occurs as a consequence of mechanical obstruction (eg, from internal hernia with strangulation, volvulus, or intussusception). Tumor compression, aortic dissection and postangiography thrombosis [ ] are other reported causes. Occasionally, blunt trauma may cause isolated dissection of the superior mesenteric artery (SMA) and lead to intestinal infarction. Because the four types of AMI share

2014 eMedicine Surgery

1218. Mesenteric Artery Ischemia (Follow-up)

with atherosclerosis, [ ] AMI is commonly considered a disease of the older population, with the typical age of onset being older than 60 years. Nevertheless, younger people who have atrial fibrillation or risk factors for MVT, such as oral contraceptive use or hypercoagulable states (eg, those caused by protein C or S deficiency), may present with AMI. No overall sex preference exists for AMI. Men might be at higher risk for occlusive arterial disease because they have a higher incidence of atherosclerosis (...) predisposing factors, clinical pictures, and prognoses. A secondary clinical entity of mesenteric ischemia occurs as a consequence of mechanical obstruction (eg, from internal hernia with strangulation, volvulus, or intussusception). Tumor compression, aortic dissection and postangiography thrombosis [ ] are other reported causes. Occasionally, blunt trauma may cause isolated dissection of the superior mesenteric artery (SMA) and lead to intestinal infarction. Because the four types of AMI share

2014 eMedicine Surgery

1219. Rhabdomyolysis (Diagnosis)

myoglobin Imaging studies generally play only a small diagnostic role but may be considered in particular settings, as follows: Radiography (suspected fracture) Computed tomography (CT) of the head (altered sensorium, significant head trauma, seizure, neurologic deficits of unknown origin) Magnetic resonance imaging (MRI; assessment of myopathy) Other tests that may be considered include the following: Electrocardiography (ECG) Measurement of compartment pressures Muscle biopsy Immunoblotting (...) Borrelia burgdorferi Clostridium perfringens Clostridium tetani Viridans streptococci Plasmodium species Rickettsia species Salmonella species [ ] Listeria species Legionella species [ ] Mycoplasma species [ ] Vibrio species Brucella species Bacillus species Leptospira species [ ] Fungal infectious agents that may cause rhabdomyolysis include the following [ ] : Candida species Aspergillus species Metabolic and genetic factors Certain genetic muscle defects are believed to cause rhabdomyolysis because

2014 eMedicine Emergency Medicine

1220. Stroke, Hemorrhagic (Diagnosis)

and may cause up to 10% of intracerebral hemorrhages. Rarely, cerebral amyloid angiopathy can be caused by mutations in the amyloid precursor protein and is inherited in an autosomal dominant fashion. Coagulopathies Coagulopathies may be acquired or inherited. Liver disease can result in a bleeding diathesis. Inherited disorders of coagulation such as factor VII, VIII, IX, X, and XIII deficiency can predispose to excessive bleeding, and intracranial hemorrhage has been seen in all of these disorders (...) . Focal neurologic deficits The type of deficit depends on the area of brain involved. If the dominant (usually the left) hemisphere is involved, a syndrome consisting of the following may result: Right hemiparesis Right hemisensory loss Left gaze preference Right visual field cut Aphasia Neglect (atypical) If the nondominant (usually the right) hemisphere is involved, a syndrome consisting of the following may result: Left hemiparesis Left hemisensory loss Right gaze preference Left visual field cut

2014 eMedicine Emergency Medicine

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