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Thus recurrent diarrheal diseases order proscar online pills mens health old school workout, by a combination of dietary and behavioral interventions order proscar 5 mg without prescription androgen hormone response element, lower respiratory tract infections and occult urinary tract coupled with improvements to the overall quality of home infection are common, and have high mortality. This explains a high systemic infections, other nutritional, micronutrients incidence of Gram­negative bacterial infections and serious deficits, anemia, and fluid and electrolyte disturbances morbidity and high mortality to viral infection like herpes • the intake of food is promoted by all available means. Serum C­reactive protein and C3 action complement levels are depressed in severe malnutrition • Possible epidemiological factors for malnutrition are but rise in presence of infections and thus behave as acute considered and attempt is made to eliminate these as phase reactants. These children are managed at home by parents under observation and Malnourished children are more susceptible to disease, supervision. They are monitored through weekly visits by 144 have a reduced capacity to learn, have deficits in cognitive paramedicals or visits to the hospital or at a nutritional function, less likely to perform well in school and are likely rehabilitation center every week. The main goal of treatment is to provide adequate calories to replace losses, to build up decades. Caution must be taken to and electrolyte disturbances are common in severely gradually build up the calories and proteins. The expected malnourished children, and found to be the poor prognostic calories and proteins are calculated on the present weight. After that, malnourished children, 11–20% is poor, 5–10% is moderate, over 2 weeks, the diet (calories and proteins) are increased 1–4% is good and less than 1% is excellent. It takes about 6 months feeding, micronutrient supplementation, broad­spectrum to achieve this target. Not all severely malnourished children ground nut, soya, and amylase­based food formulations. Majority of children Emphasis must be laid on adding enough oil/ghee/butter usually have some complications; they need hospitalization to the diet to increase calories and palatability. Basically these should be from locally available, seasonal and affordable food sources, commonly consumed by the Table 4. The diet should be liquid, semisolid or solid depending on the child’s acceptability and appetite. Frequent small feeds • Hypothermia • Infection are encouraged, increased gradually rather than one or two • Fluid and electrolyte imbalance major bulky meals. Parents are educated about proper cooking, • Raised liver enzymes clean drinking water, sanitation and personal hygiene. Home based management has the advantage of easier access by rural population, promoting early intervention in the disease, improving coverage rates and preventing nosocomial infections. However, over 80% malnutrition deaths occur in mild to moderately malnourished children as these greatly outnumber children with severe malnutrition. Hence, for better child survival, intervention is necessary for management of mild and moderately malnourished children in addition to that of severely malnourished children. Hence, there is an urgent need to identify these malnourished children timely and plan the treatment based on the need of an individual child. Phase 2: Phase of restoration or recovery (1–2 • Copper: 20 µg/kg/day weeks) when the child will increase dietary intake • Chromium: 0. During this phase the aim is to Total fluid and sodium not to exceed 75% of allowance. Feeding is designed to • Potassium: 2–5 mmol/kg/day provide 75–80 cal/kg/day and proteins 0. Breastfeeding should be continued and Starter formulas like F­75 (milk based Hypoglycemia: containing 75 cal/100 mL and 0. If 10% intravenous glucose not available, with spoon, dropper, or nasogastric tube. In the phase of restoration, the principle is to increase weight Hypothermia: Warm bed and room, keep the baby with and catch up growth as the child’s appetite has regained. Treat the calories and proteins (preferably 50% should have hypoglycemia and sepsis. When Days Frequency Volume/kg/feed Volume/kg/day congestive heart failure is due to fluid overload, administer 1–2 2 hourly 11 mL 130 mL frusemide 1–2 mg/kg, and reduce/stop fluid infusion. Diuretics should never be used to correct edema in 6–7+ 4 hourly 22 mL 130 mL Table 4. Depending on the severity, either the amount of milk may be diminished