Jon C. Aster, MD, PhD

• Professor of Pathology, Harvard Medical School
• Brigham and Women's Hospital, Boston, Massachusetts

https://www.dfhcc.harvard.edu/insider/member-detail/member/jon-c-aster-md-phd/

It is usually prudent to address the main indication first in the event that the examination needs to be aborted because of clinical instability otc pain treatment for dogs order aleve uk. If the patient remains stable pain treatment for uti cost of aleve, a comprehensive examination is carried out by first examining the heart with the probe at the midesophageal level pain treatment shingles buy aleve once a day. At this level the multiplane "omni" controller is used to rotate the scanning plane counterclockwise to slice the left ventricle into two-chamber (90 degrees) and then three-chamber (long-axis or 120-degree) views treatment of acute pain guidelines order aleve cheap. These views are optimal for assessing the left ventricle stomach pain treatment home discount 500mg aleve with mastercard, left atrium musculoskeletal pain treatment guidelines buy generic aleve 250 mg line, and mitral valve. To examine the aortic valve, the operator retracts the probe slightly and the aortic valve should be imaged just superior to the mitral valve, at approximately 30 degrees for short-axis images and 120 degrees for long-axis views. One can view the left ventricle and mitral valve in the short axis and also obtain transaortic gradients from an apical five- or three-chamber view if needed. By increasing the omni angle up to 90 degrees and rotating the transducer plane to the right, more detailed views of the tricuspid valve and right side of the heart are attainable. Finally, the thoracic aorta is usually examined in crosssectional and longitudinal views as the probe is withdrawn to document any significant atherosclerosis or other pathology. Three-dimensional echocardiography offers the potential to better visualize valvular structures (see Valvular Heart Disease) or congenital abnormalities and can be particularly useful for surgical planning. In part because current three-dimensional imaging is associated with loss of spatial and temporal resolution when compared with two-dimensional imaging, application of three-dimensional echocardiography outside the operating room is currently more limited. Still, current threedimensional probes can function as two-dimensional probes without loss of image quality and better define the course and extent of complex structures. As technologic advances improve threedimensional image quality, three-dimensional acquisition will probably become standard in echocardiography. Currently approved agents consist of perfluorocarbon gases, chosen because of their resistance to diffusion into the bloodstream; they are enclosed within either albumen or phospholipid shells. Unlike the larger bubbles created by agitating saline, commercial contrast bubbles are small enough to transit the pulmonary vascular bed and are therefore capable of opacifying the left side of the heart. Because their shells are not rigid, contrast bubbles will contract in response to the peak acoustic pressure of the sinusoidal ultrasound wave and expand when acoustic pressure is at its trough. Optimal imaging of contrast agents is based on the way in which this oscillation in size varies with ultrasound system transmit powers (mechanical index). When exposed to sound waves at lower mechanical indices, the bubbles will undergo resonant oscillation in a linear fashion, but with higher transmit frequencies, the bubbles will resonate in a nonlinear fashion. When the bubbles resonate in a linear fashion, they will behave as the surrounding tissue and reflect sound at the fundamental frequency, that is, the same frequency as was transmitted from the ultrasound system. The sequence illustrated here allows a basic survey of all the cardiac chambers and valves. Therefore to distinguish bubbles from surrounding tissue, ultrasound systems are set at mechanical indices (0. This can be particularly helpful in the intensive care unit, as well as with stress echocardiography, in which obtaining adequate images in the immediate postexercise period may be challenging. They are also helpful in detecting intracardiac masses such as thrombi and tumors and assessing their vascularity. Alternatively, two-dimensional planes can be "cut" through any part of the 3D data set. Of these choices, echocardiography continues to hold the major advantage of being the most rapid, portable, and real-time imaging modality available today. When a large number of patients need to be screened or patients need to be monitored longterm with serial examinations, the fact that ultrasound imaging involves no ionizing radiation is a particularly important consideration. It is thus ideal for monitoring valvular dysfunction, cardiotoxic chemotherapy, and cardiomyopathies. This is particularly true for pericardial effusions (see extracardiac pathology such as vascular dissection. It should be emphasized that in many cases the use of two or even more modalities is appropriate and complementary to more definitively characterize the nature and extent of an abnormality and plan appropriate treatment. Extensive aortic dissections in which one needs to precisely define the extent to which major coronary, head, and systemic arteries are involved also often calls for multimodality imaging. Echocardiography can unfortunately render a variety of artifacts that produce the false appearance of masses mimicking thrombi, tumors, or mobile tissue flaps; although most can be discerned as false findings by experienced sonographers, a minority may require additional tailored echocardiographic views, often in different tissue planes, to put the question to rest. The use of three-dimensional echocardiography and/or intravenous echocardiographic contrast agents can clarify many of these echocardiographic artifacts without the potentially nephrotoxic effects of the iodinated and gadolinium agents used in radiologic imaging. In summary, although advances in the capability of ultrasound and radiology continue to grow, familiarity with the relative advantages and limitations of each imaging modality can help determine which tool is most suitable for answering the clinical question at hand. In the unenhanced image a thrombus-like structure is visualized in the apical region (arrow). The enhanced version shows that there is no filling defect, thus suggesting that this was an acoustic artifact and not a true thrombus. Normal wall contractility (normokinesis) is seen as wall thickening caused by the contraction of individual myocardial fibers during systole. On echocardiography the radial distance between the epicardial and endocardial borders normally increases by at least 20% during systole. This pathognomonic finding will occur in the region of the left and/or right ventricle supplied by the compromised artery (at least 70% stenosis) and give the appearance of a hinge point when compared with adjacent perfused segments. Ischemia is a dynamic condition, and if sufficient blood flow is restored in time (either through a decrease in metabolic demand as when a stress test ends or through reperfusion), contractility of the affected segment can recover rapidly. However, echocardiography remains the firstline modality for detecting the characteristic respirophasic septal bounce and respiratory variations in cardiac output caused by constriction and continues to be the mainstay of follow-up regardless of treatment. Subsequently, bubbles will return to and progressively enhance the myocardium until a steady-state concentration is reached. This may be monitored by either a triggered approach in which imaging is performed on end-systolic images at increasing numbers of beats after the flash (1, 2, 3, 4, etc. The rate at which replenishment occurs and the degree of enhancement under steady-state conditions, as can be quantitated by video intensity, reflect myocardial perfusion. Akinetic myocardial segments do not thicken at all, and dyskinetic segments bulge paradoxically outward in systole, thus implying that no functioning myocardium is present. Thinning of the walls to less than 6 mm, echobrightness, and dyskinesis usually indicate scar. More refined techniques, including intravenous echocardiographic contrast enhancement to examine myocardial perfusion, low-dose dobutamine echocardiography, or regional strain analysis, may be useful in demonstrating whether segments that are still akinetic after reperfusion remain viable but hibernating. A proximal coronary artery stenosis will cause wall motion abnormality in a large