Imaging of children with anophthalmia reveals a poorly formed sciatica pain treatment options purchase toradol 10 mg free shipping, shallow orbit with only rudimentary orbital tissue back pain treatment kuala lumpur toradol 10mg on-line. Dysgenesis of the septum is more easily recognized than optic nerve hypoplasia because the chemical shift artifact generated by the interface of orbital fat and the optic nerve obscures the nerve bayhealth pain treatment center dover de purchase 10 mg toradol mastercard, making accurate assessment of nerve size impossible unless special techniques are used to correct for chemical shift oceanview pain treatment medical center discount toradol 10mg otc. Diagnosis of colobomas is made at fundoscopic examination and is confirmed by imaging pain treatment center seattle discount toradol 10mg on line, which is indicated to demonstrate the extent of the defect and to exclude associated abnormalities such as those described above pain treatment algorithm buy discount toradol 10mg. Both techniques, however, require that the patient remain still for relatively long periods with the eyes in a fixed position, as any eye movement will degrade the images obtained and hamper confident interpretation of small scleral defects. The loud noises produced by the imager during image acquisition cause further difficulties in the sleeping child. These reports describe the findings in several patients with ocular coloboma, but only a small minority confirms the presence of morning glory syndrome at fundoscopic examination. The globe is misshapen, and there is widening of the optic nerve head, which is of water density and is continuous with the vitreous humor. Thinning and eversion of the sclera at the margin of the defect may also be identified. Heterotopic adipose tissue and smooth muscle within the disk have been reported, and these should not be mistaken for tumor. Staphyloma is an inflammatory condition in which there is localized ectasia of the globe. This is not limited to the inferonasal aspect of the globe, nor does it lead to the classic fundoscopic appearance. Microphthalmos with cyst is a severe malformation of the globe with gross ectasia of the sclera, which results in a cystic structure beside the globe that may be much larger than the globe itself. The important differentiating feature is that the neck of the cyst where it connects with the globe is much smaller than the actual cyst. The choroidoscleral defects with cystic expansion of the optic nerve, together with the typical fundoscopic findings, confirm the diagnosis. Classification of spinal dysraphisms requires a rational correlation of clinical, neuroradiological, and embryological information. Spinal dysraphisms are categorized into open or closed depending on whether the abnormal nervous tissue is exposed to the environment or is covered by the integuments (Table 1). During gastrulation, the bilaminar embryonic disk, formed by epiblast (future ectoderm) and primitive endoderm, is converted into a trilaminar disk because of formation of an intervening third layer, the mesoderm. Subsequent waves 434 Congenital Malformations, Spine and Spinal Cord Congenital Malformations, Spine and Spinal Cord. Table 1 Classification of spinal dysraphisms Open With subcutaneous mass Lumbosacral Cervico-thoracic Closed Without subcutaneous mass Simple dysraphic states Complex dysraphic states 1. Intradural Disorders of midline Disorders of lipoma notochordal segmental integration notochordal formation 2. Dermal sinus of epiblastic cells migrating laterally along the interface form the interposed mesoderm, whereas cells migrating along the midline form the notochord, the foundation of the axial skeleton. Establishment of the neural plate under the induction of the notochord marks the onset of primary neurulation on about day 18. Subsequently, the neural plate starts bending, forming paired neural folds that increase in size and approach each other to eventually fuse in the midline to form the neural tube. The cranial extremity of the neural tube (anterior neuropore) closes at day 25, whereas the caudal extremity (posterior neuropore) closes at day 27 or 28. The segment of the spine and spinal cord caudad to somite 32 is formed by secondary neurulation. The tail bud, a mass of cells deriving from the caudal portion of the primitive streak, lays down an additional part of the neural tube caudad to the posterior neuropore that undergoes a process of regression, degeneration, and further differentiation, which results in the formation of the tip of the conus medullaris and the filum terminale. The conus medullaris contains a focal expansion of the ependymal canal called terminal ventricle. Expansion of the underlying subarachnoid space causes elevation of the surface of the placode above the surface of the skin. Myelocele the uncommon myelocele is differentiated from myelomeningoceles by the absence of expansion of the subarachnoid spaces ventrale to the placode. In both instances, the mass is represented by a lipoma, and the spinal cord is connected to the lipoma at the level of a placode. In lipomyeloceles, the lipomatous tissue creeps into the spinal canal through a posterior bony spina bifida and attaches to the neural placode, i. Dermal Sinus It is an epithelium-lined fistula that extends from the skin surface inward to a variable depth, and sometimes pierces the dura to reach the intradural compartment. The lumbosacral region is the most common location, although cervical, thoracic, and occipital locations are also found. Embryologically, dermal sinus tracts are traditionally believed to result from focal incomplete disjunction of the neuroectoderm from the cutaneous ectoderm. By definition, they do not contain neural elements with the possible exception of redundant nerve roots or the filum terminale. Persistent Terminal Ventricle Myelocystocele Myelocystoceles are categorized into terminal and nonterminal based on their location along the neuraxis. Terminal myelocystoceles are characterized by herniation of a hydromyelic cavity that involves the terminal portion of the cord into a meningocele. Persistence of the terminal ventricle is embryologically related to preservation of the continuity of the terminal ventricle of secondary neurulation with the central canal of the spinal cord. Differentiation of a persistent terminal ventricle from hydromyelia is based on the location within the conus medullaris immediately above the filum terminale. Diastematomyelia Diastematomyelia (literally, split cord) refers to a variably elongated separation of the spinal cord in two, usually symmetric halves. There is in fact a continuous spectrum of abnormality ranging all the way between a partially cleft cord contained in a single dural tube at one end, and completely duplicated spinal cord contained within dual dural tubes with an intervening bony spur at the other end. Embryologically, abnormal midline notochordal integration results into a variably elongated segment in which the midline notochord is replaced by two paired notochordal processes separated by intervening primitive streak cells. Each "heminotochord" induces a separate "hemi"-neural plate, which will then neurulate independently to form a "hemi"-neural tube. The resulting malformation essentially depends on the developmental fate of the intervening primitive streak tissue, which is a totipotential tissue capable of differentiating into ecto-, meso-, and endodermal lineages. If this intervening tissue differentiates into cartilage and bone, the two hemicords eventually will be contained into two