in the diet, by replacing Fortified with micro nutrients (sodium, 1. In severe lactose nesium, iron, zinc, copper, selenium, iodine, intolerance, milk will have to be temporarily completely vitamin A, vitamin D, vitamin E, vitamin K, omitted and replaced by cereals, pulses—rice, dal, soya, rice vitamin B1, vitamin B2, vitamin B6, vitamin gruel, egg, soy milk, chicken gruel/rice, curds and rice, etc, B, vitamin C, folic acid, niacin, pantothenic 12 (Table 4. In this phase, Fat 45–60% of total energy emphasis is on intensive feeding to restore lost weight, is in hospital (if not already discharged) or a nutritional catch up growth and recover emotionally and physically. The calories are gradually increased from 150 cal/kg/day to 180 cal/kg/day and proteins 1. Ideally this phase extends from 6 weeks to 26 weeks to give By now as the child is accustomed to semisolid or solid diet. Mother should be involved in caring for the baby as far as Name Constituents Calories Proteins possible (e. Dried skimmed milk Skimmed milk (60 g) 400 20 Prevention of Protein energy Malnutrition Sucrose (12 g) Prevention requires a coordinated approach of many disci­ Vegetable oil (15 g) plines: nutrition, agriculture, food technology, education, 2. Milk and rice Milk (75 mL) 79 3 health administration, social services, non­governmental Rice (5 g) organizations, community and religion. A strong political Sugar (25 g) commitment is must for tackling malnutrition in the Water (100 mL) country. Nutrition should be a priority at national and sub national levels as it is central for human, social and economic Lactose free diet development. Chicken gruel Chicken (100 g) 720 26 Glucose (40 g), Oil (50 g) Water (1 L) offered as shown in Table 4. The discharge criteria of severely malnourished child may vary and are summarized in Table 4. Provide a cheerful stimulating environment in form of structured play therapy 15–30 minutes/day. Besan Mix/ladoo Panjiri Bengal gram flour 500 9 Wheat flour Jaggery, ghee (1 part of each) 2. Maternal and child Of weight/age nutrition: global and regional exposures and health Attainment of 75%, 80–90% • Difficult to attain and associated with consequences. Maternal and child undernutrition: effective • Oral dietary intake adequate action at national level. Prolonged hospitalization • Risks of acquiring nosocomial infection International. Mumbai: International Institute for Population • Inconvenience to family and loss of Sciences; 2007. Effective international action against undernutrition: why Note: Along with medical and nutritional management providing care has it proven so difficult and what can be done to accelerate and stimulation is vital.

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Breakthrough bleeding 5 mg proscar with mastercard androgen hormone pregnancy, in our view buy discount proscar on line prostate 9 complex, is not suf- cient reason to expose patients to the increased risks associated with higher dose oral contraceptives. Any bleeding that is not handled by this routine requires investigation for the presence of pathology. Tere is no evidence that any oral contraceptive formulations that are approximately equivalent in estrogen and progestin dosage are signifcantly diferent in the rates of breakthrough bleeding. Clinicians ofen become impressed that switching to another product efectively stops the break- through bleeding. It is more likely that the passage of time is the responsible factor, and bleeding would have stopped regardless of switching and regard- less of product. Amenorrhea With low-dose pills, the estrogen content is not sufcient in some women to stimulate endometrial growth. The progestational efect dominates to such a degree that a shallow atrophic endometrium is produced, lacking sufcient tissue to yield withdrawal bleeding. It should be emphasized that perma- nent atrophy of the endometrium does not occur, and resumption of normal ovarian function will restore endometrial growth and development. Indeed, A Clinical Guide for Contraception there is no harmful, permanent consequence of amenorrhea while on oral contraception. The major problem with amenorrhea while on oral contraception is the anxiety produced in both patient and clinician because the lack of bleeding may be a sign of pregnancy. The patient is anxious because of the uncertainty regarding pregnancy, and the clinician is anxious because of the medicolegal concerns stemming from the old studies, which indicated an increased risk of congenital abnormalities among the ofspring of women who inadver- tently used oral contraception in early