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Pre-K through Grade 8

Providing spiritual and educational leadership

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Phone: 203-269-4477

Fax: 203-294-4983

8:00 A.M. - 2:25 P.M.

Monday to Friday

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P: 203-269-4476

F: 203-294-4983

11 North Whittlesey

Wallingford, CT

8:10am - 2:25pm

Monday to Friday

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By: Pierre Kory, MPA, MD

  • Associate Professor of Medicine, Fellowship Program Director, Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Beth Israel Medical Center Icahn School of Medicine at Mount Sinai, New York, New York

https://www.medicine.wisc.edu/people-search/people/staff/5057/Kory_Pierre

Median onset age 50 fi Splenomegaly fi Wispy changes to infection on finger purchase 250mg erythromycin with amex cytoplasm of B cell fi Purine analogues fi 80% remission Data Interpretation: Leukaemia & Lymphoproliferative disorders fi Normal count but atypical lymphocytes fi viral infection antibiotic 83 3147 discount 500mg erythromycin amex. Adenosine deaminase deficiency fi Arrest in embryogenesis Primary Immunodeficiency fi Most single gene disorders: range of effects bacteria genus 500 mg erythromycin with mastercard. May include macular rash fi Debate about usefulness of early treatment fi Good evidence of value of prophylactic treatment. Future prevention fi If positive: repeat, confirmatory test organised, arrangement for counselling, support and specialist assessment Other Causes of Secondary Immunodeficiency fi Malignancy fi Drugs. Eg Goodpastures Syndrome (Ab against glomerular basement membrane), haemolytic disease of the newborn. Due to lymphocytes and IgG (not IgE) fi Risk factors: fi Allergy predominates in young adults and children: while non-specific hypersensitivity is more common later in life fi Genetic Factors: One parent fi doubled risk of child having atopic disease. Both parents fi 4 times risk fi Early childhood factors important in subsequent development of allergic disease: fi High house dust mite/cat/pollen exposure in early months fi firisk fi Exposure to tobacco smoke in utero/infancy fi firisk fi Early life infections fi firisk:fi For adult, 60% chance next time fi Carry adrenaline until desensitisation (serial antigen shots fi 95% effective) fi Anaphylaxis: give 0. Allergy requires symptoms following exposure fi Expensive and less accurate than skin tests, but useful if skin tests not possible, history of anaphylaxis Challenge tests fi Mainly in research setting fi Food allergy: can do double blind, placebo-controlled food challenge. Difficult to distinguish between allergic and irritant reactions Diseases caused by Antibodies Antibodies against tissue antigens fi Cause disease specific for that cell/tissue fi Usually auto-antibodies: but may be a foreign antigen that is immunologically cross-reactive with a component of self-tissues fi Usually IgG or IgM fi Antibodies may be specific for cellular structures: eg receptors. Altered texture fi Vesicles and bullae = fluid within or beneath epidermis (blister). Eg due to trauma (eg the lump where you hold a pen) fi Parakeratosis: Nuclei are seen in the stratum corneum (would normally have died off, eg psoriasis) fi Acanthosis: thickening of the epidermis, eg due to irritation Diagnosis fi Where is it: fi Psoriasis: likes scalp and extensor elbows/knees fi Atopic eczema: likes flexor elbows and knees fi Nose & cheeks: lupus, especially if it leaves a pigment behind fi Does it itchfi Especially if overcrowding and warmer climates fi Goes for limbs and face fi Fever uncommon. Following rupture of the bullae, a moist red surface remains and varnish like crust appears fi Neonatal Impetigo: Staph Aureus. If > 1 site then systemic antibiotics fi Treatment: fi To relieve symptoms, stop new lesions, prevent complications. Resistance to fusidic acid is also growing fi Resistance is growing to topical agents. Treat with topical intranasal mupirocin or systemic rifampicin fi May progress to a carbuncle: more extensive involving subcutaneous fat. If surrounding cellulitis or if on face then need iv antibiotics Cellulitis and Erysipelas fi Infection of subcutaneous layer by Strep Pyogenes fi Symptoms: inflammation, warmth, erythema, pain, fever fi Can fi sepsis, bullae and small abscesses fi Also erythema around anus with puss and blood in stool fi May desquamate fi Impaired lymphatic drainage predisposes to recurrent cellulitis. May fi chills, fever and malaise fi Treatment: S Pyogenes still very susceptible to penicillin Diabetic Foot infections fi Due to neuropathy, ischaemia, and infection fi Causes: often S aureus, also coagulase negative staphylococci and streptococci fi Often nasal carriage of S aureus fi Treatment: anti-staphylococcal agents. Usually in children, for example from cows, dogs, cats or mice Clinical Description fi Fungal infections usually itch. Have a raised scaling margin that extends outwards fi There are several classical presentations: fi Tinea Cruris: in the groin. If feet involvement as well then systemic treatment, otherwise topical fi Tinea Capitis: Scalp. To hands by itching, where it presents with a dry, hot rash on one palm, with well defined lesions with a scaling edge fi Tinea Corpus: on the trunk. The changes occur distally, and move back to the nail fold (compared with psoriasis, which is symmetrical and moves distally from the nail fold) fi Tinea Incognito: Fungal infection treated with steroids. In young adults, causes hypoor hyper-pigmented macules with powdery scale, on upper trunk, upper arms and neck.

