Smart mote-based medical system for monitoring and handling medication among persons with dementia purchase 50mg viagra soft otc causes of erectile dysfunction include quizlet. Medication administration: the implementation process of bar-coding for medication administration to enhance medication safety purchase 50mg viagra soft mastercard erectile dysfunction funny images. Medication administration: The implementation process of bar-coding for medication administration to enhance medication safety. Unit-of-use bar coding: Balancing the challenge of technological change with improved patient safety. The use of electronic prescribing as part of a system to provide medicines management in secondary care. Evaluating the safety and efficacy of Glucommander, a computer-based insulin infusion method, in management of diabetic ketoacidosis in children, and comparing its clinical performance with manually titrated insulin infusion. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Clinician attitudes towards prescribing and implications for interventions in a multi-specialty group practice. Economic effectiveness of two different automated anesthesia medication dispensing devices at two different facilities. Transport nurse safety practices, perceptions, and experiences: the Air and Surface Transport Nurses Association survey. Improving physician communication through an automated, integrated sign-out system. Dispensing errors in community pharmacy: Frequency, clinical significance and potential impact of authentication at the point of dispensing. Methodological variability in detecting prescribing errors and consequences for the evaluation of interventions. Concordance between medication histories and outpatient electronic prescription claims in patients hospitalized with heart failure. Observational assessment of clinical outcomes associated with the use of chemistry laboratory values in the Theratrac 2 system. Anaesthesia record system on handheld computers--pilot experience and uses for quality control and clinical guidelines. Early experiences with e-Health services (1999-2002): Promise, reality, and implications. Supply of injectable drugs for individual patients using the prescription entry system. Challenge for preventing medication errors-learn from errors: What is the most effective label display to prevent medication error for injectable drug? Computer assisted satellite pharmacy consultative service in a primary care clinic. Would artificial neural networks implemented in clinical wards help nephrologists in predicting epoetin responsiveness? Developing high-specificity anti-hypertensive alerts by therapeutic state analysis of electronic prescribing records. Evaluation of accuracy of drug interaction alerts triggered by two electronic medical record systems in primary healthcare. Computerized physician order entry of medications and clinical decision support can improve problem list documentation compliance. Introduction of computer assisted control of oral anticoagulation in general practice. Healthcare informatics : the business magazine for information and communication systems 2009;26(9):30-3. The push to share data electronically--both inside and outside of the hospital walls--is forcing patient identification to the forefront. Primary care clinician attitudes towards ambulatory computerized physician order entry. The concordance of self-report with other measures of medication adherence: a summary of the literature. A meta-model of chemotherapy planning in the multi­ hospital/multi-trial-center-environment of pediatric oncology. Critical pathway for the management of acute heart failure at the veterans affairs san diego healthcare system: Transforming performance measures into cardiac care. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. Implementation of a computerized physician order entry system at a 500 bed community hospital: case for pharmacist involvement. Clinical pharmacy in a geriatric unit: Impacts of clinical pharmacy interventions prior to medical order. The effects of computerized medical records on provider efficiency and quality of care. Massachusetts Technology Collaborative and New England Healthcare Institute; 2006. Collaborative improvement in the order and delivery process of intravenous infusion medications in the neonatal intensive care unit to decrease errors and utilize technology. Centralized information system for general practitioners and out-patient medical services: Conception of realization. Building man-man-machine synergies: experiences from the Vanderbilt and Geneva clinical information systems. The impact of computerised physician order entry systems on pathology services: A systematic review. Computer-supported weight-based drug infusion concentrations in the neonatal intensive care unit. Home infusion therapy trial of a multitherapy remotely programmable ambulatory pump. Multi-tasking in practice: coordinated activities in the computer supported doctor-patient consultation. Methods, architecture, evaluation and usability of a case- based antibiotics advisor. Computerized community cholesterol control (4C): meeting the challenge of secondary prevention. Identifying medication-use system variances associated with computerized provider order entry. Healthcare financial management : journal of the Healthcare Financial Management Association 2009;63(11):38-41. Improving recognition of drug interactions: benefits and barriers to using automated drug alerts. The utility of adding retrospective medication profiling to computerized provider order entry in an ambulatory care population. Online prospective drug utilization review in community practice: Clinical and economic impact.

