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Diffuse alveolar consolidations with thickening of intraalveolar spaces in the middle and lower right lobes. Bacteriological investigations should always be undertaken even though they are posi? In most cases of bacterial empyema polymorphonuclear leukocytes are the predominant cells. In tuberculosis there is also predominance of lymphocytes in pleural fluid although in 10% of cases effusion might be neutrophilic [46]. All children with empyema or pleural effusion should be treated as inpatients [46]. Differences in management result to some extent from personal experience and availability of different treatment modalities, including experienced inter? There is agreement that due to an invasive nature of the procedure and the need for general anesthesia in younger children, a drain should be inserted instead of repeated needle thoracocenteses [46]. In an American study over 50% of all patients with moderate to severe effusions recovered with antibiotic treatment alone [54]. Once the chest tube is inserted, no more than 10 ml/kg of fluid in little children and 1. It seems prudent to ask for surgical opinion if the patient is not improving after 7 days of treatment. Another indication for surgery is bronchopleural fistula with pyopneumothorax [46]. Risk factors for the failure of tube thoracostomy include duration of symptoms > 7 days before the proce? A chest tube can be removed if fluid output is < 1 ml/kg/day calculated over the last 12 hours or 50-60 ml/day and there is no air leak [19]. That gives a chance for bacteriological diagnosis and shorter hospital stay, though not all studies confirm the latter observation [54]. Recommended route of administration is intravenous until the chest tube is removed, and then can be switched to oral route for 1 to 4 weeks or longer if the child has not fully recovered. Lung function tests results as well as exercise tolerance in most patients are normal 12 months after discharge [46,52,53]. Conditions predisposing to severe pneumonia with pleural effusion and empyema include immunodeficiencies and cystic fib? Lung abscess Lung abscess is a thick-walled cavity containing necrotic tissue 2 cm or greater in diame? It may be either primary occurring in healthy children without lung abnormalities or secondary occurring in children with underlying condi?

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Although striae are a common finding in overweight teens, purplish striae suggest underlying hypercortisolism. Acne is present in a large percentage of teenagers independent of the presence of obesity. Within a clinical scenario of obesity, irregular menses, and hirsutism in an overweight girl, significant acne could be an additional indicator suggesting hyperandrogenism. Although acanthosis nigricans is associated with uncomplicated obesity, it is also recognized as a marker of insulin resistance and thus possibly a harbinger of type 2 diabetes mellitus. A thorough cardiopulmonary, musculoskeletal, and neurologic assessment is needed, looking for evidence of hypertension, cor pulmonale, degenerative changes of the joints, slipped capital femoral epiphysis, and pseudotumor cerebri. Androgen insensitivity would not be in the differential diagnosis because the patient had normal menses in the past. In this patient, because of her obesity and positive family history for diabetes and hyperlipidemia, she is at higher than normal long-term risk for cardiovascular disease. In patients with signs of hyperandrogenism who do not desire to get pregnant, combined oral contraceptives are effective in controlling the clinical manifestations. Insulin sensitizers have been found useful in the treatment of patients with polycystic ovary syndrome because they correct insulin resistance, androgen excess, and clinical manifestations of hyperandrogenism. In contrast, depomedroxyprogesterone and long-acting progestin implants often worsen acne. Mild comedonal acne can be successfully treated with 5% benzoyl peroxide gel in most cases; moderate comedonal acne may require daily applications of tretinoin cream or gel in concentrations from 0. Topical antibiotics are effective in the treatment of moderate inflammatory and mixed acne. Severe acne may respond to tretinoin cream or gel but, if inflammatory, will often require oral antibiotics. In this patient, who will also receive combined oral contraceptives to treat other manifestations of hyperandrogenism, topical 5% benzoyl peroxide with or without topical antibiotics would be helpful as initial therapy. There has been a recent death in the family for which she may be appropriately grieving. She does not admit to feeling sad or depressed and specifically denies suicidal ideation. Nevertheless, depression is still a consideration in this girl and should be explored further. Obstructive sleep apnea is a likely possibility given her morbid obesity and enlarged tonsils. Additional history taking may reveal loud snoring, brief periods of apnea while asleep with continuing respiratory effort, and daytime somnolence. Hypothyroidism should be considered in the differential diagnosis of any adolescent with obesity, increased tiredness, and deteriorating school performance. Its broad clinical spectrum spans from transient depressive mood, which could be a justified response to the frustrations of daily life, to major depressive disorders requiring hospitalization. Despite the fact that depression is a major cause of morbidity and mortality during the second decade of life, it is estimated that two-thirds of adolescents with clinical depression go unrecognized and untreated.

