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Timothy D. Averch, MD

• Professor and Vice Chair for Quality
• University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

Although not everybody supports these changes erectile dysfunction statistics by age purchase kamagra effervescent 100 mg visa, they are being driven by changes in medical practice and society icd 9 code for erectile dysfunction due to medication buy kamagra effervescent pills in toronto. Therefore impotence symptoms purchase 100 mg kamagra effervescent visa, it is better to be prepared for these changes in the radiation oncology community and train residents for the demands they are going to face in the future impotence due to alcohol purchase 100 mg kamagra effervescent mastercard. In Europe erectile dysfunction drugs herbal discount kamagra effervescent 100 mg, specialist training programmes are the responsibility of national authorities pomegranate juice impotence cheap 100 mg kamagra effervescent. Consequently, a European standard or a European examination with formal statutory applicability cannot be expected. The best that can be achieved is an agreement on a core curriculum and a common system of evaluation of competencies. The six competencies are: (1) Medical knowledge; (2) Patient care; (3) Professionalism; (4) Communication; (5) Practice based learning; (6) Systems based practice. Through their initial certification process and maintenance of certification process, the specialty boards certify that each of their graduates demonstrates achievement and maintenance of these competencies through a lifelong process of continuing medical education, self-assessment and improvement of practice. The residency review committee, composed of specialists and administrative staff, periodically reviews every residency programme, at least every five years. The residency review committee in radiation oncology is composed of six radiation oncologists, a resident member, administrative staff and an ad hoc member from the American Board of Radiology to ensure that the training programme is reasonably aligned with the certification process. The rigorous review process includes: an on-line application outlining the programme structure and rotations; a description of facilities, the laboratory and equipment; the caseload by site; the credentials of faculty; didactic programmes; case log books of residents; and evaluation methods. A document outlining programme training requirements in radiation oncology and application forms for programmes is available at The intent of the application is to document that each training programme has the appropriate resources and systems in place to train, evaluate and assess the competence of their trainees in each of these six areas of competence. The site visitor pays particular attention to evaluation processes, not only for evaluation of residents by faculty, but also evaluation of the faculty by residents, evaluation of each component of the programme and processes for programmatic improvement. The site reviewer report and application are then evaluated by the review committee, and recommendations are made to either continue approval of the programme (with or without specific recommendations or citations), place the programme on probation, or close the programme. Each programme is approved for a specified length of time (up to a maximum of five years) and a specified number of trainees. In radiation oncology, as with many of the other medical specialties, competencies are assessed based on individual evaluations of each trainee during each of their rotations. While programmes are allowed flexibility in how they structure their rotations, trainees will typically rotate on a given service with one or two faculty, for a period of two to four months. Detailed evaluations of the resident are generated after each rotation by the supervising physician or physicians. In addition, other personnel, such as therapists, physicists, dosimetrists and nurses, will often evaluate residents in what is referred to as a 360 degree global evaluation of residents. Currently, most programmes have structured their evaluation forms such that the trainee is evaluated in each of the six competencies. Evaluations from therapists and nursing and dosimetry staff are valuable in assessing the competence of residents in communication, professionalism and systems based practice. While the supervising physician also addresses these areas, medical knowledge, patient care and practice based learning are more thoroughly assessed by the supervising physician. The programme director is expected to sit with each trainee at least twice yearly over the four year residency programme, to go over his or her evaluations and identify areas which require improvement. Case log books are also reviewed during these sessions to ensure that each trainee has the appropriate level of experience expected during the rotations. Over the course of four years of training, current requirements indicate that the resident is expected to participate in at least 450 external beam radiotherapy cases, 12 paediatric cases, 15 intracavitary brachytherapy cases, 5 interstitial cases, 10 radiosurgery cases and 6 cases involving unsealed sources. These specific requirements may be modified from time to time as procedures in the specialty evolve. As residents progress in their training, they are expected to assume increasing levels of responsibility with increasing understanding and competence in the management of the patient undergoing radiation treatments. These examinations are scored nationally such that each trainee receives a score of how he or she performed in relation to peers in equivalent training around the country. Programme directors receive scores for each resident as well as aggregate scores for their programme compared with others, so they are able to identify strengths and weaknesses in their training. In general, competencies in medical knowledge, patient care, professionalism and communication are assessed through the routine evaluation process outlined above. Practice based learning and systems based practice are not as familiar to physicians in the evaluation process and have been somewhat more difficult to assess. However, trainee involvement in quality assurance programmes, including chart rounds and other quality assurance and quality improvement initiatives; participation in multidisciplinary clinics and tumour boards; and chart reviews and clinical research projects help to fulfil these competencies. Resident involvement in research as well as quality assurance and quality improvement programmes is expected for all trainees in radiation oncology, and residents are routinely assessed and evaluated in these areas. At the completion of the four years of training, provided the trainee has fulfilled his or her requirements, including participation in the established minimum numbers of cases of external beam radiation, brachytherapy, stereotactic radiosurgery and unsealed sources, and has had satisfactory evaluations, the programme director is expected to verify that the resident has demonstrated sufficient competence to enter practice without direct supervision. These milestones will define the essential behavioural attributes to be demonstrated in each competency before a resident moves on to the next level or graduates. Development of milestones in diagnostic radiology training and some of the other medical specialties is already well under way. Radiation oncology has not yet fully developed its milestones, but this process is moving forward and will likely unfold in the next few years. This publication includes a description 243 of the various elements and components to be considered when planning and initiating a radiation oncology training programme. While it can be applied and followed in any country, the publication was tailored to the needs of developing countries. The national authority should also be responsible for the eligibility of the trainees and their subsequent certification. It is advised that the national authority create a suitable mechanism to keep those already certified as radiation oncologists updated regarding recent developments in the field through a system of lifelong learning to maintain competence within the evolving practice environment (continuing medical education). It must be recognized that in low and middle income countries, the lack of trained professionals in radiation oncology is an acute problem. Therefore, when resources are available from local or external sources to establish or upgrade radiotherapy services, there is usually a pressing need to have the staff trained in the shortest time possible. The minimum training period in radiation oncology should be three years full-time following medical school graduation or, if part-time, an equivalent period spent in the specialty. This period of three years should be regarded as the minimal period of time to cover the suggested curriculum. Over this full-time equivalent of four years, the candidate will be expected to gain a sound knowledge of radiation oncology as part of the comprehensive management of cancer as well as other diseases. During this period the candidate will work as a resident in radiation oncology and participate in seminars, conferences, teaching assignments and interdepartmental clinics, and both external beam and brachytherapy procedures [15. Levels 1 and 2 (mandatory), as described in the syllabus, are required for all radiation oncologists, and this training should be provided in all training programmes. However, all trainees should familiarize themselves with them, through didactic training and/or clinical experience. Trainee evaluation records should be permanently maintained by the training institute. Assessment mechanisms may include some or all of the following: evaluations by the faculty (supervisors); periodic interviews with the programme director; evaluation of the portfolio; and in-service, written and oral examinations. The trainee will then be certified as per the mechanism established by the national authority to practice independently as a radiation oncology specialist. Curriculum changes need to be made to accommodate topics such as cross-sectional