Administration of Blood Product Administration of blood products warrants special consideration viagra soft 50 mg low price impotence and diabetes. Several methods can be used to estimate the required volume of packed red blood cells needed to achieve a normal hematocrit buy viagra soft on line amex impotence by age. It is useful to calculate transfusion needs using more than one method in order to become familiar with each. In an emergency setting when rapid transfusion is needed, an easy estimate of required transfusion volume is 10cc per kilogram. A more accurate estimate can be obtained using the following equation: Volume of cells cc Estimated blood volume cc ( Desired Actual hematocrit change Hematocrit of packed red blood cells where the blood volume is estimated using Table 35. Regardless of the estimated volume, packed red blood cells are administered at a rate of about 2 to 3cc/kg/hour. In small infants, the response to transfusion is evaluated after every 10cc per kilogram volume in order to evaluate the need for additional transfusion and to avoid excessive transfusion. The volume of platelet transfusion depends on the type of platelets that are used. The platelet-rich plasma then is separated into a unit of fresh frozen plasma and a unit of platelets (about 50cc). These come from a single donor and are obtained from donors by having their blood cir- culated through a machine that separates the platelets and returns the rest. This method results in a platelet preparation with a volume of about 200 to 250cc per donor and is the equivalent of 6 to 8 random donor units. The advantage of using pheresed platelets is that the recip- ient is exposed to only one donor. For pheresed platelets, one-fourth unit can be given to a 5- to 25-kg patient, one-half unit to a 25- to 50-kg patient, and 1 unit to a nearly adult-sized teenage patient. Estimate Fluid Status after Surgery Monitoring of volume status in children in the perioperative period also is highly dependent on the patient’s weight. Urine output is noted in cc per kilogram per hour and compared to the general guide- lines shown in Table 35. Diapers can be weighed to estimate urine volume, which is useful in avoiding the potential trauma of bladder catheterization in small infants and children. Other sources of fluid output also are best evaluated, correcting for the child’s weight (Table 35. Although each of these represent only estimates of expected output, it is useful to use these values when evaluating initial losses and when following ongoing losses. Correct Dosing of Medications Medication dosing also is critically dependent on the child’s weight. Because seemingly small differences may lead to overdosing in a child, it is important that attention be paid to accurate dosing in children. Many children’s hospitals have developed fail-safe mechanisms, such as administration forms, pharmacy verification, and double-checking protocols, to avoid inaccurate dosing of medications. Only pediatric medication manuals should be used to dose medications given to the child in the postoperative period. Care of the Pediatric Surgical Patient 643 hospitals, it is useful to note the patient’s weight and the dose on a per kilogram basis on the patient order sheet whenever a new medication or new dosage of a medication is given. During fetal development, infancy, and childhood, rapid changes occur in physiology that usually are not observed in adult life. The unique physiology at each stage of development accounts for the occurrence of many diseases predominant in specific groups, such as necrotizing enterocolitis in premature infants, intussusception in toddlers, and appendicitis in older children and teenagers. The wide variations in physiology and the diversity of diagnoses that result from these changes account for the appeal of practicing pediatric surgery, but they can be an initial source of frustration for the student with initial experience only with adult patients. The use of principles for manag- ing adults in the perioperative period frequently is not helpful for the pediatric surgical patient. Using principles that recognize the unique- ness of each stage of development can simplify the approach to the pediatric surgical patient. To understand a generalized approach to evaluat- ing newborns with intestinal obstruction. To be able to give a differential diagnosis for the causes of neonatal intestinal obstruction and to understand the general principles for treatment. Case You are asked to evaluate a 12-hour-old newborn male infant because of bilious vomiting. Polydramnios and a dilated stomach were noted on serial prenatal ultrasounds, but amniocentesis was not performed. The infant was born at 36 weeks by vaginal delivery to a 35-year-old mother without complication. The infant has been irritable and has vomited dark-green bilious material with each of two attempts at feeding. The infant is noted on examination to have findings consistent with trisomy 21 (Down syndrome) including poor muscle tone, oblique palpebral fissures, epicanthal folds, and abnormally shaped ears. The abdominal examination shows epigastric prominence, but it is other- wise normal, and the anus is in a normal position and appears patent. Introduction A diverse range of diseases can lead to intestinal