Syndromes

  • Name of the product (ingredients and strengths, if known)
  • Bleeding
  • Belly pain
  • Muscular dystrophy
  • Celiac disease
  • Open sores (ischemic ulcers) on the lower legs

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Secondly infection 3 months after wisdom teeth removal buy 500 mg erythromycin fast delivery, it discusses the evidence related to infection zombie games buy discount erythromycin 250mg on-line issues concerning resuscitation and not-for-resuscitation virus 48 buy 250mg erythromycin with amex, and thirdly, it presents the fndings through an implementation and evaluation plan. Rural hospitals have a need to manage whatever presents itself at the door, without immediate access to highly specialist services. To do so staff have developed a broad range of skills to ensure they can provide some care from nearly every medical speciality. Focusing on a wide skill base rather than developing specifc medical expertise has given rise to a new specialty. Being consistently present enables nurses to provide continuity to these services during weekends, or when short staffng is a problem. These realities mean the rural health team might work together in a more interchangeable way and take roles not generally necessary in a larger facility. As technology has advanced, end of life decisions have become more complex because the demarcation line between avoidable death and unavoidable death has blurred. It is noteworthy that for some, if resuscitation occurs, good recovery is unlikely and being kept alive when terminal illness is present may not even be desired. Communities are comprised of increasing numbers of older persons with some areas having up to 21% of the population already over 65 years of age, and these fgures are predicted to rise. Many within the community, including older persons, suffer from chronic illnesses. As a consequence most deaths occurring are those where resuscitating to restore life confers little beneft and may indeed cause harm. This absence requires staff, often nurses who are the health professionals frequently present at imminent death, to take the appropriate course of action and make decisions that may be in direct contradiction to institutional policy (Bickley Asher, 2002). Anecdotal examples, compassionate but not legal, include responding slowly to a collapse, being somewhere else so it is too late to do anything, and non aggressive resuscitation have evolved to manage these situations. Documenting a resuscitation status for every patient admitted to hospital might be a way to overcome these diffculties. A literature search revealed that problems related to resuscitation or the decision not to resuscitate identifed in the New Zealand environment were also issues for other countries. The literature proposed various remedial actions but no defnitive solution, suggesting perhaps, that there is no perfect answer. A gap relevant to New Zealand was the lack of evidence related to the signifcance of resuscitation and advanced directive use to Maori (Wareham, McCallin & Diesfeld, 2005), perhaps fertile ground for future research. No studies on resuscitation were identifed that used randomised controlled trials, [the gold standard of clinical studies (Sackett, Rosenberg, Gray, Haynes & Richardson, 1996)], to investigate aspects of resuscitation orders. However death is a subjective experience and therefore diffcult to quantify, making qualitative and retrospective studies appropriate for this subject. On this basis evidence was evaluated and selected as indicated in the following headings: the evidence as it related to the health care team/environment In the United Kingdom staff were questioned about aspects of their existing resuscitation policies. Relating these characteristics to New Zealand rural hospitals shows similarities as most rural hospitals do not have trainee doctors and technology plays a smaller role in the health care provided. Once on the pathway, not for resuscitation documentation is required removing any ambiguity from end of life direction for patients at this stage of their illness. The evidence as it pertained to medical staff the evidence suggests that resuscitation/not-for-resuscitation policies are interpreted and used in ways contrary to the intention of the policy. Most policies require a signed statement to the effect that resuscitation will not be carried out for this patient. However medical staff often do not complete this form (Tulsky, 2005), the results being that when attending a resuscitation event, staff have to guess what the lack of form means.