anatomy, deeper knowledge of computerized treatment planning and contouring, and definition of volumes in those programmes that do not currently include these skills. If these modalities are not available in the main venue of the training programme, such exposure has to be guaranteed through partnerships with other centres and a system of rotations. Modern programmes have to include elements of systemic therapy, including cancer chemotherapy, and hormone and targeted therapy. Radiation oncology training and evaluation in developed countries have moved from the traditional knowledge based focus to training and assessment based on new competencies, such as clinical skills, attitudes, management and professionalism. A system of assessment of these competencies has to be incorporated in the training programme. It covers a wide range of subspecialties, including ionizing and non-ionizing radiation. Medical physicists work in clinical settings, academic and research institutes and the commercial sector. They fulfil an essential role in modern medicine, most commonly in the fields of diagnosis and treatment of cancer. They are part of an interdisciplinary team in a radiation oncology department dedicated to providing safe and effective treatment of cancer. Other members of the team include radiation oncologists, radiographers, dosimetrists, maintenance engineers and nurses. Their knowledge of radiation physics and how radiation interacts with human tissue and of the complex technology involved in modern treatment of cancer are essential to the successful application of radiotherapy. In addition, clinical competence, acquired through a structured clinical training programme or residency within a clinical department, is also required. This chapter will start with a review of the roles and responsibilities of medical physicists working in radiation oncology. In many hospitals, the responsibilities also include safety of the staff and the public as it pertains to the radiotherapy service and infrastructure. The duties include measurements for reference dosimetry and relative determination of absorbed dose from external radiotherapy beams and brachytherapy sources, development of methods to analyse the results of dose measurements, and checking of the accuracy of dose distributions delivered to patients. Ideally, a formal certification process is also needed for all clinical medical physics trainees before entering into clinical practice. In addition, an accreditation process, ideally through a professional organization, is needed to ensure that the curriculum meets minimum standards. The issue of clinical education is often neglected, with the assumption that an easy transition can be made from university education to clinical practice. While short courses at the clinical level can be of help, properly structured and supervised clinical training requires a longer time frame to achieve the standards necessary for a competent clinical medical physicist. The first material to be developed was for the specialty of radiation oncology medical physics [16. The following conditions should be observed for a clinical residency programme in radiation oncology: (a) the training should be carried out in a hospital. If the clinical training programme includes academic courses or thesis research work, the total allocated time for the clinical training must be extended accordingly. Even when continuous assessment is conducted, it should be complemented by oral and/or written examinations. In this case, candidates should take appropriate academic courses covering all the relevant specialties of medical physics [16. Overall, the tertiary academic education and clinical training should extend over a minimum period of typically seven years. This has resulted in incomplete preparation of the medical physicist to practice independently, as important aspects of training cannot be completed in the university setting. It should be emphasized that practical sessions in a hospital on specific topics in radiation oncology physics, such as radiation dosimetry or treatment planning, are not considered an acceptable substitute for clinical training. The practical sessions are often conducted in groups, making the assessment of individual skills impossible. A structured in-service clinical training programme is a must, as it provides better preparation for medical physicists to ensure that they are capable of independent, safe and effective practice. Such a programme should reduce the total time needed for medical physicists to reach clinical competence and also prepare them to undertake the more advanced methodologies which are being rapidly introduced in radiotherapy. Relatively few countries have developed national standards of clinical training, which is an essential part of ensuring high quality and consistent training throughout a country. During the final months of training, the resident should be able make an independent contribution to many of the duties of the medical physicist and require only limited supervision. Hence, the investment of time and efforts in training residents pays off as the residents become more experienced, thereby increasing their contribution to the routine medical physics work in radiation oncology. It is highly desirable that both the postgraduate academic programme and the clinical residency be formally accredited by a national body. The process of accreditation of academic education and clinical training programmes usually requires that the programme administrator submit a self-assessment which gives information on 254 the programme and evidence of compliance with requirements. After review of the report, an on-site visit is conducted to ensure that requirements are met. If the mission is successful, accreditation is granted for a period normally up to five years. Additional information on the requirements and process of accreditation of medical physics education programmes can be obtained through the Commission on Accreditation of Medical Physics Education Programs [16. Certification is the formal process by which an authorized body (such as a professional society or a health related committee) evaluates and recognizes the knowledge, skills and competence of an individual, which must satisfy predetermined requirements or criteria. It is a fact that in many countries no mechanism exists to certify the qualifications of a clinical medical physicist. However, all countries with a critical mass of clinical medical physicists should establish a certification process, as this is the best way to assess the knowledge, skills and core competence of candidates in a systematic way. It helps in achieving a recognized professional standard, which ensures quality and safety of patient treatment. For countries that have a low number of clinical medical physicists, certification in another country or by a regional professional society should be sought. Examples of well established certification bodies for medical physicists include the American Board of Radiology [16.

Because the liver has many detoxifying enzymes that effciently metabolize many chemicals erectile dysfunction clinic discount kamagra effervescent online mastercard, liver toxicity is usually associated only with highdose acute exposure or lower-dose chronic exposure erectile dysfunction jason best order kamagra effervescent. Changes in the serum concentrations of liver enzymes are biomarkers of liver toxicity erectile dysfunction herbal supplements order kamagra effervescent with paypal, and their magnitudes correlate with the degree of liver damage erectile dysfunction blood pressure medication generic kamagra effervescent 100 mg. Changes in gene expression are associated with several physiologic processes erectile dysfunction viagra doesn't work order 100mg kamagra effervescent mastercard, oxidative stress erectile dysfunction ulcerative colitis cheap 100 mg kamagra effervescent with amex, and apoptosis (Boverhof et al. For commonly affected orthologs or signaling pathways, the human hepatocytes were about 15-fold less sensitive than rat hepatocytes. However, the available animal data do not support a plausible link between herbicide exposure and gastrointestinal toxicity in Vietnam veterans. Diabetes, hypertension, and glomerulonephritis (acute infammation) can all increase the risk of kidney disease. In a study of cause-specifc mortality through 2005 for 180,639 Korean veterans who were alive in 1992, Yi et al. The second study sought to determine the factors contributing to a form of kidney disease not related to diabetes, hypertension, or any other recognized cause in adults in Sri Lanka (Jayatilake et al. Since the urinary pesticide results were presented for only the cases, no inference can be made about the relative risk for this kidney condition in association with 2,4-D. Age specifc hospitalization rates were calculated using the total number of annual hospitalizations published by the M inistry of Health and the average annual resident population. The exposures were not validated through serum measurements and were assumed based on deployment to Vietnam, and the study did not control for smoking or ethnicity or other potentially important risk factors. Using a prospective cohort design with an average of 16 years of follow-up, Lebov et al. End-stage renal disease was higher in women who were obese, who used nonsteroidal antiinfammatory drugs, or who had diabetes and hypertension. Thus, in a cross-sectional study, dioxin-like chemicals were associated with nephropathy among young females, but not males, though reverse causality cannot be excluded, and the effect estimate were very imprecise. High dioxin levels were associated with an increased prevalence of chronic kidney disease compared with low dioxin levels (10. Of the 424 total participants, 151 reported an occupational history of agriculture. The pesticides that were reported by participants as commonly used included 2,4-D. This study is limited by its lack of exposure validation through serum or other measures. Other Identifed Studies Two other studies of kidney and urinary disorders were identifed, but both were limited by a lack of exposure specifcity (Orantes et al. A third study was also identifed, but