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Professionalism Goals the senior trauma resident will carry out professional responsibilities, adhere to ethical principles, and demonstrate sensitivity to patients of diverse backgrounds. Systemsbased Practice Goals the senior trauma resident will demonstrate an awareness of and responsiveness to the larger context and system of health care. Furthermore, the senior trauma resident will effectively call on other resources in the system to provide optimal health care. Our primary goal is superior care of patients with musculoskeletal lesions and total commitment to returning people to a useful life. Patient Care Goals the senior tumor resident will experience inpatient, outpatient, and surgical care of patients with musculoskeletal tumors under staff supervision. Objectives - Participate in Outpatient evaluation of new and return oncology service patients; - Demonstrate a refined and advanced patient care evaluation of patients with suspected bone and softtissue tumors, such as: Able to take a detailed history, complete an appropriate and accurate physical exam, and review appropriate imaging studies to allow integration of information to formulate an appropriate diagnosis and treatment plan including observation, additional imaging or operative intervention; - Possesses advanced physical exam skills that permit the detection of distant sites of disease, familial syndromes, and other clues that assist in making a diagnosis; - Demonstrates basic understanding of the appropriate indications for nonoperative versus operative treatment. Specifically understands the role and timing of biopsy and the options regarding biopsy of a softtissue mass or bone lesion; - Is familiar with common limb salvage techniques and capable of directing a biopsy site that will facilitate future limb salvage procedures; - Possesses and is able to apply an appropriate understanding of the expected postoperative progression and rehabilitation of patients following common tumor resections, amputations and limb salvage surgeries; - Able to recommend strategies to minimize the possibility of pathologic fracture; - Demonstrates ability to perform incisional and percutaneous biopsies of bone and softtissue masses, amputations of the lower extremity and prophylactic internal fixation of lower extremity metastases independently; - Possesses and demonstrates more advanced and refined surgical skills with faculty supervision appropriate to level of training including advanced tumor resection and reconstructive skills; Wide Resection of the Distal Femur, Proximal Femur. Medical Knowledge Goals the senior tumor resident will obtain specific knowledge in problems related to trauma. Objectives - Possesses in depth knowledge of the pathogenesis and behavior of common bone and softtissue tumors; - Possesses a strong working knowledge of biopsy alternatives and techniques including common limb salvage approaches; - Recognize incidentally noted bone and softtissue lesions that merit observation as opposed to intervention; - Advanced ability to interpret the results of imaging studies in order to arrive at a narrow differential diagnosis; - Able to recommend a strategy for evaluating an adult with a malignant appearing bone lesion including the correct tests and images to detect a primary tumor, metastatic disease, or myeloma; - Demonstrates an understanding of the various surgical options to treat benign, malignant and metastatic bone and softtissue tumors. And to recommend a specific treatment approach including adjuvant therapy; - Demonstrate the ability to accurately stage a patient with neoplastic disease; - Ability to delineate those factors place a patient at risk of pathologic fracture;. Practicebased Learning and Improvement Goals the senior tumor resident will appraise and assimilate scientific evidence for patient care. Professionalism Goals the senior tumor resident will carry out professional responsibilities, adhere to ethical principles, and demonstrate sensitivity to patients of diverse backgrounds. Objectives - Maintains the strictest confidence in any and all interactions dealing with all patients; - Demonstrates respect, compassion and integrity in response to the needs of patients and their families; - Demonstrates ethical principles pertaining to patient confidentiality issues; - Demonstrates sensitivity to the culture, age, gender and disabilities of patients; - Demonstrates ability to break bad news in an empathetic way that is informative and reassuring to the patient and their family; - Maintains contact with patient and family through end of life issues as appropriate; - Promptly recognizes and acknowledges complications that arise; - Maintain adequate documentation and timely completion of medical records; - Complete teaching and rotation evaluations 167 Systemsbased Practice Goals the senior tumor resident will demonstrate an awareness of and responsiveness to the larger context and system of health care. Objectives - Maintains the strictest confidence in any and all interactions dealing with all patients; - Demonstrates knowledge of indications and their impact on costeffectiveness and efficiency of patient care; - Acts as an advocate for quality of patient care; - Able to assess, coordinate and improve the care of patients within the current health care model(s) or systems in the program; - Work as a effective member of a multidisciplinary team including radiologists, pathologists, medical oncologists and radiation oncologists; - Complete