Vimal Chadha, MD
- Assistant Professor of Pediatrics, Chair, Section of
- Nephrology, Virginia Commonwealth University Medical
- Center, Richmond, VA
- The Pediatric Patient with Chronic Kidney Disease
Caution should be exercised in high risk patients >65 years of age and patients <3 years of age as spinal assessments may be less sensitive in these age groups acne 3 day cure order generic acticin. This criteria in and of itself is not a factor in the providers decision making process to immobilize or not acne 404 nuke acticin 30gm fast delivery. Ambulatory patients should simply be eased to a sitting position on the stretcher without the use of a backboard acne conglobata purchase acticin 30gm on-line. Rapid recognition and immediate treatment of chest injuries can prove to be life-saving acne juice cleanse purchase cheap acticin on line. Seal any open chest wounds by taping three (3) sides with an occlusive dressing or use an optional commercial chest seal. Chest pain after trauma could be a sign of significant injury and not cardiac chest pain. If tension pneumothorax develops in a patient with a sealed sucking chest wound, attempt to resolve by releasing air from the seal prior to decompressing chest. Chest decompression is only indicated for a true tension pneumothorax with the signs listed above. If pelvic injury: stabilize, monitor closely, and perform Shock Protocol 4108, if indicated. Wrap severed part in sterile gauze slightly dampened with normal saline and place in sealed container (waterproof bag) immersed in ice water. In consultation with Medical Command, determine best mode of transport and most appropriate destination. This is best done by maintaining an adequate airway, oxygenation, and prevention and treatment of hypotension combined with smooth, rapid transport to an appropriate facility with minimal on-scene time. Maintain airway as indicated by Airway Management Protocol 4901 with the following special considerations in patients requiring assisted ventilation: 1. If patient is confused or unconscious, consider checking serum glucose and treat as indicated in Diabetic Protocol 4604. Do not delay treatment or transport to check serum glucose but should be done as soon as possible. Monitor airway, vital signs, and level of consciousness repeatedly at scene and during transport; status changes are important. When head injury patients deteriorate, first check for proper airway, adequate oxygenation, and adequate blood pressure. Trauma patients who have a witnessed cardiac arrest require rapid treatment and transportation. Early recognition of tension pneumothorax and immediate treatment can prove life-saving. Thermal burns: Flush the burned area with tepid water (sterile, if possible) to cool the skin. Dry chemical burns: Brush off dry powder, then flush with copious amounts of tepid water (sterile, if possible) for 20 minutes. Liquid chemical burns: Flush the burned area with copious amounts of tepid water (sterile, if possible) for 20 minutes. If signs of respiratory involvement are present such as facial burns, singed face or nasal hairs, swollen, sooty, or reddened mucous membranes, or patient was in a confined space and/or unconscious, assume inhalation injury and treat per Inhalation Injury Protocol 4304. Remove clothing from around burned area, but do not remove/peel off skin or tissue. Assess the extent of the burn using the Rule of Nines and the degree of burn severity. Cool water immersion of minor localized burns may be effective if accomplished in the first few minutes after a burn. Use soft, non-adherent dressings between areas of full thickness burns, as between the fingers and toes, to prevent adhesion. Be cautious and conservative when administering fluids to the burn patient with inhalation injury. Commonly occurring with electrical injuries are long bone fractures, cardiac dysrhythmias, and neurological deficits. Victims of lightning strikes may be in cardiac arrest, but frequently can be resuscitated quickly after intubation and assisted ventilations. Attempt to identify substance from labels, data sheets, or other personnel on scene, but do not delay treatment or transport during this process. Use alcohol, which may be found in areas where Phenol is regularly used, to dissolve the product. Sodium is an unstable metal that reacts destructively with many substances, including human tissue and water. Treatment is supportive and most patients recover in 10 20 minutes of exposure to fresh air. It produces heat and subsequent chemical and thermal injuries resulting in extreme pain to the affected areas. These patients, while in traumatic hemorrhagic shock, may present with hypotension and a normal heart rate. Many patients complain of substernal chest pain, pressure, or discomfort unrelated to an injury or other readily identifiable cause. Most patients complaining of substernal chest pain, pressure, or discomfort unrelated to an injury or other readily identifiable cause. Any patient with a history of cardiac problems who experiences lightheadedness or syncope. If transport time to a facility with these capabilities will be > 30 minutes, consider transport options in the following order. All transport destinations should be directed by consultation with Medical Command. If blood pressure is > 90 mm/hg systolic and