instead of being limited by exposure specifcity, it was limited by the fact that the outcomes examined were not diagnosed health outcomes but rather indicators of biologic effects. A hospitalization study of New Zealand Vietnam veterans found that chronic renal failure risk was statistically signifcantly increased among the veterans compared with the standardized general population of New Zealand, but there was no difference in the prevalence of other kidney or urinary outcomes (Cox et al. The thyroid also secretes calcitonin, a hormone that controls calcium concentration in the blood and the storage of calcium in bones. Concentrations of those circulating hormones are regulated primarily by a negative-feedback pathway that involves three organs: the thyroid, the pituitary, and the hypothalamus. Cells in the hypothalamus and pituitary respond to concentrations of circulating T4 and T3. The prevalence of thyroid dysfunction in adults in the general population ranges from 1% to 10%, depending on the group, the testing setting, sex, age, the method of assessment, and the presence of conditions that affect thyroid function. A mortality analysis of the Korean Vietnam veteran cohort of 180,639 male veterans did not fnd any association between herbicide exposure and deaths from endocrine diseases when the cohort was analyzed as a group (Yi et al. Levels of cortisol and corticosterone in serum and saliva were higher in those women living in the hot spot area and were positively correlated with breast-milk dioxin concentrations. Given the crosssectional nature of the work, it is of limited usefulness in assessing the association of metabolic syndrome with dioxin-like compounds. The reduction in circulating T4 concentrations is robust and has recently been proposed as a biomarker of the effect of dioxin-like chemicals (J. These data raise the possibility that cacodylic acid may also disrupt thyroid homeostasis, but there are no published epidemiologic studies that have addressed this. Vietnam veterans is complemented by the results from the Korean Veterans Health Study (Yi et al. Chloracne shares some pathologic processes (such as the occlusion of the orifce of the sebaceous follicle) with more common forms of acne (such as acne vulgaris), but it can be differentiated by the presence of epidermoid inclusion cysts, which are caused by the proliferation and hyperkeratinization (horn-like cornifcation) of the epidermis and sebaceous gland epithelium. If chloracne occurs, it appears within a few months after the chemical exposure, not after a long latent period; therefore, new cases of chloracne among Vietnam veterans would not be the result of exposure during the Vietnam War. Even in the absence of a full understanding of the cellular and molecular mechanisms that lead to the disease, several notable reviews (Panteleyev and Bickers, 2006; Sweeney and M ocarelli, 2000) have deemed the clinical and epidemiologic evidence of dioxininduced chloracne to be strong. The long period since the putative exposure has imposed methodologic limitations on the studies of Vietnam cohorts for chloracne. This analysis did not include information on or control for lifestyle factors or ethnicity. Ocular impairment arising from systemic exposure to toxic agents may be mediated by nerve damage. Cataracts can be induced by a chronic internal exposure of the lens to such chemicals as 2,4-dinitrophenol, corticosteroids, and thallium; glaucoma may be secondary to a toxic infammation or may result from topical or systemic treatment with anti-infammatory corticosteroids (Casarett and Doull, 1995). Age-specifc hospitalization rates were calculated using the total number of annual hospitalizations published by the M inistry of Health and the Copyright National Academy of Sciences. Although there are no practical methods for assessing overall bone strength, bone mineral density correlates closely with skeletal load-bearing capacity and fracture risk (Lash et al. The effects of aging on bone loss in women are well known, but many health care providers and patients are less familiar with the prevalence and effects of bone changes in older men (Orwoll et al. Individual patients have genetic and acquired risks of osteoporosis, and the osteoporosis disease process can be without symptoms for decades. Other risk factors for the loss of bone mineral density include the use of long-acting benzodiazepine or anticonvulsant drugs, previous hyperthyroidism, excessive caffeine intake, and routinely standing for less than 4 hours per day (Lash et al. Update of the Epidem iologic Literature Only one new study of bone conditions was identifed. In their work, mice in which the Ahr or Cyp1a1, Cyp1a2, and Cyp1b1 genes were deleted displayed reduced resorption and high bone mass. These fndings help to inform decisions about how to categorize the degree of association for individual conditions. The study clearly showed that self-reported hypertension rates were the highest among Vietnam-deployed sprayers (81. Known confounders, including age, race, body mass index, smoking and drinking history, and a history of radiation therapy or chemotherapy, were considered. The direct relevance of the exposure and exposed population, combined with the high quality of the study and underlying database, were persuasive in convincing the committee that there was suffcient evidence of an association. Newly and previously reviewed studies consistently show a relationship between well-characterized exposure to dioxin and dioxin-like chemicals and measures of diabetes health outcomes in diverse cohorts, including Vietnam veteran populations. It was therefore not clear to the committee as a whole whether a category change was appropriate. As further delineated below, the committee strongly believes that more work in this area is warranted. It concurs with the Update 2014 committee that it is critical that such research include animal studies in order to elucidate whether and which mechanisms for intergenerational and transgenerational effects might exist. It is, in principle, possible to do studies on the health of children and grandchildren of veterans, but it must be understood up front that such complex studies will need to be carefully planned and conducted if they are to yield meaningful results. However, after conducting a targeted search of scientifc and medical databases (delineated in Box 3-1), the committee was unable to identify any papers that addressed the outcome with the exception of Yi and Ohrr (2014) (reviewed in Update 2014), which assessed cancer incidence among Korean veterans who had served in Vietnam between 1964 and 1973. Lim ited or Suggestive Evidence of an Association Epidemiologic evidence suggests an association between exposure to herbicides and the outcome, but a frm conclusion is limited because chance, bias, and confounding could not be ruled out with confdence. The current committee did not choose to revisit this issue in general, concluding that the Update 2014 committee had effectively covered it. Several subsequent volumes (Updates 2006, 2008, 2010, 2012, and 2014; summarized in Table 12-2) have echoed and expanded on this. Many additional opportunities for progress via continuing and new toxicologic, mechanistic, and epidemiologic research exist. Without sophisticated and specifc markers of environmentally induced epigenetic activity, epidemiologic investigations will not be able to distinguish the mechanisms inducing any observed adverse health effects in exposed people or their offspring. Fully investigate whether paternally transmitted adverse effects occur in animal models. Proof-of-concept work was conducted, but the project was not carried forward due to lack of funding. The committee wishes to make clear, though, that the diffculty in conducting research on Vietnam veteran health issues should not act as a barrier to carrying out such work. Gender differences in the effects of organochlorines, mercury, and lead on thyroid hormone levels in lakeside communities of Quebec (Canada). Low clinical diagnostic accuracy of early vs advanced Parkinson disease: clinicopathologic study. Australian National Service Vietnam veterans: Mortality and cancer incidence 2005. An epidemiologic investigation of health effects in Air Force personnel following exposure to herbicides: Study protocol, initial report. An epidemiologic investigation of health effects in Air Force personnel following exposure to herbicides. Developmental exposure to 2,3,7,8 tetrachlorodibenzo-p-dioxin attenuates capacity of hematopoietic stem cells to undergo lymphocyte differentiation. A mouse strain less responsive to dioxin-induced prostaglandin E2 synthesis is resistant to the onset of neonatal hydronephrosis. Cancer and non-cancer risk to women in agriculture and pest control: the Agricultural Health Study. Use of agricultural pesticides and prostate cancer risk in the Agricultural Health Study cohort. Non-Hodgkin lymphoma risk and insecticide, fungicide and fumigant use in the Agricultural Health Study. Exposure to 2,4-dichlorophenoxyacetic acid alters glucose metabolism in immature rat Sertoli cells. Enhancing miR-132 expression by aryl hydrocarbon receptor attenuates tumorigenesis associated with chronic colitis. Pesticides, gene polymorphisms, and bladder cancer among Egyptian agricultural workers. W isconsin Vietnam veteran mortality study: Proportionate mortality ratio study results. Gastric hamartomatous tumours in a transgenic mouse model expressing an activated dioxin/Ah receptor. Agricultural pesticide use and pancreatic cancer risk in the Agricultural Health Study cohort. The interaction between pesticide use and genetic variants involved in lipid metabolism on prostate cancer risk. Pesticide use and relative leukocyte telomere length in the Agricultural Health Study. In Proceedings of the 7th National Conference on Management of Uncontrolled Hazardous W aste Sites. A relationship in adrenal androgen levels between mothers and their children from a dioxin-exposed region in Vietnam. Lead acetate induced reproductive and paternal mediated developmental toxicity in rats. An exploratory analysis of the effect of pesticide exposure on the risk of spontaneous abortion in an Ontario farm population.