obstruction in the newborn infant (Table 36. While the etiology, pathophysiology, and treatment of surgical causes of intestinal obstruction in the neonate are varied, it is helpful to use a diagnostic approach that considers 644 36. Neonatal Intestinal Obstruction 645 each disease, particularly since more than one may be present. Because several of these diseases can be life-threatening or lead to lifelong disability if not treated promptly, the diagnostic evaluation should be rapid and follows a series of logical steps (see Algorithm 36. Presentation The initial presenting signs and symptoms of neonatal intestinal obstruction are varied and include frothy oral secretions, poor feeding, bilious or nonbilious vomiting, abdominal distention, and absent or delayed passage of meconium. The timing and nature of each pre- senting finding can provide very useful information about the etiology of the intestinal obstruction. Proximal intestinal obstructions, such as esophageal atresia or congenital causes of gastroduodenal ob- struction, usually present within the first 24 to 48 hours of life. Distal obstructions, such as ileal or colorectal atresias, may present a few days after birth, while functional obstructions, such as Hirschsprung’s disease, may present as late as a few weeks to years after birth. Esophageal atresia presents with prominent oral and upper airway findings, including excessive frothy oropharyngeal secretions and repeated episodes of coughing, choking, or cyanosis that become apparent with attempts at feeding. Although poor feeding eventually is a feature of all causes of newborn intestinal obstruction, this finding may be delayed in patients with distal gastrointestinal tract or func- tional obstructions. The absence of bile in the emesis suggests that the level of obstruction is proximal to the ampulla of Vater. Bilious vomiting suggests a more distal obstruction and is an important finding, since about 25% of neonates with this finding eventually require abdominal surgery.

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Training should ensure that staff events and resource dards require members are knowledgeable about drug materials abuse trends in the community order cheap viagra soft on-line erectile dysfunction at age 31. Staff members should have allow staff from access to generic skills training such as crisis smaller programs to attend their sessions viagra soft 100 mg amex erectile dysfunction reviews. The importance ing organizations, such as the Association for of emphasizing sensitivity to patient needs Addiction Professionals, and professional should be reviewed periodically. A program physician might members, often the first to speak with patients, educate staff members about the etiology play an important role. A random-callback policy Control Plans avoids patient complaints of being unfairly Federal opioid treatment standards state that ìpicked onî by staff members. All scheduled that patients can substances should be accounted for rigorously the possibility of store medications and inventoried continuously. All from receipt through dispensing and measured take-home medica- at the beginning and end of each workday. W ithin the dispensary, remains misunderstood even among some employees should open the safe or work with health care professionals. Some treatment Transition in Federal oversight of substance providers have overcome community opposi- abuse treatment from the U. Having ade- Children and Family Services, Joint quate onsite staff is equally important in avoid- Commission on Accreditation of Healthcare ing and resolving community problems. Glezen Organizations, National Commission for and Lowery (1999) provide other practical Correctional Health Care, State of Missouri guidelines for addressing community concerns Department of Mental Health Division of about substance abuse treatment facilities. Alcohol and Drug Abuse, and W ashington Community opposition can be triggered when State Department of Social and Health Services community groups believe that they have been Division of Alcohol and Substance Abuseó informed or consulted insufficiently. The relations with the payer community (Edmunds availability of public transportation is impor- et al. Adding designed, and operated in accordance with alternative care models and longer acting accreditation standards, Federal guidelines, pharmacotherapies to the services continuum and State and local licensing, approval, and can decrease loitering, illicit transactions, ille- operating requirements. Staff and patients from the parent organizationís community should be part of a multifaceted, proactive effort relations department. Although program contacts w ith com m unity activities differ in specificity and scope, a Personal contact with community leaders per- community relations plan should address the mits open dialog, information sharing, and dis- following: cussion of community developments, needs, and problems. Occasional becoming increasingly instrumental in empow- press releases can ering patients as active participants in public community notify the public relations, community outreach, and program about specific support initiatives and in local, State, and services demon- services, activities, national community education efforts. Staff members