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For purposes of the summary in Table 2, findings related to each type of exposure in a given veteran population were counted only once. For example, some studies evaluated many different psychological stressors as risk factors for symptomatic illness in a given population of Gulf War veterans. Table 2 reports the number of different Gulf War veteran populations in which at least one psychological stressor was significantly associated with symptomatic illness. Epidemiologic studies have evaluated an extensive number of risk factors for Gulf War illness in numerous Gulf War veteran populations. As previously described, epidemiologic studies that reported only results of preliminary analyses-that is, analyses that did not adjust for confounding effects of multiple exposures-were not useful in identifying risk factors for Gulf War illness. As shown in Table 2, preliminary analyses of this type identified nearly all Gulf War exposures as significant risk factors for Gulf War illness in all Gulf War veteran populations. Illogical findings of this type are an expected result 220 Effects of Gulf War Experiences and Exposures of confounding in epidemiologic research, that is, the result of confusing the effects of multiple exposures with one another. Given the large number of exposures in theater and the high degree of correlation among exposures, epidemiologic studies that did not control for the confounding effects of multiple wartime exposures invariably produced results that were not helpful, and even misleading, for determining the causes of Gulf War illness. As detailed in Appendix A, the magnitude of associations identified by these preliminary analyses also provided little basis for distinguishing between effects of Gulf War exposures. For the majority of Gulf War exposures, median values indicated a three-to-four times greater risk for exposed, compared to unexposed personnel, in unadjusted analyses. Anthrax vaccine was consistently the weakest of identified risk factors in these analyses. That is, Gulf War illness risk for veterans who reported receiving the anthrax vaccine was usually less than twice that of veterans who did not recall receiving the vaccine, in unadjusted analyses. In contrast, Gulf War epidemiologic studies that controlled for confounding effects of multiple wartime exposures provided clear distinctions between the many Gulf War exposures of interest. Epidemiologic studies that controlled for effects of multiple exposures also identified factors that were not significantly associated with Gulf War illness. The largest number of risk factor variables assessed in Gulf War epidemiologic studies related to diverse psychological stressors during deployment. Results of adjusted analyses consistently indicated that psychological stressors during deployment were not significantly associated with Gulf War illness. Psychological stressor variables were assessed in seven different Gulf War veteran populations, using analyses that controlled for effects of other wartime exposures. As shown in Table 2, no stress-related variables were identified as significant risk factors for multisymptom illness in six of the seven Gulf War populations, after controlling for effects of deployment exposures. In addition, two of three studies that evaluated effects of sand exposures, and two studies that evaluated fuel exposures found they were not significant risk factors for Gulf War illness, after adjusting for effects of other exposures. Epidemiologic findings related to exposure to smoke from oil well fires and possible exposure to chemical agents were not consistent, as indicated in Table 2. Oil fire smoke was identified as a significant risk factor for Gulf War illness by two of four studies that controlled for effects of other deployment exposures. In three of five populations, variables potentially indicative of exposure to chemical agents. For several other deployment What the Weight of Evidence Tells Us About the Causes of Gulf War Illness 221 Table 2. Clinical Evaluations of Gulf War Veterans: Association of Deployment Exposures with Measured Clinical Outcomes associated with sign. A parameter commonly used to evaluate the likelihood of a causal relationship between an exposure and a health outcome is whether there is evidence of a dose-response pattern of association. This refers to a graded relationship between increasing levels of exposure and greater degrees of illness risk or severity. As indicated in Table 2, Gulf War epidemiologic studies have reported dose-response associations between multisymptom illness and several deployment exposures. In addition to epidemiologic research on risk factors for multisymptom illness in Gulf War veterans, a variety of studies have assessed measurable clinical outcomes in Gulf War veterans in relation to Gulf War exposures. Individually, single studies or types of information might suggest the possibility that an exposure could have caused Gulf War illness. Studies of Gulf War veterans consistently implicate only two wartime exposures as significant risk factors for Gulf War illness: use of pyridostigmine bromide pills as a nerve agent protective measure, and use of pesticides during deployment. This is consistent with what is known about the extent and patterns of these exposures in theater, and with general information from other human and animal studies. Studies of Gulf War veterans have also consistently indicated that psychological stressors during deployment are not significant risk factors for Gulf War illness. Studies of Gulf War veterans consistently indicate that serving in combat and other psychological stressors during the war are not significantly associated with Gulf War illness, after adjusting for effects of other wartime exposures. Widespread exposure to smoke from the Kuwaiti oil well fires was unique to military service in the 1991 Gulf War, and most prominently affected ground troops in forward locations. Epidemiologic findings relating oil well fire smoke exposure to Gulf War illness have been mixed, although a dose-response effect has been identified by several studies. There is little information from human or animal research to indicate whether intense exposure to petroleum smoke or vapors can lead to persistent multisymptom illness. Although studies of Gulf War veterans do not provide consistent evidence that exposure to oil fire smoke is a risk factor for Gulf War illness for most veterans, questions remain about effects for personnel located in close proximity to the burning wells for an extended period. Limited findings from epidemiologic studies indicate that higher-level exposures to smoke from the Kuwaiti oil well fires may be associated with increased rates of asthma in Gulf War veterans, and that an association with Gulf War illness cannot be ruled out. About 150,000 Gulf War veterans are believed to have received one or two 224 Effects of Gulf War Experiences and Exposures anthrax shots, most commonly troops who were in fixed support locations during the war. Although recent studies have demonstrated that the anthrax vaccine is highly reactogenic, there is no clear evidence from Gulf War studies that links the anthrax vaccine to Gulf War illness. Taken together, limited findings from Gulf War epidemiologic studies, the preferred administration to troops in support locations, and the lack of widespread multisymptom illness resulting from current deployments, combine to indicate that the anthrax vaccine is not a likely cause of Gulf War illness for most ill veterans. Pesticide use, assessed in different ways, is one of only two exposures consistently identified by Gulf War epidemiologic studies to be significantly associated with Gulf War illness. Multisymptom illness profiles similar to Gulf War illness have been associated with low-level pesticide exposures in other human populations. Pesticide use during the Gulf War has also been associated with neurocognitive deficits and neuroendocrine alterations in Gulf War veterans in clinical studies conducted many years after the war. The extent of low-level exposure to nerve agents during the Gulf War is unclear, however. Studies of Gulf War veterans have identified increased rates of brain cancer and measurable differences in brain structure and function that relate, in a dose response manner, to modeled nerve agent exposure levels resulting from the Khamisiyah demolitions. Findings from Gulf War clinical studies, and from other human and animal research, suggest that an association between Gulf What the Weight of Evidence Tells Us About the Causes of Gulf War Illness 225 War illness and low-level nerve agent exposure cannot be ruled out, for whatever subgroup of veterans were exposed. Some, like sand, solvents, and fuel exposures, have also been widely encountered by personnel in current Middle East deployments. General information from human and animal studies indicates that fuel and solvent exposures can have neurological effects compatible with symptoms of Gulf War illness but neither has been associated with Gulf War illness in studies of Gulf War veterans. Gulf War studies consistently indicate that exposures in theater were highly correlated, that is, that personnel most often experienced individual exposures in connection with multiple other exposures. Diverse findings have been reported in relation to chemical absorption, metabolism, and biological effects of mixtures of neurotoxicants, which differ from those of individual exposures. There is little information from human studies, however, including the many epidemiologic studies of Gulf War veterans, concerning combined effects of Gulf War exposures. A persuasive theoretical case can be made that exposure to mixtures of neurotoxic compounds in theater are likely contributors to Gulf War illness. Pending such assessments, it is not possible to definitively determine the extent to which mixtures of cholinergic and other neurotoxicant exposures during deployment contributed to Gulf War illness. Based on evidence from toxicological research in animals and what is known about patterns 226 Effects of Gulf War Experiences and Exposures of exposures during the Gulf War, an association between Gulf War illness and combined effects of neurotoxicant exposures cannot be ruled out. Summary: What the Weight of Evidence Tells Us About the Causes of Gulf War Illness Seventeen years after the Gulf War, answers to the question of what caused Gulf War illness remain vitally important. An extensive amount of available information now permits an evidence-based assessment of the relationship of Gulf War illness to the many experiences and exposures encountered by military personnel during the Gulf War. Gulf War studies also consistently indicate that psychological stressors during deployment are not significantly associated with Gulf War illness. Clinical studies of Gulf War veterans, studies of other populations exposed to sarin, and findings from animal studies all suggest that low-level nerve agent exposure can produce persistent neurological effects that may be compatible with symptoms of Gulf War illness. However, inconsistencies in epidemiologic studies and unreliable exposure information preclude a clear evaluation of the extent to which such exposures occurred and may have contributed to Gulf War illness. There is little reliable information from Gulf War studies concerning an association of depleted uranium or anthrax vaccine to Gulf War illness.