While recent debate involved in the rehabilitation process to strive to overcome has been limited erectile dysfunction drugs at gnc cheap generic kamagra effervescent canada, a series of replies to Byng et al shakeology erectile dysfunction buy discount kamagra effervescent 100mg online. There is no doubt that standardized aphasia batteries have played an important role in clinical and research aphasiIn this chapter drugs for erectile dysfunction list order 100mg kamagra effervescent free shipping, we have focused on impairment level ology (Kertesz erectile dysfunction doctor calgary cheap 100 mg kamagra effervescent amex, 1988) erectile dysfunction protocol + 60 days purchase discount kamagra effervescent line. Kertesz (1990) notes that they have assessment using hypothesis testing ritalin causes erectile dysfunction buy cheap kamagra effervescent 100 mg online, an approach comcontributed, for example, in the study of lesions, behavior cormonly referred to as the cognitive neuropsychological relations, cerebral dominance and recovery patterns. While the examples given here have focused on the focus here is on assessment in order to target treatment, acquired communication disorders, the same hypothesis and in this domain the question is whether performing an testing approach can easily be applied to the assessment of assessment battery provides sufficient additional information, developmental disorders in children and adults. Theories are often less them can, of course, be used to generate a hypothesis regardwell developed in these areas than at the level of impairment. In order to be most effective, hypothesis testing (2002) note that a single (functional) assessment is unlikely to should become an automatic way of thinking for the clinibe appropriate to assess all individuals from all cultures, with cian. Acquiring this way of thinking can be hard and time all impairments and in all settings. Similarly, Sacchett and consuming, but once it is well established it can guide Marshall (1992) question the appropriateness and adequacy the Hypothesis Testing Approach to the Assessment of Language 21 of a single measure of functional communication. Results of Hypothesis Testing 2: George names only In sum, the hypothesis testing approach can be applicable 52% of a set of 100 pictures correctly (well below the level to every aspect of an individual and their social context that of control subjects). Errors include circumlocutions and is, or might be, impacted by the language impairment and can descriptions. Unlike in conversation, in picture naming George produces some erroneous responses which are semantically related to their targets. Hypothesis 3: Once again, testing has confirmed the previous Hypothesis Testing: A Worked Example hypothesis (impairment of semantics or access to phonologiReferral: George was a 70-year-old man who reported cal output lexicon). Hence, the initial hypothesis is problems retrieving word this requires a task involving semantic processing without forms from the phonological lexicon. Results of Hypothesis Testing 3: George scores 38/40 Both of these impairments would predict semantic errors correct which is within the range of unimpaired controls. A semantic Hypothesis 4: George has unimpaired semantics and his impairment would also predict problems with understanding. Is there evidence of difficulties underdemanding test of semantic processing, the conclusion of standing conversationfi Results of Hypothesis Testing 1: In conversation, there Hypothesis Testing 4: Perform a more stringent test of is clear evidence of word finding difficulties (see. His reports of other situations that we used the spoken version), which have to be judged as would have necessitated comprehension. Results of Hypothesis Testing 4: George makes only Hypothesis 2: Broadly the same as hypothesis 1, but with three errors all on the abstract stimuli which is a level of firmer evidence. The fact that no phonological errors or phoperformance easily within the range of unimpaired subjects. Functional assessment of communiinvestigated using the same approach but intervention for cation: Implications for the rehabilitation of aphasic people: Reply to word retrieval could start immediately and further hypothCarol Frattali. Diagnostic tests as tools of assessment and models of information processing: A gap to bridge. An investigation of factors affecting performance on spoken word to this volume provides a theoretical description of each aspect of language picture matching. Cognitive psychology and clinical aphasiology: cognitive neuropsychology, neurology, and rehabilitation. This chapter provides a critical review of clinical assessments used to Marshall, J. Uncontrolled seizures are both psychologically and the removal of the tissue involved in seizures within the socially disruptive. Therefore, to avoid postoperative language disruption avoid postoperative aphasia, the treatment team first tries to deteror aphasia, the treatment team must ascertain whether the mine whether language will still be supported by the unoperated unoperated portions of the brain can support language. As one might imagine, uncontrolled seizures and right halves of the brain in patients undergoing unilatare both psychologically and socially disruptive. Handbook of the Neuroscience of Language 23 All rights of reproduction in any form reserved. These purposes are: language-dominant hemisphere allowed physicians to apply First, determination of which brain hemisphere is domielectroconvulsive therapy selectively to the contralateral nant for language in order to reduce postoperative language (opposite, subdominant) hemisphere, thereby reducing the impairment. Based on his observations memory performance in the unoperated hemisphere in order of psychiatric patients, Wada reasoned that this technique to predict which persons are at risk for amnesia (memory might also be useful in determining hemispheric language loss) after temporal lobe resection. Third, corroboration of dominance (and minimizing cognitive morbidity) in neurothe presumed side of seizure onset as determined by other surgical candidates. Language is lateralized in the left cerebral hemisphere for at the expense of other functions such as spatial abilities). Unfortunately, there are too few studies that have examined language lateralization Knecht, S. Protocols typically involve monitoring the extent of hemiparesis to determine the duration of the anesthesia (the effects of the anesthesia generally last between 90 and 300 s) and to ensure that assessment was conducted during adequate anesthesia (Benbadis, 2001) so that results are valid. Both the determination of speech dominance and that of memory representation are subjective. This procedure helps the team determine whether there are any abnormalities in the vessels which would increase results of patients being considered for surgery. For a compresia typically results and speech is arrested or dysarthric (the hensive review of intersite similarities and differences with patient will stop counting or slur). There is significant variability among centers in the extent to which (and how) speech and language functions are 3. The most widely used dysfunction when the hemisphere slated for surgery is anesmeasure of language is naming to visual presentation (Rausch thetized (Rausch et al. The Intracarotid Amobarbital Test (Wada Test) and Complementary Procedures to Evaluate Language Before Epilepsy Surgery 27 3. Further, there will occasionally be cross-filling of the mostly due to manufacturing problems (Buchtel et al. Although some centers estimate and because in some countries amobarbital is not availlikelihood of cross-fiow of amobarbital into the contralateral able, several other anesthetic agents have been explored. This drug is usually injected along with an anticonvulsant, however, because of its epileptogenic potential. Determination of Adequacy of Anesthesia Etomidate has also been successfully used in place of amoand Timing of Stimulus Presentation barbital. Infusion across centers are the determinations of when an adequate offers two advantages: avoiding changing levels of anesthedrug effect to begin testing is evident, timing of stimulus sia between re-administrations and allowing examiners to presentation, types of stimuli and response formats, and determine the length of anesthesia. Another short-acting anesthetic to achieve a model of how the brain will function if tissue used in the course of Wada testing is propofol (also used were removed, testing should occur during adequate drug by some as an anesthetic during epilepsy surgery), although effect. Unfortunately, the means of determining onset and the incidence of complications may be unacceptably high, duration of adequate anesthesia differ across centers. One or having occurred in 19 of 58 patients in one series (Mikuni more of the following might be used to infer acceptable level et al. Yet, other centand concentration, volume of amobarbital and saline mixers simply present stimuli during a predetermined, standard ture, rate of delivery (steady or incremental), and method of interval. When the speech-dominant hemiFor instance, a faster rate or larger volume of injection will sphere is injected, and speech arrest ensues, some clinicians typically