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  • Professor of Pediatrics
  • Professor in Medicine
  • Affiliate of Duke Molecular Physiology Institute


Aortic regurgitation may result from paravalvular leak related to northside pain treatment center atlanta aspirin 100 pills on line uneven calcification of the annulus knee pain treatment yahoo discount aspirin uk. Vascular events may require immediate surgical correction with sternotomy and cardiopulmonary bypass but carry a very high mortality risk lower back pain treatment videos cheap aspirin 100pills without prescription. Non-revascularised coronary artery disease is common and so percutaneous revascularisation may often need to back pain treatment during pregnancy safe aspirin 100pills be achieved beforehand as part of a staged revascularisation blue ridge pain treatment center buy 100 pills aspirin free shipping. As described previously pain medication for dogs list order aspirin on line, coronary obstruction may occur due to a misplaced device or valve leaflet occlusion of coronaries arising low in the sinus of Valsalva. The risk is falling possibly due to smaller catheters being used, causing less trauma or obstruction of vessels leaving the aortic arch. Embolic filters placed in the brachiocephalic and left common carotid artery 6 have led to reductions in cerebral lesions. This usually improves due to an increase in cardiac output, but factors associated with deterioration include use of contrast, hypoperfusion and 2 the need for blood transfusion. Clinical and echocardiographic follow-up of valves over 5 years is well documented and late leaflet failure is rare. There are indications that a reoperation on these patients 10 years later would not be straightforward. Surgery would initially be routine to access the aorta but then the degree of implant fibrosis into the root could result in more major surgery with aortic root replacement. The patient population in particular is challenging and will continue to benefit most from a multidisciplinary approach throughout their peri-operative course. Knowledge surrounding indications for the procedure is valuable and relevant to anaesthetists involved in peri-operative medicine clinics. Patients with severe aortic stenosis may present for non-cardiac surgery and knowledge of referral pathways outside tertiary cardiac centres is useful. Procedural concerns and anaesthetic management are applicable to a number of similar procedures performed in hybrid operating or radiology suites. There are similarities with neuroradiological procedures, thoracic and endovascular abdominal aneurysm repair. As the evidence and indication for these procedures grow, it is likely that anaesthetists will increasingly be required to facilitate safe peri-operative care in these environments. True: Nitrates will reduce systemic vascular resistance which will in turn reduce coronary perfusion. Appropriately timed atrial contractions contribute up to 40% of left ventricular preload. True: Elevated filling pressures are required to fill the non-compliant left ventricle. False: Cardiopulmonary resuscitation is unlikely to be effective through a stenosed valve. Outcomes of surgical Aortic valve replacement in high-risk patients: A Multiinstitutional study. Transaxillary Transcatheter Aortic Valve Replacement with a Self-Expanding Valve under Conscious Sedation: Case Discussion and Review of the Literature. When diagnosing murmurs, the most helpful nding is its distribution on the chest wall with respect to the 3rd left parasternal space, a landmark that distinguishes murmurs into 6 patterns. Nonetheless, this study shows that some classic physical ndings are no longer accurate, that physical examination cannot reliably distinguish severe aortic stenosis from less severe stenosis, and that classic physical ndings, despite having proven value, are absent in many patients with signicant cardiac lesions. A simple system using onomatopoeia and classifying systolic murmurs into 1 of 6 patterns is diagnostically helpful. His obser invention of the stethoscope, the British physician James vationsalong with those of Austin Flint (1812-1886), Hope fully described the characteristics of systolic mur Graham Steell (1851-1942), and others using phonocardio murs, attributing them to either abnormal forward ow over graphy during the 1950s and 1960sform virtually our semilunar valves (eg, aortic or pulmonic valve) or regurgi entire knowledge base about systolic murmurs, including the classic teaching that pathologic systolic murmurs are identiable by their location on the chest wall and by ad ditional abnormalities of the neck veins, precordial pulsa Funding: None. Conict of Interest: There are no nancial or personal relationships that could have inappropriately biased this work. During recent decades the diagnosis and treatment of Authorship: the author performed all aspects of the study and analysis heart disease have changed signicantly, and it is un of its results. In the cal ndings to transthoracic echo sociated with systolic murmurs: 1) aor multivariate analysis, variables cardiography, thereby investigat entered the model if P. Diagnostic tion severity, 3) absence of pericardial murmurs and the modern diagnostic accuracy was expressed using effusions, and 4) mitral valve E-point 3 value of the bedside examination. The indications for echocar the Seattle Veterans Affairs Med ings, although diagnostically accurate, diography included assessments ical Center. These patients were a are sometimes absent in patients with for structural heart disease (59%), convenience sample, principally progression of preexisting valvular of non-intensive care unit patients signicant cardiac pathology. With only 14 this (7%), or suspected pericardial exceptions, the author was un disease (2%). Only 7% of the echocardiograms were ordered aware of the patients diagnosis, indication for echocardi to diagnose unexplained murmurs. Using a standardized were excluded from analysis because they had diastolic or form, the author recorded the patients vital signs, arterial systolic/diastolic murmurs (n 18) or lacked complete and venous pulsations (contour, velocity, waveforms), pre echocardiograms (n 15), leaving 376 patients, 221 (59%) cordial pulsations (location, velocity, amplitude), heart of whom had systolic murmurs. The anterior chest from apex to Presence of Systolic Murmur clavicles was examined, and radiation of murmurs was As displayed in Table 2 (online), over 20 echocardiographic completely described. In addition, tricuspid regur sisted during inspiration and expiration, although their in gitation severity was independently associated with the left tensity could vary during the respiratory cycle. Pericardial continuous sounds that completely disappeared during in effusions diminished the probability of all 6 murmur pat spiration or expiration were called rubs. All murmurs were terns (ie, 60% of patients without pericardial effusions had characterized using onomatopoeia and conventional grading murmurs vs. Increasing E-point ve (Table 1) and were sorted into 6 predetermined topo graphic patterns (Figure 1). All echocardiograms were in locity also was associated with all 6 systolic murmur pat terpreted by a cardiologist independent from the bedside terns, and its association persisted after excluding patients examination. McGee Etiology and Diagnosis of Systolic Murmurs 915 Correlations between Murmur Pattern and Table 1 Denitions of Physical Findings Echocardiography Characteristic Denition Peak aortic velocity, mitral regurgitation, and tricuspid re Timing of sound* gurgitation were the 3 principal echocardiographic variables Midsystolic Both S1 (lub) and S2 (dup) distinct: associated with specic murmur patterns. Because many Lub shsh dup patients had combinations of these abnormalities, Figure 2 Early systolic S1 indistinct, S2 distinct; gap before S2 presents isolated lesions to simplify analysis. As mitral regurgitation increases Shshshshshsh from none to severe, the frequency of murmur increases ShshshshshshP from 29% to 100%: the broad apical pattern is the most Pushshshshsh common pattern, although some patients with severe regur PushshshshshP gitation have the broad apical-base pattern and others Late systolic S1 distinct, S2 indistinct: with moderate regurgitation have the isolated apical pat Lub shshshP tern. As tricuspid regurgitation increases from none to se Quality vere, the frequency of murmur increases from 21% to Blowing Pure high frequency, mimicked by the 100%: the left lower sternal pattern is the only associated sounds ahahah or shshsh (sounds produced in the front of the pattern. Delayed Denite slow increase in carotid upstroke, occupying much of Diagnostic Accuracy of Physical Examination systole and different from the early tapping sensation of the normal All Patients. The most useful nding, applicable to all carotid patients, is the specic murmur pattern detected. Two patterns (broad apical-base pattern and small apical-base pattern, top 2 rows) extend above and below this landmark, usually to both sides of the sternum. Three patterns are conned entirely below