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The treatment of choice in children older than surgery, thereby reducing the number of surgeries a child 10 years with curves greater than 50 degrees and deteriora 186 may need. When surgical intervention occurs, the goals tion of functional skills is posterior spinal fusion. This of surgery should be to improve function, decrease dis procedure uses a unit rod, a U-shaped rod with a pre-bent comfort, and prevent structural changes that may become pelvic section, that is fxed to the ilium, thereby correcting 181 188 disabling. It is prefer An understanding of atypical development and move able to delay spinal fusion until the child reaches puberty ment compensations is necessary to determine how surgery or has achieved most of the expected growth. Therefore, it has become com wounds, hardware failure, curve progression, pancreati 189 mon practice for orthopedic surgeons to perform multiple tis, and pseudoarthrosis. Despite the high complication orthopedic procedures at the same time with the goal of rate, caregiver and patient satisfaction rate is high, and the improving overall function. After surgery, the therapist should evaluate all has gained popularity over the past 20 years, especially with seating and standing devices as the alteration in alignment 183?185 access to state-of-the-art comprehensive gait analysis. Postoperative protocols can vary to posterior spinal fusion may be benefcial for improving greatly depending on the hospital, surgeon, and patient; overall spinal mobility as this may decrease the recovery therefore, the information presented here should be used period. The child is typically transferred out of bed into the new hip alignment and possible need for better motor a wheelchair by day 2. Improvement to and beyond presurgical status is 10 ambulation is expected by discharge, which occurs between expected for up to 1 year. In the nor mal hip, balanced muscle use during standing and with ambulation promotes development of the acetabulum, femoral head, and remodeling of anteversion. For children with progressing subluxation using an ambulation aid may develop painless subluxation or complete dislocation, femoral anteversion, and acetabu but seldom require surgical intervention in childhood. The lar dysplasia, combined muscle and bony surgeries are often hips of children that do not ambulate may begin to dislocate necessary to reduce the hip. Superior and posterior direction subluxation Chronic, progressive subluxation leads to acetabular is the most common pattern of hip subluxation with adduc dysplasia. The acetabulum has little potential to remodel, tor muscle spasticity being the primary cause of hip sublux even with soft tissue releases and Varus Derotation Oste ation. Complete hip reconstruction is indicated in these of subluxation requiring further evaluation from an ortho cases, and refers to a combination of muscle releases, reduc pedist. The constant cocontraction of the adductors, pelvic osteotomies, involve cutting the pelvis and adding hamstrings, and hip fexors causes the hips to be held in bone grafts to create a shelf superior to the acetabulum. In addition to the femoral head changes, the angle of femo Common postoperative precautions after bony osteotomies ral neck inclination remains high and anteversion persists. Our facility advo ity of the medial hamstrings and gluteus medius weakness cates early mobilization and weight bearing after surgery as the muscle imbalance that leads to the internally rotated to prevent skin breakdown, osteopenia, and weakness that 41 position of the hips and persistent femoral anteversion. Typically, the rehabilitation pro Left untreated, the femoral head may continue to migrate cess after hip reconstruction lasts between 6 and 12 months 194 until it is dislocated.

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The majority of this reduction would come from eliminating unnecessary antibiotic prescribing for acute respiratory conditions. The panel determined that half of all antibiotics prescribed for these conditions are unnecessary, leading to about 34 million excess prescriptions annually. Acute respiratory conditions should clearly be a target of antibiotic stewardship eforts in outpatient settings. Additionally, improving prescribing practices for other conditions, such as skin infections and acne, could reduce antibiotic use by about 13 million prescriptions annually. Figure 5 Outpatient Antibiotic Prescribing Reduction Targets 100 % 15 80 Reduction 86. Sinus infections Sinus infections are the most common reason that antibiotics are prescribed in outpatient settings in the United States, accounting for more than 17 million prescriptions annually. Although sinus infections can be caused by a number of pathogens, both bacterial and viral, treatment guidelines recommend antibiotic use only when the infection is suspected to be caused by bacteria. The panel recommended a geographic approach to setting reduction targets for prescribing antibiotics to treat sinus infections. Using this method, the ideal antibiotic prescribing rate for sinus infections was set to match the U. The panel estimated that nearly 6 million unnecessary antibiotic prescriptions are written for sinus infections each year. Adult patients account for an overwhelming majority of these and should be the primary population targeted by stewardship eforts for this diagnosis. It will be important to evaluate progress made toward these targets and to assess whether further reduction goals are warranted. About 15 million antibiotic prescriptions are written for this diagnosis each year, with 87 percent of them for patients 19 and younger. As with sinus infections, antibiotics are only sometimes recommended for treating this diagnosis. The symptoms associated with middle ear infection may be caused by a true infection (suppurative otitis media, identifed by the presence of pus) or by the presence of noninfected fuid in the middle ear (nonsuppurative otitis media). Based on current practice guidelines, the panel recommended eliminating all antibiotic prescribing for nonsuppurative cases of middle ear infections. For a suppurative diagnosis, the panel used the same approach as with sinus infections, setting the target prescribing rate to match that of the lowest prescribing region. Based on this method, the panel estimated that there are nearly 2 million unnecessary prescriptions written for suppurative middle ear infections each year.

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