territory. An acute left main occlusion will result in such extensive dysfunction (anterior septum, anterior and lateral walls) that if untreated, is usually lethal. Small collateral vessels from other unobstructed coronary arteries can develop and perfuse the peripheral territory of affected vessels, thus diminishing the dysfunctional territory. It is important to carefully distinguish between wall thickening as opposed to just epicardial or endocardial border movement during systole. The main epicardial coronary arteries each supply distinct myocardial territories, which may be mapped and evaluated during the ultrasound examination. At the basal and midventricular levels, the septal and lateral walls are further subdivided into anterior and inferior segments. False negatives, such as missing a wall motion abnormality that is present, can also occur because of poor image quality or off-axis imaging. In some cases, injection of an intravenous contrast agent can help delineate the endocardial borders. It is important to recognize that echocardiography in a patient who is free of chest pain at the time of imaging may not reveal a resting wall motion abnormality (because of decreased demand or reperfusion) and that this technique is relatively insensitive for small areas of subendocardial or microvascular ischemia. Nevertheless, when a patient has ongoing acute chest pain but echocardiography does not reveal new wall motion abnormalities, a broader differential diagnosis than epicardial coronary artery occlusion must be entertained. Possible nonischemic cardiac causes of chest pain that can be also diagnosed by cardiac ultrasound include pericarditis, aortic or coronary aneurysm or dissection, myocarditis, cardiac contusion, and ruptured mitral chordae. Noncardiac causes include pulmonary emboli (which can cause acute right-sided heart dysfunction in a distinctive pattern), as well as gastroenterologic processes. These events may appear within days of the initial infarct or may be delayed by years. For this reason, papillary muscle rupture and flail posterior leaflet occur more commonly with inferior infarcts. There is, however, overlap between the papillary muscle support of the leaflets, and only one head or a tip of a papillary muscle may be disrupted rather than the entire trunk. B, Ventricular septal defect (left panel) in the basal inferoseptum with (right panel) an intraventricular pressure gradient of 58 mm Hg by spectral Doppler. Echocardiography should define the location, type (simple or complex), and size of the defect. In contrast, inferior infarctions often involve the adjacent basal inferior septum or even the right ventricle and can be complex (with serpiginous or multiple fissures). Echocardiography Free Wall Rupture Free wall rupture is usually so acutely lethal that it is rarely imaged, but findings consist of a sudden new pericardial effusion in a patient with marked thinning and akinesis at the terminal myocardial territory of the occluded artery. The pericardial effusion may have spontaneous echocardiographic contrast or contain clot (hemopericardium). Posterior mitral leaflet flail will cause a very eccentric jet to be directed anteroseptally, and this can occasionally cause clinicians to erroneously detect a "new aortic stenosis" murmur. Tamponade demonstrate both the location and extent of the shunt at the "break" area. Mechanical causes of tamponade related to infarcts include pseudoaneurysm and free wall rupture as described earlier, but also aortic dissection (in some cases caused iatrogenically by percutaneous intervention). In some cases, fully organized thrombus has been found in otherwise echolucent pericardial effusions and is thought to be indicative of past wall rupture that has been sealed off in the interim. Simple loss of pump function in large infarcts is probably the most common reason. Thus a pseudoaneurysm is more likely to have distinguishing traits such as a narrower neck with more ragged edges and turbulent bidirectional flow (as opposed to the smoother margins and flow pattern typically seen with true aneurysms). Intravenous echocardiographic contrast agents can be very helpful in delineating the area of the perforation and extravasation into the pericardial space if the patient is sufficiently stable. Spontaneous echocardiographic contrast within the aneurysms signifies local stasis of blood flow. Accuracy is undoubtedly affected by pretest probability, image quality, and the size and type of thrombus (the mural type being more difficult to detect). Larger and more mobile thrombi, as well as those residing adjacent to hyperkinetic myocardial segments, are more likely to embolize. As the thrombi age, they tend to become less mobile, more compact, and echobright in appearance. An increase in the globular shape of the heart is quantified by the sphericity index. On two-dimensional echocardiography this is the ratio of the long-axis dimension to the short-axis dimension, and values are 1. Displacement of the papillary muscle positions inferiorly and toward the apex also contributes to tethering of the mitral leaflets at abnormal angles that restrict leaflet closure. When there is a question of whether revascularization will improve akinetic but viable areas, dobutamine or contrastenhanced echocardiography may delineate the extent of myocardium that is hibernating (hypocontractile yet viable and still perfused32). Vasospasm, inflammation or fibrosis secondary to myocarditis, swelling from intramural hematoma or edema, takotsubo cardiomyopathy (apical ballooning syndrome, see Chapter 65), and any focal myocardial insult are also causes of wall motion abnormality. With persistence of the underlying condition, the left ventricle becomes less ellipsoid and more globular in shape, and the sphericity index decreases toward 1. Ischemic heart disease is often accompanied by visible atherosclerotic plaque in the aortic root and other portions of the aorta. One clue to the presence of focal inflammatory processes is wall motion abnormalities that do not follow a coronary distribution and associated thickening secondary to edema. Approximately half of symptomatic patients with Chagas disease classically have an apical or inferobasal aneurysm, but more advanced cases may feature global hypokinesis. Although the degree of dysfunction can be impressive in stress cardiomyopathy, remarkable and complete resolution can take place within days to weeks. Historically, M-mode findings such as increased separation of the mitral E point from the interventricular septum, decreased mitral leaflet opening, and early closure of the aortic valve are known to correlate with poor cardiac output. Biatrial enlargement is frequent because the atria become the low-compliance reservoirs for cardiac inflow, particularly if atrial fibrillation is present. Because of both this variable expression and rising awareness of this entity, definitive imaging and clinical criteria for this disease continue to be refined. In general, a ratio of trabeculated to compacted layer thickness of greater than 2, as measured on short-axis views at the mid and apical levels, is considered to be consistent with noncompaction. In some cases, segmental septum and/or banana-shaped cavity, asymmetric septal hypertrowall motion abnormalities, including thinning and aneurysms, may be present and are caused by fibrofatty infiltration. Such maneuvers include the Valsalva maneuver, sudden standing, and exercise, all of which may be performed during echocardiographic evaluation of these patients. With noncompaction RestrictiveCardiomyopathies Systemic diseases that can infiltrate the heart may lead to restrictive cardiomyopathies (see Chapter 65), with the most common being amyloidosis. Advanced diastolic dysfunction is manifested both by Doppler indices and by strain imaging. A restrictive filling pattern may occur earlier than the manifestations of systolic heart failure. All these parameters of function have been shown to improve with iron removal therapy. Fabry disease is associated with accumulation of glycosphingolipid in the heart and a high incidence of cardiovascular signs and symptoms in addition to renal, dermatologic, and neurologic abnormalities. More than 80% of individuals with Fabry disease will display concentric hypertrophy, although concentric remodeling and asymmetric hypertrophy occur in a smaller proportion. Eosinophilic endocarditis and infiltration of the myocardium lead to changes that can be striking on echocardiography. The ventricular cavities themselves are small with restrictive physiology because of the fibrotic process.