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The City shall maintain current information concerning the capacities of the public services and facilities it provides. The City shall encourage other public service agencies to keep their capacity information current. Land uses and development review applications that are inconsistent with the capability of any public service agency to provide cost-effective service shall not be approved. Major extensions of services or utilities to facilitate land use change shall not be approved without a thorough review of all social, economic, and environmental factors with appropriate mitigation measures implemented, if necessary. Natural Hazard Constraints Objective 4: the distribution and intensity of land uses should consider the health, safety, and welfare of the community in regard to man-made and natural hazards. Inappropriate existing land uses within a land use compatibility zone as defined by the Imperial County Airport Land Use Compatibility Plan, shall not be expanded or enlarged beyond the requirements permitted in the zone. Future land uses within land use compatibility zone A or B as defined by the Imperial County Airport Land Use Compatibility Plan, shall meet the guidelines of the zone. Future land uses located in zone C shall be reviewed for compatibility by the City prior to approval. Future residential land uses shall not be located immediately adjacent to the railroad tracks. In the development of the outlying land use in Calexico provisions shall be made in the development plans for large lot rural residential housing. The keeping of farm or ranch animals shall be restricted to the rural residential areas and any continuation of farm or ranching activity is strongly discouraged within the City limits. Rural Residential Objective 6: Rural Residential land use shall be provided for in the development of projects within the outlining areas of Calexico as part of a master plan or planned community development. Development of rural residential units shall be appropriately buffered from adjacent land uses so as not to cause problems from any keeping of farm or ranch animals. Existing rural residential land use areas shall be encouraged to provide the City with a conformance schedule for the elimination of the farm or ranch activity upon annexation into the City limits. Neighborhood commercial activities may be located on the border of rural residential and urban land uses. Lots created as a result of a planned residential development shall not be further subdivided. Mobile homes certified under the provisions of the National Mobile Home Construction and Safety Standards may be allowed on permanent foundations in single-family residential areas where the mobile homes will be compatible with existing or future single family homes. Standards of placement on lots should be developed as specified in California State Law (Government Code Section 65852. Single-Family Residential Objective 7: Low and medium density single-family residential land uses should be encouraged, in new and in-fill areas, to provide family oriented housing in a wide range of sizes and costs. Single-family residential land uses shall be located in areas adjacent to equivalent densities in in-fill situations. New single-family residential projects shall be encouraged to have a variety of housing types and styles. Mobile homes certified under the provisions of the National Mobile Home Construction and Safety Standards may be allowed on permanent foundations in single-family residential areas where the mobile homes will be compatible with existing future single family homes. Standards for placement on lots should be developed as specified in California State Law (Government Code Section 65852. Lots in Low Density single-family residential areas shall be a minimum of 6,000 square feet. Multiple-Family Residential Objective 8: Multiple-family residential of varying types and densities are encouraged where compatible with existing land uses and the provision of public services. Multiple-family residential land uses shall be located in areas where compatible with existing land uses and in close proximity to circulation, transit availability, commercial areas, and provision of public services and facilities. Multiple-family residential projects should provide sufficient open space to balance the developed areas of the site. Multiple-family residential projects should provide recreational uses and activities such as playgrounds, picnic areas, and pools. Adequate parking based upon the number of bedrooms in individual units shall be provided as approved by the City Planning Department. Adequate access should be provided onto improved, City maintained roadways that can accommodate increased traffic. Condominium projects shall be limited to density not to exceed 20 dwelling units per gross acre. Condominium projects shall include enhanced design features such as garages, increased number of parking spaces, and recreational facilities such as pools, spas, and ball courts. Apartment projects shall be limited to 20 dwelling units per acre excepting provisions for affordable income housing as noted. Approval of the projects at the maximum density of this category shall be made on the basis of the findings by the Planning Commission and their recommendation to the City Council that the project under consideration meets and exceeds the standards of the General Plan and the Zoning Ordinance. A density bonus of up to 30 dwelling units per acre may be granted subject to affordability requirements and the granting of a Conditional Use Permit, in accordance with City policy. Apartment projects eligible for a density bonus of up to 30 units per acre shall be no less than one (1) acre in size. Multiple-family residential developments above 20 dwelling units per gross acre shall be for rental only and shall not be converted to units for sale. Approval of projects at the maximum density of this category shall be made on the basis of the findings by the Planning Commission and their recommendation to the City Council that the project under consideration meets and exceeds the standards of the General Plan and the zone. Senior citizen apartments in the Multiple-Family Residential category may receive a bonus of up to 5 units per gross acre, to a maximum of 35 units per gross acre. Approval of projects at the maximum density of this category shall be made on the basis of the City Council that the project under consideration meets and exceeds the standards of the General Plan and the Zoning Ordinance. Multiple-family residential complexes may be eligible for a density bonus as a result of providing low and moderate income housing (see Housing Element Program). The density allowed in planned residential development land use areas shall be set by conditional use permit or specific plan and shall be based upon the density of existing surrounding land uses, site conditions, and the availability of public services. The density of any planned residential development land use shall not exceed 20 dwelling units per net acre. Useable open space is desirable and shall comprise at least 30 percent of the total site area, excluding private yards, parking lot islands, and road medians. Mobile Home Parks Objective 10: Mobile home parks are encouraged in the Medium Density land use category where compatible with existing land uses and public services to provide alternative housing arrangements. Mobile home park land uses should be located in areas with similar existing uses and densities or in specific plan areas with appropriate design considerations included. Mobile home park land uses shall be located in close proximity to circulation, transit availability, commercial areas, and the provision of public services and facilities. Neighborhood commercial centers should be designed and located in such a manner so as to compliment and not conflict with adjoining residential areas. Specialty commercial uses such as swap meet sites, although typically transient in nature, should provide standard amenities such as paved parking lots, restroom facilities, shade structures, and food vendors if allowed to operate for longer than one week. Highway commercial uses along Highway 111/Imperial Avenue should encourage roadway oriented retail activity such as automobile sales, shopping centers, hotels and restaurants. Retail uses within the highway commercial zone should be located within retail centers having centralized ingress and egress points and/or frontage road access in order to minimize curb cuts along Highway 111 and Highway 98. Industrial Objective 12: Industrial land uses that provide a full range of industrial and manufacturing services are encouraged where they are compatible with existing and other planned land uses. Industrial parks are encouraged within a specific plan area or planned development within a planned community. Industrial uses shall be located so as to not create adverse impacts on surrounding land uses and/or the City circulation system. Heavy industrial land uses should be primarily designed for manufacturing, assembly, packaging, processing, fabrication, and storage. Industrial land uses shall be adequately screened to reduce glare, noise, dust, and vibrations. Noise attenuation measures such as buffer zones or noise attenuation walls shall be used to reduce outside noise levels when existing residential developments are adjacent to new or existing industrial developments. All outside storage shall be completely screened from view with permanent walls or landscaping.

