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N. Miguel, M.B.A., M.B.B.S., M.H.S.

Deputy Director, University of Florida College of Medicine

These effects may be partly offset by glucose-independent stimulation of insulin secretion [26]. All glucocorticoids cause dose-dependent insulin resistance at dosages greater than the equivalent of 7. The duration of exposure to glucocorticoids does not appear to be important, and hyperglycemia is generally reversible on withdrawing the drug. Most problems have been reported with oral glucocorticoids, but those administered topically can also induce severe hyperglycemia, especially if given at high dosage over large areas of damaged skin and under occlusive dressings [27]. This is more likely to occur in children because of their higher ratio of total body surface area to body weight [28]. The hyperglycemic potency of glucocorticoids does not follow the hierarchy of their anti-inflammatory or immunosuppressive activities. For example, deflazacort, which has similar immunomodulating effects to other glucocorticoids, produces less hyperglycemia than prednisone or dexamethasone [30]. Other commonly encountered adverse effects of glucocorticoids are hypertension and sodium and water retention. Thiazide diuretics should not be used to treat these complications, as their own hyperglycemic action synergizes with that of glucocorticoids [31]. As with glucocorticoids, post-receptor insulin resistance appears to be responsible; in vivo studies have demonstrated a decrease in insulin sensitivity in women without diabetes taking certain contraceptive pills [36,37], and a number of implantable hormonal contraceptives have been linked to alterations in carbohydrate metabolism, including impaired glucose tolerance and increased insulin resistance [38,39]. The tendency to cause hyperglycemia was particularly marked with the early pills, which had a relatively high estrogen content; the overall risk of developing impaired glucose tolerance was 35% [40], and even greater in women with a history of diabetes during pregnancy [41,42]. Impaired glucose tolerance during pregnancy remains a potent risk factor, even with the newer oral contraceptives; these women are three times more likely to develop diabetes with a progestogenonly pill than with a low-dose combined pill [43]. Most currently available combined oral contraceptives contain low estrogen dosage (25­50 g/day). Consistent with this, metabolic studies have demonstrated fasting hyperinsulinemia and reduced insulin sensitivity [36,37,45]. Reassuringly, however, recent studies, including a massive prospective follow-up of almost 99 000 non-diabetic participants [46], found no appreciable increase in the incidence of diabetes among users of current oral contraceptives [46,47]. The authors of a recent Cochrane review [48] concluded that hormonal contraceptives have little clinical impact on carbohydrate metabolism. Low-dose combined oral contraceptives are safe in younger women with uncomplicated well-controlled diabetes [49]. In contrast to the older high-estrogen pills, the effect on glucose homeostasis of low-estrogen combination pills is determined mainly by the type and dosage of progestogen, with monophasic levonorgestrel combinations having the most deleterious effect. Oral progestogen-only formulations cause only minor hyperglycemia in healthy subjects, although diabetes may develop in women who had hyperglycemia during previous pregnancies [43]. The long-acting progestogens, such as depot medroxyprogesterone (Depo-Provera) and sustained-release low-dose levonorgestrel, cause a statistically but not clinically significant deterioration in glucose tolerance in healthy women [39,50]. There is no convincing evidence that the Mirena coil is associated with any change in glucose metabolism. The metabolic adverse effects of glucocorticoids have stimulated the development of selective glucocorticoid receptor ligands with similar anti-inflammatory efficacy to glucocorticoids currently in use but with fewer adverse effects. A number of these compounds have been developed and shown in animal studies not to induce hyperglycemia [34]. Oral contraceptive pills and estrogen replacement therapy Estrogens and some progestogens used in contraceptive agents are potentially diabetogenic. This is not surprising, as endogenous sex steroids have been shown to affect glucose homeostasis in women without diabetes: insulin sensitivity rises during the follicular phase of the menstrual cycle and falls during the luteal 267 Part 4 Other Types of Diabetes Hyperglycemia induced by hormonal contraceptives is usually reversible on withdrawal of the contraceptive pill. This was true both for women taking conjugated equine estrogen alone and those taking a combination of conjugated equine estrogen plus medroxyprogesterone acetate [59,60]. It was previously thought to be secondary to both reduced glucosestimulated insulin release and to insulin resistance (Figure 16. The severity of glucose intolerance is strongly correlated with the degree of hypokalemia [67]; the impairment of insulin secretion is secondary to potassium depletion, which appears to inhibit the cleavage of proinsulin to insulin and is reversible on restoring normokalemia [73,76,77]. The result is post-prandial hyperglycemia, with elevated proinsulin concentrations between meals that may downregulate insulin receptors in peripheral tissues. Long-term studies suggest that adrenoceptor antagonists induce insulin resistance, possibly partly through weight gain [78].