Foreign bodies pain treatment center dr mckellar buy discount aleve 250 mg on line, such as indwelling catheters pain medication for dogs and humans 500 mg aleve otc, provide sites where microbes can become covered with a glycocalyx coating (biofilm) that protects them from antibiotics and immunologic destruction pain treatment endometriosis discount aleve 500 mg amex. Many antibiotics are excreted unchanged by the kidneys pain treatment arthritis buy cheap aleve 250mg online, and lower doses must be used if the patient has significant renal impairment pain relief treatment center fairfax discount 500mg aleve free shipping. Less commonly pain treatment germany cheap aleve 250 mg on line, hepatic insufficiency may require dosage adjustment for antimicrobial drugs that are extensively metabolized in the liver. For example, neonates cannot metabolize chloramphenicol, so their dosage of this drug per kilogram of body weight must be lower than the dosage given to older children or adults. Antimicrobial Activity Antimicrobial agents can be selected on the basis of laboratory tests described earlier or based on knowledge of the most common organisms causing various types of infections and the preferred drugs for these organisms (empiric selection). Adverse Effect Profile Any antimicrobial drug can cause mild to severe adverse effects, but the incidence of these effects varies greatly among different classes of drugs, and it is important to consider the probable risk-to-benefit ratio when selecting drugs for treatment. Fluoroquinolones and tetracyclines are intermediate in their adverse effect profile. In an antagonistic interaction, the combined effect is less than the effect of either drug alone. In an indifferent interaction, the combined effect is similar to the greatest effect produced by either drug alone. In a synergistic interaction, the combined effect is greater than the sum of the independent effects. Comparison of several possible interactions of two antimicrobial drugs combined in vitro. Curves to be caused by more than one pathogen (mixed infections), such as intraabdominal infections caused by both aerobic and anaerobic organisms derived from the intestinal tract. In some cases, life-threatening infections such as hospitalacquired (nosocomial) pneumonia are treated with a combination of antibiotics until the causative organism can be identified. Bactericidal drugs are usually more effective against rapidly dividing bacteria, and their effect may be reduced if bacterial growth is slowed by a bacteriostatic drug. If two bactericidal drugs that target different microbial functions are given in combination, they can exert additive or synergistic effects against susceptible bacteria (Box 37. For example, penicillins, which are cell wall synthesis inhibitors, can have additive or synergistic effects with aminoglycosides, which inhibit protein synthesis, against gram-negative bacilli such as P. Likewise, sulfamethoxazole and trimethoprim inhibit sequential steps in bacterial folate synthesis and have synergistic activity against organisms that may be resistant to either drug alone. Combination therapy may also serve to reduce the emergence of resistant organisms, such as in the treatment of tuberculosis (see Chapter 41). This is because about 1 in 106 Mycobacterium tuberculosis organisms will mutate to a resistant form during treatment with any single drug. The rate of mutation to a form resistant to two drugs is the product of the individual drug resistance rates, or about 1 in 1012 organisms. Because fewer than 1012 organisms are usually present in a patient with tuberculosis, it is unlikely that a resistant mutant will emerge during combination therapy. In the case of tuberculosis, combination therapy can delay emergence of resistance even though the drugs may not exhibit a synergistic effect against the microbe. In some cases, antimicrobial drugs are also administered prophylactically either to reduce the incidence of infections associated with surgical and other invasive procedures or to prevent disease transmission to close contacts of infected persons. Prevention of Infection Caused by Invasive Procedures Antibiotics are used to prevent endocarditis in persons with a history of valvular heart disease, such as mitral valve prolapse and rheumatic heart disease. Amoxicillin is currently considered the drug of choice, but endocarditis can be prevented by using an alternative drug. Antibiotics are routinely used to prevent wound and tissue infections that can be acquired during a wide range of surgical procedures. The choice of antibiotic depends on the most likely sources of bacterial pathogens during a particular procedure. The skin is the most common source of pathogens, especially staphylococci, during most types of surgery. The gastrointestinal tract is also an important source of pathogens when surgical procedures involve the gastrointestinal system. Prevention of Disease Transmission Antimicrobial drugs are occasionally used to prevent the transmission of a highly contagious disease, such as meningococcal infection, from an infected person or insect vector to an exposed individual. Drugs are also used to prevent malaria in persons who are traveling to regions of the world where malaria is endemic and to prevent influenza type A in populations at increased risk for these diseases. A combination of two synergistic drugs is sometimes employed to treat an infection caused by a single microbe. Review Questions For each numbered description, select the corresponding term from the lettered choices. A cell membrane constituent that transports chemotherapeutic drugs out of a target cell. The continued suppression of bacterial growth after an antibiotic has been eliminated from the body. The combined antibacterial effect of two drugs is greater than the sum of their individual effects. These include cell wall synthesis inhibitors, protein synthesis inhibitors, metabolic and nucleic acid inhibitors, and cell membrane inhibitors. They can also be characterized as narrow-spectrum, broad-spectrum, or extended-spectrum based on their range of antimicrobial activity. The most common mechanism of transferable resistance is bacterial conjugation followed by the exchange of plasmids containing resistance genes. The penicillins were the first antibiotics to be discovered, and their development inaugurated the modern era of antimicrobial chemotherapy in the 1940s. Despite the growing problem of microbial resistance to these drugs, the cell wall inhibitors have remained one of the most widely used groups of antibiotics for more than 70 years. This article describes the structure and function of the bacterial cell envelope and the pharmacologic properties and clinical use of the bacterial cell wall inhibitors. Gram-negative bacteria also have an outer membrane not found in other types of bacteria. The cell wall is much thicker in gram-positive bacteria than in gram-negative bacteria. Cytoplasmic and Outer Membranes the cytoplasmic membrane is a trilaminar membrane. It contains several transport proteins that facilitate the uptake of substances used by bacteria, and it contains the enzymes that synthesize the bacterial cell wall. It contains species-specific forms of a complex lipopolysaccharide and various types of protein channels called porins. One portion of