By O. Chenor. Fontbonne University.
What is the most appropriate entry about aims and objectives of applications of biostatistics? To evaluate probabilities in diagnosis and management and the validity of medical tools D amoxil 500 mg. Skewed is the term applied to a distribution in which the mean amoxil 500mg, median and mode are equal D amoxil 250mg. A child with a weight <3rd percentile is considered is considered suffering from “failure to thrive” 5 500mg amoxil. Charts such as bar charts (simple 250mg amoxil, multiple) 500 mg amoxil, histogram 250 mg amoxil, pie chart amoxil 250 mg, pictogram are the frst step for applying data for analysis and interpretation C . Since range denotes only the extremes of two values and nothing in between , it is not of much value Answers 1. D Clinical Problem-solving Review 1 A 6-year-old weighs 14 kg against the standard weight of 20 kg at 6 years. The observation of the child’s height falling <3rd percentile means that 97% children of his age are above and only 2% below his height. The percentile is the percentage of an individuals in the group that have attained a certain measured quantity (say a weight of 17 kg or a height of 95 cm) or a developmental milestone. Essentials of biostatistics: Reference values in medicine and validity of diagnostic tests. It health, which is now universally adopted, is as follows: is, by no means, a measurable quantity, independent of this Health is a state of complete physical, mental and vital relationship. An individual living in a state of physical, mental and T e child care covers health and disease from conception social wellbeing is said to be enjoying positive health which to adolescence. T e objective is to carry the health care is a basic human right and a worldwide social goal. T e most practical approach is to carry T is is a diferent matter that the goal could not be fully met by the set deadline. Undoubtedly, the age self-reliance, intersectoral coordination and people’s latter are a part and parcel of the community. As a matter of involvement, rural population of developing countries fact, hospitals are important component of the community must have a provision of at least the base minimum of as health centers, schools, crèches, and homes for the health services. Whereas the frst constitutes a part of social medicine, T e term, community pediatrics, denotes a synthesis of the second is a part of clinical medicine. Both have got to clinical practice and public health principles directed operate together for the rational delivery of preventive and toward providing health care to a given child and pro- curative services to the vulnerable population. T eir application, of course, varies T e aim is to achieve optimal accessibility, appropriate- from country to country. T is is important, also in view of ness, and quality of services for all children, and to advocate the fact that each country may have its special problems especially for those who lack access to care because of social needing priority attention. In the same country, there or economic conditions or their special health care needs in may also be regional variations—in fact variations from the community setting. The equipment and manpower are security; recognition; recreation; company of other children locally available at relatively low cost. Examples: Screening for thyroid disorders, blindness; long-acting Te term, anticipatory pediatrics implies anticipation of penicillin (benzathine penicillin) prophylaxis in rheumatic fever. Pediatrics, in actu- Te term, total pediatric care denotes preventive, pro- ality is largely preventive in its objective. Antenatal preventive pediatrics includes measures welfare—the total (whole) child, so to say. Postnatal preventive pediatrics includes measures and interdependence of the physical and mental health such as periodic medical checkup of infants, supervi- states of individual family members who live together. Te successful operation of the strategy can induce families to assume responsibility for their health 137 and welfare. Te essential criteria of a sound family health program are: It should be able to ofer primary, preventive and pro- motive health care, as a continuous process rather than at intervals. This is a projected concept—in a way, a further extension of the time-honored “mother and Te concept highlights the vital importance of con- child as a single unit” concept. Te health of the child is by and large dependent on mother’s Delivery health and attitudes. During care of the mother, attention Te overwhelming problems afecting the mother and the to the child (both in utero and afterwards) is nearly always child in developing countries at present revolve around the mandatory. Promotion of physical and psychological development Problem of infection in the mother as well as the child of the child as also the adolescent within the family. Mother’s health and attitudes have a considerable bearing on child’s Since the year 2005, India has been aggressively promoting health, growth and development. It is in operation in two major forms, namely— through nutrition and health education. Te much- z Immunization needed extra thrust on neonatal and adolescent health z Health check-up is the objective of this initiative. Salient features of the z Referral services initiatives have already been described in Chapter 1 z Nutrition and