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Turned even a few degrees, the clavicles will exhibit a remarkable degree of asymmetry. Identify the first rib carefully by finding its anterior junction with the manubrium and following this rib backward to the spine. Begin at the origin of the first rib at its junction with the first thoracic vertebra and trace each rib as far anteriorly as you can to the beginning of the radiolucent (and hence invisible) costal cartilage. Interspaces are useful in identifying the location of a precise shadow and are named for the posterior rib above the interspace unless the anterior rib is specified as the marker. Diaphragm higher; lung bases less well seen; transverse diameter of heart is larger. Beam only "sees" what is parallel to it; anterior ribs are more perpendicular and thus not seen very well. Should not be able to follow airways any further out as they are very thin walled; if visible (air bronchogram sign) pulmonary edema. The lung field under a missing breast will appear a little darker than the other lung field. Difference in the Level of the Hemidiaphragms Right hemidiaphragm is normally a bit higher. Normal Position Distance from gastric bubble (if it is visible) to diaphragm should be very small. Then decide whether this width exceeds the distance from the midpoint (spine) to the inside of the rib cage (half the transthoracic diameter). Still more simply, you can measure from the midline to the right heart border and see whether that distance will fit into the piece of lung field to the left side of the heart. Assessment of the cardiovascular anatomy includes assessment of heart and chamber size as well as the position and size of the great vessels.

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In the early stages of the immunization program, many generalized varicelliform rashes that occurred within the frst 2 weeks after varicella 1 Centers for Disease Control and Prevention. Both fever and measles-like rash usually occurred within 5 to 12 days of immunization, were of short duration, and resolved without long-term sequelae. In contrast, the median number of lesions in unimmunized children with varicella is more than 250. Vaccine recipients with mild breakthrough disease are approximately one third as contagious as unimmunized children. However, data from postlicensure surveillance indicate that the clinical severity may be milder and the age-specifc risk of herpes zoster is lower among immunocom petent children immunized with varicella vaccine than among children who have had natural varicella infection. Therefore, it is important that physicians obtain event-appropriate clinical specimens for 1 Centers for Disease Control and Prevention. Rare cases of vaccine-strain meningitis or encephalitis with herpes zoster have been documented; all patients recovered fully. Vaccine-associated virus transmis sion to contacts is rare (documented in only 7 immunized people, resulting in 8 second ary cases), and the documented risk of transmission exists only if the immunized person develops a rash. Once the vaccine has been reconstituted, it should be injected as soon as possible and discarded if not used within 30 minutes. Varicella diagnosed by a physician or verifcation of history of varicella disease. The second dose of vaccine is recommended routinely when children are 4 through 6 years of age (ie, before a child enters kinder garten or frst grade) but can be administered at an earlier age. Varicella vaccine should be administered to all children in this age range unless there is evidence of immunity to varicella or a contraindication to administration of the vaccine. A routine health maintenance visit at 11 through 12 years of age is recommended for all adolescents to evaluate immuniza tion status and administer necessary vaccines, including the varicella vaccine. People 13 years of age or older without evi dence of immunity should receive two 0. The recommendation for at least a 28-day interval between doses is based on the design of the studies evaluating 2 doses in this age group. For people who previ ously received only 1 dose of varicella vaccine, a second dose is necessary. As with other vaccines, varicella vaccine should not be adminis tered to people who have moderate or severe illnesses, with or without fever (see Vaccine Safety, p 41). Prevention of varicella: update of recommendations for use of quadrivalent and monovalent varicella vaccines in children, including a recom mendation for a routine 2-dose varicella immunization schedule. Varicella vaccine should not be administered routinely to children who have congenital or acquired T-lymphocyte immunodefciency, including people with leukemia, lymphoma, and other malignant neoplasms affecting the bone marrow or lymphatic systems, as well as children receiving long-term immunosuppressive therapy. Immunodefciency should be excluded before immunization in children with a fam ily history of hereditary immunodefciency. The Oka vaccine strain remains susceptible to acyclovir, and if a high-risk patient develops vaccine-related varicella, then acyclovir should be used as treatment.

