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Administration of zinc in the diet blood pressure app buy discount metoprolol 25 mg line, but not through injection arteria uterina order metoprolol 12.5 mg fast delivery, has been shown to arteria tibial posterior cheap 12.5mg metoprolol fast delivery decrease the toxicity of dietary lead (Cerklewski and Forbes arrhythmia in newborns generic 50 mg metoprolol with visa, 1976; El-Gazzar et al. However, exposure of rats whose diets contained normal (12 mg/kg) or elevated (60 mg/kg) levels of zinc to drinking water containing 20 mg Pb/L did not alter the amount of zinc or copper in the plasma, kidney, or liver (Bebe and Panemangalore, 1996). This would suggest, though it is hardly conclusive, that lead exposure does not alter zinc absorption. Both zinc and lead have been shown to bind to the N­ methyl-D-aspartate receptor site in rats, but lead does not appear to bind to the zinc allosteric site (Lasley and Gilbert, 1999). As noted previously, zinc and lead are substrates for a divalent metal transport protein that has been shown to participate in the absorption of iron (Gunshin et al. The relative importance of this protein in the absorptive transport of lead or zinc has not been determined. Co-exposure to 800 ppm zinc chloride resulted in 90% of the animals exhibiting complete or partial protection against the testicular toxicity of cobalt. No studies examining the potential effects of cobalt compounds on the toxicity of zinc were identified. The clinical manifestations of severe zinc deficiency, seen in individuals with an inborn error of zinc absorption or in patients receiving total parenteral nutrition without adequate zinc, include bullous pustular dermatitis, diarrhea, alopecia, mental disturbances, and impaired cell-mediated immunity resulting in intercurrent infections. Neurosensory changes, impaired neuropsychological functions, oligospermia, decreased serum testosterone, hyperammonemia, and impaired immune function (alterations in T-cell subpopulations, decreased natural killer cell activity) have been observed in individuals with mild or marginal zinc deficiency. Severe zinc deficiency in animals has been associated with reduced fertility, fetal neurological malformations, and growth retardation in late pregnancy (Mahomed et al. Increased zinc consumption, as supplemental zinc, has been associated with changes in health effects in humans, including decreased copper metalloenzyme activity (Fischer et al. Although the decreased copper metalloenzyme activities and cholesterol levels are not necessarily adverse in themselves, they are likely to be indicators of more severe effects occurring at greater dose levels. Several human studies provide evidence that excess zinc intake may induce copper deficiency. Severe copper deficiency has been observed in individuals 46 ingesting very high doses of zinc for over one year (Patterson et al. At lower zinc doses, more subtle signs of impaired copper status, such as alterations in copper metalloenzyme activities, are evident. Copper deficiency is thought to result from a zincinduced decrease in copper absorption. Excess dietary zinc results in induction of intestinal metallothionein synthesis; because metallothionein has a greater binding capacity for copper than for zinc, copper absorbed into the intestinal mucosal cells is sequestered by metallothionein and not absorbed systemically (Walsh et al. Bile acids are synthesized from cholesterol in the liver and carry cholesterol breakdown products to the intestines with the bile, thus providing an excretory pathway for cholesterol. Following high-level oral exposure, zinc appears to exert adverse health effects primarily through interaction with copper. Specifically, high levels of zinc can result in a saturation of the 47 carrier-mediated pathway of zinc absorption and a shift to metallothionein-mediated absorption (Hempe and Cousins, 1992). It is believed that the copper deficiency results from a zinc-induced decrease in copper absorption. Zinc-induced copper deficiency is consistent with numerous reports of effects of zinc on various biomarkers of copper nutritional status following exposures to elevated levels of zinc in humans and animals, as well as by reports indicating that copper supplementation can result in an attenuation of zinc-induced toxicity. While co-exposure to zinc has been demonstrated to alter the toxicity of a number of other metals, few studies have been conducted on the effects of co-exposure to metals (other than copper) on zinc toxicity. The available studies suggest the plausibility that co-exposure to other divalent metals may decrease absorption of zinc, but offer only limited insight as to potential effects of these metals on zinc toxicity. The few studies that have been conducted on the effect of other metals on the toxicity of zinc are not adequate to support dose response assessments for the interactions, or even qualitative assessments of the type or direction of the