health education (Pediatrics: Contemporary Trends). Objectives z For children below 3 years food is given as take- To improve the nutritional and health status of chil- home ration. Benefciaries of Services To lay the foundation for proper psychological, physical and social development of the child. Tus, ben- To achieve efective coordination of policy and imple- efciaries constitute over 40% of the total population. Te mentation amongst the various departments to pro- scheme is jointly operated by the Ministry of Health and mote child development. Training con- Children under 1 year z Supplementary nutrition sultants (drawn from community medicine or pediatrics) z Immunization provide services related to training, survey and research. Community needs to be involved through local Children of 3–6 years age group z Supplementary nutrition health committees in the preparation of nutritious food mix z Immunization for supplementary nutrition, using local foods, immuniza- z Health check-up tion, vitamin A, iron and folic acid supplementation, etc. Te services ofered to diferent categories of benef- gainful occupations even at the expense of their physical, ciaries are shown in the Table 9. Work in this case as such requires dren and mothers as a part of India’s 20-point development strength or patience rather than skill or training. According to the International Labor Organization 2012 Delivery of Services report, 168 million children around the world are engaged in child labor, accounting for 11% of the world’s child population. Te services are delivered at a community center, the According to a conservative estimate, over 80 million anganwadi (meaning a courtyard). She comes from a children aged less than 15 years are engaged in child labor local community and has had four months of training in in the world. What is remarkable is that 98% of them are in fundamentals of child development, nutrition, immuniza- the developing countries. Te Anti-slavery society believes tion, personal hygiene, environmental sanitation, antenatal the number may well be much more than 100 million care, breastfeeding, identifcation and immediate manage- since in many countries child labor may be clandestine ment of at-risk children, treatment of common day-to-day and children who both work and attend school are rarely illnesses, preschool education and functional literacy and considered as child workers. She (dhabas), as domestic servants, or street children (rag- is a graduate and has had two months special training. At the cigarette vendors, helpers in shops and small wayside State level too, social welfare is under the administrative restaurants or petty servants’ for running errands in ministry in a vast majority of the States. Drug abuse: Child laborers are frequently exposed to smoking, boozing and drugs which eventually lead to addiction and far-reaching damage to child’s health. Occupations hazards/accidents and injuries: Inci- dence of injuries while working is quite high. A glaring example of working children who leading causes include lifting of heavy weights, broken rakes through garbage dumps for polythene bags, plastic and waste paper for a living. Organized sector: Only a small proportion of working Communicable diseases: Tere is evidence that the children are in the real organized sector. Child laborers are known to All said and done, remember that the largest number of sufer from poorer growth and health status compared working children is found in households, frequently helping to their nonworking counterparts. Next comes the nondomestic work—usu- tion with denial of leisure, play and recreation, and ally agricultural in nature. All sort of work under the eponym long hours of daily work leave crippling efect on child labor nearly always discourages school attendance. Little wonder, smoking, drug addiction, smuggling and Exploitation by the parents, who have selfsh motives even prostitution are common in working children. High morbidity: Magnitude of ailments, say headache, Other factors include exploitation by the employers, backache, cold, cough, fever, conjunctivitis, scabies, bad company, begging gang, school dropout, child- pyodermas, nutritional defciency states, tuberculosis, out-of-wedlock, maladjustment in the family, death of intestinal parasitic infestations, diarrheal disease and parent(s) and juvenile delinquency. Balloon factory z Lung problems including z The period of work on each day shall be fxed in a way that no pneumonia period shall exceed three hours before he has had an interval for z Heat failure rest for at least one hour. Bidi industry z Nicotine poisoning in the form of z The period of work should be so arranged that, inclusive his easy fatigability of muscles interval for rest under subsection two, it shall spread waiting for z Nausea the work on any day. Powerloom industry z Lung problems like byssinosis and tuberculosis strategy involving the parents, employees, community, Firework/match industry z Lung problems and non-governmental, governmental and voluntary z Burns z Muscle fatigability agencies. Glass industry z Heat stroke Te highlights of Te Child Labor (Prohibition z Lung problems and Regulation) Act, 1986, in our country are listed z Conjunctivitis in Table 9. Most glaring feature of the act is that, z Reduction in life span except the family-based work or recognized school- Look industry