all requirements for compliance, risk management, and safety education. Patient Care Goals the senior spine resident will experience inpatient, outpatient, and surgical care of spine patients under staff supervision. Objectives - Make patient treatment decisions and possess a basic understanding of indications for surgical procedures with various elective pathologies as well as nonelective pathologies; - Possess an understanding of indications for surgical treatment of idiopathic scoliosis, congenital scoliosis, congenital kyphosis, various types of spondylolisthesis, various types of fractures, various types of tumors, and infections of the spine; - Perform a complete musculoskeletal and neurologic examination, including the cervical spine, thoracic spine and lumbar spine, including neurologic examination of the upper and lower extremities and be able to explain pathologies such as an absent reflex or long tract signs such as positive Hoffmann or positive Babinski and/or clonus; - Effectively participates in the decisionmaking process of issues on inhospital patients; - Display competency in performing a full office patient examination, providing a differential diagnosis and treatment plan; - Exhibit competency in exposing the spine posteriorly, performing straightforward decompressions with Kerrison posteriorly. Achieve proficiency with first assisting on operative procedures; - Effectively communicate and demonstrates care and respectful behavior when interacting with patients and families; - Demonstrate the ability to practice culturally competent medicine; - Use information technology to support patient care decisions and patient education; - Provide health care services aimed at preventing health problems or maintaining health; - Work with other health care professionals from various disciplines to provide excellent patient focused care. Practicebased Learning and Improvement Goals the senior spine resident will appraise and assimilate scientific evidence for the care of patients with spine injuries. Objectives Create and sustain a therapeutic and ethically sound relationship with patients and their families; Effectively use listening skills; Effectively provide information via various methods; Work effectively with others as a member or leader of a health care team. Professionalism Goals the senior spine resident will carry out professional responsibilities, adhere to ethical principles, and demonstrate sensitivity to patients of diverse backgrounds. Objectives - Interact in a professional manner with inpatients, outpatients, referring physicians, orthopaedic residents, attendings and all patients in the practice; - Interact effectively with both hospital patients and outpatients; - Possess some competency in effectively managing hospital patients; - Demonstrate respect, compassion and integrity in response to the needs of patients and their families; - Demonstrate ethical principles pertaining to patient confidentiality issues; - Demonstrate sensitivity to the culture, age, gender and disabilities of patients and fellow health care professionals. Systemsbased Practice Goals the senior spine resident will demonstrate an awareness of and responsiveness to the larger context and system of health care. Furthermore, the spine resident will effectively call on other resources in the system to provide optimal health care. Objectives - Demonstrate competency in coordinating all aspects of perioperative and postoperative rehabilitation and physical therapy; 171 - Demonstrate an understanding of how his/her patient care and other professional practices affect other health care professionals, the health care organization, and the larger society, and how these elements of the system affect his/her own practice; - Demonstrate knowledge of how the different types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources; - Practice costeffective health care and resource allocation that does not compromise quality of care; - Demonstrate an understanding the impact of correct coding during patient office visits; - Acts as an advocate for quality patient care and assists patients in dealing with system complexities; - Effectively partners with health care managers and health care providers to assess, coordinate and improve health care, and know how these activities can affect system performance. Our primary goal is superior care of patients with upper extremity injuries and total commitment to returning people to useful life. Patient Care Goals the senior hand resident will experience inpatient, outpatient, and surgical care of upper extremity patients under staff supervision. Objectives - Demonstrate mastery of all elements in the realm of patient care as described for the junior level resident; - Demonstrate the ability and maturity to directly supervise the junior level resident; - Effectively follows all inpatients and any patients seen in the emergency room including ensuring appropriate follow up after discharge; - Demonstrate expertise in obtaining a history and physical examination in patients with hand and upper extremity conditions and disorders; - Utilize information gathered in the history and exam to effectively generate a pertinent differential diagnosis, order necessary radiographic evaluations most appropriate to the differential diagnosis, and be able to formulate an appropriate treatment plan based on the information gathered. Medical Knowledge Goals the senior hand resident will obtain specific knowledge in problems related to upper extremity injuries.