individual dural sacs separated by an osteocartilaginous spur (type I diastematomyelia). Intradural and Intramedullary Lipoma Intradural and intramedullary lipomas are contained within an intact dural sac but are otherwise similar. Filar Lipoma Filar lipoma is an elementary anomaly of secondary neurulation characterized by a fibrolipomatous thickening of the filum terminale. The incidental finding of fat within the filum terminale in the normal adult population is estimated to be 1. Tight Filum Terminale A tight filum terminale is a short, hypertrophic filum that produces tethering and impaired ascent of the conus medullaris. Isolated cases are extremely uncommon, while 436 Congenital Malformations, Spine and Spinal Cord Caudal Agenesis Syndrome Caudal agenesis syndrome, also called caudal regression, is a heterogeneous constellation of anomalies that comprise total or partial agenesis of the caudal portion of the spinal column, anal imperforation, genital anomalies, bilateral renal dysplasia or aplasia, pulmonary hypoplasia, and lower limb abnormalities. There is a known association with maternal diabetes mellitus (1% of offspring of diabetic mothers). However, the vast majority of these anomalies involve absence of the coccyx and part of, or the whole, sacrum. Segmental Spinal Dysgenesis Segmental spinal dysgenesis is defined as the association of (i) segmental agenesis or dysgenesis of the lumbar or thoracolumbar spine; (ii) segmental abnormality of the underlying spinal cord and nerve roots; (iii) congenital paraplegia or paraparesis; and (iv) congenital lower limb deformities. Embryologically, it is related to failure of development of an intermediate segment of the notochord. The spinal cord at level of the abnormality is thoroughly absent, and the bony spine is focally aplastic. As a result, the spine and spinal cord are "cut in two," with resulting acute angle kyphosis. Unfortunately, surgery cannot restore complete functional recovery, and operated patients usually exhibit a variable association of sensorimotor deficits of the lower extremities, bowel and bladder incontinence, hindbrain dysfunction, hydrocephalus, as well as intellectual and psychological disturbances. Allergic responses can vary from mild to anaphylaxis, and occur when latex products touch the skin or mucous membranes. Clinical examination is significantly helpful to restrict the differential diagnosis. Capillary hemangioma is the least sensitive in predicting underlying malformation, although capillary hemangiomas of the lumbar region are associated with spinal dysraphisms in greater than 10% of cases. Dorsal dimples or ostia can indicate either a dermal sinus or a sacrococcygeal fistula. All fistulas opening above the gluteal crease should be presumed to violate the subarachnoid space until proven otherwise. Conversely, skin pits located within the intergluteal cleft need no further investigation as they are related to simple sacrococcygeal cysts or fistulas. Patients with caudal agenesis may have a rudimentary tail, lower limb abnormalities, or anorectal malformations. Imperforate anus is associated with surgically correctable intradural pathology in at least 10% of patients. Patients with segmental spinal dysgenesis typically have a protuberance of bony consistence along their back, corresponding to the apex of a kyphotic gibbus at level of the focal bony aplasia, and are congenitally paraplegic or paraparetic. The appearance of spinal lipomas is variable depending on the presence of dural defects. It may be smooth and regular or large and irregular, with stripes of adipose tissue that permeate the spinal cord and penetrate into the ependymal canal. The size of the spinal canal may be increased in relation to the size of the lipoma, but the size of the subarachnoid space ventral to the cord is consistently normal. In most cases, the placode is stretched and rotated eccentrically toward the lipoma on one side, whereas the meningocele develops on the other side. In such an instance, the spinal roots that emerge from the side facing the meningocele have a redundant course and may be at greater risk for damage during surgery, whereas those lying on the side of the lipoma are shorter and cause cord tethering. Unlike with lipomyeloceles, the spinal canal is dilated because of expansion of the ventral subarachnoid spaces. Filar lipomas are detected as hyperintense stripes of adipose tissue with resultant thickening of the filum terminale. Intradural lipomas are larger lipomatous masses that typically connect with an unneurulated spinal cord segment. Nonterminal myelocystoceles are located along the cervical or thoracolumbar spine; only a thin fibroneurovascular stripe emanating from a limited dorsal myeloschisis and possibly distended by focal hydromyelia enters the meningocele, while the spinal cord remains within the spinal canal. Dehiscence of the subcutaneous fat over the dome of the protruding sac is a common finding to both myelocystoceles and meningoceles. In the type I, the radiological hallmark is the osseous or osteocartilaginous septum (the "spur"), which dissects the spinal canal into two separate halves, each containing an independent dural tube, in turn containing a hemicord. Although in the archetypal case the spur connects the vertebral body to the neural arch along a midsagittal plane, "atypical" spurs are common. The spur may course obliquely and may be incomplete, in which case it may originate either from the vertebral body or from the neural arch. In some cases, the spinal canal is divided unequally, resulting in two asymmetric hemicords. In most cases, the spur is located at the thoracic or lumbar level and lies at the caudal end of the cord splitting. As a consequence, the two hemicords usually surround the spur tightly before fusing with each other to form a normal spinal cord below, whereas rostrally the splitting is much more elongated. Therefore, there is a craniocaudal sequence of partial clefting, complete diastematomyelia within a single dural tube, diastematomyelia with dual dural tubes with intervening spur, and reunion of the two hemicords, an appearance that may recall railway points. A midline, nonrigid, fibrous septum sometimes is detected at surgery; these septa may be identified on axial and coronal T2-weighted images as thin hypointense stripes interposed between the two hemicords. Rare cases of partial cord splitting are characterized by an incomplete separation of the two hemicords, which remain joined by a midline bridge. The conus medullaris is typically low, and there is a strong association with tight filum terminale. The caudal agenesis syndrome is characterized by a degree of vertebral abnormality that may range extensively, from isolated agenesis of the coccyx to absence of the sacral, lumbar, and lower thoracic vertebrae. The degree of sacral agenesis may vary, with S1 through S4 present in individual cases. Sacral aplasia may also be asymmetric, with resulting total or subtotal hemisacrum that may, in turn, be unilateral or bilateral. Full appreciation of the heterogeneous spectrum of vertebral malformation requires anteroposterior and lateral X-ray films, which constitute an essential part of the neuroradiological workup. The condition can be isolated or associated with abdominal situs inversus or situs ambiguous and accompanied by congenital heart disease. Polysplenia: Polysplenia can be isolated or associated with abdominal situs inversus or situs ambiguous and Bibliography 1. Tortori-Donati P, Rossi A et al (2000) Spinal dysraphism: a review of neuroradiological features with embryological correlations and proposal for a new classification.
