By U. Yorik. Southern Methodist University.

In con- within the first 6 days of life generic 40 mg propranolol otc, with breathing diffi- vergent strabismus or esotropia order propranolol 40mg online, the visual axes culty discount 40 mg propranolol with mastercard, shock, pneumonia, and occasionally infection converge. The danger with strabismus is that the of the spinal fluid and brain (meningitis). Late- brain may come to rely more on input from one eye onset disease presents between the seventh day and than the other, and the part of the brain circuitry that the third month of age, with a bloodstream infection is connected to the less-favored eye may fail to (bacteremia) or meningitis. The bacteria can also develop properly, leading to amblyopia (weakened infect an area of bone; a joint, such as the knee or vision) in that eye. Group B strep infection in a new- moderate strabismus is to cover the stronger eye born is a serious and potentially life-threatening with a patch, forcing the weaker eye to do enough event, particularly because fever and warning signs work to catch up. Atropine eyedrops can also be are often minimal or absent and because the newborn’s immune system is not mature. Group B strep infection of the newborn is treated, there is a high risk of major stroke in the treated aggressively with antibiotics, usually in a future. Prevention and early An operation called a carotid endarterectomy can detection are critically important. These medications act by par- tially blocking the blood-clotting function of the Streptococcus pneumoniae The most common platelets in the patient’s blood. Controlling other cause of bacterial pneumonia and middle ear infec- factors that contribute to strokes, such as high tion (otitis media) and the third most frequent blood pressure and diabetes, is also important for cause of bacterial meningitis. The strep throat (streptococcal pharyngitis), impetigo, stroke volume is not all the blood contained in rheumatic fever, scarlet fever, glomerulonephritis, the left ventricle; normally, only about two-thirds invasive fasciitis, strep skin infections, and rheu- of the blood in the ventricle is expelled with each matic fever. Neurological symp- toms of Sturge-Weber syndrome may include stricture of the esophagus, chronic See seizures and developmental delay. Sudden loss of speech, usually be eliminated or significantly modified with weakness, or paralysis of one side of the body can be speech therapy. In contrast, acute indicates very sudden stroke prevention Methods of preventing the onset or rapid change, and chronic indicates indef- occurrence of a cerebrovascular accident. For example, stenosis may be present at birth (congenital) or a sublingual medication is a type of lozenge that is acquired as part of a specific form of heart disease dissolved under the tongue. Treatment options include use of drugs sublingual gland A salivary gland that is located and surgery. See also idiopathic hypertrophic under the floor of the mouth, close to the midline. The sublingual gland is the smallest of the three major salivary glands (the parotid, submandibular, subarachnoid Literally, beneath the arachnoid, and sublingual glands). A com- ally refers to the space between the arachnoid and plete dislocation is a luxation. It normally contains submandibular gland A salivary gland that is cerebrospinal fluid. The submandibular gland is the second largest of the subarachnoid hemorrhage A bleeding into the three major salivary glands (the parotid, sub- subarachnoid, the space between the arachnoid and mandibular, and sublingual glands). For example, the subscapularis muscle originates beneath the subclinical disease An illness that is staying scapula. It is subscapularis muscle A muscle that moves the distinct from a clinical disease, which has signs and arm by turning it inward (internal rotation). Many diseases, tendon of the subscapularis muscle is one of four including diabetes, hypothyroidism, and rheuma- tendons that stabilize the shoulder joint and consti- toid arthritis, are frequently subclinical before they tute the rotator cuff. For example, a subcutaneous injection is an injection in which a subungual onychomycosis, proximal white needle is inserted just under the skin. After the injection, the drug moves into small blood suction-assisted lipectomy See liposuction. The sec- cocaine during pregnancy; infants born weighing ond-generation sulfonylureas include glipizide less than 2,000 grams (4. Sometimes referred sun protection factor A measurement of a sun- to as crib death. Using lotions that contain sunscreen can reduce the risk of skin cancer, sulcus A groove, furrow, or trench. For example, the skin is superfi- sulfonamide One of the sulfa-related group of cial to the muscles, and the cornea is on the super- antibiotics, which are used to treat bacterial infec- ficial surface of the eye. Azulfidine), sulfisoxazole (brand name: Gantrisin), and various high-strength combinations of sulfon- superior Above, as opposed to inferior. Sulfa drugs kill bacteria and fungi by inter- example, the heart is superior to the stomach, and fering with cell metabolism. Because sulfa drugs the superior surface of the tongue rests against the concentrate in the urine before being excreted, palate. See also Appendix B, “Anatomic Orientation treatment of urinary tract infections is one of their Terms. This compression may be caused by disease of any of the patients with some health conditions. Sulfa drug allergy is one