By L. Volkar. University of Colorado at Boulder. 2019.
Epidemic An epidemic is an illness that is contained in a specifc geographic area buy genuine nitrofurantoin online antibiotics for uti how many days. A fu pandemic happens when a new virus emerges for which people have little or no immunity and for which there is no vaccine safe 50 mg nitrofurantoin bacteria antibiotics. The disease spreads easily from person to person cheap 50 mg nitrofurantoin overnight delivery infection borderlands 2, sweeping across a country and around the world. It is estimated that approximately 20 to 0 percent of the world’s population became ill and that over 50 million people died, with 500,000 deaths in the U. During the Spanish fu, healthy people, as well as those who were frail, fell ill and died. Many health experts believe the next outbreak of a pandemic fu isn’t a question of if, but when. August 2007 Student Manual 5- International Association Infectious Diseases of Fire Fighers Unit 5 – Avian & Pandemic Infuenza Page left blank intentionally. Use the space below to write the reasons avian fu has the potential to become a pandemic. August 2007 Student Manual 5- International Association Infectious Diseases of Fire Fighers Unit 5 – Avian & Pandemic Infuenza Page left blank intentionally. The new strand of avian fu is one of the few avian infuenza viruses to have crossed the species barrier to infect humans, and is the most deadly of those that have crossed the barrier. In the recent outbreaks in Asia, Europe, and Africa, more than half of those infected with avian fu have died. Those who have contracted the virus have handled birds or surfaces contaminated with secretions or excretions from infected birds. August 2007 Student Manual 5- International Association Infectious Diseases of Fire Fighers Unit 5 – Avian & Pandemic Infuenza Page left blank intentionally. August 2007 Student Manual 5- 5 International Association Infectious Diseases of Fire Fighers Unit 5 – Avian & Pandemic Infuenza Page left blank intentionally. What would happen to other areas in the nation if a pandemic outbreak were to happen? August 2007 Student Manual 5- 7 International Association Infectious Diseases of Fire Fighers Unit 5 – Avian & Pandemic Infuenza Page left blank intentionally. Inter-Agency Cooperation: Establish relationships with community public health department and other emergency management groups. Defne functional roles and responsibilities of internal and external agencies, organizations, departments and individuals and establish lines of authority. Communications Plan: Establish systems and procedures (how, how often, when, what and to whom the information will be disseminated) and articulate resource requirements. Set up authorities, triggers, and procedures for activating and terminating response plan. Develop and plan for scenarios likely to result in an increase or decrease in demand for your services during a pandemic (e. August 2007 Student Manual 5- International Association Infectious Diseases of Fire Fighers Unit 5 – Avian & Pandemic Infuenza Page left blank intentionally. Ensure fre department has a written infection control policy statement defning the department’s mission in limiting the exposure of members to infectious diseases during the performance of their assigned duties and while in the fre station living environment. Ensure fre department has an experienced individual within the department designated as the infection control offcer. Ensure training and education is a component of the infection control program and includes proper selection and use of personal protective equipment, standard operating procedures for safe work practices in infection control, proper methods of disposal of contaminated articles and medical waste, cleaning and decontamination, exposure management and medical follow-up. Ensure fre department implements and enforces hand and skin washing practices and decontamination procedures. Establish ft-testing and skill training on all respirator types used to prevent exposures. Inventory Checklist Community: Develop an understanding of the local community dynamics, available resources and how they may shift during a pandemic – size and distribution of population, number and location of health facilities, quarantine sites, transportation issues, large spaces that could be transformed into healthcare or shelter facility, etc. August 2007 Student Manual 5-2 International Association Infectious Diseases of Fire Fighers Unit 5 – Avian & Pandemic Infuenza Page left blank intentionally. Impact on Staff Determine impact on staff – absenteeism due to illness or attending to ill family member or afraid to come into work and develop Contingency Plan for such an event. Evaluate staff access to, and availability of, healthcare services during a pandemic. Establish policies for restricting travel and preventing infuenza spread at the worksite. Disseminate information frequently to all staff to prevent misinformation or fears based on rumors. Establish a dedicated staff member who is responsible for disseminating information. Staff must also be able to easily provide feedback to designated staff member on what they are facing, including