She recalls that her older daughter began pubertal development when she was younger than her son is now pain treatment center ky 10mg toradol fast delivery. Which of the following is correct regarding the normal sequence of pubertal development in males and females? Which one of the following methods of contraception is associated with the highest failure rate with typical use? A healthy-appearing short 15-year-old girl presents with primary amenorrhea treatment for nerve pain after shingles generic 10 mg toradol overnight delivery, normal genitalia intractable pain treatment laws and regulations buy 10 mg toradol amex, and delayed pubertal development pain treatment for endometriosis order toradol 10 mg overnight delivery. Which of the following tests is most useful in diagnosing the most likely cause of her amenorrhea? A 15-year-old boy has had worsening left scrotal pain for the past 24 hours pain treatment for trigeminal neuralgia buy toradol 10 mg without prescription, a tender left testicle pain treatment on suboxone cheap toradol 10mg, and a bluish discoloration visible through his scrotal skin. Which of the following is correct regarding the evaluation and management of his scrotal pain? On examination you note bilateral breast enlargement and Tanner stage 5 pubertal development. A sexually inactive 14-year-old girl presents with concerns that her current menstrual period, which is painless, has lasted 13 days and is associated with a moderate amount of bleeding. This menstrual period began 2 weeks after her previous period stopped; it lasted 15 days. Which of the following statements is correct regarding the management of this problem? She does not want to terminate the pregnancy and would like advice and pregnancy-related care. They are worried because she has had diminished interest in family activities, has been fighting more often with her parents, and is spending more time alone in her room. During the past 6 months, her school performance has worsened, and her school principal recently telephoned her parents about school absenteeism. In addition, parents have noticed that she is hanging out with a new group of friends and that her appetite seems diminished. Which of the following statements regarding the management of this adolescent is most likely to be correct? A 16-year-old runaway adolescent presents to the free clinic with complaints of diffuse abdominal pain, fever, and nausea. On further questioning, she indicates she has had five sexual partners during the past year and most of the time uses condoms for protection. Pelvic examination reveals moderate lower abdominal tenderness and tenderness on palpation of her cervix and right ovary. A 14-year-old girl is brought to the office for a routine health maintenance visit. Her mother is concerned that her daughter frequently skips breakfast and eats only a small portion of her dinner, usually alone in her bedroom. She argues often with her parents, and she immediately goes to her room on coming home from school or the gym. An 18-year-old adolescent female with a single painless genital ulcer with a well-demarcated border, and painless inguinal adenopathy. A 16-year-old adolescent female with multiple painful ulcers with a purulentappearing base and irregular borders as well as painful inguinal adenopathy. Pubic hair begins to grow after the beginnings of breast development in females and testicular enlargement in males. The vaginal diaphragm has the highest rate of failure with typical use among the methods listed. Failure is often related to lack of use during each episode of intercourse, lack of knowledge regarding proper placement, lack of use of spermicide, and improper fit. Depomedroxyprogesterone acetate and oral contraceptives are very effective contraceptive agents with low failure rates. Intrauterine devices and male condoms have a higher failure rate than hormonal contraception but are usually more effective in practice than the vaginal diaphragm. This girl has primary amenorrhea, which is defined as the absence of menstrual bleeding either after age 16 in a girl with normal secondary sexual characteristics or, as in this case, after age 14 in a girl with delayed pubertal development. Disorders characterized by primary amenorrhea, normal genitalia, and delayed puberty include Turner syndrome, ovarian failure, and hypothalamic or pituitary failure. This boy presents with classic findings of torsion of the left testicular appendage, which is characterized by acute or gradual onset of scrotal pain, tenderness at the upper pole of the testicle, and a "blue dot sign" reflecting the cyanosis and torsion of the testicular appendage. This condition normally resolves without surgery, and rest and pain medication are indicated. Doppler ultrasound demonstrates normal or increased blood flow, and radionuclide imaging demonstrates normal or increased uptake on the affected side, unlike torsion of the spermatic cord. The presence of Gram-negative intracellular diplococci confirms the diagnosis of Neisseria gonorrhoeae cervicitis. Gynecomastia, the development of breast tissue, occurs in up to 60% of males during adolescence. If a male adolescent is healthy and has progressed normally through puberty, as in this case, no laboratory tests are necessary, and reassurance alone is sufficient management. Neither an estrogen level nor a karyotype would be useful in light of a male sexual maturity rating of Tanner stage 5. Although thyroid and liver disorders may result in breast enlargement, other signs or symptoms suggesting a systemic disease would likely be apparent on physical examination. She also is anemic and, as a result, needs hormonal therapy to regulate her menstrual cycles. Because of her moderate anemia, a pelvic examination should be performed to rule out other causes of abnormal vaginal bleeding before prescribing hormonal therapy. Either a daily progestin-only contraceptive or combination oral contraceptives would be effective in stopping her bleeding. Teens who are pregnant are at higher-than-usual risk of hypertension, anemia, and preterm labor. In addition, adolescent mothers have a high rate of not completing high school, have a higher-than-normal rate of unemployment, and often need welfare assistance. Adolescents who are pregnant are also at a higher risk for sexually transmitted disease. In the majority of states, adolescents are entitled to seek pregnancy-related care without parental consent. Their infants are at higher-than-usual risk for health problems, such as low birth weight. The signs and symptoms of substance abuse include disturbance in mood or sleep, decline in school performance, truancy, alterations in family relationships and peer groups, and diminished appetite. This adolescent does not meet the criteria for major depressive disorder, although depression can occur with, and result from, substance abuse. Decreased appetite alone is insufficient to diagnose anorexia nervosa or bulimia nervosa. Although both the adolescent and her parents may be interviewed jointly, she should also be interviewed independently to facilitate rapport and discussion of confidential issues. In addition to these characteristics, patients with anorexia nervosa also have amenorrhea, a weight 15% below ideal body weight for age, an intense fear of gaining weight, delays in puberty and growth, and a preoccupation with food and sometimes with exercise in order to burn calories. In addition to withdrawal from family, teens with anorexia nervosa often withdraw from friends. Insight into