of the more common allergies to med- structures or lymph nodes surrounding this vein. Patients (medications that lower the level of blood glucose) often have a persistent cough and shortness of taken by people with type 2 diabetes. Causes of superior vena cava syndrome lureas increase the secretion of insulin by the pan- include cancer and several benign conditions creas. As a consequence, second- rax), and complications of central line catheters and generation sulfonylureas are usually taken less heart surgery. Diagnosis is made via observation of typical findings and is supported by identifying a http://www. For example, a supernumerary chromosome tributes to the elasticity of lung tissue. The definition of surgeon has begun to blur in recent years as surgeons have supernumerary nipple See nipple, supernu- begun to minimize the cutting, employing new tech- merary. As a result, the person has an exquisite ability to taste Surgery can involve cutting, abrading, suturing, or accurately. In the case of supination of the arm, the palm of the surgery, cataract See cataract surgery. Fetal surgery is usually done when the the impact of the stride largely to the outer edges of fetus is not expected to survive to delivery or to live the foot. This type of foot often has a very high, rigid long after birth unless fetal surgery is performed. The ten- don of the supraspinatus muscle is one of four ten- swallowing syncope The temporary loss of con- dons that stabilize the shoulder joint and constitute sciousness upon swallowing. The sympathetic nervous system and the parasym- pathetic nervous system constitute the autonomic sweat test A simple test that is used to evaluate a nervous system. The goal of the test is to painlessly stimulate sympathetic ophthalmia Inflammation of the the patient’s skin to produce a certain amount of uveal tract of the uninjured eye (sympathizing eye) sweat, which may then be absorbed by a special fil- some weeks after a wound involving the uveal tract ter paper and analyzed for chloride content. Also known as trans- technique called iontophoresis, a minute, painless ferred ophthalmia. Elevated chloride values are been used to effect an immediate dramatic increase characteristic of cystic fibrosis. A few rare condi- in the size of the pelvic outlet to permit delivery of a tions that produce a false positive test include dis- baby.

Accreditation of the evaluation process for allied dental personnel through innovative licensure examinations should be investigated order propranolol once a day. If approaches to education generic propranolol 80mg otc, strengthened standards and when the accreditation process includes out- for continuing education credits order 80mg propranolol with amex, and outcome come assessments of the clinical skills of dental assessments for relicensure and recertification. Increased recruitment efforts will be necessary to Alternatives to live-patient examinations should assure sufficient numbers of dental hygienists, den- continue to be investigated. If successful, the profession will be able to Dental professionals have many opportunities to continue its service to the public unimpeded by meet competency requirements in a positive and ben- unnecessary regulation. The challenge is to find more effective The ability of the profession to influence public and efficient ways to continue to improve the process. Representa- dents more clinical experiences and remediation tives of the practicing dental community must be when needed. Currently, residency programs are involved in the decision-making process as Medicare, available only to the highest-ranking students. This time of great change may ics that serve populations of low socioeconomic sta- introduce operating systems that are not well thought tus. Funding of this additional educational experi- out and certainly are not well tested. Time- The profession must be proactive to ensure that proven, value-driven systems may be destroyed and the policies promoted by advocacy groups are based lives hurt in the process unless there is an appropriate on scientific fact, not anecdotal information. For deliberative process for the institution of regulatory example, increased federal regulation and the geo- change. Regulation will be beneficial if it adds safety graphic mobility of dentists have stimulated the and value to the services provided. References Outcome assessments could be a surrogate for relicensure and/or recertification. Chicago: American Dental ments as an integral part of relicensure or continued Association; 2001. Chicago: of 1999, references to "best practices" criteria are pre- American Dental Association; 1997. Continuing education courses could be strength- Transactions 1976:919; 1977:923; 1989:529; 1992:632. The Chicago: American Dental Association; 1976, Internet creates many possibilities for education as 1977,1989, 1992. A report by the Institute of Medicine, agencies, the criteria for validity, reliability, uniformi- Committee on theFuture of Dental Education. A flexible menu Health Administration) Regulations-A win-win of competency assessment mechanisms could be proposition. The relationship between the quality of dental education and the training of dental professionals is clear––all dentists are the product of dental education. The contemporary dental school provides the dental profession with two critically important benefits. As Lord Rushton wrote more than 40 years ago, dentistry became a profession when it entered the university (Rushton, 1957). Today, in 2001, the United States dental profession is stronger and healthier than ever before, and there is a legitimate sense of optimism among dental professionals about their future. United States1 dental schools have achieved immense success and unparalleled accomplishments. However, many schools are financially over extended, operate in antiquated physical facilities, and face a serious faculty shortage. This chapter explores the key issues facing dental schools and the implications of these issues for the future of the dental profession. Of no thing are we more fully assured than that the dentistry of today must either advance or give place; to attempt to confine it to its present lim- its is to seek to control that progress which is itself evolution. Dental schools develop new technolo- tor is stretched to its limit and faces difficult challenges. Dental health professionals; schools were burdened by operating with the high- est per student educational costs on the campus. Faculty members and dental school leader- ship did little to promote interaction with the rest of x Direct provision of dental care services for the the university community. Professional education and training is the most wide- The failure of some dental schools to meet the ly recognized responsibility of dental schools. The dental education community did not antic- The third responsibility, to provide direct patient ipate closure of its educational programs. This prolif- Critical review of their dental programs will eration of interactions appears to have occurred almost certainly be undertaken by private universi- because of the increasing number of dental faculty ties, which are not under state mandate to promote members who have the formal qualifications and dental education and may not maintain a funda- higher degrees, the scholarly and clinical skills, and mental mission to support dental education. Moreover, research trends merely because of the potential negative impact on the in molecular biology, epidemiology, molecular workforce, but because when prestigious private uni- genetics, bioinformatics, biomimetics, and new versities elect to close dental schools, it is a measure of diagnostic technologies have increasingly focused the declining value academe places on the dental acade- on the inter-relationships of all systems in the mia and research enterprise. This has had the effect of lessening tially compromise oral health care and promotion of traditional distinctions between the medical and the prestigious academic health centers. Some dental study, Dental Education at the Crossroads (Field, schools operate teaching/service clinics in remote 1995); by the 75th Anniversary Summit Conference geographic areas, further increasing access to care. Dental schools further serve their communi- medical school faculty, especially in research, at ties by offering extensive Continuing Dental unprecedented levels. The dental is located, the institution provides a substantial school/medical school collaboration is also evident in number of excellent jobs, and the school is therefore the curriculum of nine dental schools that share the responsible for generating very significant economic first two years of basic sciences courses with the med- activity within its service region. The high cost of dental education is the clinical educa- primary revenue source for public schools are state or tion and patient care training programs––programs university system appropriations, followed by clinic that are part of the university budget. This makes income, sponsored research/training, tuition and fees, dental care program costs highly visible to universi- other revenues, indirect cost recovery, gifts/endowment, ty financial officers. In con- The cost of clinical education and patient care trast, for private schools tuition and fees are the most training in medicine is largely borne by hospital significant revenue sources, followed by clinic income, budgets, not the university. This type of cross-sub- sponsored research, gifts/endowment, other income, sidy is not available to dental education programs. The revenue pattern for the private/state-related schools is similar to Dental School Revenues that of private institutions. One major category of funding not report- schools and is generally influenced by whether the ed is the extramural practice income of full-time institution is a public dental school, a private dental clinical faculty. For all dental schools an annual challenge is to ensure that revenues will cover or exceed expendi- x Annual revenues from state and local govern- tures. This challenge is complicated by the diversi- ment, which had been essentially level from 1979 to ty of revenues dental schools rely on to make 1991, declined from 1992 to 1998 by a total of $46 their budget. A detailed analysis by Douglass and million (constant 1998 dollars), for an average Fein reported dental school revenue trends for the annual decrease of just over 1. The trends revealed a x From 1992-1998 annual federal government major decline in federal support for dental educa- support increased by $13 million in constant dollar tion (more than 50%), while increases were noted terms, for an average annual increase of 1. The million in constant dollars, for an average annual most significant recent trends for total dental edu- growth rate of 10% over the 1992-1998 period. This repre- sents an annual average growth rate of just over Dental School Expenditures 2.