In contrast, abdomino-pelvic radiotherapy is consistently reported to be associated with poor uterine function with increased risks of late miscarriage, prematurity, low birth weight, stillbirth, neonatal haemorrhage and postpartum haemorrhage (Bath, et al. There are also case reports of uterine rupture as well as a possible increase in placental attachment disorders (placenta accreta and percreta) (Wo and Viswanathan, 2009). Not only is the effect on uterine function dose dependent, but also related to age at the time of exposure, the pre-pubertal uterus being more susceptible (Bath, et al. The risk is greatest when either is used at higher doses or in combination with each other. There are case reports of peripartum heart failure, which are probably due to exacerbation of pre-existing cardiac dysfunction originating at the time of exposure to anthracyclines or radiotherapy (Hudson, 2010). Small case reports have suggested that these pregnancies may be obstetrically high risk. In the largest cohort study of 232 consecutive oocyte donation pregnancies, there was a high prevalence of miscarriage (40% after identification of a single gestational sac), pregnancy-induced hypertension (22%), prematurity (13%), low birth weight and small for gestational age (18% and 15%, respectively), caesarean section (61%), and postpartum haemorrhage (12%) with the quoted figures relating to singleton deliveries (Abdalla, et al. Threatened miscarriage in the first trimester (with subsequent live birth) was also common in the study of Abdalla and colleagues (11%) and in a smaller study by Pados and colleagues (35%) (Pados, et al. The authors concluded that, while women with an oocyte donation pregnancy should expect a good outcome, they should be cared for in a high-risk antenatal clinic. The risk of aneuploidy is related to the age of the donor, not the recipient, and should be taken into consideration during antenatal aneuploidy screening (Bowman and Saunders, 1994; Donnenfeld, et al. Although not common, spontaneous pregnancies can occur, especially in women with a mosaic karyotype rather than 45. It is not clear whether it is the underlying karyotype or that the pregnancy was the result of oocyte donation that increases the risks. All 7 pregnancies resulted in live births without any maternal complications, although one of the offspring had cerebral palsy. However, a feature of published case studies was the inconsistent use of pre-conception cardiac screening, which might improve the outcome. Neonatal complications appeared less common than suggested by previous studies; in singleton pregnancies the preterm birth rate was 8. It is not known how many women were declined treatment based on an unfavourable pre-conception assessment and the same proportion of women was 45X0 as in the Hadnott & Bondy review (44%) (Hadnott, et al. The risk of birth defect or serious neonatal illness was 5 out of 44 (11%) live births in own oocyte pregnancies compared to 8 out of 118 (7%) live births in oocyte donation pregnancies (Karnis, 2012). However, it is not clear whether these figures include both major and minor congenital abnormalities or how many of the affected cases were due to other conditions. In a series of own oocyte pregnancies in Sweden, 2 or 3 out of 37 live births were affected by a major congenital abnormality (5. Pelvic irradiation is associated with increased obstetric risks due to poor uterine function, especially when exposure occurred before menarche. Anthracycline chemotherapy and cardiac irradiation are associated with cardiac failure, which may become clinically apparent in pregnancy. Therefore, the guideline development group strongly recommends that these pregnancies are followed with adequate obstetric surveillance, although no studies have been performed showing the effect of obstetric care on complications in these patients. Although oocyte donation is not given as a specific risk factor, consideration to prescribing aspirin should be given in these pregnancies, especially when it is the first pregnancy or in a woman with Turner Syndrome. Pregnancies in women with Turner Syndrome are very high risk and may have a maternal mortality as high as 3. Pre-conception screening, especially for cardiac risk factors, may help reduce maternal risks in pregnancy as well as identify those in whom pregnancy might be considered best avoided. B Oocyte donation pregnancies are high risk and should be managed in an appropriate obstetric unit. Women and their partners should be encouraged to disclose the origin of their pregnancy with their obstetric team. C 61 Antenatal aneuploidy screening should be based on the age of the oocyte donor. C Pregnancies in women who have received radiation to the uterus are at high risk of obstetric complications and should be managed in an appropriate obstetric unit. C Pregnancies in women with Turner Syndrome are at very high risk of obstetric and non-obstetric complications and should be managed in an appropriate obstetric unit with cardiologist involvement. D A cardiologist should be involved in care of pregnant women who have received anthracyclines and/or cardiac irradiation.