interactions. Inhalation Exposure Most of the available information on the toxicity of inhaled zinc has focused on metal fume fever, a collection of symptoms observed in individuals exposed to freshly formed zinc oxide fumes or zinc chloride from smoke bombs. The earliest symptom of metal fume fever (also referred to as zinc fume fever, zinc chills, brass founder’s ague, metal shakes, or Spelter’s shakes) is a metallic taste in the mouth accompanied by dryness and irritation of the throat. Flulike symptoms, chills, fever, profuse sweating, headache, and weakness follows (Drinker et al. The symptoms usually occur within several hours after exposure to zinc oxide fumes and persist for 24 to 48 hours. An increase in tolerance develops with repeated exposure; however this tolerance is lost after a brief nonexposure period, and symptoms are most commonly reported on Mondays and after holidays. There are many reports of metal fume fever in the literature; however, most describe individual cases and exposure levels are not known. In animals, exposure to zinc oxide results in similar effects as those reported in humans. However, subchronic or chronic studies of the toxicity of zinc following inhalation exposure in animals are not available. Similarly, no studies examining the effects of inhaled zinc on reproductive or developmental endpoints were located. The mechanisms behind metal fume fever are not known, but are thought to involve several different factors. Exposure to zinc oxide particles has been shown to elicit the release of a number of proinflammatory cytokines, leading to a persistent pulmonary inflammation which could result in some of the reported symptoms of metal fume fever, including decreased lung function and bronchoconstriction. An allergic response to zinc particles, leading to an asthmalike response, has also been proposed as a possible mechanism. However, additional mechanistic information will be required in order to adequately determine the mechanisms involved in the toxicity of inhaled zinc. Adequate studies examining the carcinogenicity of zinc in orally-exposed humans are not available. Additional data on the carcinogenicity of zinc following oral exposure are not available. While a number of studies of the effects of short-term exposure to zinc in the workplace are available, the vast majority of these focus on the more acute effects of zinc, particularly metal fume fever and its resulting sequelae. No studies adequately examining the carcinogenic effects of zinc in humans or animals were located in the available literature. Either zinc deficiency or excessively high levels of zinc may enhance susceptibility to carcinogenesis, whereas supplementation with low to moderate levels of zinc may offer protection (Mathur, 1979; Woo et al. Possible Childhood Susceptibility and Susceptible Diabetics Data in humans are not available that examine whether children are more susceptible to the toxicity of zinc than adults. Animal studies have, however, suggested that neonates and/or developing animals may be more susceptible to the toxic effects of excess zinc. Several other studies have examined the effects of zinc exposure in young animals, but have not provided data on adult animals similarly exposed for comparison. Additional data will be required to adequately assess the susceptibility of children to zinc exposure, relative to adults. Possible Gender Differences Several studies in humans have suggested that females may be more sensitive to the adverse effects of excess zinc than males. For example, Samman and Roberts (1987, 1988) reported that women experienced adverse symptoms more frequently (84% in women vs. Further data examining the potential difference in response between men and women were not located. In animal studies, it appears that if any differences between sexes were noted, the male is the more susceptible gender. Studies of reproductive function have demonstrated alterations in spermatogenesis at zinc exposure levels below those inducing alterations in female reproductive parameters (Sutton and Nelson, 1937; Pal and Pal, 1987; Saxena et al. Additional studies will be required to determine whether sex-specific differences in adverse responses to zinc exist. Thus, insufficient as well as excessive oral intake can cause toxicity and disease and a quantitative risk assessment must take essentiality into account. The principal studies examine dietary supplements of zinc and the interaction of zinc with other essential trace metals, specifically copper, to establish a safe daily intake level of zinc for the general population, including pregnant women and children, without compromising normal health and development. Choice of Principal Study and Critical Effect Available studies of oral zinc toxicity have identified a number of zinc-induced physiological changes in humans, including decreased copper metalloenzyme activities (Fischer et al. The available data indicate that the most sensitive effects of zinc are alterations in copper status.