this landmark (left lower sternal pattern, broad apical pattern, and isolated apical pattern, 3rd through 5th rows); 1 pattern is conned entirely above this landmark (isolated base pattern, bottom row). Increased ow across a semilunar valve or through a indicates that many patients lack anything diagnostic other regurgitant leak generates vibrations in the ventricles, great than a specic murmur pattern. Therefore, although classic ndings have proven the murmur of mitral regurgitation: in this lesion, blood accuracy, they are frequently absent. A new observation is the and tricuspid regurgitation, it identies 2 additional vari association between a loud S2 at the left base and signicant ables associated with systolic murmurs: the absence of peri mitral regurgitation. S2 may be loud in mitral regurgitation cardial effusions and increased E-point velocity. Pericardial because of pulmonary hypertension, absence of a loud con effusions (even if small) decrease the probability of systolic tiguous murmur obscuring S2 (ie, mitral regurgitation mur rd murmurs, probably just as pleural effusions impair trans murs are conned below the 3 rib), a freely mobile aortic mission of lung sounds. The role of E-point velocity is less valve (ie, no calcic aortic disease) or, in patients with obvious because it measures early diastolic ow over the associated aortic disease, a shorter left ventricular ejection mitral valve. Increased E-point velocity may reect elevated time (thus shortening the associated aortic murmur and lling pressures, which tense the ventricular walls and ren revealing a loud S2). This study also provides evidence supporting the hypoth crease aortic ow and thus murmur intensity. In regurgitant esis that observation of murmur intensity during irregular lesions, however, blood is owing in 2 directions, and the 4 rhythms is diagnostically helpful. After pauses in the heart diminished afterload increases aortic ow but leaves regur rhythm (from atrial brillation or extrasystoles), the next 5 gitant volume and murmur intensity unchanged. In patients longer associated with a brisk arterial pulse (the historical with aortic ow murmurs, these hemodynamic changes in small water hammer pulse), probably because modern patients are older and lack the supranormal ejection frac tions and compliant vessels of younger, historical subjects. Also, the sustained apical impulse and displaced apical impulse are not specic for aortic stenosis or mitral regur gitation, respectively, because these ndings, when found in study patients with murmurs, often signied alternative nonvalvular etiologies (eg, cardiomyopathy). Also, in con trast to descriptions of rheumatic aortic valve disease that emphasized murmurs located at the upper right sternum (the classic aortic area), this study demonstrated that aortic valve murmurs radiate symmetrically above and below the rd 3 left parasternal space, in an oblique direction to both Figure 3 Boundary of murmur patterns. The 3rd left paraster sides of the sternum, in a pattern sometimes resembling a nal space overlies both the aortic and mitral valves. If the ventri sash worn over the right shoulder (broad apical-base pat cles vibrate sufciently to produce sound, murmurs are generated tern). Vibrations of the right ventricle produce the omatopoeia (Table 1) proved useful, demonstrating holo left lower sternal pattern, whereas those of the left ventricle systolic and long systolic murmurs as more signicant than produce the isolated apical pattern, larger apical patterns (left early systolic or mid-systolic ones. Onomatopoetic descrip example of broad apical pattern, Figure 1) or, if of sufcient intensity, murmurs along the left ribs from sternum to axilla tors are also easier to convey to students than older terms (right example of broad apical pattern, Figure 1). Should the (eg, diamond-shaped, crescendo-decrescendo), proba great arteries vibrate sufciently to make sound, the bones bly because they communicate what clinicians actually above this landmark vibrate and murmurs radiate from the hear, not what was seen on a phonocardiographic tracing. Limitations of this study include a population almost en With increased velocity across the aortic valve, both the left tirely of men; whether the female breast alters the radiation of ventricle (lower ribs) and great arteries (upper sternum and the sound and the conclusions of this study is unknown. Also, clavicles) vibrate, causing the apical-base pattern and its patients consisted of a convenience sample and their examina variations. Finally, examinations were conducted by a single observer, References raising the possibility of poor reproducibility, but many studies 1. Diagramming and grading heart sounds and In conclusion, the main causes of distinct systolic murmur murmurs. Pericardial effusions, even if small, sample size estimation for diagnostic test studies. An aid to identication of the mitral valve E-point velocity further increases the likelihood of murmur of aortic stenosis with atypical localization. Haemodynamic rd explanation of why the murmur of mitral regurgitation is independent of chest wall with respect to the 3 left parasternal space. Evi but they are sometimes absent, thus illustrating both the value dence-based Physical Diagnosis, 2nd edn. Having high cholesterol, high blood pressure, or diabetes also can increase Heart disease is the leading cause of your risk for heart disease. More than doctor about preventing or treating these 600,000 Americans die of heart disease medical conditions. The term heart disease refers to several the symptoms vary depending on the types of heart conditions. For many people, common type is coronary artery disease, chest discomfort or a heart attack is the which can cause heart attack. Anyone, including children, can l Weakness, light-headedness, nausea develop heart disease. It occurs when (feeling sick to your stomach), or a substance called plaque builds up in a cold sweat. When this happens, your arteries can narrow over time, reducing l Pain or discomfort in the arms blood fow to the heart. If you have heart disease, lifestyle changes, like those just listed, can help lower your risk for complications. Talk with your doctor your risk for heart disease: about the best ways to reduce your heart l disease risk. Leadership teams seeking a competitive advantage should begin by addressing the following questions: Given your existing solutions portfolio, should your organization adopt a mindset of incremental or transformational change It refers to conditions that can lead to chest pain, heart attacks, strokes, and other related conditions. Examples include coronary artery disease, arrhythmias, and heart defects, among others. Heart disease is the leading cause of death in the United States, afecting about 600,000 people each year. Stakeholder engagement and collaboration: threat of commoditization unless they Developing organizational capabilities to identify, deliver diferentiated, high-impact solutions. Contracting and payment models: Underwriting, and support new fnancial arrangements and negotiating, and implementing new payment incentives for providers. Complementary services and solutions: Building wraparound services or solutions that supplement clinical efcacy, address value leakage, and/or improve operational efciency throughout the patient journey and care delivery continuum. Product innovation: Redefning innovation models to rapidly translate clinical and real-world insights into product oferings that clearly deliver superior system value, while also aligning regulatory strategy with overall evidence planning. Providers are interested inand MedTech companies should develop and ofera wide spectrum of diagnostic, therapeutic, and monitoring solutions that providers can leverage to manage the patient journeyenabled by the right technology, supported by evidence and a strong value proposition, and available at the right time. Concurrently, increasingly active and aware consumers are seeing more availability of digital solutions to help them participate in their health care and treatment plans. These two dynamics are impacting how care is provided along the patient journey (Figure 5). Also often App device/data connectivity enabled or required: Mobile has aggregation-platform capabilities to pull in data from phone or tablet application that is capable of or requires a multiple sources to be analyzed. Preventive care and wellness James exercises, eats a balanced diet, and uses smart devices to track health metrics such as heart rate and blood pressure. At home one day, James feels fatigued and experiences shortness of breath and chest pain. Treatment decision the physician determines James treatment path by confrming the diagnosis via consultation with the electrophysiologist, assessing the presence of comorbidities, and consulting digital-based decision-support systems. The pacemaker will help regulate and track his heart rhythm through frequent ofce checks and remote monitoring. An echocardiography revealed that James has moderate-to-severe mitral regurgitation, which puts him at an increased risk for congestive heart failure.