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The differential diagnosis includes: 1) atrial septal defect (clinical picture is almost indistinguishable), 2) total anomalous pulmonary venous return, 3) pulmonary sequestration, 4) ventricular septal defect. The diagnosis of scimitar syndrome rests on demonstration of the aberrant pulmonary veins and associated abnormalities. A contraindication for surgical repair is the presence of pulmonary hypertension, which can increase the mortality rate to >50%. The chronic, increased pressure within the pulmonary venous system can lead to pulmonary vascular and cardiac remodeling with complications of arrhythmias, right-sided cardiac failure and pulmonary vascular disease (rare). These manifest themselves to varying degrees throughout life depending on shunt size, and may be the cause of morbidity and mortality from the disease. Pulmonary Sequestration: Pulmonary sequestration is a segment of nonfunctioning lung tissue that usually does not associate with the tracheobronchial tree (airways within the sequestration rarely communicate with the trachea) and receives all of its blood supply from an anomalous systemic artery. The main distinguishing points are the tracheobronchial communication and the venous drainage. There are two different types of sequestrations: intrapulmonary (formerly called intralobar) and extrapulmonary (formerly called extralobar), which collectively make up approximately 6% of congenital pulmonary malformations. The development of these abnormalities is hypothesized to be from the development of a primitive lung bud from the foregut during embryonic development. This lesion usually occurs by itself with no associated congenital abnormalities and by definition, does not have a separate pleural covering. Communication with the tracheobronchial tree may occur via fistulas, but this is rare. Classically, intrapulmonary sequestrations do not present symptomatically until adolescence or adulthood. In fact, they are often an incidental finding on a chest X-ray performed for other reasons. When they do present clinically, it is with non-specific symptoms of cough, fever, wheezing, recurrent pulmonary infections, and rarely hemoptysis. Surgical resection of the lesion is curative and lobectomy is necessary because these are often poorly-defined masses. Extrapulmonary sequestrations differ from intrapulmonary sequestrations in many respects: 1) the presence of a distinct and separate pleura, 2) the association with other congenital abnormalities (diaphragmatic hernia, colonic duplication, vertebral abnormalities, and pulmonary hypoplasia) (5), 3) >60% of cases present in infancy before age 6 months with a 4:1 male-to-female incidence, and 4) venous drainage is normally into the right atrium via the azygous system (11). The lesion is normally asymptomatic until associated abnormalities, infection, or shunting becomes severe. Similar to intrapulmonary sequestration, if the patient is not diagnosed with an extrapulmonary sequestration during infancy because of no complications due to vascular causes. Complications are recurrent infection and hemorrhage in addition to those associated with other congenital abnormalities. Treatment is resection of the abnormality, which does not involve a lobectomy because it is a well-defined mass. Page - 319 Physical examination reveals similar findings in both intra and extrapulmonary sequestrations: 1. A systolic murmur or continuous bruit associated with the arterial supply to the lesion may be present. The differential diagnosis includes: 1) cystic adenomatoid malformation, 2) bronchogenic cyst, 3) bronchiectasis, 4) pulmonary atelectasis, 5) bronchial foreign bodies, and 6) pneumonia. Scimitar syndrome and sequestration can both be categorized as venolobar syndromes. They both involve the lung, at least to some varying degree, and they both have cardiovascular involvement or at least the potential for cardiovascular involvement. However, while the cardinal cardiac lesion in Scimitar syndrome is partial or hemianomalous venous drainage, sequestration may not have an anomalous vascular connection. Sequestration is a disconnected or abnormally communicating bronchopulmonary mass or cyst with normal or anomalous arterial supply or venous drainage (12). Sequestration is primarily considered to be a congenital lung malformation and because of the extra-parenchymal tissue, angiogenesis may occur causing an anomalous vascular supply. Scimitar syndrome, on the other hand, begins as a congenital cardiac malformation (usually an abnormal right pulmonary artery with or without other aberrant systemic arteries), which then causes abnormal lung development (ranging from minor abnormal bronchial branching all the way to a hypoplastic lung) and all of it is drained by the hallmark feature, an anomalous vein. In fact, bronchogenic cysts and extrapulmonary sequestrations have been found in association with Scimitar syndrome. It is because of these embryologic differences that on chest X-ray, sequestration usually appears as a cystic lesion or consolidation, while Scimitar syndrome has the characteristic Scimitar appearance with hypoplasia of the right lung. What shunt fraction is considered clinically significant for the manifestation of symptoms in Scimitar Syndrome? Why would you want to correct the underlying condition of scimitar syndrome early? List three or more ways in which Scimitar syndrome differs from pulmonary sequestration. Bronchial and arterial anomalies with drainage of the right lung into the inferior vena cava. Chapter 53 - Pulmonary Arteriovenous Malformations and Other Pulmonary Vascular Abnormalities. To prevent future complications such as: pneumonia, arrhythmia, and irreversible pulmonary hypertension (13). Typically, it is left-to-right venous drainage: pulmonary venous/systemic artery to the systemic venous system. Intrapulmonary sequestrations typically shunt systemic blood to the pulmonary vein (systemic artery to the pulmonary vein, which is left to left). Pregnancy was complicated by ultrasound findings of mild polyhydramnios and an abnormal fetal chest finding. Apgars of 4 (-1 for respiratory effort, gag, tone and heart rate, -2 for color) and 7 (-1 for color, respiratory effort, tone) were given, at 1 and 5 minutes, respectively. He is term in appearance, non-dysmorphic, thin appearing, in moderate to severe respiratory distress. There are no crackles or wheezing, but delayed air entry and prolonged expiration is present on the right. His abdomen is soft and non-distended, without palpable masses or hepatosplenomegaly. In the delivery room, he is given bag mask ventilation for the first minute of life with improvement in heart rate and color. A chest radiograph demonstrates cystic lesions occupying much of the lower right lung field. One of the residents thinks that this is bowel in the chest (based on its appearance) with an associated diaphragmatic hernia. But the neonatologist cautions that a diaphragmatic hernia on the right is unusual. Serial chest radiographs show that the lesions are stable over the first 24 hours. Intraoperatively, it is apparent that the lesions are contained within the right lower lobe, so this lobe is resected. Chest radiographs show that the mediastinum has returned to midline, the right upper and middle lobes compensate to fill the hemithorax. The child is weaned from the ventilator, and over time, he no longer requires supplemental oxygen. Congenital malformations of the airways and lungs make up approximately 10-15% of all malformations and are often found with other congenital anomalies (18-20%). Bronchogenic cysts are one type of a foregut cyst (a closed epithelial-lined sac developing abnormally from both the upper gut and respiratory tract). A bronchogenic cyst is thought to develop as a diverticulum of the primitive foregut. Since most form very early, usually 4-8 weeks gestation and before the development of distal airways, they rarely connect to a normal bronchus. Most are right sided, midline and in close proximity to the tracheobronchial tree. On rare occasions they can separate the connection to the airway and migrate to the periphery, parahilar area or even below the diaphragm. Five categories have been described by location: 1) paratracheal 2) carinal 3) para-esophageal 4) hilar and 5) other. They may contain normal tracheal tissue including mucus glands, elastic tissue, smooth muscle and cartilage. The cyst may contain serous (with the consistency of water) or proteinaceous fluid (2,3).

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The padding also absorbs water and sweat well, minimizing the accumulation of moisture (1). Kinks, although small, may be a potential sight of irritation causing skin breakdown and pressure injury. The procedure for splinting should always start with a general inspection of the limb. Next, the limb should be rechecked for signs of compartment syndrome and neurovascular compromise. The splint width should be approximately half as wide as the circumference of the extremity. Since the splint is used to support the limb, the posterior surface is usually used as a measuring guide. A longer length will also allow for contraction of the plaster as it crystallizes (4). Optionally, stockinette (tube sock) can be rolled over the limb and cut to a length slightly longer than needed. The stockinette should look as if a long sock with an open hole has been placed over the extremity. Take time to smooth out the stockinette to prevent pressure spots and kinks at flexion creases. Also, make sure the stockinette is positioned so that there is extra material both proximal and distal to the area to being splinted. If stockinette has been used, then the cast padding is rolled over the stockinette. Each successive roll of cast padding around the extremity should cover the previous roll by approximately 50-60% (4). Make sure that the "extra" stockinette distal and proximal to the area being splinted is not covered with cast padding. The plaster will heat up as it hardens, and this may scare and burn a child but this is unlikely. While the plaster still soft, fold the proximal and distal ends of the plaster back over itself to provide a smooth edge. An optional cast padding layer can be applied over the splint to prevent the soggy plaster from Page - 614 incorporating into the elastic wrap applied in the next step. Roll an elastic bandage over the outside of the extremity, usually in a distal to proximal fashion, securing the plaster to the extremity. Fiberglass splint materials come encased in cast padding material rather than as bare sheets of fiberglass. Once the limb has been inspected, and the proper splint width and length are selected, cut the length needed and place the fiberglass splint in water. Removed the excess water from the fiberglass splint by rolling it in a dry towel and applying pressure to remove water from the fiberglass. This can be repeated until the outside of the fiberglass splint material feels dry. Because the fiberglass is prepackaged, it has enough padding to be directly applied, but stockinette and additional cast padding can be optionally applied over the whole extremity, or just over the bony prominences (4). Once the fiberglass is placed over the extremity it should be molded to the desired shape. The padding material should be stretched over the end of the fiberglass to prevent the sharp fiberglass ends from poking the patient. An elastic bandage should then be applied to secure the fiberglass splint in place (4). The final step in any splitting procedure should be to check the extremity for signs of neurovascular compromise. Capillary refill should be brisk, and sensation to light touch and pin prick should be intact. The patient should also be able to move the distal anatomy with minimal discomfort. Because the splint is not a rigid cylinder, the elastic wrap permits some expansion due to extremity swelling preventing harmful circumferential pressure by the splint. Nevertheless, neurovascular injury may occur and produce signs such as tingling, numbness, increasing pain, and/or paresis which may indicate the development of a compartment syndrome. If any of these signs or symptoms develop, the patient should be counseled to return to the emergency department immediately. Preventative measures should be taken such as limb elevation and periodic monitoring of the distal anatomy (1). Moisture will soften the skin and the splint, promoting itching, infection, pressure sores, and cast breakdown. The patient should be given instructions for follow-up with a contact number in case of complications. Cast padding is applied to the extremity (stockinette optional), the splint material is applied as noted below, and an elastic bandage is rolled on over the extremity such that the splint material properly molds to the shape of the extremity without pressure spots. The elbow should be flexed at approximately 90 degrees to a position of comfort, and the forearm should be medially rotated 90 degrees (such that the volar side of the forearm is toward the body) with slight dorsiflexion at the wrist. If splinting a supracondylar fracture, position the forearm in a slightly pronated position. The splint should extend from the metacarpophalangeal joint to the upper arm, just distal to the axilla. The splint will be applied on the ulnar surface of the wrist and forearm and extend to the posterior surface of the upper arm. Indicated for ankle sprains and non-displaced fractures of the ankle, foot, and distal fibula. The ankle should be in the proper anatomic position, flexed at approximately 90 degrees. The splint will extend distally from the foot (plantar side of the metatarsal phalangeal joints) to the proximal lower leg (level of the fibular head near the knee), and provides support to the posterior leg and foot. The patient should be given crutches (if the child is old enough to use crutches), otherwise encourage light weight bearing or non-weight bearing on the splint. Unlike the posterior ankle splint, the ankle stirrup splint provides lateral and medial support. The ankle stirrup splint provides superior immobilization for a fracture near the ankle compared to the posterior ankle splint. The splint will wrap from the lateral surface of the calf (just distal to the knee), around the plantar aponeurosis and heel, to the medial surface of the calf just distal to the knee. Ideally, wide splint material should be used so that the bottom of the "U" will support the heel to the metatarsal phalangeal joints on the plantar side of the foot. The ankle should be flexed at 90 degrees (the same as for the posterior ankle splint). Indicated for minor fractures near the wrist, soft tissue injuries to the hand and wrist, and fractures of the carpals and metacarpals. Extend the splint from the metacarpal heads of the palm to the volar surface of the forearm proximal to the elbow. The forearm is placed in the neutral position and the wrist should be slightly dorsiflexed. The palmar end of the splint should be rolled so that the hand can rest in a flexed position over the roll. The splint material is folded on its long axis such that the ulnar side of the forearm fits into the long gutter formed by the splint. This should extend from the distal 5th finger or metacarpal to the proximal forearm (just distal to the elbow). Prevents supination and pronation of the wrist, flexion/extension of the forearm, and blunt trauma to the fracture site. This type of splint provides superior immobilization compared to the volar forearm and ulnar gutter splints. The thumb should be unopposed, and the remaining digits should be allowed 90 degrees of flexion. Indications include a nonrotated, nonangulated, nonarticular fracture of the thumb metacarpal or proximal phalanx. This type of splint can also be utilized for ulnar collateral ligament injuries, and scaphoid tenderness (fracture or suspected fracture). A thumb spica splint is often placed together with a volar wrist splint for suspected scaphoid fractures. The radial aspect of the forearm is placed in the splint so that the splint can form a long U-shape down the length of the splint (similar to the ulnar gutter, but on the radial side).