those issues experienced in the feld. August 2007 Student Manual 5-2 International Association Infectious Diseases of Fire Fighers Unit 5 – Avian & Pandemic Infuenza Page left blank intentionally. The safety/infection control and prevention offcers will be the frst line of defense for policies your department makes for the pandemic. Here are some examples of what the safety/infection control and prevention offcers will ensure. August 2007 Student Manual 5-25 International Association Infectious Diseases of Fire Fighers Unit 5 – Avian & Pandemic Infuenza Page left blank intentionally. Infuenza is spread from person to person by contact with respiratory secretions from an infected person. When an infected person coughs or sneezes, large droplets carrying the virus land on the surfaces of the upper respiratory tracts of persons who are within three feet of the infected person. The virus can also spread by direct or indirect contact with respiratory secretions – touching contaminated surfaces and then touching the eyes, nose, or mouth. Respiratory Protection During the class discussion, use the space below to take notes on respiratory protection. Surgical mask N-95 P-100 August 2007 Student Manual 5-27 International Association Infectious Diseases of Fire Fighers Unit 5 – Avian & Pandemic Infuenza Page left blank intentionally. If you taste or smell the agent, you will test another disposable mask size (or type). August 2007 Student Manual 5-2 International Association Infectious Diseases of Fire Fighers Unit 5 – Avian & Pandemic Infuenza Page left blank intentionally. Immediately after activities involving contact with a patient’s body fuids, gloves should be removed and discarded and hands should be cleaned. Do not rub eyes after using eyewear, or after handling patients or equipment until you have thoroughly washed your hands.
So went Satan from the presence of the Lord nitrofurantoin 50mg cheap antibiotics osteomyelitis, and smote Job with sore boils from the sole of his feet unto his crown discount 50mg nitrofurantoin mastercard antibiotic 9 fk unsri. According to Job 2:11-12 order genuine nitrofurantoin on-line antibiotics for acne with no side effects, his disease was so bad that it made him literally unrecognizable to his friends. And later in Job 7:5, 13-14, he states that “my flesh is clothed with worms and clods of dust; my skin is broken, and become loathsome…When I say, my bed shall comfort me, my couch shall ease my complaint; Then thou scarest me with dreams, and terrifiest me through visions. This poor man had been unmercifully hit with a series of unimaginable tragedies that wiped out his enormous wealth and killed many of his children. And while his gaping emotional wounds were still raw with shock and bewilderment, Satan hit him with a repulsive disease that bred worms. When death did not come to mercifully end his misery, he tried to escape the pain by going to sleep. Our point in recounting this event is to show you that Satan can and does attack people. Generally it is believed by most serious students of God’s word that Job’s entire trial lasted about 9 – 12 months. We’ll discuss these two reasons because what you believe about Job and his trials could help or hinder your search for healing. It is assumed that Job suffered because God in His mysterious wisdom simply decided that it should be done. This is a position that appears to be motivated by humility and unquestioned submission to the will of God. But upon closer observation, it’s seen to be a religious safety net to those who are ignorant of Satan’s abilities and activities. Whenever an unexplainable tragedy hits, God is automatically assumed to be the author. The pastor puts on his best I-feel-your-pain face and explains how God is somehow using the tragedy to teach us a lesson. Stunned and devastated by the loss, we desperately try to hold on to the unlikely possibility that God is behind the attack. Those who do, have the ability to shut down their thought processes to such a degree that they can believe something even if it’s unsupportable or ridiculous. They tenaciously cling to this belief because they are desperate to make sense of the tragedy. No Christian is eager to believe that a horrible tragedy in his or her life is without benefit. They were keen and thoughtful before the tragedy, and they are the same during and after the tragedy. These Christians won’t bite the first religious worm they see on a hook just because they are hungry for an answer. They have a hard time believing that a brutal rape, a killer cancer, or a dreadful accident is God’s way of saying I love you. Satan admitted as much when he said, “Hast thou not made an hedge about him, and about his house, and about all that he hath on every side? So the question is not could God have protected him, but why did He choose to not protect him? We discussed the traditional denomination position that says God caused the calamities for a mysterious but wise reason. This is the belief that God allowed Satan to strike Job because Job had broken down the hedge of protection. Having cast demons out of many people, I can say that certain types of fear can open the door to Satan. However, having read the