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After these twelve participants were interviewed and the data was analysed milwaukee pain treatment center milwaukee wi 100pills aspirin mastercard, theoretical saturation was near davis pain treatment center buy 100pills aspirin amex, but additional women were sought to heel pain treatment exercises 100 pills aspirin mastercard shed light on the theoretical properties of declining screening or having a lower level of education pain gum treatment best buy for aspirin. One additional participant was recruited online and three additional participants were recruited from the London-Middlesex Health Unit Prenatal Fair for a total sample of 16 participants fremont pain treatment center proven 100pills aspirin. Charmaz (2006) describes theoretical saturation as the time when gathering fresh data no longer sparks new theoretical insights treatment for uti back pain buy 100 pills aspirin, nor reveals new properties of these core theoretical properties (p. I used purposeful sampling to identify participants who had recently received the offer of prenatal screening but had not yet received results (or chosen not to participate). Indeed the use of theoretical sampling necessitates a purposeful sample to begin (Glaser, 1978), as it is impossible to sample theoretically before categories have been formed through analysis (Charmaz, 2006). Patton (1990 as cited in Coyne, 2003) describes purposeful sampling as a way of selecting information-rich cases for study in-depth those from 139 which one can learn a great deal about issues of central importance to the research (pg. Glaser (1978) further describes the initial sample as taken from groups which the researcher believes will maximize the possibilities of obtaining data and leads for more data (pg. Women were purposefully sampled through Word of mouth referrals from personal contacts and former participants who pass flyers (Appendix 3) to their contacts. These fairs occur monthly and are aimed at women in the first 16 weeks of pregnancy. I reasoned that women who are happy with the process and have no questions about it might be less likely to volunteer to be part of the study, although they are an important group to include. This prediction was true for the women recruited online, but some women recruited at the Prenatal Fair seemed to be satisfied with their experience and not have particularly strong thoughts or opinions about the topic. Theoretical sampling shaped the recruitment of new informants in order to elaborate and refine the developing categories (Charmaz, 2006). This was achieved by focusing recruitment on the emerging categories and my evolving understanding of the developing theory (Glaser, 1978). Through theoretical sampling I aimed to recruit women who chose not to participate in prenatal screening. As analysis evolved, women with lower levels of education and those 140 who were considering pregnancy termination in the event of a high-risk result were sampled theoretically through the use of screening conversations with potential participants. While Charmaz (2006) thinks it may be important to return to participants during analysis, if emerging categories require more questioning, in this project a second interview was not possible. The interview focuses on the presentation of prenatal screening and intentionally omits discussion of actual results; by the time the interview data was analyzed, participants would have likely received the results of their test, which may affect the way they remember or consider the initial presentation of the test. Charmaz (2006) emphasizes the importance of a well constructed interview guide in order to produce rich data for analysis by guiding the participant to reflect on their experiences. The questions of the interview guide should be constructed to fit the participants experience, while at the same time exploring the interviewers topic of interest. By keeping the interview guide short and open-ended, the interview can become more conversational and the interviewer can respond to the information the participant is giving, probing some points for more information (Charmaz, 2006). While the structure of the interview guide remained consistent between interviews, sub questions changed throughout data collection to reflect my evolving understanding of the developing theory at the time of the interview. New sub-questions were oriented towards expanding or elaborating existing categories (Appendix 4). I inductively analyzed data with the aim of developing theory about the process of making a decision about participating prenatal screening from the perspective of pregnant women. Charmaz (2006) sees coding strategies as flexible, provided the research includes 141 an initial code which eventually progresses to a focused code. The purpose of the initial code is to develop a coding plan; the focused code will identify core categories. I refined these ideas further into theoretical categories, with multiple, iterative rounds of coding wherein emerging insights fueled additional analysis and data collection. For the interview data, analysis began with transcription in order to perform a quick code (Glaser, 1978; Charmaz, 2006), a fast open code used to keep the researchers mind open to the possibilities of the data by using codes which are provisional, comparative, and grounded in the data (Charmaz, 2006, p. Charmaz (2006) thinks an initial quick code helps the researcher remain receptive, and sparks new ideas. Line by Line Coding: After the initial quick code, line by line coding of each transcript (Charmaz, 2000; 2004a; 2006) was completed using literal, theoretical, and metaphorical codes that are active. Glaser (1978) suggests that coding with gerunds (a noun derived from a verb, usually ending in ing) is helpful because these active words allow the researcher to identify processes. Focused Coding: Focused coding is used to make relationships and connections through some of the commonly occurring or significant codes identified in the initial process. This stage of coding requires decision making about what initial codes are analytically significant, or what codes may contribute to the formation of categories. Theoretical Coding: Theoretical coding took place after the completion of focused coding (Glaser, 1978), to examine the relationship between focused codes. Charmaz (2006) cautions that although theoretical coding can assist with precision and clarity, theoretical codes must fit your data and substantive analysis they should be suggested from earlier coding. Researchers cannot simply choose one of Glasers theoretical coding families and apply it to the data. This diagram includes different levels of coding and analytical questions which inspired the next round of coding. I engaged in memo-writing throughout the entire research process to address reflexive and methodological considerations. Memo-writing is often seen as the intermediate step between coding and writing about the theory for presentation or publication (Glaser, 1978), but Charmaz (2008) thinks this conception of memo-writing understates the importance of the process. Charmaz (2006; 2008) sees memo writing as an integral part of grounded theory, allowing the researcher to trace ideas and categories as they develop, and providing a framework for exploring, checking and developing ideas. Memos were recorded in two ways as loose notes when needed around specific pieces of data, and as 143 a journal to record my feelings and progress about the project, data, and discoveries. Charmaz (2008) recommends the following strategies for using memos effectively: 1) Title the memos for easy sorting and storage 2) Write memos throughout the process 3) Use memos to define, delineate, and compare codes 4) Include the relevant data right in the memo 5) Outline the consequences of the code/category 6) Note gaps in the data and conjectures about these gaps I managed the research memos throughout the project by opening a research-specific e mail account, where I could e-mail myself memos (written or dictated). This format allowed me to search the memos and, if needed, to circulate them to my advisory committee and record their responses. I also uploaded these memos into my data management software (N-Vivo), so I could link them directly to the data. I wrote memos after conducting each interview, transcribing each interview, coding each interview, and during each round of coding. As I have discussed earlier in this chapter, I have been committed to a reflexive approach to the research process, and to thinking carefully about possible implications of the methodological decisions I have made throughout the project. In part, this decision was theoretical, as a way of informing myself about the context in which prenatal screening takes place in Canada and familiarize myself with some of the material and terminology that my interview participants might encounter. Since it is easier to go back and re-examine texts, or change search criteria for texts than it is to re-interview participants, I wanted to go into the participant interviews with as much understanding as possible. There was also a logistical part of this decision: the use of textual data did not require research ethics permission or involve a long phase of recruitment. Others were excluded before an interview because they miscarried or because they were not receiving prenatal care from a family physician. I recruited most participants through the Prenatal