the illness is lacking, and management of eating disorders is very challenging. Input from nutritionists and therapists and the involvement of a supportive family are essential. Genital ulcers may be caused by chancroid (infection with Haemophilus ducreyi), syphilis (infection with Treponema pallidum), or herpes simplex virus types 1 and 2. Syphilis is characterized by a single painless ulcer that has a well-demarcated border and a nonpurulent base (a chancre). In contrast, chancroid is characterized by painful ulcers that have irregular borders and a purulent base. Inguinal adenopathy is present in both diseases; however, it tends to be painful in chancroid and painless in syphilis. Herpes simplex virus also causes multiple painful shallow ulcers, but the base is nonpurulent. Evaluation of the Newborn Features of the newborn examination that differ from those of children and adolescents include: A. Careful observation is necessary to assess spontaneous activity, passive muscle tone, respirations, and abnormal signs, such as cyanosis, intercostal muscle retractions, or meconium staining. Apgar scores are a simple, systematic assessment of intrapartum stress and neurologic depression at birth, conducted at 1 and 5 minutes after birth (Table 4-1). A persistently very low Apgar score indicates the need for resuscitation, and scoring should be continued every 5 minutes until a final score of 7 or more is reached. Skin Examination Texture differs with gestational age; skin is softer and thinner in premature infants. Apgar Scoring System* Score 0 1 2 Heart rate Absent < 100/min > 100/min Good, crying Respirations Absent Slow, irregular Muscle tone Limp Some flexion Active motion Cough, sneeze, cry Completely pink Reflex irritability (response to catheter in nose) No response Blue, pale Grimace Color Body pink, blue extremities *Five variables are evaluated at 1 and 5 minutes after birth, and each one is scored from 0 to 2. The final score is the sum of the five individual scores, with 10 representing the optimal score. A persistently very low score indicates the need for resuscitation, and scoring should be continued every 5 minutes until a final score of 7 or more is reached. Vernix caseosa is a thick, white, creamy material found in term infants; it covers large areas of the skin in preterm infants. Acrocyanosis and cutis marmorata (mottling of the skin with venous prominence) are frequent intermittent signs of the vasomotor instability characteristic of some infants. Subsequently, it is frequently seen during the first few days after birth but usually is not associated with serious disease (see section X). Milia are very small cysts formed around the pilosebaceous follicles, which appear as tiny, whitish papules that are seen over the nose, cheeks, forehead, and chin. Mongolian spots are dark blue hyperpigmented macules over the lumbosacral area and buttocks of no pathologic significance. These areas of pigmentation are most frequently seen in Hispanic, Asian, and African American infants. Pustular melanosis is a benign transient rash characterized by small, dry superficial vesicles over a dark macular base. Pustular melanosis must be differentiated from viral infections, such as herpes simplex, and from bacterial infections, such as impetigo. Erythema toxicum neonatorum is a benign rash seen most frequently in the first 72 hours after birth, characterized by erythematous macules, papules, and pustules (resembling "flea bites") on the trunk and extremities but not on the palms and soles. The rash occurs in about 50% of full-term infants and is found much less frequently in preterm infants. Nevus flammeus, or "port wine stain," is a congenital vascular malformation composed of dilated capillary-like vessels (a form of capillary hemangioma) that may be located over the face or trunk and may become darker with increasing postnatal age. Those located in the area of the ophthalmic branch of the trigeminal nerve (cranial nerve V-1) may be associated with intracranial or spinal vascular malformations, seizures, and intracranial calcifications (Sturge-Weber syndrome). Strawberry hemangiomas are benign proliferative vascular tumors occurring in approximately 10% of infants. Typically, the lesions are comedones, but inflammatory pustules and papules may be present. Microcephaly, or head circumference below the 10th percentile, may be familial but may also be caused by structural brain malformations, chromosomal and malformation syndromes, congenital infections. Caput succedaneum is diffuse edema or swelling of the soft tissue of the scalp that crosses the cranial sutures and usually the midline. Cephalohematomas are subperiosteal hemorrhages secondary to birth trauma confined and limited by the cranial sutures, usually involving the parietal or occipital bones. Craniosynostosis is premature fusion of the cranial sutures, which may result in abnormal shape and size of the skull. The ears should also be inspected for preauricular tags or sinuses and for appropriate shape and location. An abnormal red reflex of the retina may be caused by cataracts, glaucoma, retinoblastoma, or severe chorioretinitis. The nose should be examined immediately to rule out unilateral or bilateral choanal atresia. If this is suspected, it can be excluded by passing a nasogastric tube through each nostril. Clefts of the lip and of the soft and hard palates are easily noted by inspection, but submucous clefts in the soft portion of the palate should be ruled out by digital palpation. Micrognathia, together with cleft palate, glossoptosis (downward displacement or retraction of the tongue), and obstruction of the upper airway, can be found in Pierre Robin syndrome. Macroglossia may suggest Beckwith-Wiedemann syndrome (hemihypertrophy, visceromegaly, macroglossia), hypothyroidism, or a mucopolysaccharidosis. Epstein pearls are small, white epidermoid-mucoid cysts found on the hard palate, which usually disappear within a few weeks. Midline clefts or masses may be caused by cysts of the thyroglossal duct or by goiter secondary to maternal antithyroid medication or transplacental passage of longacting thyroid-stimulating antibodies. Neonatal torticollis, or asymmetric shortening of the sternocleidomastoid muscle, may result from being in a fixed position in utero or from a postnatal hematoma resulting from birth injury. Clavicles should be examined to rule out fractures, which may occur during delivery, most commonly of large neonates.