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Menin- gioma should appear on the differential of the patient above; epidemiologically buy 40 mg propranolol overnight delivery, these tu- mors are more common in women than men best 80mg propranolol, and tend to occur between the ages of 40 and 70 buy propranolol 80mg without prescription. Congenital pan-hypopituitarism would not explain his acute worsening nor his increased intracranial pressure. McCune-Albright syndrome consists of polyostotic fi- brous dysplasia, pigmented skin patches, and a variety of endocrine disorders including adenomas and pituitary tumors. Carney syndrome consists of myxomas; endocrine tu- mors including adrenal, testicular, and pituitary adenomas; and skin pigmentation. Paracrine regulation refers to factors released by one cell that act on adjacent cells in the same tissue (e. Insulin-like growth factor I released from chondrocytes acts on the cells that pro- duce it, which is an example of autocrine regulation. Negative feedback control is the classic model of an endocrine regulatory system (e. However, there are approximately 300,000 hip fractures annually, with incidence rates dou- bling every 5 years after age 70. The shift from arm and wrist fractures to hip fractures may be related to the way elderly people fall, with less frequent landing on the hands and more frequent direct hip trauma with increasing age. There are approximately 700,000 vertebral fractures each year in the United States. They may lead to height loss, kyphosis, and pain secondary to altered biomechanics. Other clinical trials have shown a decrease in all osteoporotic fractures, including vertebral compression frac- tures. The beneficial effect of estrogen appears to be maximal in those who start therapy early and continue taking the medication. The benefit declines after discontinuation, and there is no net benefit by 10 years after discontinuation. Raloxifene, which is approved for the prevention of osteoporo- sis, reduces the risk of vertebral fractures by 30 to 50%. Vitamin D plus calcium supplements have been shown to reduce the risk of hip fractures by 20 to 30%. The bisphosphonates alendronate and risedronate are structurally related to pyrophosphate and are incorporated into bone matrix. They reduce the number of osteoclasts and impair the function of those already present. Both have been shown to reduce the risk of vertebral and hip fractures by 40 to 50%. One trial found that risedronate reduced hip fractures in osteoporotic women in their seventies but not in older women without osteo- porosis. The newer bisphosphonates zoledronate and ibandronate may be dosed yearly or monthly. A daily injection of exogenous parathyroid hormone analogue superimposed on estrogen therapy produced increases in bone mass and decreased vertebral and nonvertebral fractures by 45 to 65%. However, preoperative control of hypertension is necessary to prevent surgical complications and lower mortality. Medications that can be used for hypertensive crisis in pheochromocytoma include nitroprusside, nicardipine, and phen- 402 X. Once the acute hypertensive crisis has resolved, transition to oral α-adrenergic blockers is indicated. Phenoxybenzamine is the most commonly used drug and is started at low doses (5–10 mg three times daily) and titrated to the maximum tolerated dose (usually 20–30 mg daily). Once alpha blockers have been initiated, beta blockade can safely be utilized and is particularly indicated for ongoing tachycardia. Liberal salt and fluid intake helps expand plasma volume and treat orthostatic hypotension. Once blood pressure is maintained below 160/100 mmHg with moderate orthostasis, it is safe to pro- ceed to surgery. If blood pressure remains elevated despite treatment with alpha block- ade, addition of calcium channel blockers, angiotensin receptor blockers, or angiotensin- converting enzyme inhibitors should be considered. Macula densa cells may function as chemorecep- tors monitoring the sodium and chloride load delivered to the distal tubule. Under con- ditions of low solute load delivered to the distal tubule, a signal is conveyed to increase juxtaglomerular release of renin. Increased potassium intake and release of atrial natriuretic peptide both decrease renin release. Pituitary microadenomas are present in ~25% of all autop- sies, independent of ante-mortem clinical disease, and are usually unsuspected. The clinical and bio- chemical phenotype of pituitary adenomas depend on the cell type from which they arise. When this triad of symptoms is found in association with hypertension, pheochromocytoma