patient has not taken Sildenafil (Viagra) or Vardenafil (Levitra) within last 24 hours or Tadalafil (Cialis) within the last 72 hours: a. If blood pressure < 90 systolic and/or patient is experiencing severe bradycardia or tachycardia, treat according to appropriate protocol. If patient has taken Sildenafil (Viagra) or Vardenafil (Levitra) within last 24 hours, or Tadalafil (Cialis) within the last 72 hours, nitroglycerin should only be given by Medical Command Physician order. If discomfort persists, consult Medical Command Physician to discuss further treatment with nitroglycerin, additional Morphine Sulfate, or Fentanyl. The goals of pre-hospital treatment should be focused on the following: prevent a neurologic or cardiovascular catastrophe, rapidly identify those patients who are in a hypertensive crisis and the body system(s) affected or potentially affected, and control symptomatic elevated blood pressure in certain situations. This protocol is only applicable to patients with hypertensive crisis without signs and symptoms of stroke. Specific problems such as chest pain, pulmonary edema, and preeclampsia/eclampsia should be treated per appropriate protocols. Drug therapy shall be considered in careful consultation with the Medical Command Physician. Patients with suspected cocaine overdose or alcohol withdrawal may exhibit similar symptoms. May repeat every 3 5 minutes up to a maximum dose 3 mg; Atropine Apply transcutaneous pacer administration should not delay implementation pads to patients presenting in of external pacing for patients. If patient has no history of a true allergy to aspirin and has no signs of active bleeding. If discomfort persists, Contact Medical Command Physician to discuss further treatment. Administration of these medications in patients > 55 years of age shall be as follows: Administer Fentanyl (Sublimaze) 0. If it is unknown whether the arrest is traumatic or medical, continue with this protocol. Note: Continue using the anti-arrhythmic medication that was administered during resuscitation.
A trend of titers is also instructive; rising titers are indicative of progressive disease while falling titers are expected during the recovery phase acne 6 dpo order discount acticin online. Diagnosis may also be confirmed through isolation of Coccidioides species in culture from bronchoalveolar lavage acne 3-in-1 coat purchase 30 gm acticin, pleural fluid acne no more book buy discount acticin, or other sites of infection (skin acne popping buy online acticin, cerebrospinal fluid). Pathologic confirmation is best established with the aid of silver or periodic-acid Schiff staining to visualize mature fungal spherules and endospores. The radiographic finding most associated with coccidioidomycosis is a lobar or multilobar infiltration. Cavitary disease may occur, and while most such lesions will resolve radiographically, a subset may become chronic. More commonly, computed tomography will allow identification of nodular or cavitary disease and will determine the extent of mediastinal involvement. Eosinophilia may be seen in peripheral blood or in cerebrospinal fluid specimens during active or convalescent disease states. These radiographic and laboratory findings, although suggestive of disease, are less sensitive and specific than complement fixation. The headaches are described as pounding, with nausea and vomiting, but no phonophobia or photophobia. She reports that her weight has increased by more than 20 lbs since her visit 1 year ago. Papilledema may be seen with increased intracranial pressure, so of the choices, this is the most likely finding in this girl. Pseudotumor cerebri is a condition in which there is increased intracranial pressure but no intracranial mass, hydrocephalus, or other structural abnormality. Medications such as isotretinoin or doxycycline can cause pseudotumor cerebri as well. Symptoms of pseudotumor cerebri include headache, nausea, vomiting, transient visual obscurations (the entire visual field briefly turns gray, as in the girl in the vignette), tinnitus, and headache that worsens with bending over. Performing the fundoscopic examination in a darkened room makes it much easier to see papilledema. In patients with new-onset headaches, clinicians should always assess for evidence of increased intracranial pressure. None of the other choices listed are associated with increased intracranial pressure. Symptoms include slowly progressive blurry vision, not transient visual obscurations as described for the girl in the vignette. It can be seen with injury to the brainstem or cerebellum, and sometimes as a medication side effect. It is not a typical finding in increased intracranial pressure, unless the increased pressure is due to a tumor or stroke affecting the brainstem or cerebellum. Orbital bruits, heard on auscultation with the stethoscope bell over the eye, are associated with vascular abnormalities such as carotid stenosis, arteriovenous fistula, or carotid cavernous fistula. The girl in the vignette does not have symptoms of an intracranial vascular abnormality, so this is not the best choice. Ptosis and pupillary miosis are 2 of the 3 findings in Horner syndrome, the third is anhidrosis. Horner syndrome can occur from disruption of the sympathetic pathway that innervates the eye, anywhere