Fair, where I had set up a table with recruitment posters and letters of information. I spoke to all participants directly and if they agreed to be contacted, I collected their contact information and e-mailed or phoned at a later date to arrange an interview. I had ads out for about a month before I attended a prenatal fair, and had received little response. The word of mouth referrals meant that I was referred to women who shared news of their pregnancy very early on; these women may have been more likely to decline prenatal screening or not be considering pregnancy termination in the event that a condition was found (Rothman, 1989). Of my final participant pool, 14 of the 16 women were recruited through ads on a pregnancy related site or at the Prenatal Fair. These women may be more active in seeking information about pregnancy than others. With that said, as discussed in manuscript four, there was one woman (Lucy) who chose not to seek information about prenatal screening and two women (Farah and Nadia) who chose to stop seeking information. All of these women were recruited through the Prenatal Fair, suggesting that perhaps attendance at the Prenatal Fair did not necessarily correlate with an interest in actively seeking information about prenatal screening. All participants were self-selected volunteers and so perhaps were more interested than average in research, or in the topic of prenatal screening. Participants were offered the choice to be interviewed in person or over the phone; most preferred to be interviewed over the phone (nine of 16 women), even those who were recruited in person (seven out of ten women), perhaps reflecting convenience. Two chose to be interviewed in their home, one in my office, one in a public library, and one in a coffee shop. Four of these interviews were longer than average, perhaps because we established better rapport, perhaps because there were few distractions, or perhaps because agreeing to meet somewhere indicated higher interest and a higher commitment of time to the interview. The women with the shortest interviews were all interviewed over the phone, all recruited at the Prenatal Fair, and all participating in prenatal screening. Compared to the other participants they had average level of education, were average age, had some but not extensive knowledge of people with disabilities. I reasoned that the results a woman received might colour her thoughts about the prenatal screening test, such as creating reassurance from anxiety in the event of a low-risk result. At the time of the interview, women who were participating in prenatal screening were on average 15. It is possible to receive results as early as 16 weeks along, which gave a very small window for transcribing and analyzing data in time for member checking. At the time of the interview, some women had the results appointment scheduled within days, making member-checking impossible for this group. I did not want to collect member-checking data from some but not all women, or to self-impose a timeline which would place pressure to conduct the analysis very quickly, meaning I might miss something important, or not be able to engage deeply with the analytical process. Instead of member-checking with the participant who provided the data, I decided to query future participants about emerging themes, and incorporate participant response to the evolving analysis in this way. There was also an ethical element to the decision not to return to the participants for member-checking: with the possibility that some women may receive high-risk results, I did not want to re-open the conversation 146 about making a decision to participate in prenatal screening, which may potentially cause emotional stress, or heighten existing emotional stress. I left flexibility in the inclusion criteria to include any pamphlet or material mentioned by a research participant. I chose to exclude books and websites, in order to keep the data collection focused and to remain within one genre of information. These inclusion criteria decisions were made to reflect the information that would be most likely be available to the interview participants in the study, but allow flexibility to account for the broad availability of information online. Many health organizations make their patient information publications available online, where they can be accessed by a broader population. Presumably any patient information materials I could find online can be accessed by my research participants. During data collection, about half of the women revealed that they were given patient information materials from their physicians. Only one could provide the title of the pamphlet, the others had discarded, forgotten, or misplaced their pamphlets. I started with one overarching research question and three sub-questions, aimed to address the three types of data I planned to collect. In the process of data collection and analysis, the questions were refined, to respond to the type of data available (in the case of the policy documents) and the evolving categories being identified through data analysis (all three types of data). An additional round of refining the research questions took place while 147 drafting each manuscript; in order to respond to what the data was saying and the particular story emerging from each data set. Manuscript one (Chapter 5) responds to the first research sub-question, "How do prenatal screening patient education materials portray concepts related to prenatal screening I began this study by reading through patient education materials in order to gain an understanding of the type of information women may receive when choosing whether or not to participate in prenatal screening. The experience of reading the patient education materials was transformative, and may be considered a critical incident (Brookfield, 1998) or a "struck-by" moment (Cunliffe, 1999). At the time I was reading this material, I was deep in the literature, as necessitated by the requirements of my program. I was aware of some literature about potentially prejudicial terms about disability, such as "handicap", but what I noticed when I read was that the tone of some documents was persuasive, rather than informative. These two thoughts, about the potential of language to be prejudicial and persuasive, inspired me to think more deeply about word choices and the impact that they may have on women. I started to read more about theories of metaphor and the constructive power of language to shape and constrain understandings of the world, and of possibilities (Lakoff & Johnson, 1980). The story I chose to tell about these data addressed the ways in which theories of metaphor disrupt the notion that communication can be non-directive. I closely examined the language and metaphors in the patient education materials to reflect upon ways in which they might be suggestive, persuasive, or otherwise directive of a particular way of thinking about pregnancy, disability and motherhood. Manuscript two (Chapter 6), began with sub-question two, "How do policies and guidelines shape the offer of prenatal screening When I wrote this research question, before I had conducted an in-depth search for policy documents, I imagined that I would find many different types of policy documents from different health 148 professions involved in prenatal screening (family physicians, obstetricians gynecologists, midwives, genetic counselors), different levels of government (provincial health insurance agencies, local health integration networks, funding formulas) and potentially some policy in the grey literature, from advocacy groups concerned with pregnancy, public health, or disability. I was also interested to note that the mention of non-directive counseling and informed decision-making merited only a brief mention, suggesting that physicians were assumed to be well acquainted with the pragmatic aspects of facilitating informed decision-making through a process of non-directive counseling. Yet, from my prior literature review I was familiar with a large body of evidence suggesting that this was not the case. At this point, I started to consider how to represent my findings in a manner that would be appealing and helpful to clinicians. From regularly reading the Journal of Obstetrics and Gynecology Canada, I knew that if I wanted to address this clinical audience, I had to write a policy or literature review piece, rather than a qualitative research piece (see section 9. With this understanding, and having identified non-directive counseling as a particular element of interest, I focused my study on this topic. Manuscripts three and four (Chapters 7 and 8) both evolved from the third research sub-question, "How do women use information when making a decision about whether or not to participate in prenatal screening The data that I collected from women about their experiences of being offered and making a decision about whether or not to participate in prenatal screening were so rich that it would be impossible to tell all of the stories that I saw within these data. During the iterative process of data collection and analysis, I quickly identified the concept of "information" as an important analytical construct, and pulled all mentions of "information" from the rest of the data, in order to consider the different ways in which women talked about this idea. This became manuscript three, through the iterative process of coding described in Figure 3, in the Data Analysis section (4.