with community improvement and and the general development expertise can support other public. A program organizations in advocacy, promotional, and counter negative support efforts. Consenting patients and staff can professional journals, sponsoring or research organize projects such as community cleanups institutions, provider coalitions, advocacy and neighborhood patrols. Such affilia- Improvement Exchange tions augment community relations efforts ï W hite House Office of National Drug Control through increased professional education and Policy (www. These forums also may present patient advisory committees, patient family 234 Chapter 14 community relations models that can be adapt- an outgrowth of providing service to the public. These patrols should features have been produced, providing impor- emphasize observation, not intervention. Logs tant, accurate information to the public about summarizing observations should be main- the science and policy of opioid addiction and tained. Media outreach can demystify treat- ment programs to provide increased treatment ment, counteract stigma, and improve fairness intensity. Communications should be logged, and staff participation in community events should be Decisions to discharge patients for loitering summarized. Letters and communications should balance consequences for the individual substantiating community complaints and the patient and public health against the need to programís followup should be on file. Confidentiality Medicine hold national and regional confer- remains paramount, so this relationship should ences that bring together treatment providers, be delineated carefully. A database explain how to improve their current treatment should be developed and updated (e. Other number and nature of community complaints sessions may focus on improving staff attitudes 236 Chapter 14 and the treatment system regarding implemen- opportunities of those stigmatized. For example, one application of commercial marketing conference, Blending Clinical Practice and technologies to programs to change social atti- ResearchóForging Partnerships To Enhance tudes. This publication proposed a unique Drug Addiction Treatment, held in April 2002 national approach to reducing stigma that (National Institute on Drug Abuse 2002), incorporates science-based marketing research, incorporated a special forum focused on the a social marketing plan, facilitation and sup- mediaís role in presenting addiction treatment port of grassroots efforts by the recovery and research issues in the context of science community, and promotion of the dignity of reporting. Performance outcome evaluation atic use of prescription drugs focuses on results, for example, patient ï reducing or eliminating associated criminal progress. Process evaluation focuses on how activities results were achievedóthe active ingredients ï reducing behaviors contributing to the spread of treatment. This improvements as guideposts and avoid terms simple evaluation would require only atten- such as ìsuccessî and ìfailure. Such a study can set a baseline and provide a bench- Process evaluation mark to evaluate the effects of changes in pro- gram practices, for example, prescribing indi- Process evaluation describes what is happening vidually appropriate dosages for patients. A process evaluation documents skills, employment, family relationships, and what actually happens during an intervention, social activities. For they take, specific problems and barriers example, evaluation of a treatment initiative encountered, strategies used to overcome these designed to reduce substance use, decrease problems and barriers, and necessary modifi- criminal involvement, and increase job skills cations to the original plan. Black patientsí use of emergency rooms for medical box, a commonly used term in this context (Ball care) to assess whether it has had other effects and Ross 1991, p. Clearinghouse for Alcohol and Drug Abuse Information at 800-729-6686 or A process evaluation can serve as a manage- www. For Substance Abuse Treatment ProgramsóA example, if a goal is to facilitate patientsí use of Manual is available at www. The process evaluation also can Outcome Measurement Resource Network that measure the intensity and duration of services is available through national. Community reinforcement approach and relapse prevention: 12 and 18 month follow-up. Long-term therapy with benzodiazepines despite alcohol dependence disorder: Seven cases reported. Psychiatric disorders in first- degree relatives of patients with opiate dependence. Prediction of 7-months methadone maintenance response by four measures of antisociality. Efficacy of daily and alternate-day dosing regimens with the combination buprenorphine- naloxone tablet. Thrice-weekly supervised dosing with the combination buprenorphine-naloxone tablet is pre- ferred to daily supervised dosing by opioid-dependent humans. Suicide: Understanding and Helping the Causes and rates of death among methadone Suicidal Person. W ound botulism associated with black patients with hepatitis B or hepatitis C virus tar heroin. International Journal of the Treatment of Drug Abuse: Research and Addictions 30(9):1177ñ1185, 1995. A risk-benefit analysis Journal of Health and Social Behavior of methadone maintenance treatment.