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As a result, situations in which two tests were done but records not retained, or where two different types of tests were not done, or where putative exposures occurred below levels detectable by monitoring equipment would not have been verified by post-hoc evaluations. The January 17-23 period coincides with the initiation of Coalition air bombing in Iraq. Seventeen metric tons of Sarin were reportedly destroyed during these attacks, which began on January 17, 1991. These thermal and visual plumes extended directly toward the areas where those same chemical warfare agents were detected and confirmed by Czechoslovak chemical specialists. There, chemical agents were detected by different units over a period of several days. The Department of Defense originally reported findings from an investigation of Czech chemical agent detections in November, 1993. Czech chemical units had the most sophisticated chemical capabilities available during the Gulf War, with detection systems that were highly sensitive for both nerve and blister agents. Thirty minutes later, a third detection was reported by another unit about 30 miles away. In each case, the initial detections were retested with a second type of detector and also found to be positive. The detected levels of nerve agents were below the sensitivity thresholds of equipment used by other Coalition partners. It can only be concluded that low levels of nerve agent might have been present in the northern part of Saudi Arabia on January 19, 1991. The challenges and conflicting conclusions described with respect to this particular incident on this single day illustrate the difficulties inherent in determining if and where military personnel might have been exposed to low level chemical agents during the Gulf War. Other reported incidents, including additional Czech detections, are also associated with both supporting and negative indicators. In the years following the Gulf War, several investigations suggested that Iraq had prepared to use chemical weapons during the Gulf War, and that some limited use may have occurred. It also documents Iraqi attempts to use sarin against the Shia population in southern Iraq in March of 1991, to quell an uprising after the U. This was thought to be because the sarin-filled bombs had not detonated when released from low-flying helicopters, the only aircraft Iraq could utilize under terms of the ceasefire. A defense intelligence bulletin in early March of 1991 had warned that Iraq might resort to the use of chemical weapons to quash the Shia rebellion. Joel Graves, a Committee member and Gulf War veteran, reported that on March 15, members of his unit, stationed south of Basra, had become acutely ill in the evening and that chemical alarms had sounded nearby. The next day, his commander informed him that mustard gas was thought to have been used in Iraqi attacks against the Shia in Basra, and may have drifted towards U. During the Gulf War, military defenses against chemical weapons emphasized detection and response to high level, acutely dangerous exposures, to protect troops from potentially dire consequences. Since the war, however, concerns have emerged about possible effects of lower level chemical agent exposures and their association with the health problems affecting Gulf War veterans. Despite extensive government efforts, substantial questions remain about the extent to which Gulf War military personnel were exposed to low-level chemical agents in theater. First, it is unlikely that low levels of airborne chemical agents would generally have been identified or documented by military personnel. Monitoring systems had little capacity to detect chemical agents at levels that do not cause immediate symptoms. Second, although the Department of Defense estimates that about 100,000 personnel may have been exposed to low levels of sarin and cyclosarin nerve agents as a result of weapons demolitions at Khamisiyah, serious questions have been raised about the accuracy of government models used to determine who was exposed, and at what levels. Third, unanswered questions and limited information related to other reported chemical events leave open the possibility that additional chemical exposures might have occurred during and after the Gulf War, in locations other than those affected by the Khamisiyah demolitions. Pyridostigmine normally does not cross the blood brain barrier in significant amounts, due to a positively charged quaternary ammonium group. Pyridostigmine administered subcutaneously had no effect on antibody response or corticosteroid levels. Health parameters were assessed under a variety of conditions, including flight simulation, exercise, and heat stress. Milder effects include abdominal and digestive discomfort, runny nose, and excess salivation and sweating, while more severe reactions can include diarrhea, muscle weakness and spasms, and vomiting. It has recently been investigated as a treatment for neurogenic orthostatic hypotension, a condition associated with impaired autonomic regulation of blood pressure. Department of Defense, 20031632 Chemical pesticides and insect repellants have been in widespread use since the middle of the last century. Many pesticides are neurotoxic by design, that is, they are developed to kill insects by attacking their nervous systems. Thousands of compounds have been developed for use against different insects and other pests, for application in different settings. The Department of Defense estimates that 64 different pesticide and insect repellant products, with 37 different active ingredients, were used by military personnel during the Gulf War. Many thousands of research studies have evaluated biological effects of pesticides in animal models and health effects in human populations. Detailed information from this large literature is compiled in comprehensive textbooks on pesticide toxicology. New findings related to toxicological effects of pesticides and insect repellants continue to emerge at a rapid pace. In recent years, this research has provided important insights into health effects of lower-level and chronic pesticide exposures in human populations, including associations with persistent symptomatic illness. This includes the Agricultural Health Study, a large interagency project to characterize acute and long term health effects in nearly 90,000 Americans who work with pesticides, and their family members. In the last several years, major reports have been released internationally by government and scientific panels concerning effects of pesticide exposures on the public health. These reports have raised awareness of recent findings on potential associations between pesticides and a broad spectrum of human diseases, including difficult-to-diagnose multisymptom conditions. This includes a review of the scientific literature on health effects of pesticides from the Ontario College of Family Physicians, which concluded that "there is a high level of consistency in results to indicate a wide range of pesticide-related clinical and subclinical health effects" and that "exposure to all the commonly used pesticides- phenoxyherbicides, organophosphates, carbamates, and pyrethrins-has shown positive associations with adverse health effects. A 2005 report on human health affects of agricultural pesticides from the British Royal Commission on Environmental Pollution described the complex issue of discerning chronic health effects resulting from unmeasured and varying combinations of pesticide exposures. The Commission noted that "the clinical awareness of general practitioners and specialists needs to be improved in order to improve the investigation of people with chronic, ill-defined health effects. It pointed out that understanding effects of pesticides on the health of Gulf War veterans is complicated by a number of factors, including variation in individual Cholinergic and Related Neurotoxicants: Pyridostigmine, Pesticides, and Nerve Agents 151 vulnerability to adverse effects of neurotoxicants, differences in the degree to which pesticides used by veterans were absorbed into their skin and circulation, and unknown effects of combinations of multiple pesticides or pesticides in combination with other exposures in theater. No conclusions were provided concerning possible associations between pesticide exposures in theater and Gulf War multisymptom illness. Information concerning health effects of the major classes of pesticides and insect repellants used during the Gulf War is briefly summarized below, with attention to health issues relevant to Gulf War veterans. Most scientific research on pesticides has evaluated effects of individual chemicals that develop over a relatively brief time period. Human research has historically focused primarily on effects of high-level exposures associated with pesticide poisoning. However, a growing body of research has evaluated human health effects of lower-level exposures and exposures experienced over longer periods of time. Nearly all studies that have evaluated effects of combinations of pesticides and repellants used in the Gulf War have been conducted in the past 12 years, using animal models, in connection with the federal Gulf War research effort. This research will be described in a later section that addresses effects of combinations of Gulf War exposures. These include chlorpyrifos, diazinon, and malathion, used in different concentrations by pesticide applicators as area fogs and surface sprays. They also include dichlorvos-containing pest strips, issued for personal use to the general military population, and azamethiphos crystals used as fly bait, which was purchased locally. A delayed reaction to poisoning by malathion or diazinon has been described in some individuals, a condition known as "intermediate syndrome. Serious cases can lead to respiratory arrest but if respiration is maintained, recovery generally takes several weeks. Symptoms 152 Effects of Gulf War Experiences and Exposures usually begin with cramping muscle pain in the lower extremities, followed by numbness, parasthesia, and progressive muscle weakness. Bendiocarb and propoxur were sprayed on surfaces and in cracks and crevices by pesticide applicators to kill flies, mosquitoes, and flying insects. In addition, fly baits containing the carbamate methomyl were issued by the military and also purchased locally, and used both by trained pesticide personnel and by individual service members.