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Using in the surgery treatment cryoprobes that freeze pathologic tissue to knee pain treatment uk order aspirin us tempe rature of n60C often allows to destroy pathologic stimulogenic focuses from the epi cardium side without the necessity to apply extracorporeal circulation, contributed to increasing both effectiveness of the procedure treatment as well as its safety. Cryoablation is particularly useful in the treatment of the pathologic changes lo cated in the areas which are hard to reach. In 59 random pa tients aged 8-40, immediately after tonsillectomy, a postoperative bed was frozen up to n20C and n32C for one minute. In patients, who underwent cryoablation, reduced pain by over 28,3% assessed through the analogue visual scale and shorter time ne eded to return to the usual diet and hospitalization time (by 4 days) was observed, comparing to the control group that did not undergo such a therapy. Moreover, cryosurgery was used successfully in the treatment of chronic rhinitis, papillomas located in nose and larynx, leucoplakia and neoplastic lesions of the na sopharynx [57,87]. Clinical applications of low temperatures Ophthalmologic diseases One of the main applications of cryosurgery in the ophthalmology is treatment of retinopathy. In ano ther research [134] in which cryoablation was applied in the treatment of premature retinopathy in 70 infants (129 eyes), positive, early results of therapy were observed in 119 eyes. After one-year observation in over 57% of eyes distinct improvement n both structural and functional was recorded. In another research [24] in thirteen premature infants (23 eyes) with retinopathy, therapeutic effectiveness of cryoablation and laser photocoagulation were compared. Results achieved with the use of each method ap plied individually and jointly were similar, while the simultaneous application of both methods secured shortening of procedure time and decrease in the number of compli cations. Clinical usefulness of cryopexy was also shown in the treatment of diabetic retinopathy, however, in this case photocoagulation is significantly more effective [141]. Cryopexy proved high therapeutic effectiveness in the treatment of small focuses of retinoblastoma. In research [65] in twenty-four children cancer focuses located on the margin of the eyeis fundus were frozen with the use of a probe with temperature of n65C for ca. In over 25% of patients destruction and cicatrization of the neoplastic lesions even after first cryoplexy procedure was achie ved. Good effects of cryoablation were also observed in a treatment of corneal squamous cell carcinoma [137]. In patients treated with the cryosurgery method four times lower fre quency of recurring neoplastic lesions comparing with the classical procedure methods was observed. Including cryoablation in the complex treatment that consists of tumorectomy pre ceded by diathermocoagulation of blood vessels, and followed by freezing the mar gins and bottom of postresective defect to temperature of n60C for 30 seconds produ ced positive esthetic and functional effect in the treatment of eyelid and conjuctival neoplasms [109, 110]. Moreover, high therapeutic effectiveness of cryoablation was observed in curing the chemical and thermal burn of cornea (accelerated regeneration of epithelium, lo wer number of concrements in cornea, improved sight ability and shorter hospitaliza tion time) [106] as well as in the treatment of viral corneal ulceration [79] and haemor rhage to the anterior chamber and vitreous body of eye [22]. Therapeutic usefulness of cryocoagulation was also proved in the treatment of glaucoma. In research [98] in treatment of 128 eyes of patients with glaucoma cry ocoagulation of the ciliary body (8 procedures lasting 55 seconds with the use of a probe with 2. Using a probe with temperature of n70C in 54% cases lower by 21 mmHg intraocular pressure was achieved, that remained 97 Cryotherapy at the same level after one year and 30 months of observation, requiring additional adjuvant therapy and in 39% of cases reoperation as well. While using a probe with temperature of n82C normalization of the intraocular pressure within the similar time of observation in 89% of cases was achieved, while the adjunctive therapy was necessary in 66% of cases and reoperation only in 7. Side effects of cryocoagulation were mainly related to rise in the intraocular pressure exceeding 55 mmHg, that occured in 10% of cases and retreated after the osmotic therapy, as well as occurring fibrin exudates in the eyeis anterior chamber in 4% of patients treated with a probe of temperature of n70C and 60% of patients treated with a probe of temperature of n82C. Gynecologic diseases Cryoablation with the use of liquid nitrogen (nitrous oxide) was also applied in treatment of many diseases of female reproductive organs. In research [62], in which treatment with the use of cryosurgery was performed in 182 women, a complete re gression of pathologic changes was observed in 86% of patients with chronic cervici tis, 89% of patients with Nabothian cyst (within 6-8 weeks) and 84. In patients with cervical dysplasia a complete regression of pathologic lesions occurred, within 7-11 weeks after cryoablation. Wi thin 2-5 year observation period the recurrences were observed only in 15% of patients with cervicitis and in one patient with cervical dysplasia. Expanding indications for applying cryosurgery results from many advantages of the therapeutic method such as: ipossibilitytodestroycompletelypreviouslydeterminedtissuevolumebothonthe skin surface and inside of any organ, ipossibilitytogainaccesstopathologiclesionsintissuethankstotheapplication of cryoprobes with small diameter, i possibility to freeze many times the recurrences after previous surgery treatment, radiotherapy as well as cryotherapy, ioccurrenceofonlyminimum tissuereactionaroundthenecrosisfocusafterfreezing, ipossibilitytoperform asurgeryalmostwithoutbleeding,eveninhighlyvascula rized organs, ipossibilitytoperform themajorityofsurgeriesambulatoryduetotheirlow burde ning character, igoodcosmeticeffect. Cryotherapy Cryotherapy is understood as an impulse stimulating surface application of cry ogenic temperature (below n100C) for a short time of 120-180 seconds in order to trig ger and use human organism physiological reaction to the cold, as well as support background therapy and facilitate kinesitherapy [33,35,153]. Cryotherapy can be applied locally on the selected body area or on the whole body n in cryochambers and cryosaunas. Local cryotherapy Due to the duration of local cryotherapy procedures, they are divided into: i short-term procedures (single application lasts from 30 seconds to few minutes), iperiodicallyinterruptedprocedures(applicationslastaquarterofanhourorso, they are repeated after a break lasting a quarter of an hour or so), ilong-term procedures(singleapplicationlasts4872 hours). In local cryotherapy devices which use liquid nitrogen, carbon dioxide or cooled air to produce low temperature are applied. Local cryotherapy with the use of liquid nitrogen In such a cryotherapy tissues are cooled by nitrogen vapour. The pressure difference between a tank and atmospheric pressure causes discharging nitrogen vapour from a tank to a nozzle-ended hose, gas temperature at nozzle outlet ranges from n196C to n160C. Local cryotherapy with the use of carbon dioxide Using carbon dioxide instead of liquid nitrogen allows obtaining temperature ca. Methodology of performing such a procedure and safety rules are similar to the previous case [135]. Methodology of local cryotherapy procedures [48,122,132] the main objective of local cryotherapy applied as a preparation for intensive ki nesitherapy is maximum cooling of the area adjacent to the organ. In order to obtain such a significant cooling of tissue, many factors have to be taken into account such as: type of used equipment and cryogen, jet speed of used gas depen dant on the vapour pressure obtained from cryoliquid, heater power, length of the cry ogenic pipe and cryogen level in dewar. The level of cooling the treated body area de pends on its surface and jet speed of cryogen vapour that may be controlled through relevant selection of the cryoprobe cross-section and a distance of a cryoprobe from the skin surface. Moreover, a very significant factor affecting the intensity of cooling is the speed of shifting a cryoprobe over the cooled surface. Each time before local cryotherapy procedure patients should dry thoroughly cle an skin with a towel in the area, in which cryotherapy is to be applied. The procedure should be performed in anatomical position of patient or in case when it is not possi 99 Cryotherapy Cryotherapy Reduced stimulus threshold Analgesia Reduced tendon reflexes Reduced pain Reduced muscular tension Prolonged relaxation Improvement of motion range Physical rehabilitation (kinesitherapy) Fig. Relationship between the application of cryotherapy and rehabilitation according to Knight [58] in own modification. Clinical applications of low temperatures ble, in lying-down or reclining position. The power of device heater should be set at maximum value, next slowly shifting of a cryoprobe