is the most likely diagnosis. Dif- ferential diagnosis for pheochromocytoma includes panic disorder, essential hypertension, cocaine or methamphetamine abuse, carcinoid syndrome, intracranial mass, clonidine with- drawal, and factitious disorder. While episode hypertension is classically described in associa- tion with pheochromocytoma, many patients have sustained hypertension that may be difficult to treat. The patient also exhibits significant orthostatic changes in blood pressure which is a common finding in pheochromocytoma. The cornerstone of diagnosis of pheochromocytoma is the documentation of elevated levels of urine and plasma catechol- amines. The usual diagnostic algorithm includes the measurement of vanillylmandelic acid, catecholamines, and fractionated metanephrines in a 24-h urine collection or plasma sample. Given the classic symptoms of this patient, panic attack is a diagnosis of exclusion because the missed diagnosis of pheochromocytoma increases the risk of adverse outcomes, including death and stroke. The mineralocorticoid-glucocorticoid hormones are a notable exception because the mineralocorticoid receptor also has a high, but not greater, affinity for glucocorticoid. An enzyme (11 β-hydroxysteroid dehydrogenase) lo- cated in renal tubules inactivates glucocorticoid, allowing selective responses to miner- alocorticoid. When there is glucocorticoid excess, the enzyme becomes oversaturated and glucocorticoid can exhibit mineralocorticoid effects. This effect is in contrast to the es- trogen receptor, where different compounds confer unique transcription machinery. Examples of hor- mones that circulate with serum-binding proteins are: T4, T3, cortisol, estrogen, and growth hormone. Most binding protein abnormalities have little clinical consequence be- cause the free concentrations of the hormone often remain normal. They all inhibit the function of thyroid peroxidase, reducing oxidation and organification of iodide.

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However buy generic propranolol 80 mg line, unlike panic disorder buy propranolol overnight delivery, palpitations purchase 40 mg propranolol, tachycardia, and shortness of breath are rare. For example, Saint John’s wort is more effective than placebo for mild to moderate depression; the mechanism is not known, although the metabolism of several neurotransmitters is inhibited by this sub- stance. Extracts of the fruit of the saw pal- metto, Serona repens, have been shown to decrease nocturia and improve peak urinary flow compared with placebo in males with benign prostatic hypertrophy. Saw palmetto extracts affect the metabolism of androgens, including the inhibition of dihydrotestoster- one binding to androgen receptors. These patients are always markedly underweight, hardly ever menstruate, and often engage in binge eating. The etiology of this serious eating disorder is unknown but proba- bly involves a combination of psychological, biologic, and cultural risk factors. This ill- ness often begins in an obsessive or perfectionist patient who starts a diet. As weight loss progresses, the patient has increasing fears of gaining weight and engages in stricter diet- ing practices. This disorder essentially occurs only in cultures in which thinness is valued, suggesting a strong cultural influence. Bulimia nervosa, in which patients continue to maintain a normal body weight but typically engage in overeating with binges followed by compensatory purging or purging behavior, has a higher than expected prevalence in patients with childhood or parental obesity. Vitamin B6 deficiency produces seborrheic dermatitis, glossitis, stomatitis, and cheliosis (also seen in other vitamin B deficiencies). A microcytic, hypochromic anemia may re- sult from the fact that the first enzyme in heme synthesis (aminolevulinic synthetase) re- quires pyridoxal phosphate as a cofactor. However, vitamin B6 is also necessary for the conversion of homocysteine to cystathionine. Consequently, a deficiency of this vitamin could produce an increased risk of cardiovascular disease caused by the resultant hyper- homocystinemia. These numbers will likely increase in the near fu- ture as the population ages and obesity is more prevalent. Recent data suggest that the frequency of uncontrolled hypertension is increasing in older adults in the United States. The presence of uncontrolled hypertension accelerates functional and cognitive decline in older adults. These data also have important implications on the frequency of cardio- vascular disease and stroke in older adults. Diabetes has