z Lung problems including—asthma z Acid burns based activities, children are not expected to work in Brass industry z Lung problems occupations concerned with agriculture, industry, etc. Child labor is closely connected with the socio-economic Major factors contributing to this malady are poverty, status of the deprived communities–say poverty, illiteracy rapid urbanization, loss of family members through disease, and unemployment. Banning it, though eventually accidents or disasters, physical and sexual abuse, etc. Children are taken away from their families, activities considered normal for the individual’s age, sex, communities and support network. Tus, Government of India (GoI) has launched Ujjawala, there are about 45 million handicapped children in the a comprehensive scheme aimed at creating protective country at present. Physical (orthopedic) Central to all welfare programs is awareness creation z Sequelae of fractures, arthritis, etc. We must z Chondrodystrophies put up concerted eforts with support from the mass media Neurologic (radio, television, press, etc. Te Te process of rehabilitation involves: discriminated girl child, if she manages to survive, grows Restoration of function (medical rehabilitation), up to show discrimination to her female children. Tis Restoration of capacity to earn livelihood (vocational vicious cycle goes on and on and is hard to break. Tis Restoration of personal dignity and confdence will eventually have a positive bearing on the status of the (psychological rehabilitation). Every year, 18–24 September is observed Naturally, multitudes of subdisciplines are required to as girl child week throughout India. Services for the handicapped must incorporate thera- Discrimination against the girl child begins even before peutics, education, and social and emotional support to her birth. Nothing short of community participation can having roaring business, ofering amniocentesis and make these services efective. Te areas of community ultrasound facilities for fnding the unborn baby’s sex participation include: and indirectly instigating abortion of the female fetus. Te Case reporting and referral to the rehabilitative services, practice attracts clients from all socioeconomic groups, Raising funds for maintenance of these services, even if the money has to be begged or borrowed. Te Now, there is a legal ban on abortion of female community needs to ofer employment opportunities in fetus following sex-determination tests. Tere truly is an unholy nexus between the parents, their advisers, sex- determination clinics and abortionists. Nutritional Status On an average, nutritional status of the girl child is poorer than that of the boy. She is provided less amount of food which again is of inferior quality as compared to a boy. Often, it is a practice to postpone onset of puberty in a young girl by restricting her food intake so that parents can buy sufcient time to arrange dowry and a suitable groom for her. In resource-limitied Morbidity and Mortality communities, household responsibilities keep millions of girls out of school. Educational Status Girl Street Child Educating the girls is hailed as the best investment a nation Te girl street child is much worse than her boy counterpart. Yet, education of girls in India She is harassed, sexually abused and often pushed into presents a sordid picture. Many parents do not wish to allow girls Tere should be no discrimination on the basis of sex. A total ban on female feticide in all States and Union Territories needs to be implemented strictly. Girl Child Abuse and Neglect Awareness of importance of various aspects of the girl child, e. She is denied very survival, local languages, posters/cartoons at prominent parts adequate food intake, education, health care, etc. She is brought up to be submissive and docile, playing second of localities, television/radio skits, and street plays, fddle to the brother. Her attitudes are molded in such a discussions/seminars by local bodies at all levels to manner that she herself gets gravely biased against her ensure participation at grassroots level. When she becomes a mother, her treatment Education of girls should be the priority—free to daughters and daughters-in-law becomes a refection of education of all girls upto secondary school level in this unhealthy bias. Girl Child Laborer Improvement of nutritional status—midday school In India alone, there are around eight million working meal program should be introduced in the municipal female children. A special supplement- ation program should be designed for the severely malnourished children. First is the and implemented, especially in regard to sexual forethought which means to anticipate the possible risk to exploitation. Second is time in order to watch the child and his Motivation of adoption of girl children and especially activities.