Infections of the small intestine (enteritis) commonly produce generalized or periumbilical abdominal cramps, large-volume diarrhea without blood, and frequently dehydration. Large-intestine infections (colitis) often produce lower abdominal pain, an unproductive urge to defecate, and frequent small-volume stools with blood and pus. Take a thorough history, including the following: · Onset of diarrhea: sudden or gradual · Frequency (times per day, last episode) · Stool consistency (soft vs. A: Assessment the differential diagnosis of diarrhea is broad and includes the following infectious and noninfectious causes. Department of Health and Human Services, Health Resources and Services Administration; 2004. If noninfectious causes are suspected, perform evaluation for these etiologies as indicated. If the patient is febrile, perform a complete fever workup as appropriate (see chapter Fever). If all study results are negative but the diarrhea persists, repeat endoscopy in 6-8 weeks regardless of the level of immunodeficiency. Symptomatic treatments · Antimotility agents such as loperamide (Imodium) in over-the-counter or prescription strengths and atropine/ diphenoxylate (Lomotil) are useful for many patients. The suggested dosage is 2 tablets after each loose bowel movement, not to exceed 8 tablets per day. These agents should not be used if patients have bloody diarrhea or if the presence of C. Patients with diarrhea related to protease inhibitors may find that taking calcium with each dose of protease inhibitors can decrease or prevent diarrhea. Avoid administering cholestyramine with other medications because it may impair their absorption. For seriously ill patients, presumptive treatment may be started while diagnostic tests are pending. Monitor effectiveness and adjust therapy according to the results of diagnostic studies and clinical response. Specific treatment with antimicrobials is guided by the pathogens identified in stool studies or on biopsy. Diarrhea owing to protease inhibitors often decreases after a few weeks without treatment. Nutrition and hydration Encourage frequent intake of soft, easily digested foods such as bananas, rice, wheat, potatoes, noodles, boiled vegetables, crackers, and soups. Encourage hydration with fruit drinks, tea, "flat" carbonated beverages, and water. Patients should avoid high-sugar drinks, caffeinated beverages, alcohol, high-fiber foods, greasy or spicy foods, and dairy products. Many patients may benefit from a trial of a lactose-free, Section 5: Common Complaints Diarrhea low-fiber, or low-fat diet. Patients should use nutritional supplements as needed or as recommended by a dietitian. In case of chronic or severe diarrhea, or significant weight loss, refer to a dietitian for further recommendations. Patients with severe diarrhea must maintain adequate hydration, by mouth if possible. Oral rehydration solutions include the World Health Organization formula, Pedialyte, Rehydralyte, Rice-Lyte, and Resol. Homemade alternatives include the following: · Combine 1/2 teaspoon of salt, 1 teaspoon of baking soda, 8 teaspoons of sugar, and 8 ounces of orange juice; add water to make 1 liter and drink. Department of Health and Human Services, Health Resources and Services Administration; 2004;55-65. Instruct patients to notify their health care provider if they develop new or worsening symptoms.