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For osteomyelitis, we could cover the Staph aureus with an anti-Staph aureus penicillin such as oxacillin, nafcillin or methicillin or a first generation cephalosporin such as cefazolin. Although there is a good chance the patient will respond, in 25% to 30% of cases, this treatment will fail and the patient will suffer the consequences of inadequate treatment which would include: death from sepsis, Staph pneumonia, spread of the osteomyelitis, chronic osteomyelitis requiring an amputation, etc. Although trimethoprim/sulfamethoxazole (Bactrim or Septra) is commonly recommended because of its broad coverage for this indication, this drug causes Stevens-Johnson syndrome more commonly than others. If the parents accept this increased risk, then this Page - 181 should be documented on the chart. Most parents are not willing to accept this increased risk since other antibiotics are available. Amoxicillin will probably work, but there is a high frequency of resistance which is generally not a probably for simple cystitis, but in a febrile 18 month old, there may be some degree of pyelonephritis as well. Thus, an acceptable answer here would also be a first generation cephalosporin such as cephalexin. Additionally, since most patients have drug plans, the difference may be negligible. If both medications are efficacious, perhaps it is best to discuss these differences with the patient and give them some input in the decision. He has had coughing and runny nose for about 5 days that has been treated with an over-the-counter cold medicine. He also has a low-grade fever of about 101 degrees axillary for the past two days. His past medical history is significant for ear infections in the past, with his last otitis media being 5 months ago treated with amoxicillin. It is estimated that otitis media comprises 23% of all office visits in the first year of life, and 40% at four to five years when these children start Kindergarten. The middle ear is a gas filled cavity in the petrous part of the temporal bone between the external auditory canal and the inner ear. Therefore, factors hindering the movement of these ossicles, such as pus or fluid in the middle ear, will adversely affect hearing. The eustachian tube allows for ventilation and clearance of fluid from the middle ear. Also, the angle of the tensor veli palatini muscle to the cartilage around the tube is variable, compared to being stable in the adult. The significance of these characteristics is that there is a greater likelihood that nasopharyngeal secretions can reflux or insufflate into the middle ear, and that clearance of the middle ear cavity of these secretions is decreased (2). These differences are the reason why there are more middle ear infections in the infant compared to the adult and older child. Otitis media is common in infants and young children with the peak age being between 6 to 18 months of age. This is due not only to anatomical factors, but immunologic as well since these children still lack many protective antibodies against viral and bacterial organisms. Also, babies are breast fed while in a vertical or semi-reclining position, compared to some babies who may be bottle-fed while in a horizontal position. The presence of cerumen and uncooperative and frightened patients complicate this. It should be noted, although controversial, that a tympanic membrane may become red in a crying child (4). This chapter will focus on two types of otitis media, namely acute otitis media and otitis media with effusion. Older children may complain of a "plugged" feeling or "popping" in their ears, which is usually bilateral. It is important to distinguish between the two diseases because the management of each is different, however, it is not easily done. If severe otalgia is present, then analgesia becomes a major therapeutic consideration. Although Auralgan otic is used for pain relief, one should be aware of allergic reactions and to make sure there is no perforation. The management of otitis media is one of many controversial subjects in pediatrics. The three most common organisms are Streptococcus pneumoniae, non-typable Haemophilus influenzae, and Moraxella catarrhalis. Other less common organisms are Streptococcus pyogenes, Staphylococcus aureus, gram negative enteric bacteria, and anaerobes (5). The choice of antibiotic is dependent on efficacy, palatability, side effects, convenience of dosing, and cost. For this reason, it is recommended that the dose of amoxicillin be increased from 40-50 mg/kg/day to 80-90 mg/kg/day in two to three divided doses. However, children who are at low risk for resistant organisms may be treated with the lower dose of amoxicillin, being 40-50 mg/kg/day. Risk factors include young age (less than 2 years), recent antibiotic use (within the last month), and day care attendance (4). In patients who are allergic to beta-lactam antibiotics, macrolides, like erythromycin plus sulfisoxazole, azithromycin, or clarithromycin, and trimethoprim-sulfamethoxazole may be used. The duration for treatment is 10 days, although azithromycin, cefpodoxime, and cefdinir are now approved for 5 days, and a single dose of intramuscular ceftriaxone is as effective as a 10-day course of amoxicillin. Also recently, azithromycin has been approved for a 30 mg/kg one time dose, or 10 mg/kg dose for three days. Other drugs that are recommended are cefprozil, ceftibuten, loracarbef, and clindamycin (6). Persistent otalgia, fever, and other systemic symptoms past 72 hours should be reevaluated. At times, tympanocentesis or myringotomy is necessary for resistant cases, at which time a culture can also be obtained. Follow-up visits are recommended 10-14 days later to determine the need for further antimicrobial treatment. Although a middle ear effusion may be present, an inflamed eardrum or persistent systemic symptoms at this follow-up visit may warrant changing the antibiotic therapy or performing a myringotomy/tympanocentesis. It is estimated that 30-70% of children will have a middle ear effusion 10-14 days later, and that without treatment, 6-26% will have a persistent middle ear effusion after 3 months, with the mean of resolution being about 23 days. Medications that have been studied are decongestants, antihistamines, oral corticosteroids, and antibiotics. The only drugs proved efficacious are oral corticosteroids and antibiotics; however, it is felt that the side effects from oral corticosteroids outweigh its benefits. Other antibiotics that have been recommended are cefaclor, erythromycin-sulfisoxazole, and ceftibuten, although these are either just as efficacious or less so than amoxicillin. If antibiotic therapy fails, then myringotomy with tympanostomy tube placement or myringotomy and adenoidectomy are recommended as the next step. Only ofloxacin otic solution is approved in children with acute otitis media with tympanostomy tubes or chronic suppurative otitis media with perforation (8). Not only do we treat otitis media for symptomatic relief, but also to prevent its complications. Fortunately, because we live in the antibiotic era, these complications are rarely seen. Only in a few children does medical therapy fail, and more aggressive measures are needed, such as myringotomy and tympanostomy tubes. As the humidity in the outer ear increases, the stratum corneum in the cartilaginous portion of the ear absorbs water, which results in edema. Edema blocks the pilosebaceous units in the ear, thereby decreasing the excretion of cerumen. A decrease in cerumen causes an increase in the pH of the external ear, in addition to decreasing its water repelling covering. The exposed skin becomes susceptible to maceration and the higher pH becomes a favorable environment for bacteria such as Pseudomonas. Bacteria can then penetrate through the dermis after superficial breakdown or through minor trauma such as with cotton applicators. The most common organisms cultured in otitis externa are Pseudomonas and Staphylococcus aureus. Other organisms that can be cultured are Enterobacter aerogenes, Proteus mirabilis, Klebsiella pneumoniae, streptococci, coagulase-negative staphylococci, diphtheroids, and fungi such as Aspergillus and Candida. Symptoms initially include pruritus and aural fullness, which then progresses to ear pain that may be severe and out of proportion to its appearance.