book of Job, I can also say that it doesn’t appear that Job opened the door to Satan’s attack. And it doesn’t appear that his fear was of the fleshly sort that results from not believing God. The Charismatic/Full Gospel explanation that Job opened the door to Satan’s attack is also a religious safety net. Folks in our circle have a desperate need to believe they are always in control of their situations. They have a desperate need to believe they can absolutely control what happens to them by using the right spiritual formulas. When tragedy strikes, they are able to assert with God-like certainty that it occurred because you did this, none of this, too little of that, or too much of the other. Yet, the dogmatic application of its inflexible rules to every situation has turned it into a doctrine of pride and presumption. For instance, according to some, financial adversity, sickness and disease, and other trials can always be linked to our action or inaction. There is no place for the sovereignty of God— except for good—in the minds of many Charismatic/Full Gospel people. Every event doesn’t fit neatly within the boundaries of our favorite religious doctrines. It’s wiser to buy a larger pair of shoes than to stubbornly cram our feet into a smaller pair that doesn’t fit. If we force ill-fitting doctrines upon situations larger than our understanding or experience, we will only injure ourselves and the cause of Christ. When we blame Job’s fear for his situation, we reveal huge gaps in our understanding of life in general and God in particular. An Examination of Job’s Fear After Job’s great calamities had come upon him, he uttered these words: “For the thing which I greatly feared is come upon me, and that which I was afraid of is come upon me. But we don’t realize that when we do so, we join those accusers who visited Job in his misery. It’s sufficient to say that very much of the entire book of Job is filled with the accusations of Job’s three friends. The last thing a person dying with cancer needs to hear is, “If you had stood in faith, this never would have happened. And this is the same haughty spirit that works in the hearts of many of those who blame Job’s trials on his fear. Just to quote one, Jesus commanded us to fear God: “And fear not them which kill the body, but are not able to kill the soul: but rather fear him which is able to destroy both soul and body in hell. But we know from his attitude and words during his trial that the something he was afraid of was not the loss of things, people, or health. Jesus had this same concern as He got closer to fulfilling His mission as the sacrifice for our sins. He was to literally become sin for us that we may 1 become the righteousness of God in Christ. This prospect of being separated from His Father’s fellowship—even for a little while—brought great distress upon Him. Finally, after a few hours of agonizing prayer in the Garden of Gethsemane, He received heavenly encouragement to go to the cross. Neither is there anything wrong with being concerned that one does not offend God.
Those that cause diseases covered in subsequent chapters are marked on the table by an asterisk; some of the less important or less well studied are not discussed or mentioned cheap nitrofurantoin 50 mg fast delivery bacteria 02 footage. These genera contain some agents that predominantly cause encephalitis; others predominantly cause febrile illnesses order nitrofurantoin 50 mg fast delivery bacterial infection symptoms. Alphaviruses and bunyaviruses are usually mosquito-borne; ﬂaviviruses are either mosquito- or tick-borne order on line nitrofurantoin virus java update, some ﬂaviviruses having no recognized vectors; phleboviruses are gener- ally transmitted by sandﬂies, apart from Rift Valley fever, transmitted by mosquitoes. Other viruses of the family Bunyaviridae and of several other groups mainly produce febrile diseases or hemorrhagic fevers and may be transmitted by mosquitoes, ticks, sandﬂies or midges. Identiﬁcation—A self-limiting febrile viral disease characterized by arthralgia or arthritis, primarily in the wrist, knee, ankle and small joints of the extremities, lasting days to months. In many patients, onset of arthritis is followed after 1–10 days by a maculopapular rash, usually nonpruritic, affecting mainly the trunk and limbs. Paraesthesias and tenderness of palms and soles occur in a small percentage of cases. Rash is also common in infections by Mayaro, Sindbis, chikungunya and o’nyong-nyong viruses. Polyarthritis is a characteristic feature of infections with chikungunya, Sindbis and Mayaro viruses. Minor hemorrhages have been attributed to chikungunya virus disease in southeastern Asia and India (see Dengue hemorrhagic fever). In chikungunya virus disease, leukopenia is common; convalescence is often prolonged. Serological tests show a rise in titres to alphaviruses; virus may be isolated in newborn mice, mosquitoes or cell culture from the blood of acutely ill patients. Infectious agents—Ross River and Barmah Forest viruses; Sindbis, Mayaro, chikungunya and o’nyong-nyong viruses cause similar illnesses. Occurrence—Major outbreaks of Ross River virus disease (epi- demic polyarthritis) have