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The nature of some chronic wounds may change with time, and the type of dressings used should be altered accordingly. Antibiotics Chronic wounds are frequently colonised by bacteria, and routine culture of wounds may lead to the identication of innocent organisms. Antibiotics should be reserved for evidence of infection as manifested by pus, cellulitis or systemic symptoms. The indiscriminate use of antibiotics in non-infected colonised wounds does not expedite healing and is likely to cause pathogenic resistance. Where deep-seated pus and necrotic tissue are present, surgery may also be necessary to eradicate infection. The use of negative pressure is thought to decrease tissue oedema, resulting in capillary dilation and increased blood ow to the wound. In addition, pathogens and other inhibitors of healing are removed from the wound. Where multiple cavities are present, the cavities may be joined by internal or external foam bridges, which distribute negative pressure throughout the wound. An occlusive dressing is then applied to maintain the vacuum with an airtight seal. Topical negative pressure therapy may be used in acute and chronic wounds, but it is contraindicated in the following situations: Necrotic tissue or eschar Exposed organs or blood vessels Unexplored stulae Malignancy in the wound. Some patients may experience pain and discomfort during the therapy, which may be ame liorated by reducing the negative pressure or periodicity of the suction. Although portable devices are available, patient mobility is impaired with the use of these devices. Topical negative pressure machines are rented on a daily basis; consequently, the therapy is expensive. Laparostomy Laparostomy (leaving the abdomen open) is a useful adjunct to managing some abdominal wounds where the abdominal wall cannot be closed, where closure may result in intra-abdom inal compartment syndrome (Box 8. Simply covering the intestine with saline-soaked gauze is not recommended due to resulting trauma and the possibility of stulae developing. Where it is anticipated that the abdomen will be primarily closed at a later stage, some form of temporary covering should be used. A cheap, commonly used covering is an empty sterile saline bag (Bogota bag), which can be sutured to the fascial sheath. Synthetic mesh can also be used in this manner and has the advantage of allowing ascites to drain. Alternatively a non-adherent dressing can be placed over the abdom inal contents, usually combined with suction to maintain adherence and reduced wound efu ent. If the fascia and skin cannot be brought together, then a permanent covering should be con sidered.

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Two species of Lutzomyia occur in south and central Texas, as well as parts of Mexico, and are probably the vectors of cutaneous leishmaniasis in Texas. It is interesting that lectins and toxins in the plant diet of Phlebotomus papatasi can kill Leishmania major promastigotes in the sand fly and in culture; these veg etation components may decrease parasite transmission in certain areas (24). Control measures against the adult flies include the use of the bacterial insecticide, Bacillus thuringiensis (52). Although not usually that painful, the bite is accompanied by intense itching and the development of a raised, ulcerative lesion at the site, most probably caused by the saliva in the puncture wound. Individuals who are particularly susceptible may experi ence severe pruritus and body swelling (blackfly fever), which is seen predominantly in children in rural areas of the northeastern United States. Similar to Hymenoptera, a Simuliidae bite occasionally results in extreme hypersensi tivity and should be considered in appropriate cases. These flies normally do not bite indoors and may fly long distances from their habitats. A massive control effort is now under way in West Africa to lower the in tensity of Onchocerca transmission to a level of infection that does not lead to visual impairment. Because flight distances are long and the larvae develop in water, control measures are difficult at best. Development occurs in fast running streams, often very deep; one species was found breeding at depths down to 190 ft (ca. Simuliids have to survive periods when the tempera ture is too low to sustain routine activities and when the rivers dry up during the off season. They can apparently reduce their respiratory rate and replace trehalose in the hemolymph by high polyhydric alcohols, thus remain Figure 24. These flies may not be present in sufficient numbers to be pests, but they can still be important vectors of the filarial Blackflies (Filariasis [Onchocerca and Mansonella spp. The bite site can become a painful blood, and swarms may attack humans as well as domestic wound that takes a long time to heal; individuals may also respond with an allergic reaction to the saliva of the fly. While most blood-sucking insects are repelled by wood fire smoke, apparently in Africa the flies are attracted to wood fires. Control measures have not been particularly successful, and loiasis continues to be a sig nificant problem in West Africa. Tsetse Flies (African Trypanosomiasis) An estimated 60 million people are at risk for African trypanosomiasis, with 300,000 to 500,000 new cases Medically Important Arthropods 681 Figure 24. The genus habitat is limited to proximity to humans or moving whole villages out of the African continent south of the Sahara. The use of insecticides has also proven to voracious blood feeders, and both can transmit parasites. Wherever there are tsetse flies, it Adult flies of the important vectors are daytime feeders is impossible to keep cattle without regular chemotherapy.