Paragonimiasis is a public health problem in countries where it is customary to eat raw crustaceans or use them for supposedly therapeutic purposes pain treatment with acupuncture cheap toradol 10 mg amex. However pain medication for dogs metacam discount toradol 10 mg, the disease is a problem in Japan as well joint pain treatment in homeopathy purchase 10 mg toradol overnight delivery, even though crustaceans are well cooked before they are eaten; in this case pain spine treatment center toradol 10mg without a prescription, the main source of infection is hands and cooking utensils contaminated during the preparation of crustaceans pain treatment center houston texas buy toradol 10 mg cheap. It is possible that man may also become infected by eating meat from animals that are paratenic hosts carrying immature parasites pain breast treatment cheap toradol 10 mg with mastercard, as evidenced by cases on the island of Kyushu, Japan, that occurred following the consumption of raw wild boar meat. The hypothesis that there are paratenic hosts is reinforced by the fact that paragonims have been observed in carnivores such as tigers and leopards that do not eat crustaceans (Malek, 1980). Transmission is always cyclic-the infection cannot be transmitted directly from one definitive host to another. The parasite must complete its natural cycle, and in order for this to happen the two intermediate hosts must be present-appropriate species of both snails and crustaceans. In endemic areas of eastern Asia, the human infection rate is high enough that man can maintain the infection cycle alone through ongoing contamination of freshwater bodies with human feces. In such areas, the role of animal definitive hosts may be of secondary importance. This experience bears out the importance of human infection in maintaining the endemic. On the other hand, in several parts of Africa, Latin America, and Asia, wild animals are more important than man or domestic animals in maintaining the infection cycle. Diagnosis: In endemic areas, paragonimiasis may be suspected if the typical symptoms are present and the consumption of raw or undercooked crustaceans is a local custom. Radiographic examination is useful, but the findings may be negative even in symptomatic patients. Moreover, interpretation of the results can be difficult in nonendemic areas because the images may be mistaken for those of tuberculosis. Specific diagnosis of pulmonary paragonimiasis is based on the identification of eggs in sputum, fecal matter, pleural effusions, or biopsies. The eggs are reddish brown, operculate, and enlarged at the end opposite the operculum. It is important to differentiate the eggs of Paragonimus from those of other trematodes, as well as cestodes of the order Pseudophyllidea, such as Diphyllobothrium. The cerebral forms can be mistaken for tumors or cysticercosis, and the cutaneous forms, for other migratory larvae-hence the interest in developing indirect tests. An intradermal test that was only weakly sensitive and of questionable specificity was widely used in the past for epidemiologic purposes. In a province of China, a 1961 study found that 24% of the persons examined had positive skin tests, and almost half of those cases were confirmed. This assay can distinguish infections caused by different species of Paragonimus (Kong et al. In addition, the polymerase chain reaction is being used to diagnose paragonimiasis (Maleewong, 1997). Control: In endemic areas, control efforts should be directed at interrupting the infection cycle by the following means: a) education of people to prevent the consumption of raw or undercooked crabs or crayfish; b) mass treatment of the population to reduce the reservoir of infection; c) elimination of stray dogs and cats for the same purpose; d) sanitary disposal of sputum and fecal matter to prevent the contamination of rivers; and e) controlling snails with molluscicides in areas where this approach is feasible. For a control program to be effective, it should encompass the entire watershed area and adjacent regions. In Latin America, where the transmission cycle appears to occur predominantly in wildlife and where human cases are sporadic, the only practical measure is to educate and warn the population about the danger of eating raw or undercooked crustaceans. A study in China investigated the possibility of destroying metacercariae in crustaceans by irradiation with cobalt-60. No parasites could be recovered from mice infected with metacercariae irradiated at 2. Some of the metacercariae irradiated at 2 kGy excysted and survived in the mice for up to 30 days. Immunoglobulin G (IgG) subclass and IgE responses in human paragonimiases caused by three different species. Clinical features and epidemiology of the recent outbreak following the Nigerian civil war. Human paragonimiasis caused by Paragonimus uterobilateralis in Liberia and Guinea, West Africa. Effect of cobalt-60 irradiation on the infectivity of Paragonimus westermani metacercariae. Paragonimiasis and tuberculosis, diagnostic confusion: A review of the literature. Paragonimiasis in Ecuador: Prevalence and geographical distribution of parasitisation of second intermediate hosts with Paragonimus mexicanus in Esmeraldas province. Etiology: the primary agents of human schistosomiasis are the small blood trematodes Schistosoma mansoni, S. There are 19 recognized species of Schistosoma, but their phylogenetic relationships are complex (Rollinson et al. Unlike the other digenic trematodes, which are hermaphrodites, the schistosomes have both male and female forms. The males are shorter and broader than the females, and they have a gynecophoral canal running along the ventral surface in which the female, which is long and thin, is permanently accommodated. Adults live in the venous system of their definitive hosts, where they mate and lay 100 to 3,500 eggs a day, depending on the species. Although all the species have a similar life cycle, there are variations in their required intermediate hosts and in the final localization of the adults in the circulatory system. The eggs are transported by the venous circulation until they form a thrombus, at which point they secrete enzymes that enable them to traverse the wall of the organ and take up residence in the lumen. From the lumen they are eliminated in feces, urine, or other secretions or excretions of the affected organ. The eggs are deposited with a zygote inside, and before leaving the host they develop a larva (miracidium). The released miracidia swim in search of a suitable intermediate host, but they lose their infectivity if they fail to find one within about 10 hours. The snail intermediate hosts belong to the following genera: Biomphalaria and Tropicorbis in the case of S. The miracidium penetrates the snail and turns into a mother sporocyst, which forms daughter sporocysts inside it, and the latter, in turn, produce fork-tailed cercariae. The time lapse between penetration of the miracidium and emergence of cercariae can be as short as 20 days, but it is usually 4 to 7 weeks. Unlike the cercariae of other digenic trematodes, the schistosome cercariae do not form a metacercaria but instead invade the skin of the definitive host directly, often penetrating via the hair follicles or sebaceous glands by enzymatic and mechanical means. This process has to be completed within 36 hours or the cercaria loses its infectivity. Penetration takes only a matter of minutes; the cercaria drops its tail in the course of penetration, and within a few hours, it transforms into a juvenile schistosome (schistosomulum), which differs from the cercaria in morphology, antigenicity, and physiology. The schistosomula travel through the bloodstream to the lungs, where they stop briefly, and then move through the circulatory and porta systems to the liver, where they reach sexual maturity and mate. About three weeks after the initial infection, the parasites travel against the blood flow to the mesenteric, vesical, or pelvic venules, depending on the species. The parasites live for several years, and there have been reports of infections lasting up to 30 years. Direct mortality is relatively low, but the infection poses a public health problem because of the chronic pathology and disability that it produces. It is believed that schistosomiasis was introduced to the Americas by slaves from Africa. Young persons 10 to 14 years of age were most affected, and the pathology was often severe (Stich et al. Before the current control program was undertaken, it was estimated that more than 10 million people were infected. In Japan, the human infection is largely under control and only a few hundred carriers remain. In the Americas, Brazil alone