lipopolysaccharide (the lipid A portion) is the endotoxin responsible for gramnegative sepsis. A, the gram- positive bacterium has a thick cell wall but does not have an outer membrane. It also has an outer membrane that contains lipopolysaccharide and protein channels called porins. Porins allow ions and other small molecules to pass through the outer membrane, including various antibiotics. Alterations in porin structure can lead to bacterial resistance to antibiotics, such as may occur with resistance to carbapenem antibiotics such as imipenem. The inner bacterial cytoplasmic membrane is the target of two peptide antibiotics, daptomycin and polymyxin. These drugs act directly on the cell membranes to increase membrane permeability and thereby cause the cytoplasmic contents to leak out of the cell. The strands of peptidoglycan in the cell wall are cross-linked by a transpeptidase reaction in which the glycine pentapeptide of one strand is attached to the penultimate d-alanine molecule of another strand. The cell wall maintains the shape of the bacterium and protects it from osmotic lysis if it is placed in a hypotonic solution. Without a cell wall, the bacterium is unprotected and inhibition of cell wall synthesis by antibiotics is often bactericidal. Because a cell wall is not found in higher organisms, inhibition of cell wall synthesis has no effect on host cells. The cell wall is synthesized during bacterial replication, and drugs that inhibit cell wall synthesis are more active against rapidly dividing bacteria than they are against bacteria in the resting or stationary phase. For the same reason, the effectiveness of cell wall inhibitors is sometimes reduced by concurrent administration of bacteriostatic antibiotics that slow the growth of bacteria. These enzymes are anchored in the cytoplasmic membrane and extend into the periplasmic space. This partly accounts for the variation in the sensitivity of different organisms to different antibiotics. Numbers indicate the steps involved in the synthesis of the cell wall of Staphylococcus aureus. In step 1, bactoprenol pyrophosphate (bactoprenol-P-P; also known as C55-isoprenyl pyrophosphate) is dephosphorylated to regenerate the carrier molecule, bactoprenol phosphate (bactoprenol-P). In step 5, the disaccharide peptide is transferred to the peptidoglycan growth point. In step 6, the cross-linking of peptidoglycan strands is catalyzed by transpeptidase, a type of penicillinbinding protein. In this reaction a glycine of one strand forms a peptide bond with the penultimate d-alanine of an adjacent strand, and the terminal d-alanine is released. Bacitracin blocks step 1, and -lactam antibiotics and vancomycin block step 6 by different mechanisms. Vancomycin binds tightly to the D-alanyl-D-alanine portion of the peptidoglycan precursor and prevents bonding of the penultimate d-alanine to the pentaglycine peptide during cross-linking of peptidoglycan strands. Penicillins Penicillin was the first antibiotic to be isolated and used to treat systemic bacterial infections. Alexander Fleming discovered penicillin when he recognized that a Penicillium fungus contaminating his bacterial cultures produced a substance that inhibited bacterial growth. Fleming investigated the antimicrobial activity of crude extracts of penicillin but was unable to isolate the antibiotic in sufficient purity and quantity for clinical use. Narrow-spectrum penicillins (penicillin G and penicillin V) are active against many gram-positive cocci. B, Administration of benzathine penicillin G produces low plasma concentrations of the drug for several weeks. Administration of procaine penicillin G produces higher plasma concentrations for about 24 hours. Probenecid inhibits the renal excretion of penicillin G, prolongs its half-life, and increases its plasma concentrations. Some of the penicillins, such as amoxicillin and penicillin V, are stable in gastric acid and can be given orally, whereas others are acid-labile and must be given parenterally, such as piperacillin. The penicillins are widely distributed to organs and tissues except the central nervous system. Most penicillins are eliminated by active renal tubular secretion and have short half-lives of about 0. The renal tubular secretion of penicillins is inhibited by probenecid, a drug that competes with penicillins for the organic acid transporter located in the proximal tubule. Penicillin G is available in two long-acting forms for intramuscular administration, procaine penicillin G and benzathine penicillin G. Penicillin G is slowly released from these two preparations for absorption into the circulation after an intramuscular injection. Benzathine penicillin G provides very low plasma concentrations of the drug for a few weeks. The narrow-spectrum penicillins, penicillins G and V, are used to treat infections caused by sensitive strains of streptococci (including pneumococci), meningococci, and spirochetes. Penicillin G is also active against Clostridium perfringens, the cause of gas gangrene, and other pathogens. Most staphylococci and gonococci and some strains of pneumococci are now resistant to penicillin G. These penicillins are not active against most other species of penicillinase-producing bacteria. Nafcillin is usually preferred when parenteral administration is required, whereas dicloxacillin can be given orally for less severe infections. The penicillinase-resistant drugs are used to treat serious staphylococcal infections, such as acute endocarditis and osteomyelitis, as well as skin and soft tissue infections. Bacteria resistant to methicillin are also cross-resistant to nafcillin and all other penicillinase-resistant penicillins. Amoxicillin can be used alone to treat respiratory tract infections caused by sensitive bacteria, including otitis media, sinusitis, bronchitis, and communityacquired pneumonia, but some strains of pneumococci (Streptococcus pneumoniae) have developed intermediate resistance to amoxicillin, and larger doses are required to treat infections caused by these organisms. Amoxicillin is also used alone for prophylaxis of bacterial endocarditis in persons with heart valve defects. Formulations of amoxicillin-clavulanate are available to treat respiratory tract infections (pneumonia, sinusitis) caused by these organisms, including a liquid suspension for treating children with otitis media (Box 38. Amoxicillin-clavulanate is also indicated for treating bite wound infections because it is active against the common pathogens causing these infections, including Pasteurella multocida and S. Ampicillin is active against Listeria monocytogenes and is used to treat meningitis and other infections caused by this organism (listeriosis). It is also used in combination with sulbactam (a -lactamase inhibitor) to treat infections caused by penicillinase-producing strains of bacteria, including bite wounds and diabetic foot ulcers. Piperacillin is active against many gram-positive and gram-negative aerobic and anaerobic bacteria, including some strains of Pseudomonas aeruginosa. Because of the possibility of an infection caused by pneumococci with intermediate penicillin resistance, she is placed on amoxicillinatadoseof90mg/kg/dayinthreedivideddoses for10days. Streptococcus pneumoniae with intermediate penicillin resistance necessitates anamoxicillindoseof90mg/kg/day.