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The decision to bacteria pilorica order erythromycin 500 mg amex give radiation first and follow with surgery or vice versa is case and clinician dependent antimicrobial copper cheap erythromycin 500mg otc. It is important to bacteria are prokaryotes safe erythromycin 250mg consider that surgical treatment within a radiation field can lead to an increased complication rate because of the decreased ability of irradiated tissue to heal. It is critical to plan the approach with advanced imaging of the tumour and with involvement of both the surgical oncologist and radiation oncologist. If the plan is to remove a mass first and follow with radiation, it will be removed less aggressively than if radiation is not part of the plan. It should be removed with a marginal excision and metal hemostatic clips should be placed in the surgical site to mark the extent of surgery for the radiation oncologist. The worst case scenario is a wide excision that yields dirty margins, because this means the patient has to endure a big surgery and radiation of a large radiation field. Radiation Therapy Radiotherapy is the treatment of neoplasia using ionizing radiation. Ionizing radiation is travelling energy that is energetic enough to result in the ejection of an electron from an atom creating a positive ion (atom minus electron). Ions created in tissue are highly reactive and cause structural alterations in critical intracellular macromolecules with lethal effects on cells. This point is critical to understanding the effects of radiation in both tumours and normal tissues. The most important factor limiting the dose that can be safely administered is normal tissue tolerance. The goal of radiotherapy is to deliver the maximum radiation dose to the tumour while keeping the dose to surrounding normal tissues below their tolerance level. The response of normal tissue depends on the proliferation rate of the cells that compose it. In general, acute (or early) and chronic (or late) toxicities affect rapidly and slowly renewing tissues, respectively. Since toxicity is dependent upon the turnover rate of cells, acute effects develop and progress during the course of treatment with resolution within approximately 2 to 8 weeks after therapy. The most commonly affected tissues include skin, mucous membranes of the oral and nasal cavities, eyes (cornea, conjunctiva, tear-producing glands), and the lower gastrointestinal tract. Acute side effects are uncomfortable and often require supportive care including antibiotics and pain medication but they are self-limiting because of rapid cellular renewal. On the other hand, late radiation effects involve slowly or non-proliferating tissues such as bone, eyes (lens and retina), nervous tissue, muscle and connective tissue. Lethally irradiated late-responding tissues may be able to maintain full or complete function until they are stimulated to divide and will, therefore, not express radiation injury until months to years after being irradiated. Since cellular renewal is slow or absent in these tissues, late radiation toxicity is serious, irreversible and is often life threatening when a critical organ is affected. Hence, the primary dose-limiting factor in radiotherapy is the tolerance of late-responding tissues in the radiation field. We use radiation in three different settings, depending on the goal of therapy: 1. The goal of therapy is to decrease pain and inflammation and to slow tumour progression. Common applications of this type of radiation therapy include palliation of bone tumours, palliation of bladder tumours and course fractionated treatment of oral melanoma. The fractionated dosing scheme allows the normal tissues to recover from the effects of radiation. Common applications of this type of radiation therapy include: bladder cancer, treatment of scars after incomplete resection of mast cell tumours and soft tissue sarcomas, nasal tumours, and preoperative irradiation of sarcomas. The major advantages of this type of radiation are that the treatment course is very short; the side effects are minimal because the dose to the surrounding tissues is small. The common applications of this type of radiation in veterinary medicine include: limb spare for appendicular osteosarcoma, brain tumours and nasal tumours. Acute side effects are most common after a course of fractionated radiation therapy.