pregnancy. We reviewed this prob- lem earlier, and emphatically stated that there is no association between oral contraception and an increased risk of congenital malformation, and there is no increased risk of having abnormal children. It is important to alert patients upon starting oral contraception that diminished bleeding and possibly no bleeding may ensue. A pregnancy test will allow reliable assessment for the presence of pregnancy even at this early stage. However, routine, repeated use of such testing is expensive and annoy- ing, and may lead to discontinuation of oral contraception. Many women are reassured with an understanding of why there is no bleeding and are able to continue on the pill despite the amenorrhea. Some women cannot reconcile themselves to a lack of bleeding, and this is an indi- cation for trying other formulations (a practice unsupported by any clinical trials, and, therefore, the expectations are uncertain). But again, this prob- lem does not warrant exposing patients to the greater risks of major side efects associated with higher dose products. Yet, studies of the low-dose preparations fail to demonstrate a signifcant weight gain with oral contraception, and no major difer- ences among the various products. The clinician has to carefully reinforce the lack of association between low-dose oral contraceptives and weight gain and focus the patient on the real culprit: diet and level of exercise. Most Oral Contraception women gain a moderate amount of weight as they age, whether they take oral contraceptives or not. The progestins in estrogen-progestin contraceptives also inhibit 5a- reductase activity in skin, further contributing to the clinical impact of oral contraceptives on hirsutism. Drugs That Affect Efficacy Tere are many anecdotal reports of patients who conceived on oral con- traceptives while taking antibiotics. Tere is little evidence, however, that antibiotics such as ampicillin, metronidazole, quinolone, and tetracycline, which reduce the bacterial fora of the gastrointestinal tract, afect oral con- traceptive efcacy. Studies indicate that while antibiotics can alter the excre- tion of contraceptive steroids, plasma levels are unchanged, and there is no evidence of ovulation. A list, which may not be com- plete, includes the following: Carbamazepine (Tegretol) Felbamate Lamotrigine Nevirapine Oxcarbazepine Phenobarbital Phenytoin (Dilantin) Primidone (Mysoline) Rifabutin Rifampicin (Rifampin) St. John’s wort Topiramate Vigabatrin Possibly valproic acid, ethosuximide, griseofulvin, and troglitazone Other Drug Interactions Although not extensively documented, there is reason to believe that oral contraceptives potentiate the action of diazepam (Valium), chlordiazep- oxide (Librium), tricyclic antidepressants, and theophylline. Because of an infuence on clearance rates, oral contraceptive users may require larger doses of acetaminophen and aspirin. Tere are two categories of migraine headaches: common migraine which is migraine without aura and classic migraine which is migraine with aura (essentially migraine headaches with visual aura or other neurologic symptoms, occurring in 30% of migraine suferers). Symptoms that indicate a premonition of a headache, such as light or sound sensitivity, poor concentration, and fatigue occurring 1 to 2 days before a headache are also not considered signs of aura. Because of the seriousness of this potential complication, the onset of visual symptoms or severe headaches requires a response. If the patient is at a higher dose, a move to a low-dose formulation may relieve the headaches; however, this practice has not been studied. True vascular head- aches (migraine with aura) are an indication to avoid or discontinue oral contraception. Oral contraceptives should be avoided in women who have migraine with complex or prolonged aura, or if additional stroke factors are present (older age, smoking, hypertension, diabetes mellitus, obesity, family history of arterial disease at a young age). One failed to fnd a further increase in stroke in patients with migraine who use oral contraception, another concluded that the use of oral contraception by migraineurs was associated with a 4-fold increase of the already increased risk of ischemic stroke. An adverse efect of low-dose oral contraceptives on stroke risk in migraineurs should have manifested itself in the data. Nevertheless, it is believed that migraineurs on oral contraceptives have an increased risk of stroke; the absolute risk in a 20-year-old woman is estimated to be 10 per 100,000 and for a 40-year-old woman, 100 per 