nozzle turned towards skin sho uld be made from maximal distance of 15 cm in older types of device or 1-3 cm in modern ones that can control the application amount and speed of liquid nitrogen vapour. The distance and speed of shifting of a cryoprobe is controlled together with apatient on the basis of increasing feeling of subjective pain or burning in cooled skin surface. Procedures are performed under visual control, with special attention to pigmen tation, while skin pallor or lividity, occuring so-called cellulitis as well as intense fe eling of pain or burning sensation, which do not disappear despite increasing of the distance between the nozzle and skin surface and speed of shifting of cryoprobe, indi cate that a procedure should be interrupted. Therapist during performing procedure should make circular movements with a nozzle in order to avoid cooling the same area all the time, because it may lead to frostbite. Time of procedure applied on one body area ranges from 30 seconds to 3 minutes, while in patients with fat deposition or large muscle mass may be extended to 5 minu tes. When few areas are cooled at the same time, total time of procedure should not exceed 12 minutes [139]. It is crucial to cool down joint along with the dynamic groups of muscles respon sible for a full range of movement in the joint with a particular attention paid to the trigger points and visible inflammatory focuses [49]. The cycle of local cryotherapy usually consists of 10-30 procedures performed once or twice a day. As local treatment with the cold is a component of cryorehabilitation, immediate ly after finishing the procedure of local cryotherapy, patients undergo 3060-minute lasting kinesitherapy, including individual exercises (at the beginning isometric mu scle exercises and exercises against gravity of joints affected by the disease process and then active proper exercises and exercises with resistance of extensor and flexor muscles in these joints). In Table 6 below are shown therapeutic parameters usually applied during the cycles of local cryotherapy procedures for particular diseases. Therapeutic parameters usually applied during local cryotherapy procedures in particu lar diseases. Disease Gas temperature at Time of Number of patientis body surface procedure procedures duration in therapeutic in minutes cycle Ankylosing spondylitis n130n160 C 10-12* 10-20 Rheumatoid arthritis n160n180 C 2-3 10-20 Degenerative joint disease n160n180 C 3 10-20 Fibromialgia n130n150 C 10* 10-20 Post-traumatic disorders of n160n180 C 3 20 locomotor system Central nervous system disorders n160n180 C 3-8* 30 with increased spasticity Discopathies n130n160 C 3 10-20 Peripheral nervous system disorders n130 C 2-3 10. In local treatment with cold other methods that are not classified as the cryothera py within a contemporary sense of the notion, are also used. Clinical applications of low temperatures Compresses with plastic bags filled with ice cubes Plastic bags keep temperature of ca. Compresses with bags filled with cooled silicone gel After cooling in a freezer, bags are put on selected joint or muscle. Manufacturer offers various sizes of bags with various heat capacity, what allows to match a bag to type and size of treated organ. Due to greater likelihood of occurring frost bite, it is recommended to keep special caution during such a procedure. Massage with an ice cube the procedure, applied mainly in sports medicine to cure the overloading syn drome of the osteo-articular system or painful muscular tension, consists of massa ging tendons, muscles or ligaments with an ice cube it is done by circular movements. Recommended time of a single procedure is few (35) minutes with 10-second break between succeeding procedures [36]. Ice slush the procedure applied mainly in patients with diseases of the nervous system in order to reduce the excessive resting muscular activity, consists of multiple submer sions of sick parts of the body in a container with partly melted snow. Compresses with ice towels Procedure, also applied to reduce excessive muscular tension, consists of putting directly on skin a well wrung wet cotton towel previously cooled in a freezer. Cooling aerosols Procedure consists of sprinkling skin surface with gaseous substances which in normal atmospheric conditions vapour heavily and take up heat from the skin and lying deeper tissues. Single application lasts 5 seconds, and when few areas are co oled at the same time total application time shouldnit exceed 30 seconds. Applicator should be kept in the distance of 1525 cm from the surface of uninjured skin. Disposable cooling compresses Procedure consists of cooling down the skin surface using bags with substances which trigger endothermic reaction when mixed. Cryochamber is a large, closed, stationary and computerized device, using liguid nitrogen, synthetic air or triple cascading system for cooling air in a chamber. It enables to stay a few patients at the same time in a proper chamber at temperature below n110C. Use of specific insulating materials and unique plastics ensures economical use of achamber through fast cooling of the air inside the chamber [6]. Synthetic air mixture of nitrogen and oxygen has temperature of n193C and is easier in exploita tion, and its use reduces costs of cryochamber construction up to 40% (most of cry ochambers manufactured and used in Poland and all over the world are supplied with liquid synthetic air). Cryochambers are usually covered with wood and have swing doors that a pa tient may easily open at any time to interrupt a procedure when a temporary indispo sition occurs. According to the authors of the research [3] the optimum effectiveness of the who le-body cryotherapy procedures may be achieved through using temperature ranging from n150C to n130C, what allows to reduce the integument temperature to ca. The calculations made in the quoted research show that increasing of temperature inside the chamber from n130C to n120C reduces the effectiveness of cryostimulation almost twice and at temperature n110C the therapeu tic effect is ten times lower. Clinical applications of low temperatures Cryochamber construction and principle of operation (NWrocaw typei) Figures 22 and 23 show the construction of a cryochamber based on an example of low-temperature cryochamber of NWrocaw typei designed by Zbigniew Raczkow ski, M. Crucial role in the cryochamber operation plays preparation of purified air in pro per temperature. Air compressed by a compressor to 1mPa is dried in adsorber, then conveyed to blow through cryopurifiers. Having blown through the system and having closed the valves conveying air, valves in the tank with liquid nitrogen are opened facilitating air flow from the tank to cool first cryopurifier to which is conveyed air compressed by a com pressor. When the first cryopurifier is cooled down, the second cryopurifier is cooled down as well. When temperature of air exhausted by the first cryopurifier reaches n100C, it closes automatically and conveys air to the next cryopurifier. When the system finishes work it is regenerated at opened valves and heaters which are tur ned on. Such a way of two-stage air purification allows to eliminate completely water vapour as well as any organic, non-organic and mechanical contamination on sorbents, what allows to reach air dew-point at n75C. Applying a double system of cryopurifiers ensures keeping stable temperature during procedure and increases its safety. After setting temperature of pro cedure and its duration on a computer keyboard and starting a controller, computer confirms device readiness to work. After patients enter a pre-chamber, then a proper chamber, doors are closed, a button, which starts to measure time of stay in a chamber, is pressed. During procedure any possible irregularities of the chamber operation are shown by a controller and notices are displayed on the computer screen. Clinical applications of low temperatures device failure direct doors from a chamber may be used for immediate evacuation. When all the procedures scheduled for a certain day are completed, before turning a cham ber off, final regeneration is always carried out. Cryochambers supplied with liquid synthetic air (n193C) Cryochambers supplied with liquid synthetic air hale simmilar construction to NWrocaw typei chambers. Its main advantage is lack of expensive, energy consuming, loud and requiring special room technical part. Direct injection of gas into procedure chamber allows quicker gaining of procedure temperature, what is more it also redu ces consumption of freezing medium, failure frequency, expoitation and service cost. What is unique, is a system of desinfection after procedure n ozone generator releases doses of gas destroying bacteria and viruses. It may be supplied by companies producing medical and technical gases in ordinary distribution. Synthetic air supplied cryochambers are manufectured in two or more patients versions, with or without vestibule. The first patented cryochamber with cooling retention system was designed in Poland by mgr ino. Nowadays there are fifty synthetic air supplied cryochambers operating in the world (Poland, Czech Republich, United Kingdom, Ireland and Slovakia).