along its course from the brain, neck, chest and up to the orbit. It is not a sign of pseudotumor cerebri, and so would not be an expected finding in the girl in the vignette. Physical examination findings among children and adolescents with obesity: an evidence-based review. The boy has been having major behavioral problems with inattention and aggression toward adults and peers, both at home and school. He has been otherwise well, with only minor illnesses, and his physical examination findings are normal. In recent years, a growing body of evidence indicates that chronic or repeated stress, such as occurs with abuse/neglect, can result in physiologic and anatomic changes. This leads to anatomic changes and physiologic dysregulation that may be lifelong, and is the basis for the chronic stress-related physical and behavioral health problems seen in adults who were abused as children. Human and animal studies show that individuals who encounter adverse events such as abuse during early development have lower overall brain volumes with architectural and size differences in the amygdala (necessary for emotional regulation), hippocampus (necessary for encoding and retrieving memory), and prefrontal cortex (the seat of executive function). In addition to central nervous system effects, there is evidence of immune hyperreactivity among children and adults with a history of abuse and neglect, a likely contributor to the observed increased incidence of asthma and elevated inflammatory markers (eg, C-reactive protein). Adults who were abused as children have higher prevalences of cardiovascular disease, lung and liver disease, hypertension, diabetes mellitus, and obesity compared with the general population. Available evidence, derived largely from retrospective studies, suggests a wide range of behavioral health consequences for children experiencing abuse and neglect, ranging from normal functioning to adverse outcomes such as school failure, unemployment, poverty, incarceration, mood disorders, post-traumatic stress syndrome, interpersonal problems, substance abuse, borderline personality disorder, somatization, psychosis, and dissociative identity disorder. The role of nature versus nurture has long been debated regarding children with these outcomes. Prevention is the ideal approach to reduce the long-term effects of child abuse and neglect; however, this is not always feasible. A supportive home, with fair and consistent discipline, is recommended for all children. However, for those who experienced early childhood adversity, this approach alone is often not sufficient. Routine discipline that is effective for a child without a history of toxic stress may be perceived as a stress-inducing threat to a previously abused child, and may cause escalation of the behavior rather than extinction. Cognitive behavioral therapy that addresses safety skills, stress management, and emotion regulation, as well as the formulation of an organized and accurate trauma narrative, has proved effective for symptom reduction in other trauma-related situations. The clinical presentation of the child in this vignette with bloody diarrhea and a history of consumption of unpasteurized cow milk is consistent with gastroenteritis caused by Campylobacter species. Campylobacter jejuni and Campylobacter coli colonize the gastrointestinal tracts of chickens, turkeys, and other farm animals and are present in their environment; rates of Campylobacter colonization in chickens are up to 80%. Transmission of Campylobacter infection occurs by ingestion of unpasteurized milk, undercooked poultry products, or contaminated water or by contact with infected animals or humans. Outbreaks of Campylobacter infection in schools following ingestion of unpasteurized milk have been reported in the United States. Person-to-person spread of Campylobacter infection has resulted in outbreaks of gastroenteritis in day care centers and hospital nurseries. The most commonly implicated diarrhea-causing Campylobacter species are C jejuni and C coli, whereas C fetus can cause intestinal infection and severe systemic infection. The Centers for Disease Control and Prevention funds the Foodborne Diseases Active Surveillance Network at 10 United States sites, and this network reported an incidence of 13. In resource-rich countries, cases of Campylobacter enteritis peak during the summer and early fall. Infection with Campylobacter species typically manifests as an acute gastrointestinal illness with fever, diarrhea, and crampy abdominal pain. The diarrhea may be watery but can become mucoid with frank blood mimicking inflammatory bowel disease. In neonates and young infants, the illness may be characterized by bloody diarrhea without fever. The illness is often self-limited with clinical recovery noted within 1 week without antibiotic therapy. Complicated disease (eg, extraintestinal infections, bacteremia) may occur following infection with C fetus or other species in immunosuppressed individuals; in addition, a prolonged course and relapses may occur in immunosuppressed individuals. Immune mediated complications including Guillain-Barre syndrome (and variant Miller Fisher syndrome), reactive arthritis, Reiter syndrome, myopericarditis, and erythema nodosum may occur following Campylobacter infection.