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Lastly, the Adell study population was composed of edentulous patients whereas 8 of 20 of Lekholm patients were partially edentulous. Both groups reported increased recession, with the same mean bridge to gingiva distance (3. Attached gingiva was present in 65% (Adell) and 51% (Lekholm) of all buccal and lingual surfaces. Probing depths were generally low, with none > 5 mm in the Adell group and 15% > 6 mm in the Lekholm study. Both groups reported minimal histological inflammation, with no inflammation in 49% of the biopsies and slight inflammation in 33% (combined results). Currently, mobility and radiographic bone loss represent the most reliable methods of detecting implant failure (Newman and Flemmig, 1988). Bacterial adherence to enamel and titanium seem to differ, with titanium exhibiting a 5-fold decrease in adherence of Actinomyces viscosus and a slight decrease in adherence of Streptococcus sanguis (Wolinsky et al. In a study evaluating colonization of newly exposed titanium implants, Mombelli et al. Eighty percent (80%) of the cultivated bacteria were Gram-positive facultative cocci. The authors concluded that in health, the subgingival implant microbiota were similar to that of the natural healthy dentition. In the partially edentulous group, there was no significant predilection for any type of bacteria at either the implant or tooth sites. The authors suggested that the differences between edentulous and partially edentulous implant sites may be the result of contamination of the peri-implant sites by pathogens from periodontal pockets. Non-motile rods, filaments, and fusiforms comprised 50% of the microflora in partially edentulous healthy implant and tooth sites. Few spirochetes, and no Actinobacillus actinomycetemcomitans, Bacteroides gingivalis, or Prevotella intermedia were noted around implant sites. As inflammation and probing depths (> 5 mm) increase, elevated levels of spirochetes and decreases in coccoid cells are noted (Rams et al. An increase in the number of Gram-negative anaerobic flora is observed, with equal proportions of Bacteroides, Fusobacterium, and vibrios (Newman and Flemmig, 1988). Failing implants have been associated with a florium which differs from that seen in health. An increase in spirochetes (31 to 56%) and motile rods (15 to 31%) with a decrease in coccoid cells (19 to 31%) was reported. The microflora associated with failing implants are very similar to that of periodontal disease. The composition of implant-associated plaque was consolidated and presented in chart form by Newman and Flemmig (1988) (See Table 1). The criteria for success may differ between studies, with many of the earlier studies not including implants that failed, but the prostheses were retained or implants left sleeping as failures. More recent studies have determined success based on a lack of mobility and lack of peri-implant radiographic radiolucency. Albrektsson (1986) proposed the following criteria for evaluation of implant success: 1) no clinical mobility; 2) no radiographic peri-implant radiolucencies; 3) < 0. The Branemark implant system has been extensively evaluated with multiple long-term studies from various investigators and centers. Adell and co-workers (1981) reported 5 to 9 year single-center success rates of 91% for the mandible and 81% for the maxilla. Seventyeight percent (78%) of the mandibular failures occurred during the first year and 13% during the second year. Implant placement in partially edentulous patients was evaluated by van Steenberghe et al. This 9-center study, which included 558 consecutively placed implants, showed a 1-year success rate of 96%.

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The four symptoms and signs include (1) a unilateral, fluctuating sensorineural hearing loss (often involving low frequencies); (2) vertigo that lasts minutes to hours; (3) a constant or intermittent tinnitus typically increasing in intensity before or during the vertiginous attack; and (4) aural fullness. The acute attack is also associated with nausea and vomiting and, following the acute attack, patients feel exhausted for a few days. As emphasized in the diagnostic scale, the diagnosis of Meniere disease is based on the longitudinal course of the disease rather than on a single attack. Electrophysiologic studies, other serologic studies, and imaging are obtained as needed. Initially, autoimmune ear disease may be clinically indistinguishable from Meniere disease. The caloric response decreases during the first decade of the disease and usually stabilizes at 50% of normal function. The distinguishing characteristics of an autoimmune ear disease include a more aggressive course and early bilateral involvement. An imaging scan is not mandatory, with a classical course of Meniere disease leading to a clinical diagnosis. Imaging should be used if the initial presentation or course is unusual and nonmedical management is planned. Hearing may be temporarily improved or stabilized by the current treatments, but the hearing does not have long-term stability. Dietary modifications and vestibular suppressants-The primary management of Meniere disease involves a sodium-restricted diet (1500 mg/d) and diuretics (eg, Diazide). In a crossover placebo study of Diazide, it was shown that diuretics seem to improve vestibular complaints but have no effect on hearing or tinnitus. Some patients benefit from dietary restrictions on caffeine, nicotine, alcohol, and foods containing theophylline (eg, chocolate). Acute attacks are managed with vestibular suppressants (eg, meclizine and diazepam [Valium]) and antiemetic medications (eg, prochlorperazine [Compazine] D. Audiology-Audiologic assessment initially shows a low-frequency or a low- and high-frequency (inverted V) sensorineural hearing loss. A glycerol dehydration test involves measuring serial pure-tone thresholds and discrimination scores during diuresis. Aminoglycoside therapy-Medically refractory patients with or without serviceable hearing may benefit from intratympanic gentamicin therapy. Intratympanic gentamicin is absorbed into the inner ear primarily via the round window and selectively damages the vestibular hair cells relative to the cochlear hair cells. Gentamicin may also decrease endolymph production by affecting dark cells in the stria vascularis. Intratympanic gentamicin has nearly a 90% vertigo control rate with a follow-up of at least 2 years; the extent of hearing loss depends on the protocol for gentamicin delivery. A variety of treatment protocols (daily, biweekly, weekly, or monthly injections) using fixed-dose or titration end-point regimens exist but a few trends are present. However, the risk of hearing loss increases as the total dose and frequency of gentamicin injections are increased. Current protocols are reducing the dose and frequency of injections to decrease hearing loss and still obtain vertigo control. Vertigo control may be obtained with some residual vestibular function, and this residual function may be useful if patients develop bilateral Meniere disease. Recent studies with monthly injections have shown a nearly 90% vertigo control with a 17% (< 10 dB) hearing loss. Steroid therapy-Acute exacerbation of Meniere disease may respond to a short burst of oral steroids. Intratympanic steroids have also been used to treat active disease and avoid the systemic complications associated with oral steroids.