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Gulf War veterans and two studies of British veterans, along with regular mortality reports provided by the U. By 1996-1997, rates of mortality resulting from both disease and accidents were nearly identical in deployed and nondeployed veterans. Later information has been published on mortality rates through the year 2000 for Gulf War veterans only, in relation to the Khamisiyah plume models, as previously described. Early results indicate that, overall, Gulf War veterans continue to have a lower mortality rate due to diseases, and a higher mortality rate due to accidents, than nondeployed era veterans. However, investigators reported that female Gulf War veterans have significantly greater mortality, overall, than nondeployed female era veterans, and excess deaths due to digestive system diseases and external causes, including motor vehicle accidents. Preliminary findings also continue to indicate that brain cancer mortality is elevated among Gulf War veterans in relation to modeled levels of exposure to nerve agents. These preliminary findings are provocative, and the Committee looks forward to further reviewing results of this important study as they are finalized. Mortality rates among British Gulf War veterans through 2006 have shown trends similar to those observed in U. Over time, excess rates of accident-related deaths identified in the years just after the war have become more comparable to those of nondeployed veterans. Ministry of Defence reported that between 1991 and 2007, veterans of the 1991 Gulf War had a higher rate of suicide, or possible suicide, than nondeployed veterans of the same era. Veterans who reported handling pesticides during the war were twice as likely as unexposed veterans to die from accident-related causes, and veterans who reported depleted uranium exposure were twice as likely to die from disease-related causes. Other Gulf War Health Issues 47 A number of theories have been put forward to explain why Gulf War veterans have experienced higher rates of fatal accidents, most prominently motor vehicle accidents. Gulf War and nondeployed veterans that have been published only include deaths that occurred before 1998. Deaths due to diseases with longer latency periods would likely only have become apparent in more recent years. Therefore, it is important that current figures for overall mortality, as well as diseasespecific mortality, for U. Additional information on mortality rates among subgroups of Gulf War veterans-defined, for example, by exposures and locations in theater and by branch of service-is also needed to determine if Gulf veteran subgroups have been affected by any causes of death not apparent when all veterans are assessed as a single group. Hospitalization Rates Among Gulf War Veterans Between 1996 and 2006, 14 studies reported rates of hospitalization in Gulf War veterans and comparison groups. They therefore do not include the vast majority of Gulf War veterans or hospital admissions. Both all-cause hospitalization rates and disease-specific hospitalizations have been similar, overall, in comparisons between active duty Gulf War and nondeployed military personnel from the same era. The first reported that Gulf War veterans were hospitalized for fibromyalgia at significantly excess rates between 1991 and 1997, but not for lupus. A second study found that a higher proportion of Gulf War Marine Corps veterans than Vietnam Marine veterans were hospitalized for musculoskeletal conditions. Results indicated a higher proportion of Gulf War than nondeployed era veterans had been hospitalized for injuries and for respiratory and digestive diseases. There is also little reason to expect that a number of other types of conditions reported to affect Gulf War veterans at excess rates would be identified by the hospitalization studies conducted to date. Nearly all studies report only on hospitalizations among active duty personnel in military hospitals. Veterans with serious conditions that might lead to hospitalization, 48 Gulf War Illness and the Health of Gulf War Veterans but who were no longer in the military, would not have been included in the studies. In addition, medical conditions shown by some studies to have affected subgroups of Gulf War veterans affected by a particular exposure, such as asthma and brain cancer, would potentially go undetected in hospitalization studies that simply compare all deployed veterans to nondeployed veterans. Further, diseases with long latency periods, potentially detectable at their later stages using hospital admission data, would not likely be found in studies evaluating hospital admissions before 2000, the most recent year for which Gulf veteran hospitalization data have been reported. An enormous amount of effort and care have been used to analyze and report military hospitalization rates in Gulf War veterans. Results of these studies have been reassuring, to some degree, by indicating that Gulf War veterans have not been admitted to military hospitals at exceedingly high rates in conjunction with the types of injuries and acute and chronic diseases that normally lead to hospitalization. Gulf War hospitalization studies have largely been used to report on disease rates that are easiest to quantify using data routinely collected for administrative purposes. Unfortunately, this "low hanging fruit" is not particularly informative with respect to the types of health problems known or expected to be of greatest concern for Gulf War veterans. Consequently, hospitalization studies have added little to our understanding of health issues related to Gulf War service. It is possible that hospitalization data may be more informative in future years, if diseases of long latency that require hospitalization emerge in sufficient numbers. It will be important, however, that any future studies of hospitalization rates in Gulf War veterans include nonmilitary hospitalizations, and determine disease-specific rates in relation to Gulf War veteran subgroups of interest. In 1995, a cover story in Life magazine reported on several children, born to Gulf War veterans, who had serious birth defects including Goldenhar Syndrome, a congenital disorder characterized by abnormal development of facial structures. Later studies used larger and/or more representative samples of Gulf War veterans, and more comprehensive methods to identify health problems in children under one year. These studies did find that a limited number of adverse birth outcomes, though rare, occurred more commonly in Gulf War veterans than nondeployed veterans. A study of over 75,0000 children born in military hospitals between 1991 and 1993 indicated that infants born to Gulf War veterans were about three times more likely to have Goldenhar syndrome-related diagnoses than infants born to nondeployed veterans. Study results indicated that Other Gulf War Health Issues 49 children born to male Gulf War veterans after the war had twice the rate of "likely" birth defects as children born to nondeployed era veterans. Children born to female Gulf War veterans had three times the rate of "likely" birth defects. Resulting adjusted estimates continued to indicate that children of Gulf War veterans had significantly more birth defects than children of era veterans. Birth defects affecting the musculoskeletal and genitourinary systems were most prominent. Naval Health Research Center also indicated an excess of birth defects in children of Gulf War veterans. This study linked Gulf War military service information to 1989-1993 data from six states with active birth defects surveillance programs. Children of male veterans had higher rates of two types of heart valve defects-tricuspid valve insufficiency and aortic valve stenosis. Male children of female Gulf War veterans were more likely to be born with hypospadias, a defect in the urethral opening. In contrast, there were similar rates of birth defects in children of Gulf War and nondeployed veterans who had been conceived before the war. Studies have also reported other adverse pregnancy outcomes in relation to Gulf War service. Military hospital data revealed a significant excess of ectopic pregnancies and spontaneous abortions among women Gulf War veterans whose pregnancies were conceived soon after their return from theater. Gulf War surveys reported higher rates of miscarriages, but not still births, in pregnancies they had fathered. A postal survey collected data on pregnancy outcomes between 1991 and 1995 reported by over 4,000 U. No significant excess of low birth weight, ectopic pregnancies, stillbirths, or miscarriages were reported for male or female Gulf War veterans, when analyzed separately. It is difficult to draw firm conclusions related to birth defects and pregnancy outcomes in Gulf War veterans, due to the diversity and limitations of study results reported to date. Information on specific types of birth defects has been inconsistent, however,362 and overall rates are still within the normal range found in the general population. Some of the remaining important questions concerning birth defects in children of Gulf War veterans might be answerable using existing data. Birth defects might also have been more problematic during certain periods after veterans returned, for example, in pregnancies conceived soon after Desert Storm, as opposed to more recent conceptions. Identifying patterns and risk factors for birth defects in defined populations can be extremely challenging, particularly for birth defects that are uncommon. This could include case-control studies to evaluate Gulf War service and specific parental exposures as risk factors for extremely rare types of birth defects. The analytic approach of the organization involves comparing proportional patterns of birth defects in different populations, in order to raise hypotheses about potential problems in a given group. This includes 33 children with Goldenhar syndrome-substantially more cases than had been identified in the large military hospital study.

