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Methodological Study Participants Prevalence Quality Scoring Manchikanti et al, From a group of 120 patients with low back pain, 72 patients 11/11 26% overall discogenic pain 2001 (378) negative for facet joint pain underwent discography. Schwarzer et al, 1995 92 consecutive patients with chronic low back pain and no 11/11 Internal disc disruption 39% (380) history of previous lumbar surgery referred for discography. An update of the systematic appraisal of the accuracy of utility of lumbar discography in chronic low back pain. A false-positive rates meta-analysis by Wolfer discography in patients with chronic pain or poorly con et al (379) pooled all extractable data from high qual trolled psychopathology, the present assessment shows ity studies performed in subjects asymptomatic of low at least fair evidence for diagnostic accuracy based on a back pain and reported the following false-positive total of 30 studies as listed in Table 5 of the systematic rates: 3% in subjects without confounding factors, 0% review (36) with 8 studies showing negativity, and the in the pain-free group, 10% in the low pressure positive remaining 22 studies showing good to fair or positive chronic pain group, 15% in prior discectomy patients, evidence for accuracy. If all patients from all subgroups are clinical and radiological association with positive lumbar combined, a total false-positive rate of 9. The authors also described that estimated to be 39% in a younger cohort of patients during discography, they noticed the end point resistance following injury (380), and 42% in a heterogenous pop to be more prevalent in asymptomatic discs. Of these, only 4 studies reported good results, with to ongoing debate on the accuracy of this test and the the remaining studies reporting limited effectiveness of lack of outcome parameters in patients undergoing provocation discography as a diagnostic tool. These 22 surgical interventions, the evidence is subject to other studies are shown in detail in Table 6 of the systematic interpretation. There is limited evidence supporting functional an Given that very few fusion studies report signifi esthetic discography or provocation discography with cantly better outcomes following discography, there local anesthetic injection. However, there is fair evi diagnostic tests was moderate to strong in 13 out of 33 dence supporting the management of discogenic pain evaluations, yielding limited to fair accuracy for lumbar with epidural injections (9,30,31). There is only limited discography compared to other non-invasive modalities evidence supporting the management of discogenic of assessment. There is fair evidence supporting the management the Holt study (754) was performed on prisoners, with of discogenic pain with epidural injections (9,30,31). In contrast, Abdi et al (765,766), Complications related to discography include disci Boswell et al (767), Bogduk et al (768), Conn et al (772), tis, subdural abscess, spinal cord injury, vascular injury, and Parr et al (30) evaluated caudal epidural injections annular strains, epidural and paravertebral abscess, and as separate procedures for various pathologies, reach local anesthetic toxicity (36). Parr et al (30), in a system the recommendations for lumbar provocation dis atic review, reaffirmed the conclusions of Conn et al cography include appropriate indications with patients (772) with review of 73 available studies. Randomized with low back pain to prove the diagnostic hypothesis trials and fluoroscopic observational studies (773-780) of the discogenic pain specifically after exclusion of meeting methodological criteria were included in the other sources of lumbar pain, only when a treatment analysis by Parr et al (30). Discogenic Pathology Pinto et al (135) in a recent systematic review and Disc herniation, discogenic pain, spinal stenosis, metaanalysis of epidural corticosteroid injections in the radiculitis, and post surgery syndrome are managed management of sciatica, included all types of studies, with various types of percutaneous interventional caudal, interlaminar, transforaminal, and fluoroscopic techniques including epidural injections, percutaneous as well as blind, with inappropriate analysis consider adhesiolysis, intradiscal therapies, and percutaneous ing active control trials as placebo control and utilizing disc decompression. They arrived at the conclusion that based on the available evidence corticosteroid in 1. The long-term effects dal, interlaminar, and transforaminal approaches were also positive; however, they were smaller size and (8,28,30,31). Further, since disc herniation or radiculitis (30), of these, only 4 trials the response to epidural injections for various patho were performed utilizing fluoroscopy. Tables 14 and logical conditions (disc herniation and/or radiculitis, 15 of the systematic review (30) show the descriptive discogenic pain without disc herniation, spinal stenosis, characteristics. There were 2 newly identified studies and post surgery syndrome) is variable, outcomes are (233,781). Of these, the study by Manchikanti et al (233) assessed based on pathology for each approach.

