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V. Ali, M.B. B.A.O., M.B.B.Ch., Ph.D.

Clinical Director, University of Miami Leonard M. Miller School of Medicine

Figure 3 this macroscopic image shows a urinary tract stone of mixed composition (calcium oxalate and calcium phosphate) after stone extraction. The divided renal function is also useful when bilateral renal stones are present as the side with the better function is treated first (1). Management of Urinary Stone Disease the management of urinary stone disease depends on the clinical presentation, stone location, stone size, and possibly on stone "hardness. If the stone does not pass spontaneously, definitive stone treatment is required and is often performed as a delayed, elective procedure. Often, however, it is difficult to determine how closely symptoms are related to a urinary tract calculus. Some studies suggest that even small nonobstructing calculi may be symptom-provoking and patients may benefit from stone removal. In other cases, the stone may be an incidental finding, and it is difficult to justify invasive treatment. Each case must therefore be considered on its merits and the benefits of intervention should be balanced against the risks of the chosen procedure (6). Conclusion Modern imaging of urinary stone disease should provide accurate information about the presence, size, and precise location of a renal or ureteric stone, as well as the intracalyceal anatomy. Recently, high quality multiplanar reconstructions and advances in threedimensional imaging have improved treatment planning. Since urinary stone disease is often a recurrent disease in young people, the radiation dose should be an issue. Strangulating Obstruction the impairment of arterial inflow or venous outflow from small bowel due to a twist in the mesentery. Small Bowel, Postoperative Strangulation Closed-loop obstruction with secondary ischaemia. Occlusion and Subocclusion, Small bowel in adults Stroke, Children 1767 Strawberry Gallbladder Diffuse form of cholesterolosis characterized by a diffuse deposition of cholesterol esters in macrophages of the gallbladder lamina propria with a granular appearance resembling those of a strawberry surface, as attested by small, yellow spots against the mucosa. As a clinical definition, such a presentation in childhood has many potential underlying causes. A practical definition of this is, "a clinical stroke syndrome presenting in a child, due to cerebral infarction in an arterial distribution. Many more suffer from long-term disability and are at risk of further strokes in the future. Many children with stroke have another medical condition, such as a cardiac disorder or sickle cell disease, increasing the likelihood of adverse neurodevelopmental effects. Although the numerical burden of disease is smaller than in the elderly, the physical, emotional, and social effects carry long-term implications on the individuals, family, and society as a whole. Pelvic Floor Dysfunction, Genitourinary Striated Muscle Muscle in which sacromeres of the contractile myofibrils are arranged as transverse or oblique striations. Rhabdomyosarcoma Stroke A clinical syndrome comprising rapidly developing signs of focal or generalized neurological dysfunction lasting more than 24 h. Stroke, Children Clinical Presentation the most common clinical presentation of stroke in childhood is an acute hemiparesis. However, the recognition of clinical stroke may be difficult in infants and young children. Focal signs may be absent in neonates and young infants in whom seizures may be the only clinical manifestation. Clinical signs and symptoms may be particularly subtle in children with sickle cell disease, and difficult to distinguish from painful crises or the effects of the treatment of such with opiates. If in doubt, the child should be examined by an experienced pediatrician and advice may be sought from a child neurologist or a tertiary center. The initial diagnostic imperative is for the confirmation of arterial ischemic stroke as well as for the exclusion of alternative treatable pathologies. Practical considerations may apply with regard to limited access to suitable imaging facilities for children.