has an estimated 8 to 12 million infected individuals. In that country, tests carried out during preparations for its schistosomiasis control program revealed a positivity rate of 22. In some localities in northeastern Minas Gerais, Brazil, 100% of the population was found to be infected. The infection has spread in some areas because of new irrigation projects and the migration of infected populations. Despite the fact that several countries have managed to reduce the occurrence of schistosomiasis through vigorous control programs, its prevalence has changed little in recent decades because of the expansion of irrigation and the human migrations mentioned earlier. Reports published in 1999, based on research in selected communities from different countries, gave the following prevalence ranges for S. The Disease in Man: Approximately 90% of schistosome infections in humans are asymptomatic. However, some patients suffer acute respiratory abnormalities with radiographic signs and unspecific symptoms similar to those of influenza. There can be more significant morbidity, and even mortality, from fibrotic reactions to parasite eggs laid in host tissue, leading especially to portal hypertension in the case of S. Between 6% and 27% of infected women suffer from genital lesions, but the nature and treatment of these lesions is not yet understood (Feldmeier, 1998). Occasionally, the eggs reach the central nervous system and produce a granulomatous reaction. When there are only a few eggs and they are widely scattered, no signs are observed, but large granulomas can cause increased intracranial pressure and focalized signs, often in the lumbosacral spinal cord (Ferrari, 1999; Pittella, 1997). The seriousness of the disease is dictated by the parasite burden and the length of time the patient has been infected; both factors affect the number of eggs that settle in host tissues, which is the main determinant of chronic pathology. School-age children and occupational groups that spend time frequently and for long periods in water, such as fishermen and rice growers, have more intense infections because of the accumulation of parasites from repeated infections. However, there is a limit to this accumulation because the schistosomes generate concomitant immunity; in other words, the adult forms of the parasite partially protect against new infections by schistosomula. The symptomatology of schistosomiasis may be divided into four phases, according to the evolution of the parasitosis. At first there are petechiae with edema and pruritus; these are followed by urticaria, which can become vesicular and last from 36 hours to 10 days. In most cases there are no clinical manifestations, although massive infections can produce pneumonitis with coughing and asthma-like crises, along with eosinophilic infiltration. The third phase develops when the parasite matures inside the liver and oviposition begins to take place in the corresponding venules. It is believed that these symptoms represent an acute immune response to antigens released by the eggs, with the formation of abundant cytokines. The fourth, or chronic or granulomatous phase, reflects the tissue response to the deposition of eggs. The antigens of the eggs that are retained in the tissues generate a cell-mediated immune response that forms granulomas around the eggs. When the granulomas become abundant in a tissue, they converge and can invade an important part of the organ. Prior stimulation of the patient by antigens of the adult parasite and the intervention of tumor necrosis factor alpha seem to play an important role in the formation of granulomas (Leptak and McKerrow, 1997). Over time, they spread to the liver and produce interlobular fibrosis and portal hypertension, ascites, and splenomegaly. In the chronic phase, the following clinical forms can be distinguished: intestinal, hepatointestinal, hepatosplenic, and pulmonary. Ultrasound revealed hepatomegaly in 35% of the infected individuals and splenomegaly in 80%, both of which were associated with a high parasite burden and were less notable in those who had already been treated with praziquantel. Mild periportal fibrosis was common, and signs of portal hypertension were observed in 2% of the subjects. The signs of chronic disease are usually persistent diarrhea and abdominal pain with hepatomegaly or splenomegaly. Papillomatous folds, pseudoabscesses, and miliary pseudotubercles develop in the wall of the bladder, and sometimes there is total fibrosis of the organ. The main symptoms are painful and frequent urination, terminal hematuria, suprapubic pain, and recurrent urinary infections. The eggs may also travel to the intestine, especially the venules that drain the rectum, and they may be eliminated in the feces. Evidence suggests that vesical schistosomiasis may be a predisposing condition for malignant tumors because of the continuous irritation produced by the eggs. Both infection and morbidity rates were higher in children aged 7 to 14 years old. Treatment with praziquantel resolved more than 80% of the urinary tract lesions within a year (Traore, 1998). Hepatomegaly occurs in approximately 50% of the cases, but portal hypertension is not seen. There is also an acute form of schistosomiasis, often referred to as Katayama fever, which develops four to six weeks after a massive primary infection with S. The clinical manifestations are similar in some respects to those of serum disease: fever, eosinophilia, lymphadenopathy, hepatosplenomegaly, and sometimes dysentery. Because of the clinical manifestations and the fact that the disease occurs at the beginning of oviposition, it is believed that this syndrome is caused by the formation of antigen-antibody complexes in the bloodstream. Prevalence rates in cattle have been found to be as high as 62% (Bangladesh), 90% (Sudan), and 92% (Zimbabwe). As in man, schistosomiasis in cattle has an acute phase, caused when recently matured parasites release large quantities of eggs in the intestinal mucosa, and a chronic phase, during which the damage is caused by the reaction to antigens produced by eggs trapped inside tissues. The former, referred to as the intestinal syndrome, occurs seven to nine weeks after a massive initial infection and causes severe hemorrhagic lesions in the intestinal mucosa, with infiltration of eosinophils, lymphocytes, macrophages, and plasmocytes, along with profuse diarrhea or dysentery, dehydration, anorexia, anemia, hypoalbuminemia, weight loss, and retarded development.