100,000. However in the American Stroke Prevention in Young Women Study, oral contraceptive use in smokers was associated with an increased risk of stroke in migraineurs with aura. We have had personal success (anec- dotal to be sure) alleviating headaches by eliminating the menstrual cycle, A Clinical Guide for Contraception either with the use of daily continuous dosing oral contraceptives or the daily administration of a progestational agent (such as 10 mg medroxypro- gesterone acetate) or the use of depot-medroxyprogesterone acetate. Women who experience an exacerbation of their headaches with oral contraception should consider one of the proges- tin-only methods. Women who have migraine without aura and who are less than 35 years of age (the risk of stroke increases with age), healthy, and nonsmoking can use combined steroid contraception. Low-dose oral contraception can be used in women less than age 35 years with hypertension well controlled by medication, and who are otherwise healthy and do not smoke. Women with pregnancy-induced hypertension can use oral contraception as soon as the blood pressure is normal in the postpartum period. Tere is evidence that the risk of leiomyomas was decreased by 31% in women who used higher dose oral contraception for 10 years. Low-dose formulations do not produce a diabetic glucose tolerance response in women with previous gestational diabetes, and there is no evidence that combined oral contraceptives increase the incidence of overt diabetes mellitus. Tere is a concern with breastfeeding women using the progestin-only minipill (discussed in Chapter 3). Oral contraception can be used by diabetic women less than 35 years old who do not smoke and are otherwise healthy (espe- cially an absence of diabetic vascular complications). A case-control study could fnd no evidence that oral contraceptive use by young women with Oral Contraception insulin-dependent diabetes mellitus increased the development of retinopa- thy or nephropathy. The recommendation that oral contraception should be discontinued 4 weeks before elective major surgery to avoid an increased risk of postoperative thrombosis is based on data derived from high-dose pills.

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Afebrile neutropenic patients with an absolute neutrophil count less than 500 per μL should receive daily prophylactic treatment with a fluoroquinolone antibiotic purchase proscar now mens health 300 workout 2014. A meta-analysis of 95 trials including 52 trials using fluoroquinolone prophylaxis showed that neutropenic patients receiving fluoroquinolone prophylaxis had significant decreases in all-cause mortality buy cheap proscar on-line prostate 40 plus, infection-related mortality, fever and documented infection with a nonsignificant trend toward increasing antimicrobial resistance [54]. Symptoms can develop at any time within the first 4 weeks of treatment with the highest incidence in the first and third weeks of treatment. Cytokine Release Syndrome In recent years, therapies attempting to engage T cells with target cancer cells have shown impressive activity in hematologic malignancies. Neurotoxicity is also frequently seen with both therapies and can manifest as encephalopathy, seizures, and neuropathies. Therapeutic Agents Treatment of aggressive hematologic malignancies typically requires toxic, myelosuppressive chemotherapy regimens. Patients are prone to life-threatening bacterial and fungal infections as a result of prolonged neutropenia, bleeding from thrombocytopenia, and organ failure from the toxic effects of chemotherapy. Selected toxicities of agents commonly used in the treatment of hematologic malignancies and their management are given in Table 94. Hemorrhagic cystitis due to cyclophosphamide lymphomas, causing inter- acrolein metabolite myeloma, and 2. Venous thrombosis from asparaginase plasma decreased antithrombotic asparagine and factors, cerebral venous sinus glutamine thrombosis 2. Additional complications of malignant hematologic diseases or their treatment, including tumor lysis syndrome and malignant epidural cord compression, are discussed in detail in Chapter 95. Selected evidenced-based approaches for managing patients with hematologic malignancies are presented in Table 94. Hyperleukocytosis Improved short-term Retrospective analysis Reduced 21-d [28] but not long-term of leukapheresis in 53 mortality in survival with vs. Prophylactic platelet transfusion Equivalent bleeding Meta-analysis of three No difference in [42] rates with platelet prospective mortality, remission transfusion