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However buy viagra soft 100 mg low price erectile dysfunction (ed) - causes symptoms and treatment modalities, the true fundamental fear viagra soft 50mg overnight delivery impotence 60 years old, resided in his inner child’s response to this event. The most significant point here is that you have to dive deeper to truly understand what’s motivating your behaviour. For Larry, what actually was underlying his fear of being late for work was an earlier fear of not being good enough. His parents were very demanding and critical and nothing that Larry did was “good enough. By being ‘perfect’ and controlling himself and his surroundings as best he could, Larry was able to minimize being yelled at or punished back when he was a child. The possibility of arriving late for work triggered Larry’s fear surrounding childhood events that occurred relating to the completion of a task in a perfect way. You can see that the thoughts and actions he expresses, in his internal conversation, reflect learned behaviour from his childhood. You yourself, are also not operating entirely from an adult perspective, but carry your own inner child. If you can come to understand your own core-wounding experiences through a mindful dialogue with your inner child, you can see how these experiences and their aftereffects are manifested in all of your stress responses. A common roadblock to meaningful change is that you probably believe that you’re making conscious adult choices about how to act in this world. However, to a large extent, your behaviour is controlled by unrecognized, conditioned, habitual, childhood coping-strategies. You’re not truly present to the events in your life, but to your inner child’s interpretation of how the event fits with your internalized, parental belief system. You judge everything you experience in order to position yourself in relation to the world so as to ultimately feel loved and safe. Talking with your inner voice is a wonderful way to understand what’s truly driving your “adult” behaviour. You have the ability to connect with your inner child through dialogues with that inner voice. Engaging in the dialogues will allow you to discover the true motives underlying how you operate in this world. The inner child’s belief system is the origin of the automatic responses and stories that you tell yourself about internal and external sensations, perceptions, experiences and events. With additional insight, you can bring empathy, support and love to the process of trying to change. You can thereby diminish the power that your inner child has over your present day-to-day experiences. It will give you more control, more perspective and that elusive peace of mind that we all dream about. The next time you become aware of an inner voice or conversation with yourself that’s going something like, “Oh I shouldn’t have done that…” look for clues that it’s really a child talking. When you become aware of your inner child, extend compassion and understanding to the child you once were and use the occasion as an opportunity to explore why you think and act the way you do. Summary • You have an inner voice that’s always commenting to you during times of stress and directing the action to be taken next. This refers to childhood events, which were very emotionally traumatic and may have related to loss, rejection, abandonment, humiliation, betrayal and/or a sense of having been overwhelmed. If you were to develop mindfulness in relation to your own thoughts, you would Adiscover that you have an inner voice that is always talking to you, usually criticizing, comparing and judging everything that arises internally and externally. In this chapter, you’ll learn a helpful stress-reducing technique, which is how to talk to your inner voice. The purpose of the inner-child dialogue is to: • discover the underlying core belief system of the inner child • examine if the core belief system is true • identify the inner child’s feelings This is an important progression that ultimately helps you to change the limiting and painful belief system of the inner child. The inner-child dialogue is a useful technique for really understanding yourself and your stress, but if you’re new to it, it’s going to seem a little strange at first. Remember, you can’t continue to handle things the way you always have and expect a different result. The other advantage of the inner-child dialogue is that, through this technique, you can truly understand that your inner voice is your inner child just trying to be safe. This understanding makes it easier to allow your thoughts to pass through your mind without taking any ownership of their content. The inner voice is really your protector, the