perfuse a more extensive vasculature, thus comprowait for speech to return before proceeding with testing (note: mising more domains of function whereas smaller volumes speech arrest may refiect motor speech disruption rather than or slower rates of injection will lead to a greater concenlanguage deficit and may also interfere with the ability to tration of drug in a smaller area, possibly leading to more respond during memory testing), whereas others continue intense or prolonged drug effects. Criteria to Establish Hemispheric respond, yet should be sufficient to create a condition modLanguage Dominance eling as closely as possible the effects of surgery. Finally, drug effect should be long enough to permit presentation of What exactly constitutes evidence for language reprean adequate number of test items, allowing the evaluation sentation in a cerebral hemispherefi One method is based on speech arrest alone and cerebral arteries are inactivated during anesthesia. Using this method, the laterality index varies adolescents is frequently couched in terms of adult research from 1 (strong right hemisphere dominance) to 1 findings. The few published empirical studies suggest that (strong left hemisphere dominance). Szabo and Wyllie (1993) noted that lana percentage correct score on a battery of language tests guage dominance was established in all children who had obtained during anesthetization of each hemisphere (using bilateral injections and at least borderline intelligence, but tests evaluating. Using this approach, scores vary from 100 (strong right hemisphere dominance) to 100 (strong left hemisphere dominance). Several studies have shown that the interhemispheric organperipheral from the sylvian fissure and represented in a larger ization of both languages in bilingual individuals is complearea. Thus, one might conclude, assuming that amobarbital mentary, that is, hemispheric dominance for the two languages effects dissipate earlier in more distant areas, that Berthier et is similar (Berthier et al. Berthier (1990) described a case study in which a bilingual patient demonstrated the Berthier, M. Selective deficit of one language in a bilingual patient might be organized within the central sylvian core, whereas following surgery in the left perisylvian area. Brain organisation for language from the perOjemann, 1983) offer an opposing view, however, demonstratspective of electrical stimulation mapping. The Intracarotid Amobarbital Test (Wada Test) and Complementary Procedures to Evaluate Language Before Epilepsy Surgery 29 Box 3. That is, such studies provide tentative data that guage studies in non-deaf individuals also indicate interhemispeak to the issue of whether findings from normal-hearing spheric organization of signed and spoken language to be individuals concerning the organization of sign language apply similar, at least in that the same hemisphere is dominant for to deaf individuals. The existence of subtle interbeen found in a right-handed individual for American Sign hemispheric differences in the organization of signed and spoLanguage, signed English, and finger spelling (Wolff et al. Thus, evidence of bilateral representation for sign lanstudies (instead we would direct the reader to numerous studies guage was not found. Cerebral organizaIn contrast, several other studies have found that the interhemition of oral and signed language responses: Case study evidence spheric organization of signed and spoken language to be comfrom amytal and cortical stimulation studies. Case report of an intracahave experienced some cortical reorganization (Wolff et al. In a follow-up study of 162 patients as well as deep electrodes implanted in the mesial tempowho underwent temporal lobectomy without mapping, ral lobes. Intraoperative right hemimetabolic or blood fiow changes correlated with performance sphere language mapping may also be helpful in identifying of language tasks. In the brain, changes in blood oxygen level have been shown to be related to neu3. Thus, it is difficult if not impossiamong protocols versus non-essential ble to ascertain whether unoperated tissue can truly support No normative database language areas language. However, using these conservative methods mised patients and pediatric populations. Another drawbacks to creating a normative database with healthy issue is how to interpret decreased activation during lancontrols, given less procedural risks. The Intracarotid Amobarbital Test (Wada Test) and Complementary Procedures to Evaluate Language Before Epilepsy Surgery 31 3. Dysnomia after left anterior temporal lobectomy without functional mapping: postoperativelyfi It is possible that functional Right hemisphere mapping in patients with bilateral language. Evaluation of adverse effects in intracarotid propofol method for determining hemispheric representation of languagefi

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Elements that make up competent mucosal barrier function are quantitatively and qualitatively limited in preterm infants erectile dysfunction injection purchase kamagra effervescent with visa. Thus impotence zoloft generic kamagra effervescent 100mg amex, shortly after term birth erectile dysfunction how can a woman help order kamagra effervescent with mastercard, mature neonatal intestinal epithelium must rapidly attenuate response to commensal organisms erectile dysfunction medication non prescription proven 100mg kamagra effervescent. Intestinal immune cells erectile dysfunction caused by vascular disease kamagra effervescent 100 mg without a prescription, including Paneth cells erectile dysfunction under 30 order on line kamagra effervescent, B (plasma cells) and T lymphocytes (fi/fi), macrophages, and gut-associated lymphoid tissue. Suboptimal systemic innate immune surveillance and pathogen clearance increase the risk in preterm infants for the development of systemic infammation, 53 sepsis, organ failure, and death following barrier breakdown. It is reasonable to posit that a lack of luminal compared with parenteral nutrients may contribute signifcantly to nonintestinal neonatal pathology such as sepsis and chronic lung disease. The underlying basis for these pathologic processes is that the intestine not only serves as a digestive absorptive organ but also is one of the largest immune organs of the body, plays a major endocrine and exocrine role, and encompasses neural tissue equivalent to that of the entire spinal cord. However, the surface area increase is even more dramatic, largely because of the villus and microvillus growth during this period of development. Professor Elsie Widdowson and colleagues were among the frst to demonstrate that the suckled pig gains 42% of its weight in the frst 24 hours after 55 birth, and this was seen in the rabbit as well. Other researchers have expanded on this work and have demonstrated not only major differences in intestinal mucosal growth with enteral feeding compared with parenteral feeding, but also increases in hepatic and superior 56 57 58 59 mesenteric artery blood fow, motility, IgA, and decreased permeability with enteral feedings. Although several physiologic benefts can be provided by minimal enteral feedings, one study suggested that at least 40% of nutritional requirements need to be supplied by the 57 19 enteral route before signifcant advantages in terms of mucosal growth are elicited. It is highly likely that protein provided by the enteral route could serve as a much greater trophic stimulus than would similar quantities of lipid or carbohydrate. Late-onset sepsis (sepsis after 3 days of life) is associated with prolonged use of intravenous catheters for parenteral nutrition. Most often, the absence of early enteral nutrition coincides with another factor that signifcantly increases the likelihood of an intestinal barrier breach: the use of broad-spectrum antibiotic treatment for suspected sepsis. Are there potential complications other than the emergence of resistant microbes and the usual short-term rare complications such as renotoxicity and ototoxicity ascribed to these antibioticsfi The presence of maternal chorioamnionitis is highest for infants delivered at the lowest gestational ages and is associated with a signifcantly higher rate of early neonatal sepsis. The frst colonization of the intestine is one of the most profound immunologic exposures faced by the newborn. This establishes a niche, allowing long-term colonization, probably as part of a bioflm located within the luminal 67 glycocalyx. Studies in mice demonstrating an increased susceptibility to hemorrhagic colitis after eradication of intestinal bacteria using broad-spectrum antibiotics also suggest that the epithelium and resident immune cells do not simply tolerate commensal bacterial but are dependent on them for homeostasis. However, the gut is far more than a mere sieve that fails to contain bacteria and bacterial products from entering the systemic circulation. Compromised epithelial tight junctions, resultant bacterial translocation, and subsequent gut-derived toxic mediator production drive systemic infammation. Although it may be argued whether gut-derived bacteremia is directly responsible for driving the destructive systemic infammatory response on the host,82 gut-derived infammation appears to make a