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Benign neoplasia skin care steps buy cheap acticin line, biphasic acne 9 days before period purchase acticin now, well delimited of the adjacent breast tissue through a delicate fbrous capsule skin care companies generic 30 gm acticin. Other locations importance of the early diagnosis of breast carcinoma acne questionnaire acticin 30gm sale, surgeons were the vulva, mentioned in 6 articles (with 7 cases reported); are faced with the dilemma of surgical treatment or monitoring. The left side was reported in 2 cases, and there was 1 case of bilateral involve ment. Tumors of extramammary breast neoplasms of the vulva: a case report and review of the tissue. In this sense, there has been a paradigm shift in medical practice regarding breast cancers in recent years, with the implementation of risk-reducing surgical procedures, such as bilateral mastectomy and salpingo-oopherectomy, which still have controversies in the indication, in addition to fears and suferings of patients, before and after the procedure. A 54-year-old female patient has been undergoing routine examinations since 2009 (49 years), as she has a family history of breast cancer. Although complementary exams did not indicate any neoplasia, the patient wanted to undergo risk-reducing surgery. After interprofessional discussion with the patient, bilateral risk-reducing mastectomy and salpingo-oophorectomy were performed. The patient had a postoperative infection, and one of the silicone prostheses was removed from her breast. In 2015 (55 years old), she underwent a new prosthesis inclusion, evolving without complications. Currently, she is being followed up and without evidence of active cancer disease. Despite the complication with the prosthesis, there was an improvement in psychological aspects that bothered her, referring to a reduction in anxiety and fear of cancer. Although benefcial, risk-reducing mastectomy has associated risks, especially in patients with advanced age and comorbidities. However, with an appropriate approach and focused on the complexities of each person, it is possible to provide the patient with a better overall psychological experience, as demonstrated in this case reported. The patient had difculties in under changes in the care model to patients with a family history of standing the surgeries and surgical risks involved, as well as the breast cancer, especially those germinative mutations of high low impact on reducing mortality in patients over 50 years of age. She was not sure how much the risk of develop A 54-year-old female patient has been undergoing routine exam ing breast cancer would be reduced with prophylactic surgery, inations since 2009 (49 years old), as she has a family history of besides the fact that her health insurance not having authorized breast cancer: a sister who died at 52, and another sister who the procedures. After extensive discussion with the patient, her was diagnosed with the disease at 50, as well as their mother, family and psychologist, a decision was made to reduce the risk who died at the age of 55, two maternal aunts, and two maternal of breast and ovarian cancer after informed consent. On the 67th postoperative day, the right prosthesis was removed due to infection and the material was sent for culture, growing Streptococcus agalactiae. Histological examination with specifc protocol with serial cuts of the specimens of the breast, ovaries, and tubes did not detect any neoplasia. In 2015 (55 years old), the patient underwent a new breast implant on her right breast, evolving without complications. Currently, she is being followed up and presents no evidence of active cancer disease Figure 2). The patient, despite the compli cation with the prosthesis, showed improvement in psychologi cal aspects that bothered her, referring to reduced anxiety and fear of developing cancer. Despite these signif cant complications, she reported improvement in psychological aspects that bothered her, referring to less anxiety and fear of death from breast cancer. Terefore, a well-prepared preopera tive discussion, which considers all dimensions of human nature, can be a key element for improving well-being and quality of life after risk-reducing bilateral mastectomy, even when there are complications, just like in the case reported, also afecting the general motivation in relation to the procedure. Comorbidities that may increase the risk of complications, such