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Blood tests are carried out to check levels of the rele vant hormones and potassium levels. If necessary, intravenous beta-blockers or transdermal clonidine can be administered. Remedial causes include pain, agitation, hypercarbia, hypoxia, hypervolaemia and bladder distension. Patients who cannot take oral medications should be given a comparable alter native. Patients require medications that block the excessive amounts of noradrenaline and adrenaline secreted by the tumour. The drug should be started at least 7? 10 days preoperatively to normalise blood pressure. Target blood pressure is less than 120/80 mmHg (seated), with systolic blood pressure greater than 90 mmHg (standing). Rarely, miosis, inhibition of ejaculation, diarrhoea and fatigue may occur on the second or third day of alpha-adrenergic blockade. In some units it is considered unhelpful, as it may cause problems with the management of hypotension once the adrenal vein is ligated. If considered essential for the management of the patient, it is commenced once alpha-blockade has been achieved. The sudden withdrawal of catecholamine when the phaeochromocytoma is resected leads to vasodilation, which in the presence of hypovolaemia can lead to intractable hypotension and shock. Hypocalcaemia Hypocalcaemia is a common problem after parathyroidectomy or thyroidectomy. The fall in serum calcium is due primarily to functional or relative hypoparathyroidism that lasts usually no more than a week. Phosphate rises in this period; if it should drop, then this more likely rep resents the hungry bone syndrome? developing. Transient hypoparathyroidism leads to reduction in bone reabsorption and intestinal cal cium absorption and, in patients with normal renal function, increased calcium excretion. Normal parathyroid tissue should recover function within 1 week, even after long-term primary (albeit mild) hyper parathyroidism. Vitamin D and calcium supplementation are useful in severe cases to decrease the duration of intravenous therapy or to avoid it altogether. This is usually made up as 540 mg elemental calcium (six 10-mL ampoules of 10% calcium gluconate) in 500 cm3 of 5% dextrose or 0. Hungry bone syndrome Patients who still have low levels of both serum calcium and phosphorus on day 3 postopera tively are said to have the hungry bone syndrome. The condition is also encountered in some patients with long standing thyrotoxicosis. Patients at risk for hungry bone syndrome must be started on an oral vitamin D analogue (alfacalcidol) and calcium immediately postoperatively. Hypercalcaemia before surgery Institution of therapy for hypercalcaemia depends on the degree of hypercalcaemia and the presence or absence of clinical symptoms: ?

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With anticipatory grief, the dying person is At ages 7-11 years, children come to realize that death still alive, but the patient and family members begin is fnal and irreversible. Often, people experiencing thinkers and have trouble comprehending anything anticipatory grief will project their feelings onto others. They may For example, children who are dying may be more afraid not understand why the person passed away and will ask of their caregivers? dying. Trough experiencing the death of a of anything traumatic happening to their caregivers, loved one, the children in this age range worry about their when in fact they are afraid of their own death and what own bodies and any bodily harm that could be done to will happen to their loved ones when they are gone. They may also be concerned regarding how others Children may also show signs of knowing about their are responding to the death. They may pretend that may show aggressive tendencies, display risky behaviors, toys are dead or draw death in their artwork. It is may become withdrawn, quiet, increasingly irritable, and important to be open and allow discussion if the child is display regressive behaviors. They will inevitably feel a interested; however, it is also important to allow the child loss of control in the world around them. They think of developmentally appropriate level so that the child will death in terms of an afterlife as well as a physical death understand, and the answers should be honest. Children and try to make logical sense of death within the larger should be allowed to participate in decisions afecting framework of life. They are the best resource separating from family and aligning with peer groups, for determining what they want and how much they can they may often want to gain support from friends outside tolerate in the end stages of their