The underlying cause is low levels of carbon dioxide associated with hyperventilation 500 mg amoxil. Terminally amoxil 250 mg, bouts of such breathing may be interrupted by spells of apnea 250 mg amoxil, the so-called Cheyne-Stokes breathing amoxil 500 mg. Kidneys also enhance excretion of ammonia and other hydro- Management of underlying condition such as diabetes gen ions amoxil 250mg. Simultaneous administration of potassium to safe- Etiology guard against risk of development of hypokalemia is Acute respiratory acidosis may follow airway obstruction strongly recommended amoxil 500mg. Clinical Features Etiology Air-hunger with use of accessory muscles (chest retr- It is caused by: actions) 250mg amoxil. Loss of hydrogen ions (vomiting in hypertrophic pyloric Cardiovascular fndings—tachycardia 500mg amoxil, bounding arte- stenosis , prolonged gastric aspiration) . Treatment Severe hypokalemia causes metabolic alkalosis by It consists in treating the underlying etiologic factor(s) and shifting hydrogen ions into the cells. Etiology Treatment It results from salicylate intoxication, hyperventilation Treatment is indicated only in cases of severe metabolic (hysterical, assisted ventilation on a respirator), hyper- alkalosis with a pH over 7. Clinical Features Severe alkalosis in association with renal failure or hyperos- molar state is an indication for hemo-or peritoneal dialysis, Over and above signs and symptoms of the underlying dis- or renal replacement therapy. At times, unconsciousness may result It means marked reduction in blood pH primarily as a from vasospasm of cerebral vessels because of hypercapnia. On an average, ing use of excessive diuretic therapy in chronic respir- fuid requirement is 100 mL/100 kcal/day. Simultaneous atory acidosis in subjects with heart failure) needs for sodium = 1–3 mEq/100 mL kcal and potassium = 3. A 5% dextrose assists in providing failure) not only energy, but also safeguarding from ketosis and 4. One should suspect a mixed acid-base disturbance Tough no single maintenance fuid is an answer for when the compensatory response falls outside the ex- all clinical situations, Isolyte P meets these conditions to a pected range. Except Defcit Therapy diabetes insipidus, acute kidney injury and heart failure It is mandatory to ascertain the pre-existing defcit, i. Fluid balance Terapy needs to be by fuid, similar in composition Clinical parameters and amount, the quantity and route of administration Biochemical parameters. Replacement of Ongoing Losses In case of severe dehydration (>10% in infants; >6% It is important to replace the ongoing losses (vomiting, in older children), restoration of the intravascular volume diarrhea, suction, aspiration) by fuids that are similar in as early as workable is important. Tis has already been briefy described in this very Chapter Additionally, the child also needs to receive fuids under “Principles of Fluid and Electrolyte Terapy”. Also, and electrolytes as replacement for the amounts lost in See Chapter 29 (Pediatric Gastroenterology). Fluid overload which demands fuid restriction to In order to provide less sodium and more potassium, 2/3rd of the normal requirement. It may be given orally or through nasogas- restriction to 2/3rd volume with extra potassium but tric tube. Intravenous fuid therapy is usually needed in severe dehydration in malnourished child: Pyloric Stenosis Initially, Ringer lactate or N/2 saline in 5% dextrose, Nonbilious progressive vomiting, often projectile and 30 mL/kg in 2 hours occurring soon after a feeding usually after 3 weeks of Ten, N/6 saline in 5% dextrose, 100 mL/kg in next 10 hours age, results in hypochloremic metabolic alkalosis. Tis N/6 saline in 5% dextrose at half the rate in subsequent is the hallmark of hypertrophic pyloric stenosis. Else, the infant is likely to until feeding is established develop potoperative apnea from anesthesia. Sodium 45 90 75 Intestinal Obstruction Potassium 40 20 20 Te gastric juice contains around 60 mEq/L sodium, Chloride 70 80 65 10 mEq/L potassium and 85 mEq/L chloride. Citrate 7 10 10 Te ileal fuid contains over double sodium (130 Magnesium 3 – – mEq/L), same potassium (10 mEq/L) and more chloride (115 mEq/L). Maintenance: Maintenance fuid therapy too is req- uired as per the standard norms. Burns Pending calculated replacement, a beginning should Defcit: Fluid replacement in burns in children more be made with any delay with Ringer lactate or normal than 10 year of age is calculated as per the Parkland saline, 20 mL/kg/hour. Important anions are chloride, bicarbonate, sulfate, organic acids and protein acids D. It is important to replace ongoing losses (vomiting, diarrhea, suction, aspiration) by fuids that are similar in composition and volume 2. C Clinical Problem-solving Review 1 A 5-year-old girl presents with progressively increasing abdominal distention and generalized weakness. Paralytic ileus which is supported by increasing abdominal distention, absent abdominal sounds and multiple fuid levels on imaging. Excess diuresis from frusemide is known to cause hypokalemia which may cause paralytic ileus. Yes, iatrogenic hypokalemia following frusemide therapy is a preventable condition. All that is needed to be done is to give supplements of potassium salt with frusemide. Hypernatremia resulting from excess loss of fuids as a result of diabetes insipidus. Proper care of the newborn babies forms the foun- z Neonatal period: First 28 days after birth z Early neonatal period: First 7 days of life dation for the subsequent life, not only in terms of longe- z Late neonatal period: More than 7th–28 days of life vity or survival, but also in terms of qualitative outcome z Perinatal period: From 28th week of gestation (or over 1000 g of without any mental and physical disabilities. Congenital malformations are utero and died during passage through the birth canal. Serious neonatal infections, also