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Transmission is via respiratory secretions and the fluid produced by skin lesions, either airborne or through direct contact. Transmission to susceptible individuals occurred at a rate of 80-90% for household members. The incubation period is 14 to 16 days and initial symptoms typically consist of fever, malaise, headache, anorexia, or abdominal pain (2). Temperature elevation is usually moderate but may be as high as 41 degrees C (106 degrees F) (5). They begin as intensely pruritic, erythematous macules which rapidly evolve into vesicles containing serous fluid. Over a 24 to 48 hour period, the Page - 236 vesicles umbilicate, the fluid clouds, then transforms into crusts before finally resolving. Healed lesions may leave residual hypopigmentation lasting weeks, but scarring is uncommon. Ulcerative lesions of the oropharynx and vagina commonly develop concurrently with the exanthem. Acyclovir and varicella-zoster immune globulin have been effective in the prophylaxis and treatment of progressive disease, as described below. The course is generally benign, although in certain populations it may be associated with several complications. Progressive varicella is characterized by visceral organ involvement, coagulopathy, severe hemorrhage, and continued lesion development. Severe abdominal pain and the appearance of hemorrhagic vesicles in otherwise healthy adolescents, immunocompromised children, pregnant women, and the newborn may be a red flag for this serious complication (5). Delivery within one week before or after the onset of maternal varicella frequently results in the newborn developing varicella, which may be severe and requires the administration of varicella-zoster immune globulin and acyclovir. A characteristic zig-zag scarring, often in a dermatomal distribution, can sometimes be seen (5). The lifetime risk for those with a history of varicella is 10%, with 75% of cases occurring after 45 years of age (5). Other viruses which commonly cause exanthems include adenovirus (rash, conjunctivitis), echovirus ("Boston exanthem" similar to roseola), and Epstein-Barr virus (see chapter on Epstein-Bar virus). A common rash associated with amoxicillin use is probably related to a viral etiology. Commonly called an "amoxicillin rash", this is a non-allergic rash which occurs when amoxicillin is used in conjunction with some viruses (which are poorly defined). Later, when the viral infection is resolved, amoxicillin use does not result in a rash. This is similar to infectious mononucleosis which results in an impressive rash with amoxicillin/ampicillin use, but no recurrence of a rash with the same antibiotic use, once the viral infection has resolved. Most amoxicillin rashes are non-urticarial which is the best (though not perfect) clue that this is probably not due to an allergic mechanism. Name the type of exanthem depicted in the case described at the beginning of this chapter. The risk of acquiring chicken pox after exposure in the healthy, varicella immunized child is less than 10%. Adverse effects of illnesses prevented by vaccines include death and damage to the central nervous system. Physical examination reveals a slightly dehydrated child with punched out, painful oral ulcers with associated small red macules on the palms and soles. Childhood vaccination against varicella: persistence of antibody, duration of protections, and vaccine efficacy. On physical exam, she is tired and subdued but not toxic in appearance with a temperature of 38 degrees C. She has enlarged posterior cervical lymph nodes bilaterally, which are mildly tender to palpation. A throat swab is obtained to test for group A streptococcal antigen, which is negative. Laboratory testing reveals a mild leukocytosis with the presence of atypical lymphocytes. Perhaps the best known is the one illustrated in the case above, the syndrome of infectious mononucleosis. The name is derived from the mononuclear lymphocytosis with atypical appearing lymphocytes that accompany the illness. Its clinical manifestations depend on the age when the infection is first acquired. Among affluent communities, however, primary infection may be delayed until adolescence or young adulthood. The virus is transmitted in oral secretions and is acquired from close contact such as kissing or exchange of saliva between children. It initially infects epithelial cells in the oropharynx, where viral replication occurs and lysis of the epithelial cell results in release of new virions into the circulation. The virus then infects B lymphocytes in the peripheral blood and the reticuloendothelial system, including the liver, spleen, and lymph nodes. It is in these cells where the virus establishes latency, via formation of a viral episome. The host mounts a cell-mediated immune response to control the number of proliferating infected B lymphocytes. Reactivation may occur intermittently with viral shedding in oral secretions of affected individuals. The onset of symptoms is often insidious, with a prodrome of malaise, headache, fatigue, fever, sore throat, anorexia, and myalgia. On physical exam, the most common finding is lymphadenopathy, which is present in 90% of cases. It often occurs in the cervical region, particularly the posterior cervical chain, but may also be generalized with involvement of submandibular, epitrochlear, axillary, and inguinal lymph nodes. Patients treated with ampicillin/amoxicillin for presumed bacterial infection characteristically develop a maculopapular rash, which may be useful in diagnosis, but it is also an annoying adverse effect that often results in an inappropriate diagnosis of penicillin allergy. The diagnosis of infectious mononucleosis may be made by clinical history, physical exam, and typical laboratory findings. Greater than 90% of patients will have leukocytosis, with white blood cell counts ranging from 10,000 to 20,000. These cells appear larger, with eccentrically placed nuclei and a larger amount of cytoplasm compared to typical lymphocytes. The most widely used test is the Monospot (trademark), a qualitative rapid slide test which detects horse red cell agglutination. Certain organisms may cause an infectious mononucleosis-like syndrome but are not associated with formation of heterophil antibodies, such as cytomegalovirus, T. These are unnecessary for the diagnosis of infectious mononucleosis when the Monospot test is positive. The presence of IgM antibodies against viral capsid antigen signifies acute infection, while the presence of IgG antibodies signifies recent or past infection. Infectious mononucleosis usually resolves in 2-3 weeks, although malaise may persist for weeks to months. Treatment is primarily supportive, with rest during the acute stage of illness and symptomatic care. Contact sports should be avoided while splenomegaly is present due to the risk of splenic rupture, although the incidence of this is low at less than 0. Treatment with acyclovir or corticosteroids has not been proven to be of benefit in uncomplicated cases. Complications may include marked tonsillar inflammation with impending airway obstruction, massive splenomegaly, myocarditis, autoimmune hemolytic anemia, aplastic anemia, thrombocytopenia, neutropenia, hemophagocytic syndrome, meningitis, and encephalitis. Genetic and environmental factors may play a role in the increased incidence of these diseases in these areas. A 16 year old male presents with sore throat, fever, and cervical lymphadenopathy. Assume the patient has infectious mononucleosis and start acyclovir and prednisone.

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Serologic testing is available and is most useful in patients with subacute or chronic pulmonary disease. However, if the patient does not improve within 4 weeks, itraconazole should be given for 6 to 12 weeks. For severe or disseminated infections, a lipid formulation of amphotericin B followed azoles by most experts; when used in adults, itraconazole is more effective, has fewer adverse cacy of itraconazole for use in children have not been established, anecdotal experience has found it to be well tolerated and effective. For severe, acute pulmonary infections, treatment with a lipid formulation of amphotericin B is recommended for 1 to 2 weeks. Severe cases should be treated initially with a lipid formulation amphotericin B followed by itraconazole for the same duration. In these instances, itraconazole should be used concurrently and therapy, and surgical intervention may be necessary for severe cases. Stable, low, and decreasing concentrations that are unaccompanied by signs of active infection may not necessarily require prolongation or resumption of treatment. If exposure is unavoidable, it should be minimized through use of approsuspected of being contaminated with Histoplasma species should be remediated. Old or abandoned structures likely to have been contaminated with bird or bat droppings should be saturated with water in an effort to reduce the aerosolization of spores during safety professionals, environmental consultants, and people supervising workers involved in activities in which contaminated materials are disturbed. Additional information about the guidelines is available from the National Institute for Occupational Safety and ( Chronic hookworm infection in After contact with contaminated soil, initial skin penetration of larvae, often involving the feet, can cause a stinging or burning sensation followed by pruritus and a papulovesicular rash that may persist for 1 to 2 weeks. Pneumonitis associated with migrating larvae abdominal pain, nausea, diarrhea, and marked eosinophilia can develop 4 to 6 weeks after exposure. Hookworms are prominent in rural, tropical, and subtropical areas where soil contamination with human feces is common. Although the prevalence of both hookworm species is equal in many areas, A duodenale is the predominant species in the Mediterranean region, northern Asia, and selected foci of South America. Reexamination of stool specimens 2 weeks after therapy to determine whether worms have been eliminated is helpful for assessing response to therapy. Despite relatively rapid reinfection, periodic deworming treatments targeting preschool-aged and school-aged children have been advocated to prevent morbidity associated with heavy intestinal helminth infections. Roseola is distinguished by the erythematous maculopapular rash that appears once fever resolves and can last hours to days. Some initial infections can present as typical roseola and may account for second or recurrent cases of roseola. Among organ transplant recipients and Primary effusion lymphoma is rare among children. Transplantation of infected tive mothers, but vertical transmission seems to be rare. Retrospective cohort studies suggest that antiretroviral therapy (particularly zid- can be treated with radiation and cancer chemotherapies. Dermatitis Parotitis Recurrent or persistent upper respiratory tract infection, sinusitis, or otitis media Category A: Mildly Symptomatic Children with 2 or more of the conditions listed but none of the conditions listed in categories B and C. T-lymphocyte count and percentage as critical immunologic parameters and as markers of prognosis. These viruses are cytopathic lentiviruses belonging to the family Retroviridae, and a variety of nonhuman primate species in sub-Saharan Africa. Three principal genes (gag, pol, and env) encode the major structural and enzymatic proteins, and 6 accessory genes regulate gene expression and aid in assembly and release of infectious virions. Most mother-to-child transmission occurs during the intrapartum period, with fewer transmission events occurring in utero and postnatally through breastfeeding. Cesarean delivery performed before onset of labor and before rupture of membranes has been shown to reduce mother-to-child intrapartum transmission. Breastfeeding should be replaced only when a nutritionally adequate and safe diet can be maintained without human milk. Only a minority of patients are ill enough to seek medical care with primary seroconversion syndrome, although more may recall a prior viral illness when queried about it later. Public health statutes and legal precedents allow for evaluation and treatment of minors for sexually transmitted infections without parental knowledge or consent, but not ment may proceed without parental consent. Health care professionals should endeavor adolescents and encouraged for adolescents who are sexually active. The newborn infant should be bathed and cleaned of maternal secretions (especially bloody secretions) as soon as possible after birth. In the United States, neonatal prophylaxis generally consists of zidovudine for 6 weeks. In some states, rapid testing of the neonate is required by law if the mother has refused to be tested. In 2 of the cases, the caregivers had bleeding gums or sores in their mouths during the time they premasticated the food. Phylogenetic testing was conducted and documented matches of the viral strains in 2 of the caregiver-infant dyads. Athletes and staff of athletic programs can be exposed to blood during certain athletic activities. Counseling of the child and family needs to be provided (see Sexually Transmitted Infections, p 177). Preexposure prophylaxis also is effective in heterosexual couples and injecting drug users. Successful transition requires careful proactive planning by caregivers in both pediatric and adult venues and a multifaceted, deliberate attention to the medical, psychosocial, life-skills, educational, and family-centered needs of the patient. It also is an ideal time to reemphasize topics of contraception, prevention of sexually transmitted infections, and safer sex practices. Although the large majority of children thy and encephalitis with status epilepticus, with resulting neurologic sequelae or death. Contact with respiratory tract dropletcontaminated surfaces followed by autoinoculation is another mode of transmission. Incidence and disease severity depend, in part, on immunity developed as a result of pre- Antigenic drift in the circulating strain(s) is associated with seasonal epidemics. Hospitalization rates among children younger than 2 years are similar to hospitalsons. However, children younger than 24 months consistently are at a substantially higher associated with development of pneumococcal or staphylococcal pneumonia in children. Methicillin-resistant staphylococcal community-acquired pneumonia, with a rapid clinical progression and a high fatality rate, has been reported in previously healthy children ity attributable to complications, such as bronchitis and pneumonia, are even greater in children with high-risk conditions, including asthma, diabetes mellitus, hemodynamically morbidity, including a sepsis-like syndrome, apnea, and lower respiratory tract disease. Fatal outcomes, including sudden death, have been reported in both chronically ill - dren, most of which have occurred in children younger than 5 years. On the basis of a modeling study ated with between 151 700 and 575 400 deaths worldwide. Public health authorities have developed plans for pandemic preparedness and response to a pandemic in the United States. Specimens of nasopharyngeal secretions obtained by swab, aspirate, or wash should be placed in appropriate transand B antigens in respiratory tract specimens are available commercially, although their men type. Decisions on treatment and infection control can be made on the basis of positive rapid diagnostic test results. However, serologic testing rarely is useful in patient management, because 2 serum samples collected 10 to 14 days apart are required. High levels of resistance to amantadine and rimantadine persist, and these drugs should not be used unless resistance patterns inhibitors (oseltamivir and zanamivir) and resistant to adamantanes (amantadine and rimantadine). Resistance to osel- inhibitors and resistant to adain collaboration with local and state health departments. Treatment may be considered for any otherwise healthy believed to be warranted by his or her pediatrician. The greatest impact on outcome should be considered if later in the course of illness, especially for hospitalized patients. Only zanamivir, which is administered by inhalation, does not require the most common adverse effects of oseltamivir are nausea and vomiting.