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Little antigen is released, and the infection probably remains hidden from the immune response. Cell-mediated immunity appears to play little or no role in protection against rabies virus infection. The incubation period is usually long enough to allow generation of a therapeutic protective antibody response after active immunization with the killed rabies vaccine. Epidemiology Rabies is the classic zoonotic infection spread from animals to humans (Box 50-3). In urban rabies, dogs are the primary transmitter, and in sylvatic (forest) rabies, many species of wildlife can serve as transmitters. In the United States, rabies is more prevalent in cats because they are not vaccinated. Virus-containing aerosols, bites, and scratches from infected bats also spread the disease. In Latin America and Asia, this feature is a problem because of the existence of many stray unvaccinated dogs and the absence of rabiescontrol programs. Although rare, there are cases of rabies transmission via corneal and organ transplants. Because of the excellent dog vaccination program in the United States, sylvatic rabies accounts for most of the cases of animal rabies in this country. Statistics for animal rabies are collected by the Centers for Disease Control and Prevention, which in 1999 recorded more than 8000 documented cases of rabies in raccoons, skunks, bats, and farm animals, in addition to dogs and cats (Figure 50-3). In South America, vampire bats transmit rabies to cattle, resulting in losses of millions of dollars each year. Although underreported, it is estimated that rabies accounts for 55,000 deaths (mostly children) annually worldwide, with at least 20,000 deaths in India, where the virus is Percent transmitted by dogs in 96% of cases. In Latin America, cases of human rabies primarily result from contact with rabid dogs in urban areas. In Indonesia, an outbreak of more than 200 human cases of rabies in 1999 prompted the killing of more than 40,000 dogs on the islands. The incidence of human rabies in the United States is approximately one case per year, due in large part to effective dog vaccination programs and limited human contact with skunks, raccoons, and bats. Since 1990, human cases of rabies in the United States have been caused primarily by bat variants of the virus. The World Health Organization estimates that 10 million people per year receive treatment after exposure to animals suspected of being rabid. After a long but highly variable incubation period, the prodrome phase of rabies ensues (Table 50-1). The patient has symptoms such as fever, malaise, headache, pain or paresthesia (itching) at the site of the bite, gastrointestinal symptoms, fatigue, and anorexia. The prodrome usually lasts 2 to 10 days, after which the neurologic symptoms specific to rabies appear. Hydrophobia (fear of water), the most characteristic symptom of rabies, occurs in 20% to 50% of patients. Focal and generalized seizures, disorientation, and hallucinations are also common during the neurologic phase. Paralysis (15% to 60% of patients) may be the only manifestation of rabies and may lead to respiratory failure. This phase almost universally Box 50-4 Clinical Summary Rabies: A 3-year-old girl was found to have a bat flying in her bedroom. There was no evidence of any bite wound or contact, and the bat was caught and released. Three weeks later, the child developed a change in behavior, becoming irritable and agitated. This state quickly progressed to confusion, uncontrollable thrashing about, and inability to handle her secretions. Laboratory Diagnosis the occurrence of neurologic symptoms in a person who has been bitten by an animal generally establishes the diagnosis of rabies. Unfortunately, evidence of infection, including symptoms and the detection of antibody, does not occur until it is too late for intervention.