responsible for pseudobulbar palsies and auditory defcits. T e topic around 1/3rd of neonatal deaths, include congenital is discussed under hypoxic-ischemic encephalopathy infections (T)oxoplasmosis, (O)ther agents, (R)ubella, elsewhere in this very Chapter. Te most common site vical roots), Klumpke paralysis (due to involvement of is the parietal or occipital bone. Cephalhema- toma: Collection is blood, between skull bone and overlying pericra- nium, limited by suture line; disappears slowly in a few weeks. Note the shrew like facies due to hypoplastic mandible (micrognathia), glossoptosis and high-arched Fig. Tese conditions are discussed cleft palate and posterior displacement of tongue) and elsewhere in diferent chapters. In this infant, who died within 24 hours of this stillborn baby also had anencephaly and hemicrania, the defects birth, membranous skull as well as cerebral hemisphere were absent. High-risk Situation Maternal: Te situations in relation to high-risk preg- nancy in which the mother is sufering from an adverse factor, e. The Golden Minute Concept According to this concept, if by the end of one minute of ini- tial steps directed at stabilization, satisfactory outcome is not forthcoming, assisted ventilation becomes mandatory. Once positive pressure ventilation or supplementary oxygen admi- nistration is begun, assessment should consist of simultane- ous evaluation of three vital characteristics, namely heart rate, respiration and the state of oxygenation rather than the color (earlier criterion). Te previous guidelines included the question Is the amniotic fuid clear of meconium and evidence of infection? Around 10% newborns need some resuscitation to begin In case answer to all these three questions is yes, the breathing at birth. Understandably, neonatal resuscitation infant is not in need of any resuscitation. If it is no to any is a real emergency, requiring participation of everyone in of the questions, the infant is in need of initial steps in the labor/delivery room. Te fact that 70% of the babies with stabilization which too are a part of resuscitation. Often a good antenatal check-up indicates Resuscitation Equipment whether resuscitation is likely to be needed. A weak fetal It should be obligatory on the part of each and every heart of less than 100 beats/minute or its irregularity during delivery room to maintain an easily accessible neonatal the late stage of labor is a sign of progressive asphyxia that resuscitation tray which is cross-checked and replenished will need resuscitative measures. If there is meconium-stained amni- suction, suction catheters 10 F or 12 F, feeding tube 6 F, 20 mL otic fuid, suction should be done when head is delivered syringe. Tis is termed intrapar- z For bag and mask ventilation: Neonatal resuscitation bag, face tum suctioning. After the delivery of the infant, residual masks (fullterm and preterm sizes), oxygen with fowmeter and meconium in the hypopharynx should be suctioned out tubing. Tactile stimulation: If the depressed baby fails to have z Medications: Epinephrine, normal saline, sodium bicarbonate, respiration despite drying and suctioning, additional naloxone and sterile water. If it A radiant warmer ready for use fails, endotracheal intubation should be performed. All resuscitation equipment immediately available and Endotracheal intubation: It is done after the baby is in good working order delivered to remove secretions from the lower airway. It At least one trained person (preferably two) skilled in is indicated in all babies who are depressed and meco- neonatal resuscitation. An appropriate-sized bag and Over and above the maintenance of temperature, the mask is selected. Then, bagging is started at a rate of 40–60/ should be completed as far as possible within 15 seconds minute for 15–30 seconds, using enough pressure to cause chest of birth. A—Airway: Anticipate and establish an open airway by: Evaluation z Positioning of the neonate. C—Circulation: Maintain the circulation with: z If heart rate less than 80/minute, start chest compressions. Signs of improvement: Opening the Airway z Rising heart rate Positioning: Te neonate should be placed on his z Spontaneous breathing back/ side with the neck slightly extended to straighten z Improving color. Equipment Endotracheal tube of appropriate size, neonatal laryngoscope with straight blades of size 0 for preterms and 1 for term babies. Procedure z The newborn is placed on a resuscitation table (high enough and with fat surface) in a supine position with fully extended neck at the edge of the table. It is good to place folded towel or blanket beneath the shoulders to facilitate this position. As he opens the infant’s mouth with the index fnger and the thumb of the right hand, his left hand introduces the lighted laryngoscope (infant size) into the nasopharynx upto the epiglottis. When lar opening formed by vocal cord and arytenoid cartilage) as viewed the glottis is visible, a curved endotracheal tube is gently inserted through laryngoscope. Make sure that it is not pushed too far to prevent its entry into the right bronchus. If the response is poor, still eforts have got to be contin- third of the sternum that compress the heart against the ued as long as the heart beat exists. Details are given in In order to prevent hypoxia during intubation, provide free fow Box 17. It consists of