Standard general prophylaxis Cephalosporins should not be used in persons with intermediate-type hypersensitivity reaction to penicillins or ampicillin. Prevention of infective endocarditis: Guidelines from the American Heart Association: A guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Endothelialization process of prosthetic material occurs within 6 months after the procedure. Theseinclude highfeverlasting5daysormore,plusatleast4ofthefollowing5 criteria: (1) Bilateral,painless,bulbarconjunctivalinjectionwithoutexudate (2) Erythematousmouthandpharynx,strawberrytongue,orred crackedlips (3) Polymorphousexanthem(maybemorbilliform,maculopapular,or scarlatiniform) (4) Swellingofhandsandfeetwitherythemaofpalmsandsoles (5) Cervicallymphadenopathy(>1. Diagnosis, treatment, and long-term management of Kawasaki disease, Council on Cardiovascular Disease in the Young, American Heart Association. Subacute phase (11­25 days after onset of illness):Resolutionoffever, rash,andlymphadenopathy. Moderateorhigh-riskmedicalconditionincludinghistoryof prematurity,verylowbirthweight,congenitalheartdisease(repaired ornonrepaired),recurrenturinarytractinfections,knownrenalor urologicmalformations,familyhistoryofcongenitalrenaldisease,solid organtransplant,malignancyorbonemarrowtransplant,treatment withdrugsknowntoraisebloodpressure,othersystemicillness associatedwithhypertension. High static Bobsledding Field events Gymnastics*, Rock climbing Sailing Windsurfing*, Waterskiing*, Weight-lifting*, Fencing Field events (jumping) Figure skating* Football (American)* Surfing Rugby* Running (sprint) Synchronized swimming Bodybuilding*, Downhill skiing*, Skateboarding*, *Danger of bodily collision. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. Electrocardiographic criteria for diagnosis of acute myocardial infarction in childhood. Cardiac troponin I in pediatrics: normal values and potential use in assessment of cardiac injury. Developmental modulation of myocardial mechanics: age- and growth-related alterations in afterload and contractility. Heartmurmur Femoralpulsestoexcludeaorticcoarctation PhysicalstigmataofMarfansyndrome Brachialarterybloodpressure(sittingposition)§ *Parental verification is recommended for high school and middle school athletes. Judged not to be neurocardiogenic (vasovagal); of particular concern when related to exertion. Auscultation should be performed in both supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction. Arterial oxygen tension and response to oxygen breathing in differential diagnosis of heart disease in infancy. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Introduction: eligibility recommendations for competitive athletes with cardiovascular abnormalities. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Wheal: Erythematous, well-circumscribed, raised, edematous lesion that appears and disappears quickly B. Crust: Exudative mass consisting of blood, scale, and pus from skin erosions or ruptured vesicles/papules 4. Scar: Formation of new connective tissue after damage to epidermis and cutis, leaving permanent change in skin 6. Pathogenesis: Benign vascular tumor with a phase of rapid proliferation followed by phase of spontaneous involution. Many begin to regress by 6 months, with a rate of 10% complete involution per year. Clinical presentation: Newborns may demonstrate pale macules with threadlike telangiectasias that later develop into hemangiomas. Atypical clinical findings, growth pattern, and equivocal imaging should prompt tissue biopsy to exclude other neoplasms or unusual vascular malformations. Decision to treat should be based on location, size, pattern, age of patient, and risk of complications. Propranolol (Hemangeol)3 (a) Nonselective -adrenergic blocker given orally; should be initiated under careful supervision of a pediatric dermatologist or other practitioner experienced in management. Chapter 8 Dermatology 207 (b) Patients should be clinically screened for cardiac disease. Electrocardiogram and/or echocardiogram are not required but obtained only when indicated.