occurred in Australia, chieﬂy from January to May. In 1979, an outbreak in Fiji spread to other Paciﬁc islands, including American Samoa, the Cook Islands, and Tonga. Barmah Forest virus infection has been reported from Queensland, the Northern Terri- tory and western Australia. Chikungunya virus occurs in Africa, southeast- ern Asia, India, and the Philippines; Sindbis virus throughout the eastern hemisphere. O’nyong-nyong virus is known only from Africa; epidemics in 1959–1963 and 1996–1997 involved millions of cases throughout eastern Africa. Transovarian transmission of Ross River virus has been demonstrated in Aedes vigilax, making an insect reservoir a possibility. Susceptibility—Recovery is universal and followed by lasting ho- mologous immunity; second attacks are unknown. Inapparent infections are common, especially in children, among whom the overt disease is rare. Preventive measures: General measures applicable to mosqui- to-borne viral encephalitides (see Arthropod-borne viral enceph- alitides, I9A, 1–5 and 8). Control of patient, contacts and the immediate environment: 1) Report to local health authority: In selected endemic areas; in many countries, not a reportable disease, Class 3 (see Report- ing). Epidemic measures: Same as for arthropod-borne viral fevers (see Dengue fever, 9C). Identiﬁcation—A group of acute inﬂammatory viral diseases of short duration involving parts of the brain, spinal cord and meninges. Signs and symptoms of these diseases are similar but vary in severity and rate of progress. Most infections are asymptomatic; mild cases often occur as febrile headache or aseptic meningitis. Severe infections are usually marked by acute onset, headache, high fever, meningeal signs, stupor, disorientation, coma, tremors, occasional convulsions (especially in in- fants) and spastic (rarely ﬂaccid) paralysis. These diseases require differentiation from tick-borne encephalitides (see below); encephalitic and nonparalytic poliomyelitis; rabies; mumps meningoencephalitis; lymphocytic choriomeningitis; aseptic meningitis due to enteroviruses; herpes encephalitis; postvaccinal or postinfection encephalitides; and bacterial, mycoplasmal, protozoal, leptospiral and mycotic meningitides or encephalitides. This is especially true of West Nile virus infection, which has become the most common cause of arboviral encephalitis since 1999 in the U. Cases due to these viruses occur in temperate latitudes in summer and early fall and are commonly limited to areas and years of high temperature and many mosquitoes. Reservoir—California group viruses overwinter in Aedes eggs; the true reservoir or means of winter carryover for other viruses is unknown, possibly birds, rodents, bats, reptiles, amphibians or survival in mosquito eggs or adults; the mechanisms probably differ for each virus. Viraemia in birds usually lasts 2–5 days, but may be prolonged in bats, reptiles and amphibia, particularly if interrupted by hibernation. Susceptibility—Susceptibility to clinical disease is usually highest in infancy and old age; inapparent or undiagnosed infection is more common at other ages. In highly endemic areas, adults are largely immune to local strains by reason of mild and inapparent infection; susceptibles are mainly children. Live attenuated and formalin- inactivated primary hamster kidney cell vaccines are licensed and widely used in China. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Case report obligatory in several countries, Class 2 (see Reporting). Report under appropriate disease; or as “encephalitis, other forms”;or “aseptic meningitis,” specify cause or clinical type when known. Enteric pre- cautions appropriate until enterovirus meningoencephalitis (see Viral meningitis) is ruled out. Epidemic measures: 1) Identiﬁcation of infection among horses or birds and recog- nition of human cases in the community have epidemiolog- ical value by indicating frequency of infection and areas involved. International measures: Spray with insecticide those air- planes arriving from recognized areas of prevalence. Infectious agents—A complex within the ﬂaviviruses; minor anti- genic differences exist, more with Powassan than others, but viruses causing these diseases are closely related. Ixodes persul- catus in eastern Asia is usually active in spring and early summer; I. The age pattern varies in different regions and is inﬂuenced by opportunity for exposure to ticks, consumption of milk from infected animals or previously acquired immunity. Reservoir—The tick or ticks and mammals in combination appear to be the true reservoir; transovarian tick passage of some tick-borne encephalitis viruses has been demonstrated. Mode of transmission—Bites of infective ticks or consumption of milk from certain infected animals. Ixodes persulcatus is the main vector in the eastern areas of the Russian Federation, I. Larval ticks ingest virus by feeding on infected vertebrates, including rodents, other mammals or birds. Control of patient, contacts and the immediate environment: 1) Report to local health authority: In selected endemic areas; in most countries not a reportable disease, Class 3 (see Reporting). Identiﬁcation—Clinical manifestations of this viral infection are inﬂuenza-like, with abrupt onset of severe headache, chills, fever, myalgia, retroorbital pain, nausea and vomiting. Virus can be isolated in cell culture or in newborn mice from blood and nasopharyngeal washings during the ﬁrst 72 hours of symptoms; acute and convalescent sera drawn 10 days apart can show rising antibody titres.