Rifampin is also used to eliminate staphylococcal carriage and to treat staphylococcal infections in combination with vancomycin and gentamicin treatment for severe shingles pain order aleve 250 mg on-line, such as staphylococcal endocarditis pain treatment centers of america buy discount aleve 250 mg on-line. Rifampin is occasionally used to treat Legionella pneumophila infections in combination with a macrolide or a fluoroquinolone drug pain treatment and management order 500 mg aleve free shipping. The major drawback of rifampin is the tendency for microbes to acquire resistance during exposure to the drug midwest pain treatment center fremont ohio cheap aleve 250 mg line. Because of the potential for the emergence of resistance during treatment shoulder pain treatment youtube buy discount aleve 250mg on-line, rifampin is never used alone to treat active infections treatment for dog neck pain cheap 250 mg aleve free shipping. The adverse effects of rifampin are usually mild, but the drug can impair liver function, elevate serum bilirubin and transaminase levels, and cause hepatitis. Liver function should be tested during treatment, and rifampin should be discontinued if signs or symptoms of hepatic dysfunction become evident. A hypersensitivity reaction, manifesting as a flulike illness with chills, fever, fatigue, and headache, develops in as many as 50% of persons taking rifampin. High-dose intermittent therapy can also cause renal disease, leukopenia, and thrombocytopenia. Rifapentine and Rifabutin Rifapentine is a longer-acting rifamycin derivative whose microbiologic activity is similar to that of rifampin. Rifabutin is administered orally once a day with food to reduce gastrointestinal irritation. The drug is highly lipophilic, is widely distributed to tissues, and reaches substantial intracellular concentrations. As with rifampin, rifabutin induces cytochrome P450 enzymes and may reduce serum concentrations of drugs metabolized by these enzymes. Patients should also be monitored for adverse liver reactions, and it may cause nausea, headache, and other side effects. The drug interacts with cytochrome P450 enzymes, and dosage adjustments may be needed if other drugs affecting or metabolized by P450 enzymes are given concurrently. For the treatment of leprosy, rifampin is usually combined with dapsone or with dapsone plus clofazimine. It is never used alone because of the probability that organisms will become resistant to it during treatment. Clofazimine Clofazimine is a phenazine dye that has antimycobacterial and antiinflammatory effects. In addition to its antimicrobial effects, the drug enhances the phagocytic activity of neutrophils and macrophages. Clofazimine is used in combination with dapsone and rifampin to treat lepromatous leprosy. This reaction is characterized by tender erythematous skin nodules with inflammation of subcutaneous fat and acute vasculitis. Clofazimine is usually combined with corticosteroids to treat leprosy that is complicated by erythema nodosum leprosum. Clofazimine is slowly and incompletely absorbed from the gut, with a bioavailability of about 55%. The highly lipophilic drug is widely distributed to tissues and macrophages, has a long half-life (about 70 days), and remains in the body for years. Adverse effects of clofazimine include gastrointestinal distress (anorexia, nausea, vomiting, abdominal pain, and diarrhea), photosensitivity, and discoloration of body secretions and the skin. Because clofazimine can elevate hepatic enzyme levels and cause hepatitis, use of the drug is avoided in persons with hepatic disease. Thalidomide Thalidomide was once banned because it caused phocomelia (congenital abnormalities of the limbs) in offspring of women who took it during pregnancy. Subsequent investigations have shown that the drug has immunomodulating actions (see Chapter 45) that are beneficial in the management of several conditions. The World Health Organization now recommends multidrug therapy for most persons with leprosy. Multidrug therapy has been shown to hasten the eradication of bacteria, to reduce the duration of active disease, and to prevent worsening of disabilities in persons with leprosy. In addition, multidrug therapy appears to reduce overall costs, increase patient compliance, and increase the motivation and availability of leprosy workers. Sulfones the sulfones have served as the foundation of drug therapy for leprosy for several decades. These compounds are related to the sulfonamides and have a similar mechanism of action. Dapsone, or diaminodiphenylsulfone, is the sulfone that is most commonly used in the treatment of leprosy. Individuals who have glucose-6-phosphate dehydrogenase deficiency may exhibit hemolytic anemia resulting from the oxidation of erythrocyte membranes by dapsone. Persons with a high acetyltransferase activity will have comparatively lower plasma levels of which drug Pathogenic fungi include yeasts (exist as single cells), molds (multicellular filamentous forms or hyphae), and dimorphic organisms that exist in both yeast and mold forms. Fungal infections include superficial (mucocutaneous), subcutaneous, and systemic infections. Superficial mycoses include infections of the skin, hair, and nails caused by dermatophyte fungi, most commonly Epidermophyton, Microsporum, and Trichophyton species that feed on keratin in the outer layer of these tissues. Dermatophyte skin and hair infections typically present as a pruritic (itchy) rash and erythema. Ringworm is a colloquial term for an annular (ring-shaped) lesion with a scaling rash and a clear center. Mucocutaneous mycoses are usually caused by yeasts, most often Candida albicans and other Candida species. Affected patients may have oral candidiasis ("thrush"), vaginal candidiasis, or Candida infections of the axilla, groin, and gluteal folds (including so-called "diaper rash" in infants). Less common yeasts causing mucocutaneous infections include Malassezia furfur (formerly called Pityrosporum orbiculare), which causes tinea versicolor, a skin infection characterized by hypopigmented and hyperpigmented macules, typically in the shoulder girdle area. The subcutaneous mycoses involve the dermis, subcutaneous connective tissue, and muscle. These infections are usually caused by puncture wounds contaminated with soil fungi and include chromomycosis, pseudallescheriasis, and sporotrichosis. Systemic mycoses are fungal infections of the internal organs and tissues and include urinary tract infections, pneumonia, meningitis, esophageal infections, and septicemia (blood infection). Some systemic infections also involve the skin, muscle, joints, and other tissues. The systemic mycoses are most commonly caused by members of the genera Aspergillus, Blastomyces, Candida, Coccidioides, Cryptococcus, and Histoplasma. These conditions either suppress cellular immunity or facilitate colonization and infection by fungi. For example, there has been an increased incidence of invasive infections caused by Aspergillus, Scedosporium, and Fusarium species in recipients of hematopoietic stem cell