Given the wide range of facilities that house elephants allied pain treatment center pittsburgh buy toradol 10mg without a prescription, each must develop its elephant management program based on its specific set of circumstances northside hospital pain treatment center atlanta ga generic toradol 10mg fast delivery. When a facility develops its elephant management program pain treatment ladder buy 10mg toradol free shipping, it should consider its goals in regard to the elephants; the design of the enclosure; experience and ability of the handlers; the number ocean view pain treatment center buy discount toradol 10mg, age treating pain in dogs with aspirin cheap toradol 10 mg line, gender pain shoulder treatment order 10 mg toradol with amex, and demeanor of the elephants; finances; administrative directives; and education, conservation, and research. The elephant management style(s) used by a facility must be carefully studied and all ramifications considered. Protocols and action plans need to be developed to reflect the elephant management styles that are adopted. To provide the best care possible for the el- T Management ephants, it is important that the method of elephant management selected is appropriate for the facility, staff, and elephants involved, and not simply a decision of convenience. It was recently recognized that approaches to elephant management and behavior training have developed into a continuum of management techniques. These range from the handler working immediately next to the elephant, to the handler working the elephant only through or from Kim Whitman Elephants, similar to this one in Sri Lanka, have been living and working with humans for thousands of years. Management 15 Houston Zoo, Anita Schanberger Above: On one end of the management continuum is the handling of an elephant through or from behind a barrier. Right: In the middle of the management continuum, the elephant can make physical contact with the handler to differing degrees. Below: the other end of the management continuum puts the handler in immediate contact with the elephant. Albuquerque Biological Park Busch Gardens Tampa/Deborah Olson 16 Elephant Husbandry Resource Guide behind a barrier, to a large array of techniques in between with a varying amount of direct, or potentially direct, physical contact between the elephant and handler allowed. For example, the elephant handlers may manage the cows and calves directly, but only manage an adult bull from behind a protective barrier or confined in a restraint device. Or, the handlers may choose to manage one or more of the cows from behind a barrier. The management technique or techniques within the continuum that a facility uses to attain its goals should be a means to an end so that the handlers are able to safely meet or exceed the established minimum standards of elephant care (see Husbandry, p. As stated previously, on one end of this management continuum is the handling of an elephant through or from behind a barrier, and by very careful handler positioning relative to the elephant. The handler is positioned so that the elephant cannot grab, tusk, kick, or contact the handler in such a way as to cause injury. The elephant is not physically confined except for the fact that it is in its enclosure, which allows the elephant to refuse to respond to commands given and leave the presence of the handler. The elephant is trained to respond and change location or position through the use of targets, cues, guides, and reinforcements (see Training, p. This is the technique recommended for use with adult male elephants and female elephants that do not respond reliably, in order to safely work more closely with the handler. The level of safety afforded the handler is directly related to the design of the barrier and the positioning of the handler in relation to the elephant and the barrier. Used correctly, the barrier does provide an increased level of protection for the handler, but it does not prevent all chance of injury. The handler must take care to understand the Lee Richardson Zoo Albuquerque Biological Park Above: the elephant is not confined except for its enclosure and there is no contact with the handler. Management 17 Buffalo Zoo this end of the management continuum provides more opportunities for elephant-public interaction. In the middle of the management continuum are the facilities that have barriers through which the elephant can physically contact the handler to differing degrees during the training and husbandry care process. In some cases, the elephant may be trained to interact physically with the handler. The reasons many management systems have maintained the contact between the elephant and the handler are: 1) the temperament of the elephant; 2) the increased control of the elephant and the use of additional techniques and tools for behavior modification; 3) a greater opportunity for the elephant and handler to physically interact; 4) an additional means to participate in research and education programs; and 5) to reduce the amount of facility modification required. However, it must be cautioned that working with the elephant in this range of management systems compromises the safety of the handler to varying degrees. A common misconception by some practicing this range of systems within the continuum of elephant management is that the elephant will not act aggressively, if the handler uses predominately positive reinforcement in the training process (see Training, p. Therefore some handlers put themselves in potentially hazardous positions believing they are safe from injury. There are no data that would support this belief, and unfortunately the injuries caused and/or aggressive actions demonstrated by elephants toward their handlers underscores the necessity of following strict safety and training protocols. The other end of the management continuum puts the handler in immediate contact with, and next to , the elephant. Being in close contact with the elephant requires a high level of skill and ability from the handler. The elephant is trained not to push, strike, or displace the handler with any part of its body. At this point in time and with our current level of understanding of elephant training and management, if both the elephant and its handler are properly trained and suitable for the endeavor, a wider range of behaviors and activities can be accomplished from this end of the continuum. Training protocols can be used to develop 18 Elephant Husbandry Resource Guide highly tractable elephants that can be easily moved from location to location, exercised in a wide variety of ways, cared for, examined, and treated intimately and on demand. This end of the continuum provides a substantial degree of flexibility in the management of the elephant, and greater opportunities for the elephant to experience spaces outside of their exhibit, interact with the public, and participate in scientific investigation, education, and entertainment-based activities. But it must be cautioned that working with the elephant in this system Indianapolis Zoo, Eric Sampson the management continuum that puts the elephant in immediate contact with the handler allows greater flexibility for husbandry procedures. Therefore, it is critical that facility management and the elephant manager understand the need to develop a well-trained, qualified staff and a consistent elephant training program prior to deciding on this end of the continuum. The elephant must be trained to be responsive to all commands given, and the handler must have the ability to obtain a reliable response from the elephant at all times. Due to the need for behavior control of the elephant, an elephant that is repeatedly noncompliant or aggressive should not be handled in this manner. Sedgwick County Zoo Management 19 Rosamond Gifford Zoo at Burnet Park, Michele Delperuto this male elephant made a successful transition from one end of the management continuum to the other. Initially, he was handled directly and trained to respond to a wide variety of commands. Though there are a diversity of approaches, all of the methods within the management continuum have many qualities in common such as: q the training process uses both classical and operant conditioning (See Training, p. Every facility should have an elephant restraint device (see Tools and Equipment, 61). A good elephant program involves all of the handlers working as a team with consistency being the foundation. Consistency helps remove confusion and enhances the communication on the part of the elephant and the handlers. It is the responsibility of the facility management to have thoroughly discussed these q