randomized trials. Prophylactic antibiotics during neutropenia Use of prophylactic Meta-analysis of 100 Compared to [54] antibiotics in trials (10,275 placebo, antibiotic afebrile patients). Lloyd-Thomas A, Dhaliwal H, Lister T, et al: Intensive therapy for life- threatening medical complications of haematological malignancy. Evison J, Rickenbacher P, Ritz R, et al: Intensive care unit admission in patients with haematological disease: incidence, outcome and prognostic factors. Kroschinsky F, Weise M, Illmer T, et al: Outcome and prognostic features of intensive care unit treatment in patients with hematological malignancies. Azoulay E, Mokart D, Pene F, et al: Outcomes of critically ill patients with hematologic malignancies: prospective multicenter data from France and Belgium—A Groupe de Recherche Respiratoire en Réanimation Onco-Hematologique Study. Lim Z, Pagliuca A, Simpson S, et al: Outcomes of patients with haematological malignancies admitted to intensive care unit. Pulte D, Gondos A, Brenner H: Expected long-term survival of patients diagnosed with acute myeloblastic leukemia during 2006–2010. Lo-Coco F, Avvisati G, Vignetti, M, et al: Retinoic acid and arsenic trioxide for acute promyelocytic leukemia. Dhedin N, Huynh A, Maury S, et al: Role of allogeenic stem cell transplantation in adult patients with Ph-negative acute lymphoblastic leukemia. Bug G, Anargyrou K, Tonn T, et al: Impact of leukapheresis on early death rate in adult acute myeloid leukemia presenting with hyperleukocytosis. Leukapheresis and low-dose chemotherapy do not reduce early mortality in acute myeloid leukemia hyperleukocytosis: a systematic review and metaanalysis. Garcia-Sanz R, Montoto S, Torrequebrada A, et al: Waldenstrom macroglobulinaemia: presenting features and outcome in a series with 217 cases. Koyama T, Hirosawa S, Kawamata N, et al: All-trans retinoic acid upregulates thrombomodulin and downregulates tissue factor expression in acute promyelocytic leukemia cells: distinct expression of thrombomodulin and tissue factor in human leukemic cells. Falanga A, Iacoviello L, Evangelista V, et al: Loss of blast cell procoagulant activity and improvement of hemostatic variables in patients with acute promyelocytic leukemia administered all-trans retinoic acid. De Stefano V, Teofili L, Sica S, et al: Effect of all-trans retinoic acid on procoagulant and fibrinolytic activities of cultured blast cell from patients with acute promyelocytic leukemia. Tapiovaara H, Alitalo R, Stephens R, et al: Abundant urokinase activity on the surface of mononuclear cells from blood and bone marrow of acute leukemia patients. Hummel M, Rudert S, Hof H, et al: Diagnostic yield of bronchoscopy with bronchoalveolar lavage in febrile patients with hematologic malignancies and pulmonary infiltrates. Azoulay E, Mokart D, Rabbat A, et al: Diagnostic bronchoscopy in hematology and oncology patients with acute respiratory failure: prospective multicenter data. Gafter-Gvili A, Fraser A, Paul M, et al: Meta-analysis: antibiotic prophylaxis reduces mortality in neutropenic patients. Hilbert G, Gruson D, Vargas F, et al: Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. Because a patient’s prognosis has a significant impact on the choice of treatments, it is of paramount importance for the intensivist and the care team to determine the following: a. The prognostic implications and the expected impact of treatment are then weighed and appropriate therapy instituted or modified. Obstruction results in venous hypertension, with the severity of ensuing signs and symptoms dependent on the site of obstruction and the rapidity with which the block occurs. The major collateral, the azygous vein, joins posteriorly just over the right mainstem bronchus and drains the posterior thorax. As a result, it is extremely susceptible to extrinsic compression by adjacent lymph nodes or the aorta, with subsequent stasis, occlusion, or thrombosis. If obstruction occurs distal to the azygous vein, collateral flow through the azygous can adequately compensate for diminished return. This more circuitous route results in significantly higher venous pressures, which can result in interstitial edema of the head and neck as well as extrinsic compression of the larynx or trachea. Non- Hodgkin lymphoma, breast cancer, and other neoplasms make up the remainder of the malignant causes. In patients with benign causes, extensive collateral flow often develops that minimizes symptoms for months to years. Acute compression by tumor or thrombosis does not allow time for collateralization, and venous hypertension inevitably