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Parasites that cannot form cysts must rely on direct transmission from host to host or require an arthropod vector to complete their life cycles (see Table 68-4). In addition to cyst formation, many protozoan parasites have developed elaborate immunoevasive mechanisms that allow them to respond to attack by the host immune system by continuously changing their surface antigens, thus ensuring continued survival within the host. Reproduction among the protozoa is generally by simple binary fission (merogony), although the life cycle of some protozoa. Animalia (Metazoa) Helminths the nutritional requirements of helminthic parasites are met by active ingestion of host tissue, fluids, or both, with resultant tissue destruction, or by more passive absorption of nutrients from the surrounding fluids and intestinal contents (see Table 68-3). The muscular motility of many helminths expends considerable energy, and the worms rapidly metabolize carbohydrates. Nutrients are stored in the form of glycogen, the content of which is high in most helminths. Similar to respiration in protozoa, respiration in helminths is primarily anaerobic, although the larval forms may require oxygen. A significant proportion of the energy requirement of helminths is dedicated to supporting the reproductive process. In general, helminthic parasites lay eggs (oviparous), although a few species may bear live young (viviparous). The resulting larvae are always morphologically distinct from the adult parasites and must undergo several developmental stages or molts before attaining adulthood. The major protective barrier for most helminths is the tough external layer (cuticle or tegument). Worms may also secrete enzymes that destroy host cells and neutralize immunologic and cellular defense mechanisms. Similar to protozoan parasites, some helminths possess the ability to alter the antigenic properties of their external surfaces and thus evade the host immune response. This is accomplished in part by incorporating host antigens into their external cuticular layer. The amebae, ameboflagellates, and certain other protozoa accomplish this assimilation by the rather primitive process of pinocytosis or phagocytosis of soluble or particulate matter (see Table 68-3). The flagellates and ciliates generally ingest food at a definitive site or structure, the peristome or cytostome. The ingested food material may be retained in intracytoplasmic granules or vacuoles. Arthropods Arthropods have segmented bodies, paired jointed appendages, and well-developed digestive and nervous systems. Cyst Cyst Oocyst Oocyst Trophozoite Indirect (fecal-oral) Direct (venereal) Fecal-oral route Fecal-oral route Fecal-oral route Fecal-oral route Fecal-oral route Direct (venereal) route Direct inoculation, inhalation Anopheles mosquito Ixodes tick Fecal-oral route, carnivorism Phlebotomus sandfly Reduviid bug Tsetse fly Fecal-oral route Fecal-oral route Fecal-oral route Fecal-oral route Direct skin penetration from contaminated soil Direct skin penetration, autoinfection Direct skin penetration, autoinfection Carnivorism Mosquito Mosquito Chrysops fly Biting midges or blackflies Simulium blackfly Ingestion of infected Cyclops Mosquito Ingestion of metacercaria encysted on aquatic plants Metacercaria on water plants Metacercaria encysted in freshwater crustaceans Worldwide Worldwide Worldwide Worldwide Worldwide Worldwide Worldwide Worldwide Tropical and subtropical areas North America, Europe Worldwide Tropical and subtropical areas North, Central, and South America Africa Worldwide Areas of poor sanitation Worldwide Worldwide Tropical and subtropical areas Tropical and subtropical areas Tropical and subtropical areas Worldwide Tropical and subtropical areas Tropical and subtropical areas Africa Africa, Central and South America Africa, Central and South America Africa, Asia Japan, Australia, United States China, Southeast Asia, India Worldwide Asia, Africa, India, Latin America UrogenitalProtozoa Trichomonas vaginalis BloodandTissueProtozoa Naegleria and Acanthamoeba spp. Trypanosoma cruzi Trypanosoma brucei Sporozoite Pyriform body Oocysts and tissue cysts Promastigote Trypomastigote Trypomastigote Egg Egg Egg Egg Filariform larva Filariform larva Filariform larva Encysted larva in tissue Third-stage larva Third-stage larva Filariform larva Third-stage larva Third-stage larva Third-stage larva Third-stage larva Metacercaria Metacercaria Metacercaria Metacercaria Nematodes Enterobius vermicularis Ascaris lumbricoides Toxocara spp. Trichuris trichiura Ancylostoma duodenale Necator americanus Strongyloides stercoralis Trichinella spiralis Wuchereria bancrofti Brugia malayi Loa loa Mansonella spp. Cercaria Direct penetration of skin by freeswimming cercaria Africa, Asia, India, Latin America Cestodes Taenia solium Taenia saginata Diphyllobothrium latum Echinococcus granulosus Echinococcus multilocularis Hymenolepsis nana Hymenolepsis diminuta Dipylidium caninum Cysticercus, embryonated Ingestion of infected pork; ingestion of egg or proglottid egg (cysticercosis) Cysticercus Sparganum Embryonated egg Embryonated egg Embryonated egg Cysticercus Cysticercoid Ingestion of cysticercus in meat Ingestion of sparganum in fish Ingestion of eggs from infected canines Ingestion of eggs from infected animals, fecal-oral route Ingestion of eggs, fecal-oral route Ingestion of infected beetle larvae in contaminated grain products Ingestion of infected fleas Pork-eating countries: Africa, Southeast Asia, China, Latin America Worldwide Worldwide Sheep-raising countries: Europe, Asia, Africa, Australia, United States Canada, Northern United States, Central Europe Worldwide Worldwide Worldwide Sexes are separate. Respiration by aquatic forms is via gills and by terrestrial forms is via tubular body structures. Physicians today must be prepared to answer questions from patients about protection from malaria and the risks of drinking water and eating fresh fruits and vegetables in remote areas where they may be traveling. With this knowledge of parasitic diseases, the physician can also evaluate signs, symptoms, and incubation periods in returning travelers, make a diagnosis, and begin treatment for a patient with a possible parasitic disease. The risks of parasitic diseases in immunosuppressed individuals and those with acquired immunodeficiency syndrome must also be understood and taken into account. Proper education regarding parasitic diseases in medical curricula cannot be overemphasized as a requirement for physicians whose practice includes travelers to foreign countries and refugee populations. Many of the important parasites responsible for human diseases are transmitted by arthropod vectors or are acquired by consumption of contaminated food or water. The various modes of transmission and distribution of parasitic diseases are presented in appropriate detail in the following chapters; however, the data in Table 68-4 are provided as an outline. Which morphologic form is important in the transmission of protozoa from host to host?