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In addition, in cases with an indication for preoperative antibiotic prophylaxis, the dentist will need to write a prescription for the patient. This section discusses the protocol for writing a prescription, with several examples. The section will then discuss the commonly prescribed drugs used by dentists before and after surgery. Note that the information in this section is a short summary of the information dentists must know to properly use these drugs and prescribe. It is not intended to substitute for a more comprehensive pharmacology course on the topics of analgesics and antibiotics. Prescriptions for Drugs Drugs that carry significant side effects, toxicities, or abuse potential are usually only available by prescription. Therefore, when the dentist needs to give such drugs to a patient, the doctor must ``write' a prescription. Whether in hard copy or electronically created and transmitted, prescriptions have a standardized format. Most practices and institutions have their official name, address, and telephone number at the top of the prescription. Next, the doctor enters the name of the prescribed drug, the unit dosage, the number of doses, and the dosing instructions. On some forms, the line the doctor signs signifies whether the pharmacist filling the prescription may or may not substitute a generic drug for a brand name drug, if the doctor wrote for a brand name drug. The antibacterial spectrum of penicillin includes the gram-positive cocci (except for staphylococci) and oral anaerobes. Penicillin G is given parenterally, and penicillin V and amoxicillin are preferred for oral administration. The penicillins have little toxicity, except for allergic reactions, which occur in about 3% of the population. Amoxicillin and ampicillin are semisynthetic penicillins that are more effective against gram-negative rods than is penicillin. Amoxicillin has the advantage of a longer serum half-life than ampicillin and penicillin, making its effective duration and its dosage interval longer. Although both penicillin and amoxicillin are effective in treating odontogenic infections, amoxicillin is often preferred to penicillin because its longer dosage interval improves patient compliance. Amoxicillin is given 3 times per day; penicillin V and ampicillin are given 4 times per day. Penicillinase-resistant penicillins, such as methicillin and dicloxacillin, were effective in the past for penicillinase-producing staphylococci. Because more than 85% of staphylococcus strains, especially methicillin-resistant Staphylococcus aureus, have become resistant to this class of penicillins, their usefulness has diminished. A large number of cephalosporins are available and are roughly divided into 4 generations on the basis of their activity against gram-negative organisms. First-generation cephalosporins have a similar activity to penicillin, including activity against gram-positive cocci and some strains of gram-negative bacteria such as Escherichia coli, Klebsiella, and Proteus mirabilis. First-generation cephalosporins, however, are not as effective against oral anaerobes as are the penicillins. Second-generation cephalosporins have broader activity against gram-negative bacteria and increased activity against anaerobic bacteria. The second generation has less activity against gram-positive cocci compared with the first generation. Third-generation cephalosporins are much more active against enteric gram-negative rods but are decidedly less active than first- and second-generation cephalosporins against gram-positive cocci. Fourth-generation cephalosporins are designed to be effective against enteric gram-negative rods, especially Pseudomonas aeruginosa, which is not generally encountered in odontogenic infections. Two oral cephalosporins are effective in odontogenic infections: 1) cephalexin and 2) cefadroxil. Although neither of these is the drug of first choice for treating odontogenic infections, they can be useful in certain situations in which a bactericidal antibiotic is necessary and the first-line antibiotics cannot be used. Patients who are allergic to penicillin drugs should be given cephalosporin antibiotics with caution.

Clinically manifested diverticulitis has been thought to have its pathologic basis in an abscessed diverticulum obstructed by a faecalith, but studies of resected sigmoid colons have failed to produce evidence to support this view. Instead, the outstanding lesion was found to be a perforation in the fundus of a diverticulum, with surrounding peridiverticular or pericolic inflammation. This type of diverticulosis, which is frequently symptomatic, has been referred to as painful diverticular disease or spastic colon diverticulosis. Micro perforations of the tip of the diverticula are an important factor leading to inflammation and symptomatic disease (3). The involvement of diverticula by granulomatous colitis may cause an increased incidence of diverticulitis. Diverticulitis, Gastrointestinal Tract 645 Clinical Presentation the clinical diagnosis of diverticulitis is suggested by abdominal pain that is most commonly located in the left lower quadrant. The classic clinical features are left lower quadrant pain, tenderness, fever and leukocytosis. Urinary symptoms may occur if the affected colonic segment is close to the bladder. A lower quadrant abdominal or rectal mass may be palpated, but associated rectal bleeding is uncommon and suggests an alternative diagnosis. About 85% of cases of acute diverticulitis involve the descending or sigmoid colon; however, rightsided disease may also occur and is reported more frequently in persons of Asian descent. Sigmoid diverticulitis may mimic acute appendicitis if a redundant colon is in the suprapubic region or lower right quadrant. Some distortion of the diverticula arising from the lateral wall of the descending colon (arrow), indicating moderate diverticulitis. Imaging the radiological evaluation of patients with acute diverticulitis has a number of objectives: to confirm the clinical findings and rule out other colonic or pelvic disease and to evaluate and stage the degree of inflammatory disease. Direct visualisation of the colon with sigmoidoscopy or colonoscopy has little or no place in evaluation except where bleeding is a major feature or the presence of a significant polyp or carcinoma is suspected. Although the process of diverticular disease and diverticulosis are well-visualised, the changes associated with diverticulitis are less reliably demonstrated. Although distortion and spiculation of the diverticulae may suggest diverticulitis. Ultrasound Ultrasound is the most commonly requested investigation for non-specific abdominal pain. Hypo-echoic wall thickening with associated collection may often be seen in the affected sigmoid segments particularly in a patient with a full bladder as an acoustic window. Plain Radiographs Plain films may reveal the consequences of complicated diverticulitis such as free air or loculated air within sealed-off collections. In most patients, however plain radiographs are unhelpful except to exclude significant complications on admission to hospital. Contrast Enema Examination Contrast enema examination has been the traditional method of imaging patients with suspected diverticulitis whether with water soluble agents or barium. Shorter oral preparation up to 1 h prior to imaging or no oral preparation may be appropriate depending on degree of clinical condition. It is however preferable in all cases except where there is absolute contraindication to image during intravenous contrast administration. The most consistent feature is the presence of inflammatory change in the pericoloic fat. The changes range from very fine linear stranding to large phlegmonous collections or frank abscess formation. Although most collections or abscesses are confined to the sigmoid mesocolon sepsis can spread to involve other spaces and planes such as the psoas muscle. Once signs of inflammation are seen throughout the abdomen the disease has become Stage 3 and surgical intervention is invariably required. Stage 1 is characterised by an abscess or inflammatory mass less than 3 cm in diameter confined to the mesocolon. Antibiotic therapy usually suffices and patients rarely Diverticulitis, Gastroinstestinal Tract. Thickened sigmoid loop with intramural and extramural sinus and fistula formation, (solid arrow), pericolic inflammation and phlegmon (double arrow). Intramural and extramural diverticula Induration, thickening or increased vascular markings within sigmoid mesentery Inflammation, phlegmon or abscess in pericolic fat Pericolic sinus or fistulae Associated pelvic abscess or peritonitis Signs of perforation. Table 2 Surgical stage 0 1 2 3 4 Hinchley classification of stages of diverticulitis Management May settle spontaneously or with antibiotic treatment Conservative.