as signifcant heart or lung disease, obesity, diabetes, smok ing, steroid use, or chronic anticoagulation9 should also be con sidered upon surgery indication of surgery. Final aspect of bilateral risk-reducing mastectomy with Bilateral prophylactic mastectomy reduces the risk of devel complications in a patient over 50 years of age. Risk redutora de risco em mulheres com mutacoes deleterias nos reduction and survival beneft of prophylactic surgery genes brca1 ou brca2. Costs include medications and infusion supplies, and do not dence in Brazilian women, below non-melanoma skin cancer1,2. About 75% of all breast cancers have a luminal biological profle (positive hormone receptors), based on the immunochemistry profle3. We analyzed the cost of adjuvant chemotherapy with the the two most widely used adjuvant chemotherapy schemes in most frequently used regimens for luminal tumors (docetaxel + tumors with a luminal profle. Instituto Nacional de Cancer Jose Alencar Gomes claudin-low intrinsic subtype of breast cancer. Materials and methods: A fowchart of the procedures performed in the diagnostic investigation is discussed, associating a clinical case, and conducting a review on the topic. Results: In the assessment of late and recurrent periprosthetic seromas, prior communication from the surgeon and the pathologist is essential, aiming at the adequate collection and storage of the aspirated material. The material must be promptly fractionated for microbiological assessment by culture, immediate or transoperative cytologic assessment, immunophenotyping by fow cytometry (10 mL), direct cytopathological examination, and obtaining cell block material (50 mL). For fow cytometry, the material must be sent fresh, 70% alcohol or 10% bufered formalin can be added for the other procedures. Therefore, a multidisciplinary approach cant on the right, and large ipsilateral periprosthetic collec and observance of a protocol of procedures are necessary to tion Figure 1). Negative radiological fndings: (A) mammography; (B) breast ultrasound; (C) magnetic resonance; (D) positron emission computed tomography. During the surgical procedure, a direct include breast swelling, asymmetry, pain, tumor mass around the cytological examination was carried out using cytospin implant, and local hyperemia7,8. The presentation as a tumor mass smears of the aspirated fluid, with the suppurative and/or with lymph node involvement is rare, being observed in only 10% infectious process being discarded. Subsequently, separate to 20% of patients, who may have cutaneous lesions, contraction sample syringes were collected for microbiological assess of the implant capsule, and even B symptoms7. In patients with a non-compliant mass or irregularities Cytomorphological, microbiological, immunohistochemis in the capsule, the diagnosis is facilitated by clinical suspicion try, and fow cytometry analyses ruled out lymphoma and infec and the possibility of performing core biopsy, but this situation tious processes, showing only fbrosis and a mild reactive and is uncommon. Clinical and surgical fndings: (A) preoperative; (B) emptying of the seroma; (C) yellowish seroma; (D) total capsulectomy; (E) capsule without vegetation with the full textured prosthesis. By investigating rearrangements of T sitivities are 46%, 50%, 50%, and 64%, respectively17. The presence of a previous infectious and/or infammatory The pathologist must be informed in advance about the case, process is related to the development of seromas, which may the date of the procedure, and the time that the material will be be secondary to infections, trauma, or rupture of the prosthe sent. At the same time, for fow cytometry immunophenotyping, the malignant transformation occurs through the infltration of it is recommended that at least 10 mL of aspirated fuid be col infammatory cells present in the seroma. In the presence of a tumor mass, the concomitant resec Tere are several advantages in performing the cell block tion of the tumor is suggested, with free margins20, since patients since the cytocentrifugation of the collected fuid makes it pos with complete resection present better outcome14. However, when hol, or 10% bufered formalin can be added, depending on the there is only diagnostic suspicion, the indication of bilaterality preference of the laboratory18,19. The estab not recommended, and there are no indications for the investiga lishment of a multidisciplinary approach with the