transplants in recent decades. However, drugs that are selectively toxic to fungi have been developed and are available to treat fungal infections in humans and animals. This action increases fungal plasma membrane permeability and allows the cytoplasmic contents to leak from the cell. The polyene drugs also bind to a lesser degree to cholesterol in mammalian cells, and this may account for their ability to damage renal cell membranes and cause toxicity. The allylamine drugs and the azole derivatives block distinct steps in ergosterol biosynthesis, but these groups of drugs have little effect on cholesterol biosynthesis in humans. Allylamine drugs, such as terbinafine, inhibit squalene epoxidase, which converts squalene to squalene-2,3-oxide, the immediate precursor of lanosterol. The azoles such as fluconazole inhibit 14-demethylase, a fungal cytochrome P450 enzyme that converts lanosterol to ergosterol. The fungal cell wall surrounds the plasma membrane and normally protects the cell from osmotic and mechanical stress. Griseofulvin acts by binding to fungal microtubules and thereby inhibiting microtubule function and mitosis. The mechanism of action of tolnaftate is uncertain, but it appears to inhibit squalene epoxidase in a manner similar to allylamine drugs such as terbinafine. Examination confirms diffuse scaling and hair loss without noticeable inflammation, and posterior cervical lymphadenopathy is present. Amphotericin B tends to be used for treating severe mycoses, whereas the azoles are used for less severe infections. Flucytosine is usually administered in combination with amphotericin B for the treatment of systemic Cryptococcus or Candida infections. The selective toxicity of these drugs is a result of the difference in the sterols found in fungal and mammalian cell membranes. Fungal cell membranes contain ergosterol, whereas mammalian cell membranes contain cholesterol. Polyene Antibiotics the polyene antibiotics are produced by various soil organisms of the family Streptomycetaceae and include amphotericin B, natamycin, and nystatin. Each of these compounds consists of a macrolide (large lactone) ring containing conjugated (side-by-side) double bonds (polyene), with acidic and basic side groups. These drugs are amphoteric because the acidic and basic groups are capable of either donating or accepting a proton (hydrogen ion, H+), respectively. Amphotericin B has greater antifungal activity than amphotericin A, which is not used clinically. Amphotericin B is the only polyene drug used to treat systemic and subcutaneous mycoses. The other polyene drugs are limited to topical application for the treatment of superficial and mucocutaneous mycoses. Amphotericin B is available as a deoxycholate complex and as three lipid formulations for parenteral administration. As with other polyene antibiotics, it is not absorbed from the gastrointestinal tract. The dosage of amphotericin B depends on the site and severity of the infection and on the immune status of the patient. Concentrations of the drug in cerebrospinal fluid are only 2% to 3% of those in plasma, because amphotericin B does not penetrate the blood-brain barrier very well. Nevertheless, the drug is usually administered intravenously to treat fungal meningitis because of the problems associated with intrathecal administration of the drug. Amphotericin B is extensively metabolized in the liver, and the metabolites are slowly excreted in the urine. The drug exhibits a biphasic half-life, with an initial half-life of about 24 hours and a terminal half-life of about 15 days. The synthesis of ergosterol is inhibited by allylamine drugs and by azole derivatives. Amphotericin B and other polyene antibiotics bind to ergosterol in fungal cell membranes and increase membrane permeability. Caspofungin prevents fungal cell wall synthesis by inhibiting -1,3 glucan synthase (A) and the synthesis of -1,3 glucan (B). Other components of the fungal cell wall include -1,6 glucan (C), mannoproteins (D), and chitin (E). It is also active against certain pathogenic protozoa and is used in the treatment of leishmaniasis and amebic encephalitis (see Chapter 44). Although polyene antibiotics have been used to treat fungal infections for nearly 50 years, relatively few cases of clinical resistance to these drugs have been reported. Fungi that do become resistant to polyenes often have a reduced content of ergosterol in their cell membranes. Amphotericin B has been called "ampho-terrible" because it is one of the most toxic antibiotics in use today. Renal toxicity reduces the glomerular filtration rate and contributes to the development of hypokalemia and hypomagnesemia. Electrolytes (especially sodium, potassium, and magnesium) should be monitored weekly during treatment and replacements administered as needed. Lipid formulations of amphotericin B cause less renal toxicity and should be used in persons with renal impairment and those who are intolerant of the traditional deoxycholate formulation. Many clinicians prefer these formulations for treating most systemic fungal infections. These preparations include amphotericin B cholesteryl sulfate (Amphotec), amphotericin B phospholipid complex (Abelcet), and amphotericin B liposomal complex (AmBisome). The lipid formulations have unique pharmacokinetic characteristics that reduce renal drug concentrations and toxicity. After intravenous administration, the lipid formulations are sequestered by cells of the reticuloendothelial system in the liver and spleen, which slowly release amphotericin B into the circulation over several days, resulting in lower but more sustained plasma levels of the drug. In addition to causing nephrotoxicity, amphotericin B can cause acute liver failure, cardiac arrhythmias, and hematopoietic disorders such as anemia, leukopenia, and thrombocytopenia. The drug frequently causes less severe but unpleasant infusion-related effects, including chills, fever, headache, nausea, and vomiting. The severity of these minor adverse effects can be lessened by pretreatment with corticosteroids, antipyretic drugs. Nystatin and Natamycin Nystatin, which is active against Candida species, is available in various topical formulations, including the following: creams, ointments, and powders for mucocutaneous candidiasis; orally administered tablets and suspensions for intestinal candidiasis; and vaginal tablets for vaginal candidiasis. Natamycin is active against Aspergillus, Candida, Fusarium, and Penicillium species and is available as an ophthalmic suspension for the treatment of fungal blepharitis, conjunctivitis, or keratitis. Azole Derivatives the azole antifungal agents are synthetic drugs used in the treatment of various mycoses (see Table 42. These drugs possess a five-member ring containing two or three nitrogen atoms, which constitute the diazole (imidazole) and triazole compounds, respectively. Single-dose or short-term use of fluconazole for vaginal candidiasis remains category C. The triazole congeners include efinaconazole, fluconazole, itraconazole, posaconazole, terconazole, and voriconazole.