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Also mitral regurgitation fi earlier aortic valve closure Fixed splitting Doesnfit change with respiration fi atrial septal defect and both atria have equal volumes Reversed splitting P2 occurs before A2 antibiotics used for urinary tract infections order 500 mg erythromycin otc, and gap increases on expiration antibiotics for acne side effects buy 250mg erythromycin with mastercard. Due to antibiotic japan generic 250 mg erythromycin mastercard delayed left ventricular emptying (left branch bundle block, severe aortic stenosis, coarctation of the aorta, or large patent ductus arteriosus) Extra Heart Sounds Description Cause S3 Low-pitched mid-diastolicfi Pathological when fi ventricular compliance, so get S3 even when filling is not rapid Left Ventricular S3 Louder at apex than at sternal Normal under 40 years and in pregnancy. Donfit confuse with widely split S2 (snap is higher pitched) th th 22 4 and 5 Year Notes fi Systolic ejection click: early systolic high-pitched sound over aortic or pulmonary areas. Is caused by pulmonary or aortic congential stenosis and is followed by a systolic ejection murmur fi Non-ejection systolic click: high pitched systolic sound over the mitral area. Due to mitral prolapse and atrial septal defects fi Diastolic pericardial knock: may occur if there is a sudden cessation of ventricular filling in constrictive pericardial disease Heart Murmurs Timing of Murmurs Murmur Nature Cause Pan systolic Pan-systolic: extend from S1 to S2, Ventricular leakage: Mitral or loudness and pitch vary during tricuspid regurgitation, ventricular systole septal defects Ejection (mid) systolic Intensity greatest in early to midTurbulent flow through an orifice: systole then wanes Aortic or pulmonary stenosis, hypertrophic cardiomyopathy, atrial septal defect Late systolic Noticeable gap between S1 and Mitral valve prolapse or papillary murmur, and continues to S2 muscle dysfunction Early Diastolic Begins with S2 and fades Regurgitation through a leaky (decrescendo). Listen over left sternal edge for changes in the systolic murmur of hypertrophic cardiomyopathy, and over the apex for mitral valve prolapse. Other murmurs will be quieter due to fileft and right filling fi Squatting or leg raise (fipreload): fivenous return and fiarterial resistance fi most murmurs are louder fi Handgrip (fiafterload): aortic stenosis quieter Lungs, Abdomen and Legs fi Percuss and ausciltate lung bases on the back for pulmonary oedema, then check for sacral oedema fi Abdomen: fi Tender or enlarged liver fifi If strip wider than 5 mm then lymph node enlargement fi Arch of azygous in tracheal bronchial angle, just above carina. On the lateral film, fiarea of contact between the heart and the sternum fi Left ventricle enlargement: Elongates along its long axis fi apex shifts down and out. If unsure, take another film lying on side (De Cubitus view) and see if fluid level shifts. If the opacity is heterogeneous (eg polka-dots) then pneumonia, if homogenous (a smear) then effusion fi Miliary pattern: occurs in Tb, fungi, Thyroid cancer, pneumoconiosis, rarely Sarcoid fi Cysts fi cystic bronchiectasis. The presence of these should bias treatment decisions towards treatment at any level of risk. If collateral circulation, can recannalise thrombis fi Haemorrhage: a weak little new artery in the plaque bursts fi pushes plaque against opposite wall Aortic Aneurysm Aetiology fi Severe arteriosclerosis fi 20% familial incidence fi defect in connective tissue component (fi Long ulnar, femur, weak aorta, and high arched pallet Clinical fi 75% occur in abdominal aorta. Easy to repair cf thoracic and thoraco-abdominal cases fi Often asymptomatic fi incidental finding fi Can cause back pain (due to retroperitoneal blood). Famous for causing proximal aortic aneurysms Physical/Chemical Agents fi Irradiation, trauma, vascular toxins, sulphonamides, penicillin Arteritis syndromes fi See Vasculitis, page 282 Other Vessel Abnormalities fi Arteriosclerosis: fi = Thickening and loss of elasticity of arterial walls. Particularly seen in kidneys fi Hyperplastic arteriosclerosis: concentric rings of increased connective tissue and smooth muscle give arteries an onion skin appearance. Signifies acceleration/malignancy of the hypertension fi Fibromuscular dysplasia: non-inflammatory thickening of large and medium sized muscular arteries causing stenosis. Long term follow up necessary fi Treat 72 older adults for 5 years to prevent 1 death, treat 43 for 5 years to prevent one cerebrovascular event fi Aim of treatment: diastolic < 90 fi Rules of thumb: fi Use low doses of several agents, rather than increasing doses of one drug (especially thiazides) fi First line: thiazides (with or without a potassium sparing agent) and/or fi-blocker (atenolol most used in trials). Caused by reversible spasm in normal to severely atherosclerotic coronary arteries.

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References:

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  • http://www.lebauerpt.com/uploads/1/3/9/4/1394925/mark_barnes_the_basic_science_of_mfr.pdf
  • http://medcraveonline.com/MOJT/MOJT-04-00081.pdf
  • http://www.aabb.org/tm/Documents/AABB-Donor-Iron-Deficiency-RBDM-Assessment-Report-Supplemental-Material.pdf

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