observance of a tion of sentinel lymph node. Axillary lymphadenectomy has rarely7 clinical and laboratory investigation protocol is fundamental for been recommended, due to lymph node involvement by lymphoma14. Breast implant-associated anaplastic large arising in association with saline breast implant: expanding cell lymphoma: A comprehensive review. Ronchi A, Montella M, Argenzio V, Lucia A, De Renzo A, Alfano anaplastic large cell lymphoma: a review. Breast Implant-Associated the Management of Patients With Breast Implant-Associated Anaplastic Large Cell Lymphoma. Achieving Reliable Diagnosis in Late Breast Diagnose and Treat Breast Implant-Associated Anaplastic Large Implant Seromas: From Reactive to Anaplastic Large Cell Cell Lymphoma. Breast implant-associated anaplastic large cell lymphoma: sensitivity, specifcity, and anaplastic large cell lymphoma From diagnosis to treatment. Scientifc events are spaces for discussion in the face of scientifc advances, innovation and consensus. In them, space is opened for the presentation of clinical studies, translational studies, experience reports and videos, with the best-designed studies being selected and awarded.
He is anorexic and has lost 2-3 pounds over the past week acne 11 year old buy acticin with mastercard, thought to be due to recurrent acne wallet discount 30 gm acticin with mastercard, crampy abdominal pain skin care essentials purchase acticin 30 gm without a prescription. There are extensive ecchymoses on his scrotum with swollen acne 1cd-9 buy acticin visa, weeping red involvement of the corona of the glans penis. He may have a borderline effusion of his left knee and 2+ swelling, erythema, tenderness, pain-on-motion and limitation-of-motion of the right ankle. His skin exam is positive for slightly raised petechial rash on his legs, most prominent on his ankles, posterior thighs and buttocks. A skin biopsy demonstrates leukocytoclastic vasculitis on light microscopy and IgA staining of the vascular endothelium on fluorescent microscopy. The vasculitides of childhood are a complex and poorly understood group of inflammatory conditions whose etiologies appear to be on an immune basis. Several classification schema have been proposed based on: 1) vessel size, 2) presumed immunopathophysiology, or 3) organ involvement. Target lesions, ecchymosis, lymphangitic streaks and purple or bloody suffusions are sometimes seen. Occasionally the rash involves the upper extremities and I have seen the rare child with a generalized rash of the entire body to include involvement of palms, soles, and even the scalp. Histopathologically, leukocytoclastic vasculitis is observed and immunopathologically, IgA is deposited in involved vessel walls and the renal glomerulus. Large joints of the lower extremities are most commonly involved, especially ankles and knees. The gastrointestinal tract is commonly affected and most often, crampy abdominal pain is the primary manifestation. Rarely intussusception complicates the picture and obstruction or perforation may necessitate emergency surgery. Corticosteroids must be reserved for serious complications of the disease and should not be instituted for treatment of the rash or arthritis. Although occasionally seen in children, it is distinctly far more common in adults. Microscopic polyarteritis is a necrotizing vasculitis, which affects small vessels (capillaries, venules and arterioles) in the kidneys and lungs. Hypersensitivity vasculitis: Cutaneous involvement includes palpable purpura, papules, urticaria, erythema multiforme vesicles, pustules, ulcers and necrosis. The patient is usually asymptomatic, but occasionally complains of burning/tingling. With regard to treatment, one must: 1) exclude systemic involvement, and 2) identify and remove offending allergens/agents, most often medications. Those patients with the lupus-like syndrome may require corticosteroid treatment and those with normal complement levels are usually self-limited. Cryoglobulins are antibodies that precipitate in the cold and resolubalize on warming. Cryoglobulinemic vasculitis is associated with autoimmune conditions in childhood. Immune complexes of mixed cryoglobulins, deposit in vessel walls, activate complement and produce recurrent palpable purpura with cutaneous ulceration. These would include systemic lupus erythematosus juvenile rheumatoid arthritis, dermatomyositis, scleroderma, and Behcet disease. Patients present with fever, malaise, weight