major contribution to host injury. Preclinical investigation showed that chorioamnionitis exposure led to impaired development of intestinal innate immune defense, tight junction distribution and vascular function. Even more discouraging, most infants 90,91 that do not die suffer signifcant neurodevelopmental morbidity. Factors contributing to white matter injury (consisting largely loss of premyelinating oligodendrocytes) in the preterm infant include an increased sensitivity to ischemia and infammation and resultant vulnerability to free radical attack 94 (reactive oxygen and nitrogen species) and excitotoxicity. Each of these factors contributes to white matter injury seen on brain magnetic resonance imaging. These data strongly support that the presence of an intense infammatory response during a sensitive phase of neurodevelopment has signifcant, long-term neurodevelopmental consequences in preterm infants. A summary of contributing factors and outcomes related to gut infammation and bacterial translocation is shown in Figure 19-3. The specifc pathophysiology of white matter injury in preterm infants is an exciting area of translational research with much yet to be learned. Opportunities for Intervention Early Feeding Initiating gut priming and establishing enteral feeding is paramount for reducing gut-driven pathology in preterm neonates. Preterm milk contains a higher concentration of immunologic factors such as lactoferrin, lysozyme, and IgA, which may help to counter the developmental 119 defciencies in the preterm intestine. Immunomodulation and Enhancement of Gut Integrity As each investigation peers deeper into the molecular pathology of gut injury associated with critical illness and gut-derived infammation, other sources with potential for benefcial gut immunomodulation have been identifed. Examples of 121-123 these include prebiotics and probiotics, polyunsaturated fatty acids (metabo124 125 126 lites of 3/6 fatty acids), bovine lactoferrin, and gangliosides. Summary Although it is clear that infammation-derived pathology has a devastating impact on the preterm infant, mechanisms driving the preterm-specifc activation of gut-derived infammation remain less well characterized than their adult counterparts. The Neonatal Gastrointestinal Tract as a Conduit to Systemic Infammation and Developmental Delays 301 10. Intestinal microbial ecology in premature infants assessed with non-culture-based techniques. Fecal microfora in healthy infants born by different methods of delivery: permanent changes in intestinal fora after cesarean delivery. Factors controlling the bacterial colonization of the intestine in breastfed infants. Infuence of early gut microbiota on the maturation of childhood mucosal and systemic immune responses. Investigation of the intestinal microbiota in preterm infants using different methods. The intestinal bacterial colonisation in preterm infants: a review of the literature. Reported medication use in the neonatal intensive care unit: data from a large national data set. New insights into the pathogenesis and treatment of necrotizing enterocolitis: Toll-like receptors and beyond. Increased expression and function of integrins in enterocytes by endotoxin impairs epithelial restitution. Toll-like receptor-4 inhibits enterocyte proliferation via impaired beta-catenin signaling in necrotizing enterocolitis. Lymphocytes bearing the gamma delta T-cell receptor in normal human intestine and celiac disease. Endotoxin induced chorioamnionitis prevents intestinal development during gestation in fetal sheep. Infammation in the developing human intestine: A possible pathophysiologic contribution to necrotizing enterocolitis. Glucocorticoid responsiveness in developing human intestine: possible role in prevention of necrotizing enterocolitis. Changes in the organs of pigs in response to feeding for the frst 24 h after birth. Minimal enteral feeding induces maturation of intestinal motor function but not mucosal growth in neonatal dogs. Early feeding, antenatal glucocorticoids, and human milk decrease intestinal permeability in preterm infants. Neonatal candidiasis among extremely low birth weight infants: risk factors, mortality rates, and neurodevelopmental outcomes at 18 to 22 months. A multicenter study on the clinical outcome of chorioamnionitis in preterm infants. Early-onset sepsis in very low birth weight neonates: a report from the National Institute of Child Health and Human Development Neonatal Research Network. Management of the human mucosal defensive barrier: evidence for glycan legislation. Metagenomic analyses reveal antibiotic-induced temporal and spatial changes in intestinal microbiota with associated alterations in immune cell homeostasis. The Neonatal Gastrointestinal Tract as a Conduit to Systemic Infammation and Developmental Delays 303 74. Procession to pediatric bacteremia and sepsis: covert operations and failures in diplomacy. New concepts of microbial translocation in the neonatal intestine: mechanisms and prevention. The intestinal microbiota in health and disease: the infuence of microbial products on immune cell homeostasis. Systemic infammation increases intestinal permeability during experimental human endotoxemia. No longer an innocent bystander: epithelial toll-like receptor signaling in the development of mucosal infammation. Infuence of the critically ill state on host-pathogen interactions within the intestine: gut-derived sepsis redefned. Role of the gut in multiple organ failure: bacterial translocation and permeability changes. Proteomic biomarkers of intra-amniotic infammation: relationship with funisitis and early-onset sepsis in the premature neonate. Neonatal gut barrier and multiple organ failure: role of endotoxin and proinfammatory cytokines in sepsis and necrotizing enterocolitis. Proinfammatory and anti-infammatory cytokine responses in preterm infants with systemic infections. The role of the intestinal barrier in the pathogenesis of necrotizing enterocolitis. Neonatal infection and long-term neurodevelopmental outcome in the preterm infant. Neurodevelopmental and growth impairment among extremely low-birth-weight infants with neonatal infection. Adverse neurodevelopment in preterm infants with postnatal sepsis or necrotizing enterocolitis is mediated by white matter abnormalities on magnetic resonance imaging at term. Recurrent postnatal infections are associated with progressive white matter injury in premature infants. Neurodevelopment of extremely preterm infants who had necrotizing enterocolitis with or without late bacteremia. Late-onset septicemia in a Norwegian national cohort of extremely premature infants receiving very early full human milk feeding. Feeding strategies for premature infants: benefcial outcomes of feeding fortifed human milk versus preterm formula. Association of human milk feedings with a reduction in retinopathy of prematurity among very low birthweight infants. Human milk intake and retinopathy of prematurity in extremely low birth weight infants. Benefcial effects of breast milk in the neonatal intensive care unit on the developmental outcome of extremely low birth weight infants at 18 months of age. Persistent benefcial effects of breast milk ingested in the neonatal intensive care unit on outcomes of extremely low birth weight infants at 30 months of age. Human milk enhances antioxidant defenses against hydroxyl radical aggression in preterm infants. Potential role of the intestinal microbiota of the mother in neonatal immune education. Gangliosides protect bowel in an infant model of necrotizing enterocolitis by suppressing proinfammatory signals. Durable alteration of the colonic microbiota by the administration of donor fecal fora. Erythropoietin protects intestinal epithelial barrier function and lowers the incidence of experimental neonatal necrotizing enterocolitis. Increased epidermal growth factor levels in human milk of mothers with extremely premature infants. As old and intuitive as this concept may be, it has reentered the consciousness of the research community only in the past 20 years. As a result, the overall interest in the specifc experiences and mechanisms through which different perinatal environments lead to adult-onset diseases has exploded. This interest is an important research priority because it is an avenue for preventing adult diseases such as diabetes, obesity, and hypertension before they exact a direct toll. The continuum of early nutrition experienced by humans varies greatly within a single population, let alone between different populations. As a result, most epidemiologic studies interested in understanding the adult consequences of fetal and neonatal nutrition have used poor growth, particularly in utero, as a marker of poor nutrition. Therefore, an important assumption of this chapter is that poor nutrition leads to poor growth, in both the fetus and the young child. Infants included in this group may be small for multiple reasons, including normal genetic variation. This famine occurred as a result of German reprisal for a general railway strike intended to disrupt the transport of German reinforcements toward Allied liberation move1,2 ments. Daily rations in Amsterdam dropped from 1800 kcal/day in December of 1943 to 400 to 800 kcal/ day in April of 1945.