results in symptoms, which include dyspnea, cough, dysphagia, and edema of the face, neck, upper torso, and extremities. Physical signs include jugular venous distention, edema of the face or upper extremities, dilated venous collaterals, plethora, stridor, and tachypnea. These abnormalities could be mistaken for metastatic disease and should be further evaluated in patients in whom therapy would be changed in the presence of isolated metastases. The approach may include sputum cytology, bronchoscopy using endobronchial ultrasound-guided needle aspiration, transthoracic needle aspiration, biopsy of palpable lymph nodes, mediastinoscopy, thoracotomy, or video-assisted thoracoscopy. With rare exceptions, it is safe to wait to institute treatment until the underlying cause of the syndrome has been established. Treatment Once the diagnosis is established, initiation of therapy depends on the etiology, the severity of symptoms, the acuity of presentation, and the goals of treatment. If patients are minimally symptomatic, the azygous is patent, and treatment is focused on palliation, observation is a reasonable option. Although radiation is often considered in addition to chemotherapy even in the palliative setting, 80% of these patients have a complete or partial response of their symptoms to chemotherapy alone [5].

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Other structures that are accessible to pathogens include the mastoid air cells purchase on line proscar prostate zonal anatomy mri, the jugular foramen purchase proscar 5 mg with visa prostate cancer overview, cranial nerves (especially the facial nerve), the internal carotid artery, and the dura mater of the posterior cranial fossa. Mastoiditis Acute mastoiditis is an uncommon complication of otitis media, seen primarily in children and young adults. Inflammation spreads from the middle ear to the modified respiratory mucosa lining of the mastoid air cells, by direct invasion of the bone or through the mastoid emissary veins. The closed space infection leads to accumulation of purulent exudate, increased pressure, and bony necrosis. Pain, typically postauricular, fever, and abnormal tympanic membranes are the most common findings on presentation, and a fluctulent mass may be noted, causing anterior displacement of the auricle [36]. In a review of 202 hospitalized children, the most frequent culture result was “no growth” (30%), followed by Streptococcus pneumoniae (21%), skin flora (14%), Pseudomonas aeruginosa (7%), Streptococcus pyogenes (7%), and Staphylococcus aureus (4%) [37]. Treatment includes broad-spectrum antibiotics that can adequately penetrate cerebrospinal fluid and surgical intervention for those who fail to improve within 24 to 72 hours. Often a cholesteatoma or epidermal inclusion cyst within the tympanomastoid compartment may be involved and may become secondarily infected [39]. Uncomplicated chronic otitis media and mastoiditis are treated medically with local hygiene, topical antibiotics often including a corticosteroid, and oral, or infrequently parenteral, antibiotics [39]. Diabetic microangiopathy, impaired chemotaxis and phagocytosis, combined with the ability of Pseudomonas aeruginosa to invade vessel walls, causes vasculitis with thrombosis, leading to the characteristic pathophysiology of this of this disorder [40]. Spread of infection is anteriorly toward the parotid compartment or downward into the temporal bone; spread to the mastoid is less common [34]. Patients with acquired immunodeficiency syndrome may develop infection from a wider variety of organisms and may accumulate less granulation tissue in the external auditory canal [43]. Thus, if there is a high clinical suspicion, technetium-99 bone scans should be obtained, and are positive in close to 100% of cases [40]. Surgical interventions may not be required, but management does require biopsy and culture, and may require debridement and drainage of associated abscess [40]. The duration of treatment is not clearly defined and complete response is defined by resolution of signs and symptoms. These structures include the epiglottis, aryepiglottic folds, arytenoids, pharynx, uvula, and tongue base. In the pediatric population, increased awareness and prophylactic airway control have reduced overall mortality to less than 1% [49,50]. Although this disease at one time affected primarily children, with the introduction of the conjugate vaccine for Hemophilus influenza type b (Hib), there has been a dramatic decline in pediatric infections, and supraglottitis is becoming a disease of adults. Adults with