Diseases

• Oculopharyngeal muscular dystrophy
• Bull Nixon syndrome
• Chanarin Dorfman syndrome ichthyosis
• Depression (clinical)
• Rodini Richieri Costa syndrome
• Cataract ataxia deafness
• Hypogonadism
• Ventricular fibrillation, idiopathic

Nuclear Medicine Nuclear medicine plays no particular role in the diagnosis of acute ischemia. Diagnosis Diagnosis based on the clinical and angiographic findings is usually easy to make. It is more difficult to detect the underlying source of acute occlusion, the extent of the thrombosed arterial segment, and the best appropriate therapeutic approach. As usual, a correct diagnosis in time and rapid onset of treatment are mandatory for limb salvage and they need to be implemented in each center dealing with acute disease. It is, however, true that acute ischemic states are frequently overseen or neglected also by the patient. To achieve a successful and enduring result, at least one lower limb artery or a major collateral has to be reopened down to the foot in order to establish a sufficient outflow situation and to avoid early rethrombosis. Thrombolysis has some drawbacks that prevent its widespread use in subacute and acute thrombosis and embolic disease. In particular, in advanced stages a treatment duration of up to 24 h may worsen the clinical situation with an unpredictable outcome. Furthermore, the subset of patients with acute ischemia are frequently of older age and their comorbidities often contraindicate the use of thrombolytic agents. Fogarty embolectomy via a femoral or popliteal approach is a quick method in the case of circumscribed thrombi, but it may become difficult in concomitant atherosclerotic stenoses or extensive thromboses including the lower limb arteries. In older thrombi, wall adhesion of the occluding clots can complicate removal of clots by use of Fogarty embolectomy balloons and sometimes additional instruments are required. Many different mechanical devices were developed with enthusiasm, introduced into clinical practice, tested as insufficient and have disappeared from the market. The Kensey catheter is an early example of this not-too-small family of disappointed hopes. In the meantime, however, some valid instruments and techniques are available which allow successful and relatively safe and timely removal of clot material. Manual aspiration Hydrodynamic thrombectomy Rotational thrombectomy Atherectomy Stent placement In addition, a number of other devices or treatment options are under development and evaluation and their number is still growing. Henry M, Amor M, Henry I et al (1998) the Hydrolyser thrombectomy catheter: a single-center experience. Gorich J, Rilinger N, Sokiranski R et al (1998) Mechanical thrombolysis of acute occlusion of both the superficial and the deep femoral arteries using a thrombectomy device. Hopfner W, Bohndorf K, Vicol C et al (2001) Percutaneous hydromechanical thrombectomy in acute and subacute lower limb ischemia. Zeller T, Frank U, Burgelin K et al (2002) Long-term results after recanalization of acute and subacute thrombotic occlusions of the infra-aortic arteries and bypass-grafts using a rotational thrombectomy device. Mesenteric ischemia is a condition in which the mesenteric arteries do not deliver enough blood and oxygen to the small and large intestines. This makes it difficult for the intestines to digest food and can cause segments of the intestine to die. It was studied more intensively in the mid-nineteenth century after case reports by Virchow and others. When lodgment occurs, the embolus lodges at the site of division of the inferior mesenteric artery into the left colic, sigmoidal, and superior hemorrhoidal arteries. In such instances, collateral flow from the middle colic and middle hemorrhoidal arteries (through the vascular arcades of the inferior mesenteric artery distal to the embolus) may sustain the perfusion of the left colon (2). Hemorrhagic infarction is the common pathologic pathway, whether the occlusion is arterial or venous. Damage to the affected bowel portion may range from reversible ischemia to transmural infarction with necrosis and perforation. The mucosal barrier becomes disrupted as the ischemia persists, and bacteria, toxins, and vasoactive substances are released into the systemic circulation.