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Modified Clavien classification in percutaneous nephrolithotomy: assessment of complications in children prehypertension pubmed purchase metoprolol 50 mg without a prescription. Successful percutaneous nephrolithotomy in children: multicenter study on current status of its use pulse pressure 2012 buy online metoprolol, efficacy and complications using Clavien classification blood pressure scale metoprolol 50mg discount. Safety and efficacy of percutaneous nephrolithotomy in infants arteria occipitalis cheap metoprolol 12.5mg, preschool age, and older children with different sizes of instruments. Experience of percutaneous nephrolithotomy using adult-size instruments in children less than 5 years old. Factors affecting complication rates of percutaneous nephrolithotomy in children: results of a multiinstitutional retrospective analysis by the Turkish pediatric urology society. Tubeless mini percutaneous nephrolithotomy in infants and preschool children: a preliminary report. Percutaneous nephrolithotomy in children: lessons learned in 5 years at a single institution. The “mini-perc” technique: a less invasive alternative to percutaneous nephrolithotomy. Single-step percutaneous nephrolithotomy (microperc): the initial clinical report. Comparison of shockwave lithotripsy and microperc for treatment of kidney stones in children. Feasibility of totally tubeless percutaneous nephrolithotomy under the age of 14 years: a randomized clinical trial. Early postureteroscopy vesicoureteral reflux-a temporary and infrequent complication: prospective study. Hydrodilation of the ureteral orifice in children renders ureteroscopic access possible without any further active dilation. Endoscopic manipulation of ureteral calculi in children by rigid operative ureterorenoscopy. Treatment of distal ureteral stones in children: similarities to the american urological association guidelines in adults. Factors affecting complication rates of ureteroscopic lithotripsy in children: results of multiinstitutional retrospective analysis by Pediatric Stone Disease Study Group of Turkish Pediatric Urology Society. When is prior ureteral stent placement necessary to access the upper urinary tract in prepubertal childrenfi Pediatric flexible ureteroscopic lithotripsy: the children’s hospital of Philadelphia experience. Single-institutional study on role of ureteroscopy and retrograde intrarenal surgery in treatment of pediatric renal calculi. Robotic nephrolithotomy and pyelolithotomy with utilization of the robotic ultrasound probe. The process of formation of cystic dilatation of the vesical end of the ureter and of diverticula at the ureteral ostium. Histology of upper pole is unaffected by prenatal diagnosis in duplex system ureteroceles. Impact of prenatal diagnosis on the morbidity associated with ureterocele management. How prenatal ultrasound can change the treatment of ectopic ureterocele in neonatesfi Ectopic ureteroceles in infants with prenatal hydronephrosis: use of renal cortical scintigraphy. The role of 99mtechnetium dimercapto-succinic acid renal scans in the evaluation of occult ectopic ureters in girls with paradoxical incontinence. Clinico-pathological correlation in duplex system ectopic ureters and ureteroceles: can preoperative work-up predict renal histologyfi Ureterocele eversion with vesicoureteral reflux in duplex kidneys: findings at voiding cystourethrography. Incontinence due to an infrasphincteric ectopic ureter: why the delay in diagnosis and what the radiologist can do about it. Pseudoureterocele: potential for misdiagnosis of an ectopic ureter as a ureterocele. A meta-analysis of surgical practice patterns in the endoscopic management of ureteroceles. Management of ectopic ureterocele associated with renal duplication: a comparison of partial nephrectomy and endoscopic decompression. Effectiveness of primary endoscopic incision in treatment of ectopic ureterocele associated with duplex system. Ectopic ureterocele: clinical application of classification based on renal unit jeopardy. Long-term outcome of transurethral puncture of ectopic ureteroceles: initial success and late problems. Clinical evolution of vesicoureteral reflux following endoscopic puncture in children with duplex system ureteroceles. Ureterocele associated with ureteral duplication and a nonfunctioning upper pole segment: management by partial nephroureterectomy alone. Ectopic ureter with complete ureteric duplication: conservative surgical management. Surgery for duplex kidneys with ectopic ureters: ipsilateral ureteroureterostomy versus polar nephrectomy. Laparoscopic ipsilateral ureteroureterostomy in the management of ureteral ectopia in infants and children. Bilateral single ureteral ectopia: difficulty attaining continence using standard bladder neck repair. Bilateral single ectopic ureters with hypoplastic bladder: how should we treat these challenging entitiesfi