voice that recognizes when you have strayed from your created belief system. You should view the voice as that of your beautiful inner child who is trying to help you. If you keep this in mind, it may be easier to bring a sense of self-compassion to any conversations that you have with your inner child. There is the surface level on which you, as an adult, have numerous worries and concerns in response to stressful events. However, it’s the underlying realm of the inner child that truly gives a stressful event its motivational drive. Have you ever noticed that in some situations there’s an emotional or psychological intensity that appears disproportionate to what’s actually happening? This is why connecting with the inner child, and truly understanding the experience from the inner child’s perspective, can be so useful. Talking to Yourself You’re directly and intimately feeling the emotions and physical sensations that the inner child is experiencing and so you can authentically understand and express support to the inner child. The initial process of dialoguing follows this sequence: Dialogue: A Friendly Chat with Your Inner Child • 167 1. Inquire: Time to ask some questions Mindfulness: Bring Awareness to Your Inner Voice Initially, to start an inner-child dialogue, you’ll want to bring mindful- ness into play. When practicing mindfulness, you bring your attention to the present moment without trying to change it and are simply present to whatever is being experienced. You’re bringing awareness to what’s being said, and what’s felt emotionally and physically. When a more emotionally charged thought arises and you notice your inner voice commenting, create some space around that sensation. Just observe it; notice what it’s saying to you from a place of awareness, acceptance, non-judgment, non-attachment and compassion. It can be very difficult not to identify with what the inner voice is saying and you may want to even amplify, or add to, what you’re hearing. The initial ability to let the voice say what it needs to say, for as long as it needs to say it, without interfering, is the first step. When you’re upset, you probably feel like talking to a friend and sharing with him or her what it is that you’re experiencing.

The other lesions causing cyanosis order viagra soft mastercard impotence young, in which markedly abnormal anatomy exists order 100mg viagra soft with mastercard erectile dysfunction drugs pictures, such as transposition of the great vessels and total anomalous pulmonary venous return, are referred to as “complex lesions. The parent usually is most observant of abnormalities in the child’s behavior, especially if there is an older sibling with whom to compare the child’s behavior, as in the case pre- sented above. Family history is relevant, as there may be as much as a threefold increase in the incidence of congenital disease when a prior sibling has been born with a congenital defect. Signs and symptoms of congestive heart failure should be sought from the parent, espe- cially recurrent respiratory infections or difficulties feeding (shortness of breath, sweating). Cyanosis may appear early in neonates born with transposition of the great vessels or some other complex lesion. Perfu- sion of the pulmonary circulation may have been dependent on a patent ductus arteriosus communicating between the descending tho- racic aorta and the pulmonary artery. As the ductus begins to close in the first hours and days of life, decreased pulmonary blood flow and cyanosis, either from hypoxia or new right to left flow, occurs. Heart Murmurs: Congenital Heart Disease 261 Prostaglandin may be necessary to maintain this fetal circulation (patent ductus) until diagnostic studies can be completed. Other infants do not develop signs of cyanosis until they are a few months of age. Signs of cyanosis related to tetralogy of Fallot may not appear until several months of life as pulmonary outflow obstruction (and right-to-left shunting) increases. The physical examination is directed to a systematic evaluation of the infant or child. Findings consistent with congestive heart failure or chronic hypoxemia are sought. With obstructive lesions, this usually is consistent with the murmurs of aortic or mitral stenosis. Ventricular septal defects usually have a continuous “machinery-type” murmur over the ante- rior chest. The murmur of an atrial septal defect is related to increased blood flow across the pulmonic valve and not to the flow across the atrial septum. This murmur is thus loudest over the pul- monary outflow tract to the left side of the sternum. A systolic murmur heard loudest in the back is suggestive of coarctation of the aorta, especially if lower extremity pulses are decreased. Hepatomegaly