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When comparing single-rooted to multi-rooted teeth, there was a trend for slightly better results for single-rooted teeth. These similar results can be maintained over time in patients with proper oral hygiene levels. Probing depths shallower than the critical probing depth tend to lose attachment following the procedure. The results also showed that the level of oral hygiene established during healing and maintenance is more critical for the resulting probing depths and attachment levels than the mode of treatment used. Sites with initial probing depth exceeding 3 mm responded equally well to non-surgical and surgical treatment. One side of both the maxilla and the mandible were treated with modified Widman flap. Patients were recalled every 2 weeks, and examination was performed at 3 and 6 months after the completion of treatment. Lateral incisors, canines, and premolars in the maxilla and mandible in 16 patients diagnosed with advanced periodontitis were used for study. The plaque index and bleeding on probing were assessed prior to and 3, 6, and 12 months after treatment. Probing depths and clinical attachment levels were assessed prior to and 1 year after treatment. Radiographs were taken using the bisecting angle technique before and 1 year after treatment, and the bone level was expressed as a percentage of the distance from the apex of the tooth to the normal bone level. Angular bony defects corresponding to 15% or more of the distance between the normal level of the bone and the apex of the involved tooth were located. Sixteen (16) patients with advanced periodontitis were subjected to supra- and subgingival scaling and oral hygiene instructions. Patients were then recalled regularly for the next 5 years Surgical and non-surgical treatment resulted in pocket reduction which was maintained over the 5 years. No correlation was found between oral hygiene and recurrence of periodontitis, suggesting subgingival scaling at frequent recalls is an important factor in halting the progression of disease. The results reported are essentially the same as those reported by the university studies, thus confirming the validity of university research and its applicability to the private practice setting. The study population consisted of 16 patients with 2 or more sites with > 6 mm of clinical attachment loss in the posterior dentition. All patients had a baseline examination including the plaque index, gingival index, probing depth, clinical attachment levels, mobility, and furcation status. The clinical attachment level measurements were classified as 0 to 2 mm; 3 to 5 mm; and > 6 mm. Quadrants were randomly assigned to 1 of 3 treatment groups: scaling and root planing, modified Widman flap surgery, or osseous surgery. At 1 year post-treatment, osseous and modified Widman surgery had significantly greater probing reduction when compared to scaling and root planing. For pockets > 7 mm, osseous and modified Widman surgery had significantly greater reduction when compared to scaling and root planing. For pockets 1 to 3 mm, osseous surgery had significantly greater clinical attachment loss when compared with scaling and root planing. The results indicate that at 1 year, scaling and root planing, osseous surgery, and the modified Widman procedure were equally effective in treating moderate to advanced periodontitis. Sixteen (16) patients with moderate periodontitis were treated in private practice by periodontists highly competent in performing scaling and root planing, modified Widman flap, and osseous surgery. At the 5-year evaluation, plaque and gingival indices were reduced and maintained throughout the study with no difference between treatment methods; 1 to 3 mm probing depths increased insignificantly but were stable at 3 years; 4 to 6 mm pockets were reduced significantly, but diminished over time. There was a difference between scaling and root planing compared to osseous surgery at 3 and 4 years, but not at 5. All 3 procedures reduced pocket depth significantly, with no difference between procedures at 5 years. Sixteen (16) patients were treated for moderate periodontitis with either scaling and root planing, modified Widman flap, or osseous surgery. Evaluation were made after the hygienic phase, postsurgery, 6 weeks, 6 months, and at yearly intervals for 5 years. Pockets 1 to 3 mm showed significant loss of attachment; 4 to 6 mm pockets, as well as > 7 mm pockets, showed an insignificant gain of clinical attachment with no difference among procedures.