Syndromes

• Hepatitis
• Stool ova and parasites exam using a microscope
• Persons whose immune systems are weakened by disease or medicines (such as after organ transplant).
• Low level of one or more types of blood cells
• Arthritis
• Bypass surgery is done to reroute blood around the compression or remove the area that is causing the symptoms.
• Get plenty of sleep. Sleeping 8 to 10 hours a night and taking naps during the day can help you recover from a flare-up more quickly and may even help prevent flare ups.
• Reduced urine output
• Sensory changes
• Low birth weight

The exposure that the patient receives is a function of the strength and duration of the current applied to the x-ray tube (or more precisely and accurately tailbone pain treatment yoga purchase aleve now, a function of the number northside pain treatment center atlanta order on line aleve, strength pain treatment guidelines 2014 order aleve 250 mg with visa, and duration of the x-ray photons produced-milliamperage pain treatment suboxone discount aleve 500mg visa, kilovoltage pain treatment for postherpetic neuralgia order cheap aleve on-line, and milliseconds) otc pain medication for uti order aleve 500 mg amex, size of the focal spot, distance from the tube to the patient, and degree to which the x-rays are blocked and scattered within the patient. Most patient exposure is not a result of the x-rays that penetrate but rather those that interact with body structures and are slowed and changed and, in the process, deposit residual energy in tissue. As the amount of tissue that attenuates photons increases, the amount of energy deposition within the patient will increase. Patients who are very thin will require an inherently lower x-ray dose to achieve diagnostically satisfactory deposition of x-ray photons on an imaging medium and will have less deposition of energy within the body. In patients who are obese, a higher x-ray dose will be necessary to penetrate the patient and produce a diagnostic exposure. The increased soft tissue in these patients also causes more dispersion of the x-ray beam and results in a higher dose. Scatter not only leads to deposition of energy in the patient but also deposits energy in surrounding structures, including personnel, if they are close to the patient (as with fluoroscopy), and the recording medium. That is, the film or digital plate is altered not only by the incident x-rays intended to produce the image. The more scatter deposited on the recording medium, the more the image quality is denigrated and the worse the resolution-the signal-to-noise ratio is decreased. As a result there is increased divergence of the x-rays from the midline point source and relative magnification. Depth of inspiration is therefore likely to be decreased in comparison to an erect film, which Patient makes the heart appear relatively larger and provides less optimal visualization of the lungs because they are not optimally expanded. Inherently, then, resolution is poorer with portable radiographs, thus making them less accurate and useful. In addition, the radiation dose to both patients and personnel is generally greater. With optimal technique and a cooperative patient who can hold a deep inspiration, the result is a study that Patient clearly and accurately depicts very small structures, such as the contour of small pulmonary arteries. With radiographic film, the incident x-rays (and scattered photons) alter the silver iodide crystals in an emulsion. When the film is developed, these alterations produce an image reflecting the extent to which the x-rays have interacted with specific areas of the film. There is inherently very high resolution of structures because of the small size of the silver iodide crystals and their sensitivity to incident x-ray photons. This information is then directly the patient to the source, the greater the x-ray divergence and resulting geometric downloaded and can be viewed and postprocessed. The inherent resolution with both is very similar to that of conventional radiographic film, but the elimination of analog-to-digital conversion eliminates some noise and thus the overall resolution tends to be as good as with conventional film-screen radiographs. This adds speed and availability and obviates the problem of lost films-all films are digitally archived-and the need to go to a remote location to review a film. B, A line drawing in the frontal projection demonstrates the relationship of the cardiac valves, rings, and sulci to the mediastinal borders. Storage of digital images, even though initially can be seen coursing superiorly and posteriorly relative to the right. Integration with a system-wide is normally obscured by the main pulmonary artery and both atria. The radiation exposure to the patient should always be kept in mind when any radiographic study is ordered or performed. The atrium constitutes the upper portion of the and cumulative effect are not known. The amount of information present is huge, and there are countless relevant variables that must be evaluated: the soft tissues, bones and joints, pleura, lungs and major airways, pulmonary vasculature, mediastinum and its contents, heart (and specifically its chambers), the aorta, and areas below the diaphragm and above the thorax. It is imperative to take a systematic and standardized approach, based first on assessment of the anatomy, then the physiology, and finally the pathology. The heart overlies the thoracic spine, roughly 75% to the left and 25% to the right of the spine. The mediastinum is narrow superiorly, and normally the descending aorta can be defined from the arch to the dome of the diaphragm on the left. The pulmonary hila are seen below the aortic arch, slightly higher on the left than on the right. The apex is often not clearly delineated for a reason related to x-ray attenuation. The heart is distinguishable from the lungs because it contains water-density blood rather than air. Fat has a density greater than that of air and marginally less than that of blood. As it thins out toward the left lateral chest wall, it is progressively less dense, which explains the hazy, poorly marginated appearance of the apex. The borders of the cardiac silhouette are normally moderately but not completely sharp in contour. A, With a pulmonary window and level, the lung fields, including the pulmonary vasculature, are well visualized but the mediastinal structures are not well defined. Note also flattening of the diaphragms and increased lung lucency, indicative of chronic obstructive pulmonary disease. B, Rewindowed, the mediastinal structures are now well seen and show a dilated, calcified aortic root and descending thoracic aorta. There is evidence of chronically elevated pulmonary venous pressure with moderate (not marked) pulmonary vascular redistribution. Note enlargement of the left ventricle, which is extending below the diaphragm and compressing the gastric bubble (arrowheads). Also note the apical fat pad, seen as the hazy density on the frontal view (A, arrow) and as the anterior, retrosternal, well-delineated, wedgeshaped density on the lateral view (B, arrow). The aortic arch is generally visible because the aorta courses posteriorly and is surrounded by air. Lungs and Pulmonary Vasculature Lung size varies as a function of inspiratory effort, age, body habitus, water content, and intrinsic pathologic processes. For example, because lung distensibility decreases with age, the lungs normally appear subtly but progressively smaller as patients age, even with maximal inspiratory effort. The pulmonary arteries are usually easily visible centrally in the hila and progressively less so more peripherally. C, Diagram of the lateral projection of the heart showing the position of the cardiac chambers, valve rings, and sulci. The sharp horizontal contour of the left ventricle is suggestive of an anterior wall aneurysm. This effect of gravity on the distribution of normal