rhythmic compressions (120/min; ratio 3:1) of lower third of the sternum if heart rate remains <60/minute. In the two-fnger technique, the fnger tips (middle fnger in case of history of maternal narcotic drug administra- with index fnger or ring fnger), one hand are employed to compress tion. The rate of chest compressions should be 120 beats/minute and depth 1–2 Pulse Oximetry cm. During the procedure, fngers of thumbs must never be taken Te new guidelines have emphasized the use of pulse of the sternum in between compressions. Evaluation: Thirty seconds of chest compression should be followed by recheck- Supplementary Oxygen ing of the heart rate. If it is below 80 beats/minute, the procedure should continue along with bag and mask ventilation with 100% oxy- Te new guidelines stress the need for employing room air gen, plus medication (vide text). If heart rate is more than 80/minute, providing 21% oxygen (rather than using 100% oxygen) in stop chest compression but continue ventilation until heart rate both term and preterm infants for better survival. Te same dose z When resuscitation is anticipated z When positive pressure is administered for more than few breaths may be repeated every 5 minutes. Volume expanders: Normal saline, whole blood, 5% z When supplementary oxygen is administered. The breathing efort that follows sucking the nose frst may allow secretions in SpO2 in target range. In case blended oxygen is not avail- the mouth to be suddenly aspirated into the lower airway. Tere- week gestation should be initiated with oxygen (21 to after, it can be titrated to achieve the target Saturation of 30%) and oxygen titrated to achieve preductal oxygen oxygen (SpO ) values. Use of blended air oxygen mixture saturation approximating the range achieved in 2 should be judicious and guided by pulse oximetry. York-based anesthesiologist, in 1953, Apgar score is a Do not in Neonatal Resuscitation quantitative assessment of neonate’s condition at birth, especially with reference to the respiratory, circulatory Tese are listed in Box 17. It is of no use for taking a decision regarding the steps Brushing the soles of the feet stimulates crying and is of resuscitation. Apgar scoring system is employed to plan management of the newborn after resuscitation has been accomplished. Physical Characteristics Simple measures to prevent hypothermia in frst hours of life (use of plastic wraps, skin-to-skin contact and Te normal fullterm newborn weighs around 3. Routine intubation for tracheal suction is no longer Te head circumference is about 35 cm (range 32. Assessment of heart rate remains critical during frst Te chest circumference is approximately 3 cm less minute of resuscitation. Miscellaneous z Posture is of partial fexion z Palpability of liver and spleen is usual z Palpability of kidneys may be present in some z Sinuses are small and underdeveloped z Only solitary mastoid cell in antrum Fig. Ear drum placed more American Heart Associatioin/American Academy of Pediatrics recom- obliquely mendations of 2015. Te external auditory canal is relatively short and rounded rather than fattened anteroposteriorly. In other words the trunk is relatively larger and the Te maxillary and ethmoid sinuses are small. Te midpoint of the length (stature), frontal and sphenoidal sinuses are poorly developed. Te traumatic efects of labor may be encountered in the 35,000/mm ) on frst couple of days after birth.
Demonstration of dual A-V nodal pathways in patients with paroxysmal supraventricular tachycardia amoxil 250mg. Demonstration of dual atrioventricular nodal pathways utilizing a ventricular extrastimulus in patients with atrioventricular nodal re-entrant paroxysmal supraventricular tachycardia 250 mg amoxil. Double atrial responses to a single ventricular impulse due to simultaneous conduction via two retrograde pathways amoxil 500 mg. Morphology of the cardiac conduction system in patients with electrophysiologically proven dual atrioventricular nodal pathways 500 mg amoxil. Treatment of supraventricular tachycardia due to atrioventricular nodal reentry amoxil 250 mg, by radiofrequency catheter ablation of slow-pathway conduction 500mg amoxil. Elimination of atrioventricular nodal reentrant tachycardia using discrete slow potentials to guide application of radiofrequency energy amoxil 500mg. Clinical 250mg amoxil, electrocardiographic and electrophysiologic observations in patients with paroxysmal supraventricular tachycardia . The essential role of atrioventricular conduction delay in the initiation of paroxysmal supraventricular tachycardia . Comparison of right and left atrial stimulation in demonstration of dual atrioventricular nodal pathways and induction of intranodal reentry. Effect of atrial stimulation site on the electrophysiological properties of the atrioventricular node in man. Effects of the pacing site on A-H conduction and refractoriness in patients with short P-R intervals. Multiple anterograde atrioventricular node pathways in patients with atrioventricular node reentrant tachycardia. The effects of propranolol on induction of A-V nodal reentrant paroxysmal tachycardia. Concealed bypasses of the atrioventricular mode in patients with paroxysmal supraventricular tachycardia revealed by intracardiac electrical stimulation and verapamil. Effect of digitalis in patients with paroxysmal atrioventricular nodal tachycardia. Antegrade