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Guidance on correct use of the method is only available at centres with trained service providers. The main objective of antenatal care is to give information on: y Screening, prevention, and treatment of complications y Emergency preparedness y Birth planning y Satisfying any unmet nutritional, social, emotional, and physical needs of the pregnant woman y Provision of patient education, including successful care and nutrition of the newborn y Identification of high-risk pregnancy y Encouragement of male partner involvement in antenatal care 16 16. If none, passing urine reassure Morning sickness (nausea & vomiting) Avoid unnecessary medication Avoid antiemetics in the first trimester. If severe anaemia(Hb 7 g/dL) or patient has heart failure f Refer patient to a well-equipped facility for further management If Hb >7 g/dL f Give combination of ferrous and folic acid 3 times daily f Review the mother every 2 weeks (Hb should rise by 0. Pregnant women with chronic hypertension should continue to follow the lifestyle modifications for controlling hypertension such as: y No alcohol y Regular moderate exercise, brisk walking for 30 minutes at least 3 times a week y Smoking cessation. The most common causes of bleeding in the first six months (<26 weeks gestation) are abortion and ectopic pregnancy Abortion (miscarriage) occurs when the foetus is lost before 28 weeks of pregnancy. Cause y Not known in the majority of patients y May be intentional (induced abortion) y May be spontaneous (often as a result of fever) y If mother has more than 2 miscarriages, refer for assessment Differential diagnosis y Pregnancy outside the uterus (ectopic pregnancy) y Other causes of bleeding from the vagina. Then 60-160 mg daily in 3-4 divided doses, adjusted to uterine activity, for max 48 hours If vaginal bleeding with abdominal pain (intermittent or constant) f Suspect and treat as abruptio placentae (see 16. It is characterised with hypertension, proteinuria with or without oedema and, may result into maternal fits if not managed appropriately. Examine every hour once an 8 cm dilatation has been reached f Observe change of shape of foetal head (moulding), foetal position, and caput. Also do uterine palpation, vulva inspection and estimation of degree of blood loss f Refer to postnatal ward 16. Induction is contraindicated in para 5 and above and in patients with a previous scar. Causes y Poor management of 3rd stage of labour y Failure of the uterus to contract y Failure of the placenta to separate. Causes y Tone: failure of uterus to contract, precipitated labour y Tissues: such as retained placenta (in part or whole) or membranes which may lead to atony as well as infection in the uterus y Tears. Resuscitation and management of obstetric haemorrhage and possibly hypovolemic shock 2. Signs and symptoms usually occur after 24 hours, although the disease may manifest earlier in settings of prolonged rupture of membranes and prolonged labour without prophylactic antibiotics. Healthcare providers should be aware of the medical and psychological needs of the postpartum mother, and sensitive to cultural differences that surround childbirth, which may involve eating particular foods and restricting certain activities. Postpartum care services the mother and baby should be seen at 6 hours after birth and again before discharge if in a health facility (and anytime the mother reports concern about herself and her baby) or approximately 6 hours after delivery at home. The routine follow up visits are at 6 days and 6 weeks, and have the following components: y Counselling y Assessment and management of observed or reported problems. General counselling y Breastfeeding/breast care y Nutrition, ferrous and folic acid supplements, avoid alcohol and tobacco 718 U G A N D A C L I N I C A L G U I D E L I N E S 2016 16. Refer to hospital y If not pre-eclampsia, give/continue appropriate antihypertensive as in non-pregnant women (section 4. If not better, teach the mother how to express breast milk from the affected breast and feed baby by cup, and continue breastfeeding on the healthy side 16. Risk factors y Previous psychiatric history y Recent stressful events y Young age, first baby (primigravida) and associated fear of the responsibility for the new baby y Poor marital relationship, poor social support Clinical features y Starts soon after delivery and may continue for a year or more y Feelings of sadness with episodes of crying, anxiety, marked irritability, tension, confusion y Guilty feeling of not loving baby enough y Loss of positive feeling towards loved ones y Refusal to breast feed baby y Ideas to harm the baby Postpartum psychosis y Distortions of thinking and perception, as well as inappropriate or narrowed range of emotions (see section 9. It is one of the major causes of maternal morbidity making the women with the condition suffer from constant urinary incontinence which can lead to skin infections, kidney disorder or death if left untreated. Reassure mother she has enough milk f Ensure correct positioning/ attachment f If thrush: teach how to treat at home (apply gentian violet paint 4 times daily for 7 days with clean hands, use a soft cloth) Well y Feeding well (suckling effectively Baby >8 times in 24 hours) y Weight >2,500 g or small baby but eating and gaining weight well y No danger signs y No special treatment needs 17.