acute supraglottitis usually present in their 40s and 50s, with a male preponderance, and children usually present between the ages of 2 and 5 years [52]. Pathogenesis and Pathophysiology Among children, the inflammation is mainly restricted to the epiglottis because of loose mucosa on its lingual aspect. Swelling reduces the airway aperture by curling the epiglottis posteriorly and inferiorly, accentuating the juvenile omega shape. When edema spreads to involve the aryepiglottic folds, respiratory distress can occur as inspiration draws these structures downward, further exacerbating the obstruction and resulting in stridor. The adult airway is relatively protected because the larynx is larger and the epiglottis is shaped more like a spatula. In adults, numerous bacterial, viral, and fungal organisms have been implicated, including Hemophilus influenza type B, Streptococcus pneumonia, Staphylococcus aureus, Streptococcus spp. Non-bacterial agents include Candida albicans, and viruses such as Herpes simplex, Parainfluenza, Varicella zoster, and Epstein-Barr. McKinney and Grigg [57] described a case of epiglottitis after general anesthesia administered via a laryngeal mask. Diagnosis History and Physical Examination For children, the classic presentation is of a 3-year-old child who initially complains of a sore throat followed by dysphagia and/or odynophagia, which then progresses within hours to stridor. The progression of symptoms can be remembered as the four “Ds”: dysphagia, dysphonia, drooling, and distress. Children with acute supraglottitis rarely present with coughing that may help to distinguish them from those with laryngotracheobronchitis or croup [51]. Among adults, the classic presentation is more the exception than the rule, and as such, the frequency of misdiagnosis has been reported as high as 60% to 75% [49,52]. More than 90% of adults seek medical attention complaining of sore throat with or without dysphagia [56,59]. Many patients report antecedent upper respiratory tract infections [59,60], and between 60 and 90% will have an elevated temperature [51]. Other less common signs and symptoms are respiratory distress, muffled voice, drooling, and stridor [49,50,53,55,58]. Children and adults often prefer an upright posture with the neck extended and mouth slightly open [59]. Patients who present early in their disease course have more severe symptoms, fever, and leukocytosis, and those presenting within 8 hours of the onset of symptoms are more likely to have signs of upper airway obstruction [62]. Evaluation of patients with suspected supraglottitis depends, in part, on their age and the severity of their symptoms. An artificial airway should be established in the controlled setting of an operating room, where an examination can be performed with less risk of airway obstruction. For older children and adults, supraglottitis should be considered when sore throat and dysphagia seem to be out of proportion to visible signs of pharyngitis. In this situation, if the patient has no respiratory distress, examination of the larynx and supralaryngeal structures is recommended. Other supraglottic structures may be edematous as well, resulting in the inability to visualize the vocal cords [51]. Diagnostic Tests Although considered the classic radiographic finding, the “thumb sign,” indicating a swollen epiglottis. When there is significant clinical suspicion, direct visualization of the structures should be performed [64]. The radiograph should be taken in the upright position to avoid pooling of secretions posteriorly and potentially increasing the obstruction, and the patient must be observed at all times by someone skilled in airway management. Lateral radiographs of the neck obtained with soft tissue technique in a 2-year-old child (A) and a 42-year-old adult (B). There is epiglottic (e) swelling (thumb sign), thickening of the aryepiglottic folds (a), and narrowing of the vallecula (arrow) in both patients. An elevated white blood cell count and C-reactive protein level may identify a patient at higher risk. Throat cultures are positive in less than 33% of the cases, and blood cultures detect a causative agent in less than 20% of the cases [52,55]. Swab culture of the epiglottis obtained under direct visualization may better reflect the causative agent, and has been positive in up to 75% of the cases [55,58]. Because immediate airway control is a priority, recognizing other pediatric illnesses presenting with a sore throat and not requiring this intervention is important [65,66].

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