Unilateral multicystic erectile dysfunction unable to ejaculate kamagra effervescent 100mg lowest price, dysplastic kidney is the most common cystic disease of the newborn and the second most common infant abdominal mass after hydronephrosis erectile dysfunction vitamin kamagra effervescent 100 mg online. Vesicoureteral reflux refers to the retrograde flow of urine from the bladder into the upper urinary tract psychological erectile dysfunction wiki buy cheap kamagra effervescent. It occurs at a rate of 1 per 1000 in the general population impotence pronunciation kamagra effervescent 100mg amex, but is 8 to 40 times more frequent in families with a history of reflux in a sibling erectile dysfunction korea order cheapest kamagra effervescent and kamagra effervescent. Of those diagnosed with neonatal reflux impotence marijuana facts purchase 100mg kamagra effervescent overnight delivery, there is a male predominance, whereas females predominate when diagnosed after the newborn period. Vesicoureteral reflux may occur because the ureteral bud arises ectopically, leading to a laterally placed ureteral orifice and short submucosal bladder tunnel, which allows reflux. Reflux may also occur if there is incomplete or delayed development of the intrinsic smooth muscle of the distal ureteral segment (5,6). Vesicoureteral reflux predisposes an individual to pyelonephritis by facilitating the transport of bacteria from the bladder to the upper urinary tract. The immunologic and inflammatory reaction caused by a pyelonephrotic Page 461 infection may result in renal injury or scarring. Extensive renal scarring causes reduced renal function and may result in permanent renal damage or renal failure (7). Vesicoureteral reflux is graded as follows: Grade I results in urine reflux into the distal ureter only. An ectopic ureter is defined as a ureter that drains into any location other than the bladder trigone. Embryologically, the delayed entry of the ureteral bud into the bladder results in a more distal and medially positioned ureteral orifice. In some instances, the ureter may not even incorporate itself into the bladder but may enter other structures. In females, this may include the urethra, introitus, vagina, uterus, and fallopian tube. In males, the ectopic ureter may enter the bladder neck, prostatic urethra, epididymis, seminal vesicles, or vas deferens. Ureteral ectopia in a duplicated system is 6 times more common in females than males. Ureteral ectopia in a non-duplicated collecting system is more common in boys (8). Ureteroceles are a cystic dilation of the distal ureter at the level of the ureteral orifice (intravesical ureter). These upper pole segments usually demonstrate varying degrees of renal dysplasia (8). Posterior urethral valves (a congenital membrane that obstructs or partially obstructs the posterior urethra) occur in boys (1 per 5000 to 8000), with greater than 50% diagnosed in the first year of life. It is felt that the etiology is failure of regression of the terminal segment of the mesonephric duct, which is normally represented by the plicae colliculi, which results in a congenital membrane that obstructs or partially obstructs the posterior urethra (5,6,9). The Eagle-Barrett Syndrome (Prune Belly Syndrome, Triad Syndrome) is characterized by a dilated, non-obstructed urinary tract, deficiency of abdominal wall musculature (a visibly obvious deficiency of abdominal wall musculature with a distinct flabby abdomen), and bilateral cryptorchidism (undescended testes). The incidence is 1 per 35,000 to 50,000 live births with 95% of the cases occurring in boys. The syndrome is a result of in utero urinary tract obstruction and a specific mesodermal injury between the 4th and 10th week of gestation. Older children and adults who present with calculi, flank pain, nausea and vomiting, hematuria, non-specific abdominal complaints, especially if intermittent in nature, during periods of high urine flow, may have ureteropelvic junction obstruction (3). Daytime incontinence, infrequent voiding, poor urinary stream, chronic severe urinary frequency, and complicated enuresis may suggest bladder outlet obstruction (from urethral obstruction or posterior urethral valves) (9). Children may present with clinical pyelonephritis, fever, abdominal/flank pain, malaise, nausea, vomiting, cystitis with dysuria, frequency, urgency, and urge incontinence. Patients with ureteral ectopy and/or ureteroceles may be picked up initially with prenatal ultrasound. Ureteroceles may also present with a palpable abdominal mass or cystic intralabial mass (the result of a large ureterocele that has prolapsed through the urethral lumen) (8). For the infant noted to have hydronephrosis on prenatal ultrasound, an ultrasound on day 2 of life should be performed. Ultrasound is the mainstay of screening and can provide excellent morphological evaluation in experienced hands. The degree of hydronephrosis and caliectasis can be seen, together with the renal size, parenchymal thickness, and some subjective assessment of the renal cortical texture. The presence and morphology of the contralateral kidney, and the distal ureter should be evaluated. Renal and ureteral duplication may be noted on ultrasound, as well as the presence of a ureterocele in the bladder. If no hydronephrosis is present at one month of age, the evaluation can then stop. Posterior urethral valves show a characteristic appearance of a prominent bladder neck, dilated posterior urethra, and a bulging membrane at the distal aspect of the verumontanum. Reflux grade is important because more severe reflux is associated with higher rates of renal injury, and treatment success varies with reflux grade (7). Follow-up cystography is done using radionuclide cystography because radiation exposure is less than with standard contrast cystography. It can also show obstruction by demonstrating the washout from the kidney, augmented by the administration of a diuretic 20 minutes after administration of the initial tracer (1,3). Sequential images, computer generated time-activity curves, and calculated halftimes will determine the degree of washout of the tracer in the area of interest. Prolonged washout times (called washout half-times) are often associated with true urinary tract obstruction. Page 462 Diminished renal function is definitely present when the split function is less than 35% to 40% (10), while good renal function is demonstrated by split function values of 45% to 50%. A poor washout half-time is greater than 20 minutes, and a good washout half-time is less than 10 to 12 minutes. It defines the collecting systems anatomy well, and can be very useful with ectopic kidneys, duplicated kidneys, and ureters, as well as with megaureter. Urodynamics (bladder function studies) are indicated when a functional obstruction is suspected (neurogenic, or non-neurogenic). Serum blood chemistries, especially creatinine, are also useful in these patients, and should at least be obtained early on to help establish baseline renal function. It is important to emphasize that imaging studies cannot be taken and evaluated in isolation, but must be evaluated in conjunction with the other imaging, laboratory, and clinical findings over time, especially with a period of observation (with serial studies), before definitive surgery is considered. Ureteropelvic junction obstruction is the most common cause of congenital hydronephrosis. Diuretic renography/renal scan will show an obstructive pattern (prolonged washout half time). Ureterovesical junction obstruction is the second most common cause of congenital hydronephrosis. Dilated ureters (megaureters) are divided into