The mucous membranes lining the vagina broader issues of importance that should be are also potentially more susceptible than those considered by anyone working in sexual health order nitrofurantoin in united states online infection zombie movie. In addition buy cheap nitrofurantoin 50 mg line antibiotic injection rocephin, menstruation Module 7 nitrofurantoin 50 mg on line antimicrobial antibiotic, Part I Page 201 may increase risk of infection, due to the bleeding, providing an easier route of access for organisms. Similarly, the “passive” or “non-active” partner in a gay relationship is more likely to become infected. Medicine has been principally responsible for attaching deviancy labels to sexual practices decreed as not “normally” practiced. Sexuality and sexual health Nurses and midwives are expected to provide non- judgemental holistic care to their patients; however, sexual health is often overlooked, or only dealt with in the context of illness and disease. Gay and lesbian identity A great variety of pejorative terms have been used to describe individuals who have same-sex partners. Men who have sex with men and identify as being homosexual are usually comfortable with being called Gay. Gay men and lesbian women see their identity and the outward expression of that identity as being central to their sexuality and self-esteem. Neonatal • Urethral discharge chlamydia is most commonly demonstrated as • Mucoid or mucopurulent urethral discharge conjunctivitis and pneumonia. Untreated chlamydia can lead to the • Ectopic pregnancy – the risk increases by seven complications described. Complications in men • Approximately 1% of men with chlamydia will develop reactive arthritis. Chlamydia walking is currently diagnosed using laboratory tests on • Painful movement as a result of tenosynovitis swab and urine samples taken from the patient. Methods of treatment Uncomplicated infection Contact tracing of women and asymptomatic Azithromycin 1 g as a single dose or Doxycycline men 100 mg two times per day for seven days. All sexual partners over the six months preceding the (Doxycycline is cheaper than Azithromycin, but diagnosis, or the last sexual partner if the most has a 20% chance of causing gastro-intestinal recent sexual contact was more than six months disturbances and occasionally photosensitivity; prior, should be traced. These treatments have a less than 95% efficacy, so Follow-up pregnant women should be followed up carefully Patients diagnosed with chlamydia should be seen to ensure there has been no treatment failure. In patients treated with treatment, sexual intercourse should be avoided for Erythromycin, a second test should be taken after one week after treatment. Testing for chlamydia should be offered to the • Ensure that contact tracing has taken place if the following groups: person has arranged to contact their partner Module 7, Part I Page 205 Gonorrhoea themselves. Gonorrhoea infects the Nursing care mucous membranes of the urogenital tract, oro- See Appendix 4. Modes of transmission Sexual transmission Through vaginal and insertive and receptive anal sex. Untreated opthalmitis may lead to conjunctival destruction, corneal ulceration and blindness. Treatment is with ceftriaxone 50 mg/kg (max 125 mg) in a single intramuscular dose. In many industrialized countries, there has been an overall decline in the incidence of gonorrhoea over the last decade. Reported gonorrhoea in Sweden and Norway has declined from 10 000 cases each in 1981 to almost zero in 2000. Reports from France and the United Kingdom in 2000 have shown an increase in gonorrhoea since 1997, particularly in men, with suggestions of an increase in high risk Page 206 Module 7, Part I sexual behaviour, especially in gay men. In men: Rectal gonorrhoea in men is associated with It is reported that the burden of gonorrhoea in receptive anal sex. It is most commonly developed countries tends to fall on deprived, inner asymptomatic, but clinical features may include: city populations. Over 90% of gonococcal • Menorrhagia infections in the pharynx are asymptomatic and • Mucopurulent cervical discharge have a spontaneous cure rate of nearly 100% after • Xervical erythema 12 weeks of infection. Urethral gonorrhoea; incubation is 1–14 days or • Ectopic pregnancy (see previous notes). It is treatable • Sysuria with antibiotics, but may require surgery to drain • Less commonly, epididymal tenderness or swelling the abscess. It occurs Rectal infection in women can occur after receptive within 7 to 30 days after transmission. Features anal sex but is also associated with perineal include acute arthritis, tenosynovitis, dermatitis, contamination with cervical secretions where no or a combination of the three. It is estimated that 35– 50% of women with gonococcal cervicitis also have Complications in men infected rectal