and retrograde conduction characteristics in three patterns of paroxysmal atrioventricular junctional reentrant tachycardia. Observations in patients with supraventricular tachycardia having a P-R interval shorter than the R-P interval: differentiation between atrial tachycardia and reciprocating atrioventricular tachycardia using an accessory pathway with long conduction times. Determinants of tachycardia induction using ventricular stimulation in dual pathway atrioventricular nodal reentrant tachycardia. The determinants of atrioventricular nodal re-entrance with premature atrial stimulation in patients with dual A-V nodal pathways. Effects of atropine on induction and maintenance of atrioventricular nodal reentrant tachycardia. Initiation of atrioventricular nodal reentrant tachycardia in patients with discontinuous anterograde atrioventricular nodal conduction curves with and without documented supraventricular tachycardia: observations on the role of a discontinuous retrograde conduction curve. Analysis of anterograde and retrograde fast pathway properties in patients with dual atrioventricular nodal pathways: observations regarding the pathophysiology of the Lown-Ganong- Levine syndrome. Nonuniform anisotropy is responsible for age-related slowing of atrioventricular nodal reentrant tachycardia. Sequence of retrograde atrial activation in patients with dual atrioventricular nodal pathways. Presence and significance of the left atrionodal connection during atrioventricular nodal reentrant tachycardia. Classification and differential diagnosis of atrioventricular nodal re-entrant tachycardia. Classification of electrophysiological types of atrioventricular nodal re-entrant tachycardia: a reappraisal. Incidence, determinants and significance of fixed retrograde conduction in the region of the atrioventricular node. Entrainment of atrioventricular nodal reentrant tachycardias during overdrive pacing from high right atrium and coronary sinus. With special reference to atrioventricular dissociation and 2:1 retrograde block during tachycardias. Retrograde block during dual pathway atrioventricular nodal reentrant paroxysmal tachycardia. Unmasking and modulation of the excitable gap in atrioventricular nodal reentrant tachycardia: new insight into the microreentry substrate. Atrioventricular nodal reentrant tachycardia: studies on upper and lower ‘common pathways’. High resolution mapping and dissection of the triangle of Koch in canine hearts: evidence for subatrial reentry during ventricular echoes. Paroxysmal supraventricular tachycardia with Wenckebach block: evidence for reentry within the upper portion of the atrioventricular node. Atrioventricular nodal supraventricular tachycardia with 2:1 block above the bundle of His. Electrophysiologic characteristics and radiofrequency catheter ablation in atrioventricular node reentrant tachycardia with second-degree atrioventricular block. Atrioventricular nodal reentry tachycardia: electrophysiologic comparisons in patients with and without 2:1 infra-His block. Atrioventricular block in the atypical form of junctional reciprocating tachycardia: evidence supporting the atrioventricular node as the site of reentry. The effects of ouabain on induction of atrioventricular nodal re-entrant paroxysmal supraventricular tachycardia. Effects of oral verapamil in patients with atrioventricular reentrant tachycardia incorporating an accessory pathway. Acute and chronic effects of verapamil in patients with paroxysmal supraventricular tachycardia. Effect of verapamil on retrograde conduction in atrioventricular nodal reentrant tachycardia. Termination of paroxysmal supraventricular tachycardia with a single oral dose of diltiazem and propranolol. Adenosine: electrophysiologic effects and therapeutic use for terminating paroxysmal supraventricular tachycardia. Acute management of paroxysmal supraventricular tachycardia: verapamil, adenosine triphosphate or adenosine? Comparative clinical and electrophysiologic effects of adenosine triphosphate and verapamil on paroxysmal reciprocating junctional tachycardia. Effects of procainamide on atrioventricular nodal re-entrant paroxysmal tachycardia. Serial electrophysiologic testing of multiple drugs in patients with atrioventricular nodal reentrant paroxysmal tachycardia. Effects of oral disopyramide phosphate on induction of paroxysmal supraventricular tachycardia. Effects of intravenous and oral disopyramide on paroxysmal atrioventricular nodal tachycardia. Effects of propafenone on induction and maintenance of atrioventricular nodal reentrant tachycardia. The effects of carotid sinus pressure in re-entrant paroxysmal supraventricular tachycardia. Electrophysiologic characteristics of concealed bypass tracts: clinical and electrocardiographic correlates. Observations in patients showing A-V junctional echoes with a shorter P-R than R-P interval. Anatomic and electrophysiologic substrate of the permanent form of junctional reciprocating tachycardia. Tachycardia-induced cardiomyopathy: a reversible form of left ventricular dysfunction. Reversibility of tachycardia-induced cardiomyopathy after cure of incessant supraventricular tachycardia. Concealed retrograde bypass tracts and enhanced atrioventricular nodal conduction. An unusual subset of patients with refractory paroxysmal supraventricular tachycardia. Sudden sinus slowing