been linked with physical decline, while hypertension has been linked with cognitive decline. Diabetes and stroke are most consistently associated with a diminished capacity for functional recovery in the elderly. A decline in functional status should prompt a search for medical illness, dementia, change in social support, or depression. Screening for functional status should include assessment of ac- tivities of daily living, gait and balance, cognition, vision, hearing, and dental and nutri- tional health. In fact, delirium is often associated with a decreased level of consciousness, and patients can appear withdrawn or aloof, rather than agitated, combative, or anxious. Another crucial diagnostic criterion is that the patient’s mental state represents a clear, acute deviation from their baseline status. Some 3–5% of falls result in fracture, and falls are an indepen- dent risk factor for nursing home placement. All older adults should have at least annual fall risk assessment and be asked about falls during clinic visits. Fall prevention necessi- tates a multidisciplinary approach including management of medical conditions associ- ated with falls, limitation of psychotropic medicines (especially benzodiazepines), frequent visual examinations, interventions such as tai-chi geared towards stabilizing gait, and close examination of circumstances associated with past falls. The heels, lat- eral malleoli, sacrum, ischia, and greater trochanters account for 80% of pressure sores. In older adults and nursing home resi- dents, the development of a pressure sore increases mortality fourfold. A fairly innocuous-appearing lesion can progress to a deep, easily infected, and very difficult-to-manage stage 4 decubitus ulcer in a very short period of time without aggressive wound care and off-loading by nursing staff. Stress incontinence, due to dysfunction of the urethral sphincter, is common in women and uncommon in men. The most common risks are previous childbearing, gynecologic surgery, and menopause. Kegel ex- ercises may be useful, but surgery is considered the most effective intervention. Oxybuty- nin and bladder training exercises are sometimes effective for urge incontinence, which is more common in men. Close monitoring for hyperglycemia and diabetes is useful in elderly patients with incontinence, but this patient does not describe polyuria and her past vaginal deliveries and pelvic surgery put her at risk for stress incontinence. The lack of cranial nerve involvement and other corti- cal deficits, in the presence of upper extremity and lower extremity deficits, suggests a high cord lesion. These often lead to differing ipsilateral and contralateral sensory defi- cits, as in this patient. The combination of left side motor deficit and right side sensory deficit makes the cortical lesion unlikely. Gastrointestinal amyloidosis is another possibility in this patient, though his early satiety and bloating are typical for gastropare- 28 I. Treatment can include pro-motility agents, such as metoclopramide as well as dietary changes that this patient has already instituted on his own. Gastric cancers may present with early satiety and vomiting as well as weight loss. Diverticulosis and irritable bowel syndrome present with lower gastrointestinal symptoms. Prochlorperazine is an antidopaminergic agent that suppresses emesis by acting centrally at the dopamine D2 receptors. This class of agents is most effective for the treatment of medication-, toxin-, and metabolic-induced emesis. However, these agents freely cross the blood-brain barrier and can cause anxiety, galactorrhea, sexual dysfunc- tion, and dystonic reactions. Scopolamine is an anticholinergic that may cause delirium, stupor, and other neurologic side effects, but not tardive dyskinesia. Mycoplasma infection can cause a cough acutely or a postinfectious cough that persists for as long as 8 weeks. The patient’s protracted mild clinical course is typical for this process, and his alcoholism is a clear risk factor as well. The superior segment of the right lower lobe is the most com- mon site of aspiration and lung abscess, followed by the posterior segment of the right upper lobe and the superior segment of the left lower lobe. Wegener’s granulomatosis may cause cavitary masses, but they are usually multiple and would not have putrid sputum. Squamous cell lung cancer may also cavitate by outgrowing its blood supply and may be secondarily infected, although usually not with this degree of anaerobic characteristics. Embolization of bronchial arteries feeding the suspected area may stop the bleeding.