three primary categories: refluxing megaureters, obstructed megaureters, and non-obstructed, non-refluxing megaureters. Secondary megaureter may occur because of extrinsic processes such as tumors, retroperitoneal fibrosis, and vascular malformation. Another cause is functional ureteral obstruction such as with neuropathic bladder disease in those with spinal dysraphism (12). Posterior urethral valves are the most common cause of lower urinary tract obstruction and occurs in males. The newborn physical exam may reveal a palpable distended bladder, a palpable prostate on rectal exam, poor urinary stream, and signs and symptoms of renal and pulmonary insufficiency. In females, the most common cause of anatomic bladder outlet obstruction is a ureterocele that has prolapsed into the urethra (urethral prolapse may resemble a large doughnut shaped mass in the perineum). Primary vesicoureteral reflux may present initially as hydronephrosis in the newborn. It tends to be of higher grade and with a male predominance when presenting in the newborn period (11). Other causes of hydronephrosis or apparent hydronephrosis, are the multicystic, dysplastic kidney, ectopic ureter, megacalycosis, simple renal cyst, urachal cyst, ovarian cyst, hydrocolpos, sacrococcygeal teratoma, bowel duplication, duodenal atresia, anterior meningocele, and the prune belly syndrome (1). Neonates with better than 35% renal function are followed with repeat scans at 3 to 6 months, then at 12 months of age, and surgery is indicated only when there is clear deterioration in renal function (1). Most patients being followed with observation received antibiotic prophylaxis (1). Indications for surgical repair (open ureteral reimplant, sometimes with tapering), include deterioration of renal function, breakthrough pyelonephritis, pain, or calculus formation (12). When a ureterocele is present, the best initial management is endoscopic incision of the ureterocele (1,8). Treatment is centered on securing adequate drainage of the urinary tract, initially by placement of a urinary catheter and later, by primary cystoscopic ablation of the valves, vesicostomy, or upper urinary tract diversion. Persistent bladder dysfunction should be treated with anticholinergics, alpha blockers, and clean intermittent catheterization, as indicated (6,8). Reflux tends to resolve over time as the intravesical segment of the ureter elongates, with the greatest rate of spontaneous resolution occurring in the lowest grades of reflux (approximately 15% per year) (6,7,11). The radionuclide cystogram is performed by many because the radiation done to the gonads is lower than with a standard cystogram. Medical management with antibiotic prophylaxis is considered successful if the child remains free of infection, develops no new renal scarring, and the reflux resolves spontaneously. Noncompliance and allergic reactions to the prescribed medications may also lead to failure of medical management (7). Failure of medical management/antibiotic prophylaxis is an indication for surgical repair of the refluxing ureter. Open surgical management (ureteral reimplant) involves modifying the abnormal ureterovesical attachment to create a 4:1 to 5:1 ratio of length of the intravesical ureter to ureteral diameter. Ectopic ureters are treated surgically based upon whether the patient presents with single or duplex systems, how well each moiety functions, and whether there is ipsilateral lower pole reflux. Partial nephrectomy and ureterectomy are indicated for upper pole moieties that are nonfunctioning or very poorly functioning (less than 10% of total function). In those with upper pole function and no evidence of lower pole reflux, ureteropyelostomy or high ureteroureterostomy are reasonable approaches. Ureteral reimplant (ureteroneocystostomy) is a good option for patients with upper pole function and lower pole reflux (8). The management of ureteroceles is similar to ectopic ureteral management in that the approach taken is dependent upon many variables (single or duplex systems, ipsilateral or contralateral reflux, obstruction, and degree of function present). The goals of surgery are to preserve renal function, correct obstruction and reflux, eliminate urinary stasis and infections, and preserve urinary continence with minimal morbidity and mortality (8). Management options include observation, transurethral incision of the ureterocele, upper pole nephrectomy with partial ureterectomy, ureteroneocystostomy with ureterocele excision, high ureteroureterostomy, and transvesical ureterocele repair. Prune Belly Syndrome (Eagle-Barrett Syndrome) treatment involves optimization of urinary tract drainage, management of renal insufficiency, and antibiotic prophylaxis. Surgical repair of reflux, orchiopexy, and abdominal wall reconstruction is performed later in childhood (6). There are proponents of excision of these kidneys due to a risk (albeit a very small risk) of malignant transformation. Although there are some centers that treat severe hydronephrosis prenatally related to obstructive uropathy, this is very controversial. The consensus is that intrauterine intervention should be considered only if persistent or progressive oligohydramnios develops in a fetus with a normal karyotype, there are no other life threatening anomalies, and fetal immaturity that precludes delivery (2,6). These procedures should only be performed at tertiary referral centers with extensive experience with fetal surgery. The widespread use of obstetrical ultrasound has resulted in the detection of antenatal hydronephrosis as a common presentation of congenital renal, ureteral, bladder, and urethral anomalies. What is the initial imaging study that should be done to evaluate a newborn with a history of antenatal hydronephrosisfi What are the two most common causes of newborn hydronephrosis and how are they distinguished one from anotherfi How does antibiotic prophylaxis for the management of vesicoureteral reflux prevent renal scarringfi The American Urological Association, Pediatric Vesicoureteral Reflux Clinical Guidelines Panel, Report on the Management of Primary Vesicoureteral Reflux in Children: Clinical Practice Guidelines. Surgery Versus Observation for Managing Obstructive Grade 3 to 4 Unilateral Hydronephrosis: A Report from the Society for Fetal Urology. The treatment is centered on securing adequate drainage of the urinary tract; initially by placement of a urinary catheter, and later by transurethral ablation of the valves. A vesicostomy (surgical formation of a cutaneous bladder stoma) may be done as a temporizing measure if the infant cannot undergo transurethral ablation of the valves. In infants noted to have good (35 to 40% or greater) split function on the renal scan, then serial ultrasound and diuretic renal scans (at 3 to 6 months of age, then at 12 month of age) may be used to follow the patient nonsurgically, on antibiotic prophylaxis. A ureterocele is a cystic dilation of the distal ureter at the level of the ureteral orifice. A ureterocele which has prolapsed into the urethra is the most common cause of congenital bladder outlet obstruction in females. Transurethral incision of the ureterocele is a minimally invasive treatment for symptomatic ureteroceles. The ectopic insertion of the ureter into the bladder wall laterally results in a short intravesical ureter (a short submucosal bladder tunnel), which acts as an incompetent valve during urination, allowing urine to reflux back up into the ureter. The antibiotic prophylaxis sterilizes the urine, and thus prevents bacteria ascending up the refluxing ureters, from causing pyelonephritis and renal scarring/damage.