with junctional escape: a common mode of initiation of juvenile supraventricular tachycardia. Localization of the accessory pathway in the Wolff-Parkinson-White syndrome from the ventriculo-atrial conduction time of right ventricular apical extrasystoles. A technique for the rapid diagnosis of atrial tachycardia in the electrophysiology laboratory. First postpacing interval after tachycardia entrainment with correction for atrioventricular node delay: a simple maneuver for differential diagnosis of atrioventricular nodal reentrant tachycardias versus orthodromic reciprocating tachycardias. Differentiation of atypical atrioventricular node re-entrant tachycardia from orthodromic reciprocating tachycardia using a septal accessory pathway by the response to ventricular pacing. Para-Hisian entrainment: a novel pacing maneuver to differentiate orthodromic atrioventricular reentrant tachycardia from atrioventricular nodal reentrant tachycardia. A new criterion reliably distinguishes atrioventricular nodal reentrant from septal bypass tract tachycardias. Identification of concealed posteroseptal Kent pathways by comparison of ventriculoatrial intervals from apical and posterobasal right ventricular sites. Role of extrastimulus site and tachycardia cycle length in inducibility of atrial preexcitation by premature ventricular stimulation during reciprocating tachycardia. Electrophysiologic mechanisms of functional bundle branch block at onset of induced orthodromic tachycardia in the Wolff-Parkinson-White syndrome. Ventriculo-atrial conduction time during reciprocating tachycardia with intermittent bundle-branch block in Wolff-Parkinson-White syndrome. Changes in ventriculoatrial intervals with bundle branch block aberration during reciprocating tachycardia in patients with accessory atrioventricular pathways. Dissociation of atrial electrograms by right and left atrial pacing in patients with atrioventricular reciprocating tachycardia. Ventricular fusion during resetting and entrainment of orthodromic supraventricular tachycardia involving septal accessory pathways. The preexcitation index: an aid in determining the mechanism of supraventricular tachycardia and localizing accessory pathways. Retrograde atrial preexcitation following premature ventricular beats during reciprocating tachycardia in the Wolff-Parkinson-White syndrome. Spontaneous termination of circus movement tachycardia using an atrioventricular accessory pathway: incidence, site of block and mechanisms. Observations on mechanisms of circus movement tachycardia in the Wolff- Parkinson-White syndrome. Role of different tachycardia circuits and sites of block in maintenance of tachycardia. Spontaneous termination of paroxysmal supraventricular tachycardia following disappearance of bundle branch block ipsilateral to a concealed atrioventricular accessory pathway: the role of autonomic tone in tachycardia diagnosis. Effect of verapamil studied by programmed electrical stimulation of the heart in patients with paroxysmal re-entrant supraventricular tachycardia. Blocking effect of verapamil on conduction over a catecholamine- sensitive bypass tract in exercise-induced Wolff-Parkinson-White syndrome. Beneficial effect of intravenous diltiazem in the acute management of paroxysmal supraventricular tachyarrhythmias. Comparison of the electrophysiologic effects of intravenous and oral verapamil in patients with paroxysmal supraventricular tachycardia. Verapamil-induced retrograde conduction block in a concealed atrioventricular bypass tract. Effects of oral disopyramide phosphate on induction and sustenance of atrioventricular reentrant tachycardia incorporating retrograde accessory pathway conduction. Clinical efficacy and electrophysiologic effects of intravenous and oral encainide in patients with accessory atrioventricular pathways and supraventricular arrhythmias. Suppression of incessant supraventricular tachycardia by intravenous and oral encainide. Repetitive supraventricular tachycardia: clinical manifestations and response to therapy with amiodarone. Demonstration of sustained sinus and atrial re-entry as a mechanism of paroxysmal supraventricular tachycardia. Sustained symptomatic sinus node reentrant tachycardia: incidence, clinical significance, electrophysiologic observations and the effects of antiarrhythmic agents. Electrophysiological characteristics, pharmacological response, possible mechanisms, and effects of radiofrequency ablation. Comparison of resetting and entrainment of uniform sustained ventricular tachycardia. Electrophysiologic and pharmacologic characteristics of automatic ectopic atrial tachycardia. Ectopic automatic atrial tachycardia in children: clinical characteristics, management and follow-up. Reversibility of left ventricular dysfunction after successful catheter ablation of supraventricular reentrant tachycardia. Time course of improvement in ventricular function after ablation of incessant automatic atrial tachycardia. Regression of a dilated cardiomyopathy after radiofrequency ablation of incessant supraventricular tachycardia. Multiple reentrant tachycardias due to retrograde conduction of dual atrioventricular bundles with atrioventricular nodal-like properties. Participation of fast and slow A-V nodal pathways in tachycardias complicating the Wolff-Parkinson-White syndrome.
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