disease. Rituals are a central part of Orphans and Vulnerable Children death and grieving for communities around the world. Children younger these roles can increase the trauma experienced by than 2 years are more at risk of parental neglect because the mourner. The loss of their caregiver may of 3 and 10 years, children sufer increasingly from lack have direct negative efects on their clinical outcomes. Adolescents, aged care with overwhelmed new caregivers who cannot 11-17 years, are made vulnerable by the poverty that bring all children to a doctor when needed. However, the two groups diferentiated with their long-term outcomes in terms of weight gain, with the Approximately 15. When the family loses a primary caregiver new caregiver does not notice the adjustment difculties who provided economically for the family, the efects of the orphan in the frst 6 months because the child may can be widespread. The family may be forced to move to be well behaved with a new caregiver or too traumatized a diferent region to help earn additional income. In Institutions often fail to provide adequately for the Northern Africa, the Middle East, Latin America, Asia, physical and psychosocial needs of children, and they and sub-Saharan Africa, young women have a harder actually cost more than direct monetary assistance to time fnding employment because of poorer educational families that foster orphans. Some of these will lose property or inheritance when the relatives of constraints include restriction from extensive traveling the deceased come to claim items such as cars, work for employment and lack of available jobs for young equipment, or electronics. Educational opportunities are lacking the loss felt by the surviving children in the family.

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Factors influencing risk of kernicterus Reduced albumin binding capacity Prematurity, asphyxia, acidosis, hypoalbuminemia and infections Competition for binding sites Displacement of bilirubin from its albumin binding sites by drugs. Acute bilirubin encephalopathy It is the clinical manifestation of bilirubin toxicity seen in the neonatal period. Intermediate phase: hypertonia of extensor muscles (with opisthotonus, oculogyric crises and retrocollis), irritability, seizures, fever. All infants who survive this stage develop chronic bilirubin encephalopathy (clinical diagnosis of kernicterus). Neonatal Care Protocol for Hospital Physicians 233 Chapter 21: Hyperbilirubinemia? Advanced phase: pronounced opisthotonus (although hypotonia replaces hypertonia after about 1 week of age), shrill cry, apnea, seizures, coma and death. Chronic bilirubin encephalopathy (Kernicterus) It is marked by athetosis, deafness, limitation of upward gaze, dental dysplasia and intellectual deficits. If bilirubin toxicity is suspected, treatment is an immediate exchange transfusion, preceded by phototherapy until the exchange starts. Neonatal Care Protocol for Hospital Physicians 234 Chapter 21: Hyperbilirubinemia Conjugated Hyperbilirubinemia Conjugated hyperbilirubinemia is a sign of hepatobiliary dysfunction. Conjugated hyper bilirubinemia is defined as an increased level of direct bilirubin >15% of the total serum bilirubin. Others: spontaneous perforation of common bile duct, and cholelithiasis Neonatal hepatitis/cholestasis Idiopathic neonatal hepatitis? It is defined as intrahepatic cholestasis in which the characteristic giant-cell hepatitis lesion is present on liver biopsy but for which no cause is identified. Neonatal Care Protocol for Hospital Physicians 235 Chapter 21: Hyperbilirubinemia Miscellaneous? The presence of nonhepatic findings will provide helpful clues to specific diagnosis, such as the following: > Signs of sepsis > Galactosemia: failure to thrive, vomiting, cataracts, and Gram-negative bacterial sepsis. Supportive management Promotion of bile flow and prevention of malnutrition, vitamin deficiencies, and bleeding are the goals. Neonatal Care Protocol for Hospital Physicians 237 Chapter 21: Hyperbilirubinemia? If both direct and indirect bilirubin are high, exchange transfusion is probably safer than phototherapy. Neonatal Care Protocol for Hospital Physicians 238 Chapter 22 Neonatal Respiratory Disorders Chapter 22: Neonatal Respiratory Disorders Neonatal Respiratory Disorders Respiratory problems are the most common difficulty seen in neonatal care units especially in preterm infants. Birth initiates a dramatic change from the intrauterine state, in which the placenta is the primary organ of respiration, to life outside the uterus, in which the lung is the organ of gas exchange.

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