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These surgeons contend that the controlled removal of the adenoids makes both 347 nasopharyngeal stenosis and velopharyngeal insufficiency less likely to occur. Efficacy of tonsillectomy for recurrent throat infection in severely affected children: results of parallel randomized and nonrandomized clinical trials. The fascial margins of the parapharyngeal space are complex, comprising different layers of the deep cervical fascia. As it curves around the lateral side of the pharyngeal mucosal space, the middle layer of the deep cervical fascia forms the medial fascial margin. The lateral fascial margin is formed by the medial slip of the superficial layer of the deep cervical fascia as it curves around the deep border of the masticator and parotid spaces. Posteriorly, the parapharyngeal space fascia is made up of the anterior part of the carotid sheath, formed by the fusion of all three layers of the deep cervical fascia. Extending from the medial pterygoid plate to the styloid process, the tensor veli palatini and its fascia divide the parapharyngeal space into pre- and post-styloid spaces. The prestyloid compartment, bound anteriorly by both the medial pterygoid muscle and the mandible, contains fat, minor or ectopic salivary glands, the internal maxillary artery, and the branches of V3 (ie, the mandibular branch of the trigeminal nerve). Understanding these fascial compartments and spaces facilitates the accurate interpretation of images and preoperative diagnosis. General Considerations A wide spectrum of benign and malignant neoplasms may be encountered in the parapharyngeal space, synonymous with the pterygomaxillary space, the pterygopharyngeal space, the pharyngomaxillary space, and the lateral pharyngeal space. These masses include primary neoplasms, masses extending from adjacent regions, and metastatic tumors. Modern imaging has advanced the understanding of this complex anatomic area, aiding in the diagnosis and management of tumors within the parapharyngeal space. Several large series of retrospective and single institution studies have contributed to the rational management of these tumors. Mass effect may result in symptoms of pressure, characterized by dysphagia, dysarthria, and airway obstruction that may manifest as sleep apnea or snoring. Trismus suggests infiltration into the pterygoid muscles or a mechanical obstruction of the coronoid process. Otologic symptoms most commonly relate to eustachian tube dysfunction, resulting from compression of the cartilaginous portion of the eustachian tube by a tumor. Prestyloid space Intraparotid mass Fat planes between tumor and parotid gland lost Parapharyngeal fat displaced anteriorly and laterally Carotid artery displaced posteriorly Extraparotid mass Fat planes between tumor and parotid gland preserved Parapharyngeal fat displaced anteriorly and laterally Carotid artery displaced posteriorly Poststyloid space Schwannoma Fat planes between tumor and parotid gland preserved Parapharyngeal fat displaced anteriorly and laterally Carotid artery displaced anteriorly and/or medially* Smooth enlargement of involved skull base foramen Paraganglioma Fat planes between tumor and parotid gland preserved Parapharyngeal fat displaced anteriorly and laterally Carotid artery displaced anteriorly and/or medially Ragged, irregular enlargement of involved skull base foramen *Sympathetic chain schwannomas may displace the carotid artery posteriorly or anteriorly. Carotid body paragangliomas typically splay the internal and external carotid arteries. Displacement of the medial wall of the oropharynx and tonsil is usually the first sign of a parapharyngeal space lesion. Alternately, the mass may be found posterior or inferior to the angle of the mandible, as one would see with a mass in the neck or in the parotid gland. A careful cervical and bimanual intraoral evaluation allows the clinician to formulate an impression of the extent of tumor. The tumor may arise from a nerve, or it may cause compression of the adjacent neural structures. Patients with schwannoma or paraganglioma of the vagus nerve may present with vocal cord paralysis. It is important to ask specifically for a history of hypertension, hypertensive episodes, facial flushing, or tachyarrhythmia. Only when a mass is very large is the parapharyngeal space fat completely obscured. Tumors in the post-styloid parapharyngeal space, presumed to be nerve sheath lesions or paragangliomas, dis- place the parapharyngeal fat anteriorly and laterally. Tumors originating from the deep lobe of the parotid gland may occasionally pass through the stylomandibular tunnel and have a dumbbell-like appearance. Radiographic visualization of carotid artery displacement is highly correlated with tumor groupings. Salivary gland tumors tend to displace the carotid artery in a posterior direction, whereas neuromas and glomus tumors distort the carotid sheath compartment in an anterior direction. The precise blood vessels supplying the tumor can be determined and occluded before surgery.


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