intravascular lung volume is reflected in a normal perfusion lung scan. Because the radionuclide is generally administered with the patient supine, there is a greater concentration posteriorly than anteriorly, as confirmed by the count A rates. Conversely, if the patient is sitting or standing when the radionuclide is injected, the count rate is greater at the lung base than at the apices. The angles that the lungs make with the diaphragm are normally sharp and clearly seen bilaterally on frontal and lateral views because the pleura is usually tightly applied to (not separated from) the ribs. This contour is made up of the left atrium and ventricle, which lie toward the left side of B the thorax. There is a prominified in comparison to the left (see nent apical fat pad on the lateral view (black arrows). This sign, although sometimes still referenced, is not accurate and should not be relied on. The aorta and great vessels normally dilate and become more tortuous and prominent with increasing age, thereby leading to widening of the superior mediastinum. B, A lateral view demonstrates thin, irregular calcification of the pericardium around the left ventricular There are additional important anatomic concontour. Patients who are obese may not be able to fully expand their lungs, thus making a normal heart appear slightly larger. There may also be lack of definition of the right heart branches) are in the middle zone; and the small arteries and arterioles, border on the frontal view because of compression by the sternum which are normally below the limit of resolution, are in the outer zone. Marked kyphosis, as may occur with osteoporotic 15 the Chest Radiograph in Cardiovascular Disease 265. Note the hazy right mediastinal silhouette on the frontal view caused not by cardiac or pulmonary abnormalities but by pectus excavatum (arrow), as seen on the lateral view. Any system must incorporate a routine that includes a deliberate attempt to look at areas that are easily ignored. Such areas include the thoracic spine, neck (for masses and tracheal position), costophrenic angles, lung apices, retrocardiac space, and retrosternal space. These areas are evaluated to define mediastinal position, cardiac and aortic situs, and the presence of pleural effusions, scarring, or diaphragmatic elevation. Dextrocardia and a right descending aorta are rare, particularly in adults, but are easy to check for and are important to recognize because of their association with congenital cardiac and abdominal situs abnormalities. Vessels should be larger in the lower part of the lung and sharply marginated in both the upper and lower zones. In normal individuals, the vessels taper and bifurcate and are difficult to define in the outer third of the lung. They are uniformly enlarged and can be traced almost to the pleura, but their margins remain clear. At pressures of 12 to 18 mm Hg, the vessel borders become progressively hazier because of increasing extravasation of fluid into the interstitium. This effect is sometimes evident as Kerley B lines, which are horizontal, pleural-based, peripheral linear densities. It is best to define pulmonary vascularity by looking at the middle zone of the lungs. It is most commonly seen as an isolated finding in congenital heart disease, typically tetralogy of Fallot. Less commonly, it is the result of primary pulmonary hypertension or chronic pulmonary emboli (see Chapter 74). Note the engorged hila bilaterally with the typical pattern of pulmonary edema on the right. Also note the intra-aortic counterpulsation balloon with a radiopaque tip at the top of the descending aorta (small arrow) and the balloon expanded in the aorta below it (large arrow). Regardless of these limitations, it is important to evaluate the pulmonary vascular pattern routinely because it can provide a great deal of information. After assessing overall heart size and the pulmonary vascular pattern-as a reflection, in general, of left-sided heart physiologic status-the individual chambers should be examined. Second, because of its location, as the left atrium enlarges, it elevates the left main stem bronchus. This bowing is distinguishable from the tortuosity seen with progressive atherosclerosis, which involves the descending thoracic aorta in its upper portion or diffusely. In mitral stenosis the left atrium dilates progressively over time (because of a progressive increase in pressure in this low-pressure left-sided chamber), there is consequent progressive evidence of pulmonary vascular redistribution, often with Kerley B lines, and eventually the right ventricle becomes dilated and enlarged. In contrast, in mitral regurgitation, with increased volume in the left atrium and Left Atrium Right Atrium Right atrial enlargement is essentially never isolated except in the presence of congenital tricuspid atresia or the Ebstein anomaly. A, Frontal view showing normal heart size, mild vascular redistribution, and marked focal enlargement of the left atrium (small arrow), which extends to the right of midline (large arrow). B, Lateral view showing a dilated right ventricle with filling in of the retrosternal airspace. B, Lateral view confirming prominence of the pulmonary outflow tract and main and left pulmonary arteries (arrows). Such dilation is thought to be caused by a jet effect directed through the stenotic valve to the main pulmonary artery and the left main pulmonary artery, which is directly in line with it. The right main pulmonary artery comes off at a fairly sharp angle and is not generally affected by the jet from the stenotic valve. The dilation is seen as a prominent left hilum on the frontal view and a prominent pulmonary outflow tract on the lateral view. It is often possible to define the pathology by a combination of the pattern of dilation and associated cardiac abnormalities. Dilation of the aortic root is seen with aortic valve disease (both stenosis and regurgitation) but more frequently has other causes, such as longterm, poorly controlled systemic hypertension or generalized atherosclerosis with ectasia. The left ventricle generally hypertrophies in response to increased afterload rather than dilating as it does in response to the increased volume that occurs with aortic regurgitation. The presence or absence of aortic valve calcification may help in the differentiation. Over time, however, dilation of the and enlargement of the ascending aorta, which has created a convex right border of the mediastinum. This calcification (black arrowheads) lies below a line drawn from the left main bronchus to the anterior costophrenic sulcus, which localizes it to the mitral valve. The calcified aortic valve in this patient lies more anteriorly and above this line (white arrowhead). Pleural calcification is easily distinguishable from pericardial calcification and is essentially pathognomonic for asbestos exposure. It is associated with a high risk for malignant mesothelioma but is not diagnostic of this type of tumor. A, Frontal view diomegaly and pulmonary vascular redistrishowing a prominent aortic root to the right of midline (arrowheads). B, Lateral view demonstrating calcification of the aortic valve leaflets (arrows). Aortic regurdiffer, their appearances are similar; there is focal prominence of the gitation may be caused by dilation of the valve or by aortic dissection anterolateral cardiac contour with true aneurysms, there may be into the valve ring. In tertiary syphilis, now rarely seen, the characlinear myocardial calcification, and the cardiac margin is unusually teristic finding is marked dilation of the aorta from the root to the sharp because the area of the aneurysm does not have normal arch, with an abrupt return to normal diameter at this level. After percutaneous repair, delay appropriate diagnosis and intervention, as in the case of sushowever, the septal repair device can often be identified.

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