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The cause of the perinatal outcome was reviewed in 486 pregnant patients increased frequency of minor dysrhythmias southern california pain treatment center agoura cheap aspirin line, usually prema with rheumatic heart disease; out of which 304 patients ture beats pain treatment in osteoporosis order aspirin online now, may be related to hip pain treatment without surgery generic aspirin 100pills with amex the adaptation of the heart to pain treatment for carpal tunnel syndrome buy aspirin 100 pills low cost (63 pain treatment uti buy line aspirin. Forty eight patients underwent percutaneous balloon 250 bpm pain treatment toothache aspirin 100 pills overnight delivery, usually below 200 bpm. If there is no response, it should be is crucial in helping minimize further complications and mor attempted on the left side for another 10 seconds. It is especially vital to diagnose mitral stenosisthe sinuses should never be massaged simultaneously. Severe mitral stenosis tient may attempt a Valsalva manoeuvre during the carotid with symptoms or with signifcant pulmonary arterial hyper massage to increase the effectiveness of the procedure. Important Points Studies have shown that there are no signifcant deleterious l In normal pregnancy, circulation is hyperdynamic. They from the potentially harmful effects of the blood loss that compared maternal and perinatal outcome of pregnancy in occurs at parturition. This effect may concluded that maternal and perinatal outcome was better exceed the functional capacity of an ailing heart. Fetal complications, which included l Immediately after the placental separation, the obstruc tive effect of the pregnant uterus on venous return disap rate of prematurity (25% vs 11. A patient with heart disease showed better mean gestational age than the uncorrected may not tolerate this increase in blood volume. Infective endo l the pregnant cardiac patient should have effective pain carditis was not found in any of the patients. Maternal relief during labour and should labour in the lateral mortality was seen in four cases in the cyanotic group, two supine position. In the majority of cases, the anaesthesia of which were in women with Eisenmenger syndrome. In of choice is epidural blockade administered by an expe acyanotic heart disease, one case died undelivered and one rienced obstetric anesthesiologist. An exception to this rule is the patient with aortic access to specialized cardiac care, noncompliance with stenosis. Careful history taking and clinical examina with bed rest, (b) decrease the preload with diuretics, tion remains the key to diagnosing heart disease early. A (c) improve the cardiac contractility with digitalis and multispeciality team approach in institutions experienced in (d) reduce the after load with vasodilators. Pregnancy in cyanotic con significantly reduced left ventricular ejection fraction genital heart disease. Outcomes of l Patients with surgically corrected congenital abnormalities pregnancy in women with tetralogy of Fallot [see comment]. Current state a systemic right ventricle than in a systemic left ventricle of knowledge on aetiology, diagnosis, management, and therapy of pe and assessment of the systemic right ventricle ejection ripartum cardiomyopathy: A position statement from the Heart Failure fraction is an important prognostic index of cardiac com Association of the European Society of Cardiology. Myocarditis and long-term sur come of cardiovascular surgery and pregnancy: A systematic vival in peripartum cardiomyopathy. Contractile Diseases (National Institutes of Health) workshop recommendations reserve in patients with peripartum cardiomyopathy and recovered left and review. Joyal D, Leya F, Koh M, Besinger R, Ramana R, Kahn S, Jeske W, on Confdential Enquiries into Maternal Deaths in the United Kingdom. Troponin I levels in patients with Centre for Maternal and Child Enquiries, London; 2008. Troponin I levels in patients with preeclamp complications in pregnant women with cardiac diseases referred to a sia. Outcome of pregnancy in growth in the Marfan syndrome: A prospective study [see comment]. Pratibha D, Atrial FibrillationExecutive Summary A Report of the American Kiranmai D, Usha Rani V, GeetaVani N, Government Maternity Hospital, College of Cardiology/American Heart Association Task Force on Nayapul, Hyderabad. Surgeons, Area Hospital, Kamareddy, Practice Guidelines and the European Society of Cardiology Commit Nizamabad. Percutaneous bal Guidelines for the Management of Patients With Atrial Fibrillation). These Dermatological disorders in pregnancy can be classifed as changes are not associated with any maternal or fetal risk follows: and resolve postpartum. Most common hyperpigmentation is darkening of the l Physiologic skin changes in pregnancy lineaalba called lineanigra. Melasma (cholasma or mask of l Pre-existing skin diseases affected by pregnancy 1 pregnancy) is seen in about 70% of pregnant women. The l Pruritus in pregnancy malar pattern is usually common; however, usually the central l Dermatoses in pregnancy face is affected called centrifacial pattern. It occurs due to Correct diagnosis is therefore essential for appropriate melanin deposition and worsens with exposure to visible and treatment. The epidermal form of melasma is more responsive to treatment as compared to the dermal form. Physiologic Skin Changes in Pregnancy Mild cases can be treated with azelaic acid. Persistent me Endocrine and metabolic changes during pregnancy result lasma can be treated postpartum with topical hydroquinone in various skin changes. These include pigmentary changes (24%) and a broad-spectrum sunscreen, with or without a like hyperpigmentation and melasma, vascular changes like topical retinoid and mild topical steroid. It is treated with systemic steroids like prednisone Pre-existing Skin Diseases Affected (maximum dose: 60 mg/day). Systemic antibiotics Pre-existing skin diseases usually aggravate during preg should be started in the presence of super infection. Those which Maternal risks include tetany, seizures, delirium, renal may improve include acne, atopic dermatitis, autoimmune failure and cardiac failure. Eczema (Atopic Dermatitis) Only in those patients not responding to the earlier Eczema is the most common dermatosis seen in pregnancy. It mentioned treatments, termination of pregnancy may be usually persists, but remission has been noted in about 25% of resorted to as the eruption resolves promptly afterward. Generally, the lesions resolve postpartum, but recur earlier Smoking can be a causal factor. In the presence of infection, erythromycin or Melanomas that develop during pregnancy are thicker and may penicillin are to be given. Some become pregnant after diagnosis of melanoma is to be individu patients may develop acne frst time during pregnancy, alized. Specialized opinion should be obtained and a multidisci while some may show both worsening and improvement plinary team approach is recommended. Comedonal acne is treated with ben zoyl peroxide, while infammatory acne is treated with Pruritus in Pregnancy azelaic acid, topical erythromycin or clindamycin or oral erythromycin. All these medications are safe during Pruritus has been noted in about 20% of pregnancies. The various causes of Chronic plaque psoriasis is the most common type pruritus in pregnancy and the management options are enu of psoriasis in pregnancy. It usually occurs as a group of discrete sterile pustules at the periphery of erythematous patches. These It is a rare autoimmune bullous disease of pregnancy and lesions are noted all over the body sparing the face, hands puerperium. This is followed by a rapid generalized bullous and direct immunofuorescence is negative. Specifed dermatoses of pregnancy Neonatal vesiculo bullous lesion may be noted in 10% of Systemic diseases with skin involvement cases due to transplacental transfer of antibodies. These eruptions are mild and resolve spontaneously in a few Allergic reactions weeks without any treatment. Drug eruptions Early urticarial lesions are treated with topical steroids Pruritus associated with striae gravidarum with or without oral antihistaminics. After birth, the neonate the disease resolves spontaneously in the postpartum should be assessed for neonatal lesions. Recur rence in subsequent pregnancies is frequent and occurs Pruritic Urticarial Papules and Plaques earlier and in more severe forms. Management depends upon cause Allergic and drug reactions Pruritus, no jaundice, no eruption, no systemic diseases and no specific dermatosis Interahepatic cholestasis of pregnancy Hyperemesis gravidarum Chapter | 17 Other Medical Disorders in Pregnancy 289 occurs mainly in male fetuses. Oral range from fatigue, fever, arthralgia, myalgia, weight loss, histaminics may be added. Refractory cases may require skin rashes, lymphadenopathy, nephropathy, effusions oral steroids. Recent studies have shown resolution with (pleural and pericardial), seizures and psychosis. Prurigo of pregnancy affects between 1 and 300 pregnant the American College of Rheumatology devised criteria females. It usually least 411 clinical and laboratory criteria at one time or resolves immediately after delivery and is then seen as seriously. The rate of fares during pregnancy or postpar Pruritic Folliculitis of Pregnancy tum varies between 15% and 60%. It usu noted in women with active prepregnancy disease and in ally develops as pruritic follicular erythematous papules those who discontinue medication during pregnancy. The condition develops in the last two months of pregnancy and Lupus Nephritis in Pregnancy resolves immediately after delivery. It is associated with Women with lupus nephropathy may worsen during preg low-birth weight, but no maternal risks. This in turn may increase risk of maternal and fetal the exact etiology is unknown and culture and special complications. There may be increased proteinuria in pa stains should be performed to rule infectious folliculitis. Pregnancy should be avoided in patients with ac Autoimmune diseases are most common in women of tive lupus nephropathy, nephrotic syndrome and severe reproductive age, hence they are commonly encountered hypertension. Malar rash Fixed erythema, fat or raised, over the malar eminences, tending to spare the nasolabial folds 2. Discoid rash Erythematous raised patches with adherent keratotic scaling and follicular plugging, atrophic scarring possible in order lesions 3. Photosensitivity Skin rash as a result of unusual reaction to sunlight, by patient history or physician observation. Arthritis Nonerosive arthritis involving two or more peripheral joints, characterized by tenderness, swelling or effusion. Pleuritis convincing history of pleuritic pain or rubbing heard by a physician, or evidence of pleural effusion b. Positive fnding of antiphospholipid antibodies based on (1) an abnormal serum level of IgG or IgM anticardiolipin antibodies, (2) a positive test result for lupus anticoagulant using a standard method or (3) a false-positive serologic test for syphilis for 6 mo 11. It is found to be more benefcial than Hematologic steroids as maintenance therapy. The dos Renal ages remain the same as those used in nonpregnant states, but Hematuria 111 can be reduced in cases of remission. Usually, prednisolone or methyl Elevated serum creatinine 1 11 prednisolone is used. Indomethacin is safe for Lupus dermatitis is a most common feature and is seen on short-term use, but if used after 32 weeks can lead to prema the face or scalp. Lesions appear in the frst few days of life ture closure of fetal ductus arteriosus, oligohydramnios and and may resolve after 6 months. If either of the above is prolonged, the test is repeated with a In nonpregnant patients, azathioprine and cyclophos mix (usually 1:1) of patient and normal platelet-poor plasma. However, they are If mixing studies do not correct the prolonged clotting time(s), lupus anticoagulant is suspected. This results in narrowing of the spiral arterioles, Preeclampsia intimal thickening, acute atherosis and fbrinoid necrosis. No therapeutic modality is useful in re leading to increased production of adhesion molecules, cyto ducing the rate of preeclampsia. Vascular thrombosis One or more clinical episodes of arterial, venous or small vessel thrombosis, in any tissue or organ. For histopathologic confrmation, thrombosis should be present without signifcant evidence of infammation in the vessel wall. One or more unexplained deaths of a morphologically normal fetus at or beyond the 10th week of gestation, with normal fetal morphology documented by ultrasound or by direct examination of the fetus, or b. One or more premature births of a morphologically normal neonate before the 34th week of gestation because of (i) eclampsia or severe preeclampsia defned according to standard defnitions or (ii) recognized features of placental insuffciency, or c. Three or more unexplained consecutive spontaneous abortions before the 10th week of gestation, with maternal anatomic or hormonal abnormalities and paternal and maternal chromosomal causes excluded. Anti-b2-glycoprotein-I antibody of IgG and/or IgM isotype in serum or plasma (in titer. The precipitating factors identifed include infection, the postpartum period for at least 6 weeks by starting surgery, discontinuation of anticoagulant therapy and use of warfarin. Early and aggressive treatment in a critical care unit is Usually, prednisone and low dose aspirin have been used essential. However, an increased of pregnancy loss thrombosis should be treated with streptokinase or urokinase. The various maternal, obstetric and l Optimizing perinatal outcome by reducing the risk of risks of heparin therapy should be explained to the pregnancy loss, placental insufficiency, preterm delivery patient. Patients on throm neously once daily, or boprophylaxis with heparin should not be given heparin Enaxaparin 30 mg, or Dalteparin 5000 U, subcuta neously q12h following the onset of labour. Warfarin should heparin level (anti-Xa activity) in the therapeutic range be used for anticoagulation prophylaxis and continued l Low-molecular weight heparin for at least 6 weeks postpartum.

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