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Resolution of severe bronchiectasis after removal of long-standing retained foreign body. His mother is unsure if he had eaten anything else with the potato chips and does not think the child turned blue during the choking and gagging episode. He returned to his normal activity shortly after the episode occurred, but since then, he has had a few intermittent coughing spells. He has a normal physical exam except for an occasional low-pitched, monophonic expiratory wheeze heard best over the sternal notch. Since end exhalation films were unable to be obtained, decubitus films were performed. The right lateral decubitus film (right side down) shows air trapping on the right as evidenced by failure of the mediastinum to shift toward the dependent side. The patient is discharged the next morning with follow up scheduled with his pediatrician in the next few days. Of children younger than 15 years, toddlers seem to be the most vulnerable for foreign body aspiration (77% of deaths) (1). Some reasons for this are related to their developmental age such as: 1) exploration of their environment by putting objects into their mouths; 2) learning to walk and run; 3) inadequate dentition; 4) immature swallowing coordination; and 5) supervision by an older sibling. Baharloo, et al, found that 91% of foreign bodies aspirated by children (<8 years old) were organic in nature with peanuts accounting for 54% of that number (2). Meat (especially hot dogs) and other types of nuts are also frequently found on bronchoscopy. They also found that children, unlike adults, did not have a significant difference between the foreign body being found in the right or left bronchial tree (2). This may be explained by the fact that children have symmetric bronchial angles until about 15 years of age. At that time, the aortic knob has developed fully, causing the left mainstem bronchus to be displaced, which creates a more obtuse angle at the carina favoring the right mainstem for a foreign body (3). There are three distinct clinical phases that occur after a foreign body is aspirated (4). The patient will usually experience choking, gagging, coughing, wheezing, and/or stridor. The second phase is the asymptomatic period that can last from minutes to months following the incident. The duration of this period depends on the location of the foreign body, the degree of airway obstruction, and the type of material aspirated. The ease with which the foreign body can change its location is also a factor in the duration of this period. Airway inflammation or infection from the foreign body will cause symptoms of cough, wheezing, fever, sputum production, and occasionally, hemoptysis. Some of these illnesses are: asthma, croup, pneumonia, bronchitis, tracheomalacia, bronchomalacia, vocal cord dysfunction, or psychogenic cough (4). Page - 312 the diagnosis and treatment of an aspirated foreign body depends on which clinical phase the patient has on presentation. History, as always, is the best determinant of how suspicious one should be of a potential aspiration. However, this is often complicated by the fact that the event may be unwitnessed, witnessed by a person not present for history taking, or witnessed by an older sibling who may have had a role in the aspiration and chooses not to say anything. On physical exam, the classic findings consist of cough, unilateral decreased breath sounds, and unilateral monophonic wheezing. Although 75% of patients have one or more of these findings, only 40% have all three (5). If stridor (inspiratory and/or expiratory), aphonia, or hoarseness is present, the foreign body is most likely in the larynx or cervical trachea. Since most foreign bodies are not radiopaque, one must rely on indirect findings suggestive of the presence of a foreign body such as: mediastinal shift, atelectasis, and hyperinflation. It has been reported that imaging studies have a sensitivity of 73% and a specificity of 45%, however, up to 20% of patients will have both negative history and radiographic evaluation (6). For patients who present early, radiographic studies must look for evidence of air trapping. However, many foreign body aspirations involve both main stem bronchi or the foreign body is in the trachea. If the expiratory view looks the same as the inspiratory view, this implies bilateral air trapping. Expiratory views rely on timing, so these are sometimes deceiving (an "expiratory view" could have been really taken during inspiration). In a lateral decubitus view, the mediastinum should shift downward toward the dependent side. Thus, if a decubitus view looks the same as an upright inspiratory view, this suggests air trapping on the dependent side. If the patient presents in the first clinical phase, the family and/or health care professional should be advised to follow the recommendations of the American Academy of Pediatrics and American Heart Association (7). Unless there is a complete airway obstruction, spontaneous coughing and respiration should be the only treatment encouraged. Blind finger sweeps should never be performed in infants or children since this may push the foreign body further downward into the airway. Infants with complete airway obstruction should have back blows and chest thrusts performed while children with complete airway obstruction should have abdominal thrusts performed in either the supine position or by the Heimlich maneuver. Once the patient is brought to the hospital, the patient will require rigid bronchoscopy for visualization of the airway and removal of the foreign body. Flexible bronchoscopy does not have a role in this situation because it is not the optimal tool for control of the foreign body or the safety of the patient during the removal procedure. The other situation in which patients commonly seek medical attention is usually the third clinical phase. At this point in time, clinical suspicion based on the history, exam, and ancillary studies must be used to determine the appropriate course of action. In many such instances, a foreign body is not suspected and the foreign body remains untreated. Such patients return with "recurrent pneumonia" which is actually a pneumonia or atelectasis which has never resolved because the foreign body is still there. If foreign body aspiration is suspected in this phase, the patient should undergo direct airway visualization by bronchoscopy (flexible or rigid). Even if the patient has expectorated a foreign body, direct visualization is recommended to ensure there are no additional foreign bodies present and to determine if there is any compromise of the airway from inflammation. If there is airway edema and/or inflammation present on direct visualization, a short course of oral corticosteroids may be useful. Complications arising from foreign body aspiration depend on the location and type of foreign body aspirated (organic vs. If the foreign body is successfully removed within 24 hours of the incident, the complication rate is very low. However, the longer the foreign body remains in the airways, the more likely inflammation and thus, complications will occur. Potential complications include: bronchial stenosis, bronchiectasis, lung abscess, tissue erosion/perforation, and pneumomediastinum or pneumothorax. True/False: Foreign body aspiration is sufficiently uncommon that it need not be considered in a patient with a chronic cough. Which radiographic imaging study would be the most helpful if a foreign body aspiration is suspected in a child (<3 y. True/False: Aspirated foreign bodies in children are more likely to be in the right main-stem bronchus than the left main-stem bronchus. Why should a blind finger sweep never be done in a child with a foreign body aspiration? What physical exam sign/symptom is most worrisome in terms of degree of airway compromise? Tracheobronchial Foreign Bodies: Presentation and Management in Children and Adults. May last minutes to months depending on location, type, and ease of movement of the foreign body. Organic material is worse to aspirate because it will cause a more intense inflammatory response, thereby increasing the risk for complications. Additionally, most organic material is non-radiopaque making it more difficult to visualize. A blind finger sweep may reposition the foreign body causing a complete airway obstruction.