loss, arthralgias, myalgias, rhinitis, sinusitis, nasal and oral ulceration. Churg-Strauss syndrome was initially reported under the descriptive title of allergic granulomatosis and angiitis. Takayasu arteritis (also known as pulseless disease of Japan) involves the aorta and its branches. It is exceedingly uncommon in children; however it is seen in teenagers from Micronesia and should always be considered in an adolescent girl with severe hypertension and a peripheral or abdominal bruit. Non-specific symptoms such as malaise and arteralgia (pain over blood vessels) are seen early on as the disease progresses. The involved vessels progressively narrow producing inequality in pulses, claudication and ischemia. The diagnosis should be suspected in young women with a systemic inflammatory illness, altered arterial pulses, or bruits. The diagnosis is confirmed by angiography and in our recent experience, treatment is often accomplished by interventional radiology/angiography procedures such as angioplasty. The terms "purpura", "petechiae", and "ecchymosis" are frequently used in the clinical descriptions of vasculitic and other conditions. The implied difference is that purpura have a sharply demarcated border and imply that vasculitis is the etiology, while ecchymosis has a diffuse border which implies that trauma or a hemorrhagic diathesis is the etiology. Which immunoglobulin is prominently involved with the lesions of Henoch-Schonlein purpura Name three connective tissue diseases of childhood, which are sometimes complicated by vasculitis. He presents with his mother to your office with a two day history of bilateral eye drainage. He had been in good health until two days ago when he developed yellow drainage and mild periorbital swelling. Review of systems is negative except for the recent development of a cough that he "probably caught from his older brother". There is mild conjunctival injection with moderate amounts of mucopurulent drainage bilaterally. Coarse breath sounds are appreciated bilaterally with occasional rales and fine expiratory wheezes. You swab the conjunctiva for gram stain, culture and chlamydia direct fluorescence antibody staining. Initially shocked, she admits that six months ago she and her husband had separated briefly, but are now back together. Ophthalmia neonatorum is the most common ocular disease in the newborn, occurring in 2-12% of neonates (includes chemical conjunctivitis). The major causative agents of neonatal conjunctivitis are chemical, chlamydial and bacterial. The mode of infectious transmission is believed to be acquisition during passage through a colonized or infected birth canal (1,2). While nearly every bacterial species has been implicated, ocular infection with Neisseria gonorrhoeae is felt to be one of the most serious because of its potential to damage vision and cause blindness (1,3). Consequently, Chlamydia trachomatis is now the most common infectious agent causing neonatal conjunctivitis in approximately 0. Recognizing the irritant effects of silver nitrate (frequently causes chemical conjunctivitis), 0. However, none have been shown to consistently prevent chlamydial conjunctivitis or nasopharyngeal colonization (1-4,6-9). Inflammation due to chemical irritation (usually silver nitrate drops) is first appreciated 6-12 hours after birth with spontaneous resolution by 24-48 hours. Beginning with a mild inflammation and serosanguineous drainage, gonococcal ophthalmia soon results in thick, profuse purulent discharge and tense eyelid edema with marked chemosis (swelling of the conjunctiva) (2,10). Chlamydial conjunctivitis in the neonate can present from 3 days to beyond 6 weeks postnatal age, but most commonly occurs during the 2nd week of life. Infants present with conjunctival inflammation, mucopurulent discharge (that may be profuse), eyelid edema and pseudomembranes in the palpebral conjunctiva (5,10). Chest radiograph reveals bilateral, diffuse, patchy infiltrates and hyperinflation. The list of causative agents of ophthalmia neonatorum includes, but is not limited to , chemical irritants, Neisseria gonorrhoeae, Chlamydia trachomatis, Staphylococcus aureus, group A or B streptococcus, S. Shortly after birth, ophthalmic prophylaxis for gonorrhea should be administered to all infants, including those delivered by cesarean section since ascending infection can occur. Two drops of a 1% silver nitrate solution or a 1 cm ribbon of antibiotic ointment (0.