Transdermal dihydrotestosterone therapy and its effects on patients with microphallus. Early determination of androgen-responsiveness is important in the management of microphallus. Congenital hypogonadotropic hypogonadism and micropenis: effect of testosterone treatment on adult penile size why sex reversal is not indicated. Timing of elective surgery on the genitalia of male children with particular reference to the risks, benefits, and psychological effects of surgery and anesthesia. The effect of clitoral surgery on sexual outcome in individuals who have intersex conditions with ambiguous genitalia: a cross-sectional study. Total urogenital sinus mobilization: a modified perineal approach for feminizing genitoplasty and urogenital sinus repair. Feminizing genitoplasty: a synopsis of issues relating to genital surgery in intersex individuals. Germ cell tumors in the intersex gonad: old paths, new directions, moving frontiers. Long-term risk of end stage renal disease in patients with posterior urethral valves. Influence of initial therapy on progression of renal failure and body growth in children with posterior urethral valves. The long-term outcome of posterior urethral valves treated with primary valve ablation and observation. Implications of prenatal ultrasound screening in the incidence of major genitourinary malformations. Endoscopic reappraisal of the morphology of congenital obstruction of the posterior urethra. Long-term renal function in the posterior urethral valves, unilateral reflux and renal dysplasia syndrome. Impact of prenatal urinomas in patients with posterior urethral valves and postnatal renal function. A systematic review and meta-analysis of the effectiveness of fetal cystocopy as an intervention for congenital bladder neck obstruction.

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Short-term progAuxilio Mutuo Hospital Transplant Center Puerto Rico nosis is good blood pressure varies greatly discount metoprolol 100mg visa. Department of Nephrology and Rheumatology blood pressure medication cause weight gain best metoprolol 25 mg, Children’s Hospital of Results: From 1977-2013 pulse pressure septic shock buy 12.5mg metoprolol amex, 146 children blood pressure up at night generic metoprolol 12.5mg, female: 39%, Hispanic Shanghai, Shanghai Jiaotong University, Shanghai China (Caribbean): 100%, age: 14yrs (2-18yrs) were transplanted. Intravenous iron sucrose therapy for the severity scores of glomerullar and tubulo-interstitial lesions in peditreatment is more effective. Sinha2 and fibrinogen as well as protein C were elevated while prothrombin time 1 Department of Paediatric Nephrology, Evelina London Children’s and activated partial thrombplastin time were shortened. Comparison of Tertile 3 versus Tertile 1 showed no significant Methods: Clinical and pathological data was retrospectively analyzed in difference in aetiology (70. The degrees of glomerular whereas those with other primary renal disease had a faster decline of and tubulointerstitial lesions were scored according to the Katafuchi 1. Multiple regression analysis identified 2168 Pediatr Nephrol (2019) 34:1821–2260 Age (fi=-0. Infants were further stratified into lights opportunities to improve renal outcomes. Identified proteins were clustered according to maternal diabetes status and gestaR. Methods: this was an observational, study in a higher secondary school Conclusions: Urine proteomic profiles are unique between infants based in India. Anonymous survey was performed by distributing the modified the functional pathways that are affected. Questionnaires were returned by 138/138 teachers ney, underwent a pre-emptive live-related renal transplant from her father. The possibility of a medical cause graft function with creatinine 47umol/l on day 1. Results: On day 9 she had an acute drop in her haemoglobin (Hb) At least one aspect of toilet requests was a frequent hassle in 43/ to 69g/l and then on day 10 it dropped further to 57g/l associated 108 (39. Toilet requests are misunagain to 60 and then 54g/l and she required a second transfusion. It has previously this interesting and rare case is something to consider when faced with been demonstrated that exposure to maternal diabetes in pregnancy repost-transplant anaemia. Literature review of passenger lymphocyte syndrome Introduction: A 10-year-old female patient was admitted to our following renal transplantation and two case reports. Am J Transplant department complaining of persistent microematuria since she 2013 Jun;13(6):1594-600. Begum5, AmpliSeq™panels for inherited glomerular diseases was utilized to idenR. Her Bangabandhu Sheikh Mujib Medical University, Dhaka Bangladesh, sister is heterozygous for all three mutations. In fact recent studies reported that University, Dhaka Bangladesh, 7 Professor & Ex chairman, Dept. This association is reported to affect phenotype severity and prognosis suggesting that mutations in multiple glomerular Background: Renal transplant is the most preferred renal replacedisease genes explain some of the expression variability in nement therapy for end stage renal disease. The deep phenotyping of all family members will plantation in children who received a renal allograft at allow clarifying genotype-phenotype correlations. Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from January 2006 to December 2018 was studied. Survival analysis at cies including hemorrhagic stroke contributing to rare but serious child12month, 5yearand 10 year showed functional graft in 90%, 66% hood morbidity and mortality. Grange synrecipients died due to non adherence and poor compliance of the drome is an ultra-rare disease characterized by multiple stenosis or occludrug. Eight patients are doing well with attending school and colsion of the renal, abdominal, coronary and cerebral arteries, which can leges and one got married and doing normal life. At one year Conclusion: Renal transplantation is a successful treatment of end of age, she experienced seizures and sequential hemiparesis caused by a stage renal disease in children and live –related donor had an left thalamic hemorrhage without cerebral vascular anomalies. Caridi3 ed with intracerebral hemorrhagic stroke without anomalous brain artery 1U. The phenotype in our patient may help better understand Dipartimento di Medicina e Chirurgia, Universita di Parma Italy, this ultra-rare syndrome. In 20% of patients, Department of Pediatrics and Adolescent Medicine, Juntendo University the diagnosis occurred accidentally, after 3 months of age. All patients kept normal renal function and Blood Pressure vated in the first week of life and decreased to reach a plateau after several above the 90° centile for sex, age and height during follow-up (range 1weeks. The aim of this study was to investigate maternal and neonatal 19 years,mean 8 years). Multiple regression analysis showed that urinary tract dilation, especially in the first year of life. Our current guideline recommends correction of no Kingdom, approximately half of all transplant recipients are greater than 0. Patients Survival analyses were presented using Kaplan Meier method using Cox age 6 months to 18 years were included in the study if they had proportional hazard modelling. Results: 5643 transplants were performed in 4953 individuals (59·4% M) Multivariate logistic regression was used to determine the relationwith a mean recipient age of 11·8 (± 9·9). Patients reResults: 337 children had a sodium measurement of at least 150mmol/L ceived induction with basiliximab and a triple immunosuppressive regiduring the study period. The most comResults: Ktx recipients in the study period were 53 (16 females), with a mon primary admission units of the cohort were cardiac services (21. Within the 53 pts, 15 (28,3%) have 0-2 mismatches to donor; 32 Conclusion: the optimal rate of correction of hypernatremia in (60,3%) 3-4 and 6 (11,32%) 5-6. Graft survival is 98% at 1 year and 92% at 3 children is important to delineate to avoid complications associatand 5 years. These results will inform our future clinical practice guidelatter performed graft biopsies for clinical indication (renal function deteriolines in the management of hypernatremia. Demographic, clinical and Department of Pediatrics, All India Institute of Medical Sciences, New relevant laboratory data were collected. Delhi India Results: 11 children were identified, age of onset ranged from 5months to 5 years. Enrolment was closed in August sex-matched 30 healthy children were included in this single cen2018 and outcomes will be analysed in August 2019. Hypertension were more frequent in renal Shenoy scar group than in hypoplasia group [(6/29) vs (1/28)(p=0. The median time to relapse after rituximab with more compensatory growth of the healthy kidney may carry risk for was 7 months (range 2 23 months). Two children with hypogammaglobulinaemia required abdominal pain are common in children suffering from the hemohospital admission with sepsis at 3 weeks and 7 months after rituximab. But it is very rare in Conclusions: In our centre persistent hypogammaglobulinaemia was notchildren. Here, we report a case of a child with atypical ed in nearly a third of the patients following rituximab. Although most hemolyticfiuremic syndrome and then acute pancreatitis occurred patients are asymptomatic, the long term significance of this is unknown. A 8 years old boy was referred to our unit for diagnosed as hemolytic uremic syndrome. The renal pathology 1 Department of Pediatrics, Istanbul University-Cerrahpasa Turkey, showed thrombotic microangiopathy and sclerosing glomerulone2 Department of Pediatric Nephrology, Istanbul University-Cerrahpasa phritis. The atypCerrahpasa Turkey, 5 Department of Biochemistry, Istanbul ical hemolytic uremia syndrome was considered. Subsequently, 3 days later, the child suddenly appeared coma with hyperglycemia and acidosis. