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Fetal Foot Measurement

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181. Shock and Pregnancy (Follow-up)

of fetal hypoxia, particularly when they are recurrent and combined with decreased variability. Abnormalities of FHR patterns may be further evaluated by using results from a fetal biophysical profile. The fetal biophysical profile consists of an ultrasound determination of fetal movements, fetal breathing movements, limb tone, amniotic fluid volume, and reactivity to nonstress testing. Fetal acid-base measurements from scalp blood sampling are used in labor to assess the state of fetal physiology (...) . A pH less than 7.20 indicates fetal hypoxia, whereas a pH greater than 7.25 predicts a favorable outcome. Fetal pH monitoring can be performed only when membranes are ruptured. Fetal oxygen saturation is a new intrapartum fetal monitoring technology, which is expected to provide a more complete and accurate assessment of the fetal condition. This technique directly and objectively measures fetal oxygen status during labor and delivery. Fetal pulse oximetry has been approved for use

2014 eMedicine.com

182. Sickle Cell Anemia (Follow-up)

therapy is emerging as a possible cure for severe SCD. Experimental approaches include modification of autologous stem cells with lentiviral vectors to add normal globin genes, gene editing to correct the sickle cell disease mutation, and manipulations to enhance production of fetal hemoglobin. [ ] Successful results in individual patients has been reported, and clinical trials are planned or in progress. [ , ] Next: Hydroxyurea Therapy Although several pharmacological agents have been studied (...) for the treatment of SCD, the only drug currently approved by the US Food and Drug Administration (FDA) for the treatment of SCD is hydroxyurea. For frequent and severe pain, long-term hydroxyurea is currently the accepted treatment. [ ] Hydroxyurea increases total and fetal hemoglobin in children with SCD. [ ] The increase in fetal hemoglobin retards gelation and sickling of RBCs. Hydroxyurea also reduces levels of circulating leukocytes, which decreases the adherence of neutrophils to the vascular endothelium

2014 eMedicine.com

183. Myelomeningocele (Diagnosis)

, and the placode-containing remnants of nervous tissue can be observed in the center of the lesion, which is filled with cerebrospinal fluid. Myelomeningocele in a newborn. Blood tests, amniocentesis, or both can be used to screen for neural tube defects. These typically are used in combination with fetal ultrasonography. (See Workup.) Prenatal detection and postatal closure in the first few days of life are clinically associated with lower levels of care and fewer complications in spina bifida. [ ] Treatment (...) of coordinating with multiple doctors and can ensure the availability of necessary services. Transitioning from pediatric to adult care has been reported to maintain quality-of-life measures. [ , ] The physical medicine and rehabilitation specialist assumes a significant role in coordinating the many treatment components that together allow patients to gain maximum function and, particularly, independence. (See Treatment.) Participation in the care of patients with major, chronic physical disabilities

2014 eMedicine.com

184. Neovascular Membranes, Subretinal (Diagnosis)

: what's new. Ann Acad Med Singapore . 2002 May. 31(3):399-404. . Hunt DW, Margaron P. Status of therapies in development for the treatment of age-related macular degeneration. IDrugs . 2003 May. 6(5):464-9. . Hooper CY, Guymer RH. New treatments in age-related macular degeneration. Clin Experiment Ophthalmol . 2003 Oct. 31(5):376-91. . Frennesson C, Nilsson SE. [Age-related macular degeneration--new possibilities for prophylactic measures]. Lakartidningen . 2002 Aug 8. 99(32-33):3194-7. . Fong DS. Age (...) . Br J Ophthalmol . 1996 Apr. 80(4):314-8. . . Castellarin AA, Nasir M, Sugino IK, Zarbin MA. Progressive presumed choriocapillaris atrophy after surgery for age-related macular degeneration. Retina . 1998. 18(2):143-9. . Zhang X, Bok D. Transplantation of retinal pigment epithelial cells and immune response in the subretinal space. Invest Ophthalmol Vis Sci . 1998 May. 39(6):1021-7. . Algvere PV, Berglin L, Gouras P, Sheng Y. Transplantation of fetal retinal pigment epithelium in age-related

2014 eMedicine.com

185. Diabetes Mellitus, Type 2 (Diagnosis)

their SMBG data, but they should also reevaluate the ongoing need for and frequency of SMBG at each routine visit. Approaches to prevention of diabetic complications include the following: HbA1c every 3-6 months Yearly dilated eye examinations Annual microalbumin checks Foot examinations at each visit Blood pressure < 130/80 mm Hg, lower in diabetic nephropathy Statin therapy to reduce low-density lipoprotein cholesterol See and for more detail. Next: Background Type 2 diabetes mellitus consists (...) measurements to confirm reduced pancreatic volume in individuals with a median 15-year history of diabetes mellitus (range, 5-26 years). [ ] This may also explain the associated exocrine deficiency seen in prolonged diabetes. Beta-cell dysfunction Beta-cell dysfunction is a major factor across the spectrum of prediabetes to diabetes. A study of obese adolescents by Bacha et al confirms what is increasingly being stressed in adults as well: Beta-cell dysfunction develops early in the pathologic process

2014 eMedicine.com

186. Dermatologic Manifestations of Hematologic Disease (Diagnosis)

criteria) for definite APS. The criteria, developed by consensus among international clinical and laboratory experts, were originally referred to in 1999 as the Sapporo criteria [ ] and then modified at a meeting in Sydney in 2006. [ ] The primary diagnostic criteria include arterial thrombosis, venous thrombosis, recurrent fetal loss, and thrombocytopenia. One of the listed primary criteria is required for diagnosis, combined with a sustained elevated titer of immunoglobulin G (IgG) anticardiolipin (...) . [ ] According to the Cooperative Study of Sickle Cell Disease, approximately 25% of patients with sickle cell disease in the United States have a history of active ulcers or developed ulcers during the 8 years of observation. The incidence is low in children younger than 10 years because of the protective effect of persistent fetal hemoglobin. Other risk factors for developing leg ulceration are anemia, male sex, combined HLA-B35 and HLA-Cw4, and antithrombin III deficiency. Based on clinical experience

2014 eMedicine.com

187. Breech Presentation (Diagnosis)

, and the entire fetus is extracted. Total breech extraction should be used only for a noncephalic second twin; it should not be used for a singleton fetus because the cervix may not be adequately dilated to allow passage of the fetal head. Total breech extraction for the singleton breech is associated with a birth injury rate of 25% and a mortality rate of approximately 10%. Total breech extractions are sometimes performed by less experienced accoucheurs when a foot unexpectedly prolapses through the vagina (...) subjects in the planned vaginal delivery group, 591 (56.7%) had vaginal deliveries. Indications for cesarean delivery included: fetopelvic disproportion or failure to progress in labor (226), nonreassuring fetal heart rate tracing (129), footling breech (69), request for cesarean delivery (61), obstetrical or medical indications (45), or cord prolapse (12). The composite measurement of either perinatal mortality or serious neonatal morbidity by 6 weeks of life was significantly lower in the planned

2014 eMedicine.com

188. Viral Infections of the Mouth (Diagnosis)

currently unproved. [ , , ] HHV-7 has been isolated from the saliva of healthy adults and has been implicated as one cause of roseola infantum and febrile seizures in children. HHV-8 is associated with (KS), and evidence links it with body-cavity lymphomas and Castleman disease. Pathophysiology Herpesvirus family members are icosahedral DNA viruses. A herpesvirus measures approximately 100 nm without an envelope or 150 nm with an envelope. HHVs replicate in the host cell nucleus. Infected saliva (...) infection as measured by HPV detection in oral rinses (discussed above), oral HPV has to be considered as a sexual transmitted virus and requires counseling of patients by healthcare providers. This counseling must include informing the patients of the up-to-date knowledge on the mode of transmission of oropharyngeal HPV and the possible risks associated with it. This issue is pertinent to deciding on HPV vaccination especially for male patients. Finally, for this reason, younger adolescents

2014 eMedicine.com

189. Viral Infections and Pregnancy (Diagnosis)

is possible with examination at 5 or more weeks following the initial time of suspected VZV infection in the first trimester. Ultrasonographic findings include limb abnormalities such as hypoplasia, stippling of the epiphyseal plates, and club-foot deformities. Ventriculomegaly may also be present. Fetal echocardiography should be performed to assess for fetal cardiac abnormalities, with a follow-up postnatally in infants with CRS to evaluate for cardiac defects, including patent ductus arteriosus (...) Infections and Pregnancy Updated: May 02, 2017 Author: Teresa Marino, MD; Chief Editor: Christine Isaacs, MD Share Email Print Feedback Close Sections Sections Viral Infections and Pregnancy Background Viral infections in pregnancy are major causes of maternal and fetal morbidity and mortality. Infections can develop in the neonate transplacentally, perinatally (from vaginal secretions or blood), or postnatally (from breast milk or other sources). The clinical manifestations of neonatal infections vary

2014 eMedicine.com

190. Breech Presentation (Follow-up)

, and the entire fetus is extracted. Total breech extraction should be used only for a noncephalic second twin; it should not be used for a singleton fetus because the cervix may not be adequately dilated to allow passage of the fetal head. Total breech extraction for the singleton breech is associated with a birth injury rate of 25% and a mortality rate of approximately 10%. Total breech extractions are sometimes performed by less experienced accoucheurs when a foot unexpectedly prolapses through the vagina (...) subjects in the planned vaginal delivery group, 591 (56.7%) had vaginal deliveries. Indications for cesarean delivery included: fetopelvic disproportion or failure to progress in labor (226), nonreassuring fetal heart rate tracing (129), footling breech (69), request for cesarean delivery (61), obstetrical or medical indications (45), or cord prolapse (12). The composite measurement of either perinatal mortality or serious neonatal morbidity by 6 weeks of life was significantly lower in the planned

2014 eMedicine.com

191. Lyme Disease (Diagnosis)

the following image for examples of each stage). Only larvae, nymphs, and adult female ticks require blood meals, and only ticks in the nymphal and adult stages can transmit B burgdorferi. Magnified ticks at various stages of development. The life cycle of Ixodes ticks spans 2 years (see the image below). The adult lays eggs in the spring, and the larvae emerge in the summer. The larvae feed once, in late summer, on any of a wide variety of small animals (eg, the white-footed mouse) . The following spring (...) , the larvae emerge as nymphs. Nymphs feed once, in the spring and summer. The white-footed mouse is the preferred feeding source of nymphs, but other animals apparently suffice. Nymphs molt into adults the following fall and feed once on a larger animal, with the white-tailed deer being the preferred host. Life cycle of the Ixodes dammini tick. Courtesy of Elsevier. Ticks can acquire B burgdorferi from feeding on an infected animal host during any of the three life-cycle stages. Unless the tick has fed

2014 eMedicine.com

192. Lyme Disease (Diagnosis)

the following image for examples of each stage). Only larvae, nymphs, and adult female ticks require blood meals, and only ticks in the nymphal and adult stages can transmit B burgdorferi. Magnified ticks at various stages of development. The life cycle of Ixodes ticks spans 2 years (see the image below). The adult lays eggs in the spring, and the larvae emerge in the summer. The larvae feed once, in late summer, on any of a wide variety of small animals (eg, the white-footed mouse) . The following spring (...) , the larvae emerge as nymphs. Nymphs feed once, in the spring and summer. The white-footed mouse is the preferred feeding source of nymphs, but other animals apparently suffice. Nymphs molt into adults the following fall and feed once on a larger animal, with the white-tailed deer being the preferred host. Life cycle of the Ixodes dammini tick. Courtesy of Elsevier. Ticks can acquire B burgdorferi from feeding on an infected animal host during any of the three life-cycle stages. Unless the tick has fed

2014 eMedicine.com

193. Lyme Disease (Diagnosis)

the following image for examples of each stage). Only larvae, nymphs, and adult female ticks require blood meals, and only ticks in the nymphal and adult stages can transmit B burgdorferi. Magnified ticks at various stages of development. The life cycle of Ixodes ticks spans 2 years (see the image below). The adult lays eggs in the spring, and the larvae emerge in the summer. The larvae feed once, in late summer, on any of a wide variety of small animals (eg, the white-footed mouse) . The following spring (...) , the larvae emerge as nymphs. Nymphs feed once, in the spring and summer. The white-footed mouse is the preferred feeding source of nymphs, but other animals apparently suffice. Nymphs molt into adults the following fall and feed once on a larger animal, with the white-tailed deer being the preferred host. Life cycle of the Ixodes dammini tick. Courtesy of Elsevier. Ticks can acquire B burgdorferi from feeding on an infected animal host during any of the three life-cycle stages. Unless the tick has fed

2014 eMedicine.com

194. Lyme Disease (Diagnosis)

the following image for examples of each stage). Only larvae, nymphs, and adult female ticks require blood meals, and only ticks in the nymphal and adult stages can transmit B burgdorferi. Magnified ticks at various stages of development. The life cycle of Ixodes ticks spans 2 years (see the image below). The adult lays eggs in the spring, and the larvae emerge in the summer. The larvae feed once, in late summer, on any of a wide variety of small animals (eg, the white-footed mouse) . The following spring (...) , the larvae emerge as nymphs. Nymphs feed once, in the spring and summer. The white-footed mouse is the preferred feeding source of nymphs, but other animals apparently suffice. Nymphs molt into adults the following fall and feed once on a larger animal, with the white-tailed deer being the preferred host. Life cycle of the Ixodes dammini tick. Courtesy of Elsevier. Ticks can acquire B burgdorferi from feeding on an infected animal host during any of the three life-cycle stages. Unless the tick has fed

2014 eMedicine.com

195. Cancer and Rehabilitation (Diagnosis)

of the patient with cancer are described below. Preventive interventions Preventive (or "preventative") interventions lessen the effect of expected disabilities and emphasize patient education. Preventive measures also include approaches to improving the patient's physical functioning and general health status. In addition, psychological counseling before treatment can assist with the early identification of adjustment issues to allow for prompt intervention. Restorative interventions Restorative (...) exercise, sports, psychoeducation, and information. Measurements were performed before and after 6 weeks of rehabilitation to assess symptom-limited bicycle ergometry performance, muscle force, and QOL (on the RAND-36 instrument, Rotterdam Symptom Checklist [RSCL], and Multidimensional Fatigue Inventory [MFI]). Statistically significant improvements were found in symptom-limited bicycle ergometry performance, muscle force, and several domains of the QOL instruments (RAND-36, RSCL, and MFI

2014 eMedicine.com

196. Charcot-Marie-Tooth Disease (Diagnosis)

of the CMT neuropathy score as a measure of disability. Neurology . 2005 Apr 12. 64(7):1209-14. . Burns J, Ouvrier R, Estilow T, Shy R, Laurá M, Pallant JF, et al. Validation of the Charcot-Marie-Tooth disease pediatric scale as an outcome measure of disability. Ann Neurol . 2012 May. 71(5):642-52. . . Siskind CE, Panchal S, Smith CO, Feely SM, Dalton JC, Schindler AB, et al. A review of genetic counseling for Charcot Marie Tooth disease (CMT). J Genet Couns . 2013 Aug. 22(4):422-36. . Media Gallery Foot (...) syndrome eventually are likely to become distinguishable. Next: Pathophysiology Charcot-Marie-Tooth disease (CMT) is actually a heterogeneous group of genetically distinct disorders with a similar clinical presentation. CMT-1A is a disorder of peripheral myelination resulting from a duplication in the peripheral myelin protein-22 ( PMP22 ) gene. [ , ] PMP22 -related neuropathies should be viewed as the consequence of impaired neuron–Schwann cell interactions that are likely to be operative during fetal

2014 eMedicine.com

197. Catatonia (Diagnosis)

and to not move [ ] ) Automatic obedience (following all commands of the examiner including inflicting harm on self and others) Stereotypies (eg, nose wrinkling; repetitive movements of the mouth and the jaw; repetitive eye movements; repetitive tapping of the foot, the finger, or the hand; and repetitive abdomen patting, shoulder shrugging, or body rocking) Preservation (the inappropriate repetition of acts) Echophenomena (echolalia [repeating the movements of others] and echopraxia [repeating the words (...) disorders Deficits in fetal cortical development may result in and other developmental disorders. [ ] These deficits, in turn, likely produce dysfunction in cortical and subcortical glutamatergic pathways, resulting in the symptoms and signs of catatonia. [ , ] Individuals with developmental disability, autism, or other developmental disabilities may be particularly vulnerable to developing catatonia. [ , , , , , , ] Imbalances in the excitatory-to-inhibitory ratio (EIR) may play a role. Baguley

2014 eMedicine.com

198. Anterior Cruciate Ligament Injury (Diagnosis)

physical examination. Lachman test The Lachman test is the most sensitive test for acute ACL rupture. It is performed with the knee in 30° of flexion, with the patient lying supine. The amount of displacement (in mm) and the quality of endpoint are assessed (eg, firm, marginal, soft). Asymmetry in side-to-side laxity or a soft endpoint is indicative of an ACL tear. Although difficult to measure, a side-to-side difference of greater than 3 mm is considered abnormal. Pivot shift test The pivot shift test (...) is performed by extending an ACL-deficient knee, which results in a small amount of anterior translation of the tibia in relation to the femur. During flexion, the translation reduces, resulting in the "shifting or pivoting" of the tibia into its proper alignment on the femur. It is performed with the leg extended and the foot in internal rotation, and a valgus stress is applied to the tibia. Anterior drawer test The anterior drawer test is performed with the knee at 90° flexion, with the patient lying

2014 eMedicine.com

199. Assessment of Neuromuscular Transmission (Diagnosis)

foot muscle. If facilitation less than 100% is seen in a hand muscle, another hand muscle should be tested. Nerve stimulation at 20 Hz may be used instead of voluntary contraction to activate the muscle, although the authors find the voluntary contraction technique to be more sensitive and less painful. The size of the maximum CMAP after stimulation for 5-7 seconds is compared with that of the initial response (see image below). Measuring the area of these CMAPs is difficult, so the amplitudes (...) . Bradycardia is a possible adverse effect, particularly in elderly patients, and ECG monitoring is advisable in this patient population. should be available at the bedside when performing the Tensilon test. Supportive respiratory measures should also be readily available when administering Tensilon because some patients are rather sensitive to even a small dose. Worsening weakness after administration of these doses of Tensilon (a paradoxical response) is also indicative of impaired neuromuscular

2014 eMedicine.com

200. Rheumatoid Arthritis (Treatment)

and symptoms and quality of life, all biologic agents significantly retard radiographic progression of joint erosions. Biologic DMARDs include agents such as adalimumab, certolizumab, etanercept, golimumab and infliximab. DMARDs represent the most important measure in the successful treatment of RA. These agents can retard or prevent disease progression and, thus, joint destruction and subsequent loss of function. Successful DMARD therapy may eliminate the need for other anti-inflammatory or analgesic (...) with an initial onset of previously undiagnosed possible RA require symptomatic treatment with NSAIDs and rapid referral for definitive diagnosis and institution of DMARD therapy. A delay of as little as 2-3 months in initiating joint-sparing therapy results in significant irreversible joint damage measured radiographically at 5 years. In patients with known disease, increased pain, edema, and dysfunction are characteristics of rheumatoid flare (exacerbation). Flares may be local or systemic in nature

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2014 eMedicine.com

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