mucosa. Rectal gonorrhoea in • Epididymitis, a unilateral testicular pain and women is usually asymptomatic. Male urethral swab • 15–19 year olds at particularly high risk • Low socioeconomic status • Past history of gonorrhoe • Early onset of sexual activity Prognosis Gonorrhoea generally remains localised to the initial sites of infection. The complications of gonorrhoea leading to serious morbidity are commoner in areas where access to diagnosis and treatment is more difficult. Diagnosis Diagnosis is made by identification of the organism Neisseria gonorrhoea at the site of infection Diagram 6. Female urethral swab through: • Microscopy; direct visualization of Gram stained specimens allows diagnosis of gonorrhoea when Gram negative diplococci are seen within polymorphonuclear leucocytes. Rectal gonorrhoea is more likely to be diagnosed through microscopy if a proctoscope has been used to collect the sample. Speculum examination and tests Worldwide, resistant strains have developed to penicillins and quinolones. Antibiotics for Swab Cervix Cervical swab being taken gonorrhoea should be selected to clear over 95% of infection in the local area. Ceftriaxone has been used worldwide effectively as a single dose with as yet no noted resistance. Speculum Co-infection with chlamydia trachomatis Up to 40% of adults with genital gonorrhoea infection also have chlamydia. Treating for both infections simultaneously after a diagnosis of Cervical swab gonorrhoea is made is recommended. Cervical smear Screening Testing for gonorrhoea should be offered to the following groups: Methods of treatment • patients with signs or symptoms attributable to Uncomplicated genital infection gonorrhoea; Ceftriaxone 250 mg intramuscularly as a single • individuals attending sexual health clinics; dose; Ciprofloxacin 500 mg as a single oral dose; • anyone diagnosed with another sexually Ampicillin 2 g or 3 g plus Probenecid 1 g orally as transmitted infection; and a single dose in regions where penicillin resistance • sexual partners of patients with gonorrhoea. Ceftriaxone 250 mg intra- urethral infection muscularly as a single dose; Cefotaxime 500 mg See Appendix 2 for partner management. Other Eastern European countries including Module 7, Part I Page 209 Contact tracing of men and women with asymptomatic infection and infection at other sites Trace all sexual partners in the three months preceding the diagnosis. Follow-up Patients diagnosed with gonorrhoea should be seen again after treatment has been completed in order to assess efficacy of treatment. In some sources, retesting is only recommended if an unusual treatment regime has been used.
Ventricular septal defect murmurs may be 2–5/6 in intensity and harsh in quality cheap nitrofurantoin antibiotics for urinary tract infection australia, it is best heard over the left lower sternal border discount nitrofurantoin 50 mg on-line bacteria mitochondria. A mid-diastolic rumble at the apical region is often heard in large ventricular septal defects due to the increased flow across the mitral valve nitrofurantoin 50mg with amex bacteria names and pictures. The degree of cardiomegaly and increased vascular markings is proportional to the amount of left to right shunting. In pulmo- nary vascular obstructive disease, the cardiac size is normal with no evidence of increase in pulmonary vascular markings, but the pulmonary artery segment at the mid left border of the cardiac silhouette may be more prominent. Left atrial dilatation and left ventricular hypertrophy may be seen in moderate ventricular septal defect. Most chest leads, particularly the right chest leads in this tracing show increase in anterior (tall R waves) and posterior (deep S waves) forces indicating right and left ventricular hypertrophy. Echocardiography can measure the right ventricular and pulmonary pressures by assessing the pressure gradient across the defect as well as assess the degree of shunting. Echocardiography can also identify associated lesions such as aortic valve prolapse and regurgitation, coarctation of the aorta, or double-chambered right ventricle. Cardiac Catheterization Cardiac catheterization is typically not required for diagnosis since echocardiography can provide all details required to plan management. Cardiac catheterization is indicated in older children with pulmonary hypertension to assess the pulmonary vascular resistance prior to surgical repair. Therapeutic interventional cardiac catheterization has been increasing in recent years. Device closure of muscular ventricular septal defect is now performed in many centers due to the difficulty accessing these defects surgically and the ability to close such defects effectively without the need for surgery. Device closure of the membranous ventricular septal defect is still under investigation, but soon will become more widely used. Small ventricular septal defects can be managed conservatively in patients with no history of congestive heart failure or pulmonary hypertension. Surgical closure is indicated in symptomatic infants including congestive heart failure, failure to thrive or recurrent respiratory infections and those who fail medical management. Surgery is also