may be a consistent finding in the presence of congestive heart failure. Examination of the periphery is crucial in looking for signs of cyanosis, clubbing, or microemboli, which may be present in right-to-left shunting. Diagnostic Studies Routine chest x-ray may be diagnostic, especially to a well-trained pediatric radiologist. Over- or undercirculation of the lungs may be present along with cardiomegaly and other deformities of the base of the heart. The classic “figure of eight” appearance of the heart is asso- ciated with transposition of the great vessels. When the cardiac sil- houette has the appearance of a boot and the infant is cyanotic, tetralogy of Fallot will be suspected. The electrocardiogram can reveal left or right ventricular hypertrophy as well as conduction abnor- malities associated with some complex congenital deformities. Echocardiography is an accurate diagnostic tool and can be used for definitive diagnosis and planning for surgical correction in the majority of infants and children requiring surgical intervention. Cardiac catheterization and angiography may be required to confirm the diagnosis and aid in planning surgical correction in more complex situations. Treatment The ultimate goal of therapy is to reverse symptoms or, alternatively, restore as normal an anatomy as possible. In the emergency setting, palliation may be all that is possible by surgical intervention. Pharmacologic methods used to maintain the patency of a patent ductus or to enhance its closure have made many surgical interventions less of an emergency. The infant is maintained by medical treatment of congestive heart failure until the proper time for surgery arrives. In contrast to surgery in the adult, stenotic lesions in infants and children can be quite challenging due to the absence of a suitable valve substitute. Pulmonic stenosis usually is corrected transvenously by balloon dilatation in the catheterization laboratory. Any resulting pulmonic insufficiency, if the stenosis is the only lesion, is not of concern. Mitral stenosis may be amenable to open commissurotomy, but some form of shunting and correction to bypass the stenotic lesion may be necessary. Aortic stenosis, if the annulus is of adequate size, may be susceptible to open commissurotomy. Otherwise, the Ross pro- cedure, in which the patient’s own pulmonic valve is transplanted to the aortic position, seems to be the best option since there is the likeli- hood that the valve will continue to grow as the child grows. Severely cyanotic infants or those in profound heart failure may require immediate diagnosis and surgical intervention. Especially in complex situations or when the remainder of the heart has not devel- oped, palliative procedures are performed. When this is necessary, the goal is to establish sufficient blood flow to maintain life. Emergent atrial septostomy may be required for a neonate with transposition of the great vessels. Profoundly cyanotic infants may require the creation of adequate blood supply to the pulmonary circulation. A modification of the classic Blalock-Taussig shunt (subclavian artery to pulmonary artery) is per- formed and can be closed when the definitive procedure is performed. The presence of profound pulmonary overcirculation, which may occur with a large ventricular septal defect or aortopulmonary window, may require pulmonary artery banding to restrict pulmonary blood flow. The dominant approach to many of these lesions now is one of total correction in infancy rather than palliation with later correction. Lesions that lead to overcirculation of the pulmonary vasculature must be corrected early in life or palliated before irreversible pulmonary hypertension develops. Repairs of atrial septal defects usually can be delayed until a child reaches 3 or 4 years of age and can be corrected before he/she begins school. The risk of endocarditis is increased sig- nificantly in these patients as well as in older patients with a patent ductus. Results With increasing refinements in the techniques of pediatric cardiac surgery, the operative mortality for many of these procedures has dropped dramatically with improved long-term survival. It is no longer uncommon to see adults who have undergone corrective surgery as children parenting their own children. Heart Murmurs: Congenital Heart Disease 263 Summary A heart murmur present in a child or an infant with signs and symp- toms of congestive heart failure or cyanosis is indicative of a signifi- cant mechanical lesion within the heart. A relatively simple method of classification of these potentially complex lesions is based on the pre- senting symptom of the patient, either congestive heart failure or cyanosis.

By Z. Farmon. University of Saint Francis.