q q q q Elephants handled in a method at one end of the management continuum have been transitioned successfully to another method within the continuum when the facilities are appropriate and the handlers are well-trained and experienced. However, it has been reported that serious noncompliance issues (unresponsiveness, aggression, etc. In other instances, the social hierarchy of the elephant herd changed, resulting in increased aggression between elephants that previously had been compatible. Possessing a good foundation and understanding of the commands and their associated behaviors has helped many elephants and handlers make this transition. It is strongly recommended that all young elephants, especially bulls, be taught the basic behaviors using direct handler contact without barriers to maximize their potential should barriers be introduced in the future. Effective training enhances our ability to care for elephants; for example, an elephant that is trained to stand patiently and quietly, or to enter a restraint device without hesitation, will enjoy better health as a result of the training. People have been training elephants for centuries, but in the last 10 to 15 years there have been dramatic improvements in training practice and knowledge of training theory. For the training of elephants to be as successful and efficient as possible, the elephant handler must be familiar with training theory, the advantages and disadvantages of various tools and methods, and the terminology associated with training. The following review is a small sampling of the information available, and is not meant to be a comprehensive discussion of elephant training. It is meant instead to stimulate greater interest in, and discussions about, training. Learning can also be described as changes in behavior that occur as the result of practice or experiences (Dewsbury 1978). When humans dictate that practice, the E Training process is called training (Mellen and Ellis 1996). Given this very broad definition, virtually every direct and indirect interaction that handlers have with their elephants can be viewed as a form of training. Skinner) suggested that the mechanisms of learning were the same in all animals ("learning is learning"). However, as comparative psychologists and ethologists, led by Keller and Marion Breeland, studied learning throughout the 20th century in a broad range of species, Six Flags Marine World Training-for husbandry procedures, for enrichment, and for exercise-is critical to the success of an elephant program. Training 21 Six Flags Marine World Log work can be a good training exercise, using both classical and operant conditioning to train the behavior. This was called "constraints on learning" or "preparedness to learn" (Dewsbury 1978; Mellen and Ellis 1996). In order to select the most effective and appropriate techniques to train (shape) elephant behavior, it is necessary to consider three things: 1. For example, it may make more sense to ask an arboreal animal to position itself or "station" on a perch off the ground. This may be simplistic, but it makes no sense to try to train an elephant to jump. For example, a captive-born elephant raised in close contact with humans may be trained substantially differently than a wild-caught elephant brought in as an adult. This, at some point, generally ceases as the elephant gains maturity and develops into an elephant whose primary role is breeding (Sevenich, MacPhee, and Mellen 2002). Learning, or conditioning, for all animals (including humans) is generally described as either classical or operant. In very simple terms, classical conditioning is the process through which a stimulus that formerly had no effect on a particular reflex acquires the power to elicit that reflex. The important thing to remember is that the response is reflexive; the animal has no control over its response. In animal training, classical conditioning is commonly used to establish a bridge (or bridging stimulus). A bridge is a term for the association between the stimulus, such as a whistle, clicker, or the word "good," and a tangible reward, a primary reinforcer, such as food. The bridge is a stimulus that pinpoints in time the precise moment of a desired behavior and bridges the gap in time between that point and when the animal may receive reinforcement. Creating a bridge is very important as often times it is very difficult to present the actual reinforcment at the correct time in order to reinforce the desired behavior. The bridge is a secondary or conditioned reinforcer because it acquires 22 Elephant Husbandry Resource Guide its effectiveness through a history of being paired with primary reinforcement. Therefore, a very simple example of classical conditioning is an elephant learning to associate the sound of a clicker with food. Initially, the stimulus is meaningless, but when paired with the food it will become a reinforcer itself over time. When the bridge is correctly conditioned, it is used to reinforce correct behavior. At the same time, overuse of a bridge or reinforcement will diminish its effectiveness by desensitizing the elephant to its use. Operant conditioning (also known as instrumental conditioning) occurs when the frequency of behavior is modified by the consequences of the behavior. The fundamental principle of operant conditioning is that behavior is determined by its consequences. In other words, when the consequences that immediately follow a behavior are something that the animal seeks to encounter (reinforcement), the likelihood of that behavior being repeated increases. For example, the elephant enters a holding area and the elephant receives a food reinforcement. After making this association, the elephant is more likely to enter the holding area at its next opportunity. Conversely, when the consequences following a behavior are some- thing that the animal seeks to avoid (punishment), the likelihood of the behavior being repeated decreases. The elephant that reaches for a tree limb protected by "hot wire" (see Tools and Equipment, p. This type of learning is called operant because the animal "operates" on its environment. It should be understood that all animals learn through a combination of reinforcement and punishment. When the lion catches the gazelle, the lion has been reinforced and the gazelle punished. On the other hand, when the gazelle escapes, it has been reinforced and the lion has been punished. Reinforcement and punishment are closely intertwined, and one cannot exist without the other. Some scientists use the term complex learning as a "catchall" category for types of learning not described by classical or operant conditioning. One such example is observational learning, where one animal learns how to perform a particular behavior simply by watching another animal; or latent learning, where rats ran through a maze faster if they had been allowed to first explore the maze. Many young elephants learn their behavior and routines through watching their mother and herd mates. They are probably watching very closely everything that goes on, including how their dam interacts with handlers and how their dam approaches North Carolina Zoological Park Using targets (see Tools and Equipment, p. Thus, a young elephant may learn to enter a restraint chute by imitating the behavior of its mother. Habituation is the declining or waning of a behavior as the result of repeatedly presenting a stimulus. In this example, the stimulus (loud noise) went from being aversive to the elephant to being neutral.
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