indicated in children with significant left to right shunting and ven- tricular dilatation prior to 2 years of age. Infants with large ventricular septal defect and pulmonary hypertension should have surgical repair between 3 and 12 months of age. Mortality is higher in the presence of multiple ventricular septal defects, other associated defects, and in young infants less than 2 months of age. Surgical complications may include: residual ventricular septal defect, right bundle branch block or complete heart block, or injuries to the tricuspid or aortic valve. If the repair was performed through the ventricle (ven- triculotomy), this will cause a ventricular scar that might affect its function and may also cause ventricular arrhythmias. Indications for closure of ventricular septal defects of the muscular type using interventional cardiac catheterization approach are similar to that of surgical approach. Maintaining a good dental hygiene is important, but endocarditis prophylaxis is not indicated based on the most recent recommendations of the American Heart Association. Case Scenarios Case 1 A 3-month-old male infant presented with a 2-week history of decreased feeding, shortness of breath, cough, and wheezing. The diagnosis of bronchiolitis was made by the primary care physician and he was admitted to the general pediatric floor for further management. On physical examination, the infant was in respiratory dis- tress, his heart rate was 142 bpm, respiratory rate was 66 breaths per minute, blood pressure was 90/50 mmHg, and oxygen saturation was 98% while breathing room air. The precordium was hyperactive, there was 3/6 holosystolic murmur at the left sternal border and no diastolic murmur. The abdomen was soft, the liver was palpable (3 cm below costal margin), the peripheral perfusion was normal, and there was no peripheral edema noted. Khalid and Ra-id Abdulla The respiratory distress in this child is most likely secondary to a congestive heart failure rather than simple bronchiolitis. The presence of an active precordium, heart murmur, and a palpable liver are signs of left to right shunt, pulmonary over- circulation, and volume overload. The murmur and the respiratory distress did not develop earlier in life due the high pulmonary vascular resistance at birth that prevents significant left to right shunting. This usually drops in the first few weeks of life causing an increase in pulmonary circulation and volume overload. This emphasizes the importance of followup in young infants as a normal newborn exam may not exclude the presence of a congenital heart disease. Echocardiography provides an accurate assessment regarding the type and size of the ventricular septal defect. Treatment with anti-congestive heart fail- ure medications is warranted in this patient. This may include diuretics, such as furosemide (Lasix); inotropic agent, such as digoxin; and after load reducing agent, such as captopril. Indication of surgical closure depends on the size of the defect and response to medical therapy. If the infants continue to be symp- tomatic in spite of medical management then surgery is recommended. Interventional cardiac catheter closure of defect is recommended if they are of the muscular type. Chest examination shows minimal retractions, there is normal vesicular breath sounds bilaterally with no wheezing or crackles, cardiac examination revealed an active precordium, and there is normal upper and lower extremity pulses. Cardiac auscultation showed a grade 2/6 holosystolic murmur at the lower left sternal border, the abdomen was soft with no hepatomegaly. Echocardiography revealed a moderate apical muscular ventricular septal defect with left to right shunting; there is mild right ventricular dilatation. Cardiac catheterization was performed and hemodynamic data showed a signifi- cant left to right shunt with a Qp: Qs ratio of 2. The angiogram confirmed the diagnosis of a moderate size apical ventricular septal defect. Ventricular septal defect device closure was performed during the catheterization procedure with no adverse effect and effective elimina- tion of left to right shunting. Defects in the apical region of the ventricular septum are difficult to close surgically due to their loca- tion. Device closure of muscular ventricular defects is now possible using specially made devices. The proximity of the aortic and atrioventricular valves and the con- duction pathways to the membranous, inlet, or outlet ventricular defects, makes it more difficult to close these defects with a device, although experimental attempts are underway to develop such devices and methodologies, particularly those for perimembrenous ventricular septal defects. On the other hand, muscular defects are remotely situated from any vital structures and thus more amenable to device closure. They present with increased work of breathing or an increasing need for mechanical ventilatory support. The murmur in these premature infants tends to be systolic rather than continuous. Pharmacological agents such as indomethacin and ibuprofen are the first line of management in this age group. In the rare instances where this is not pos- sible, surgical ligation is performed.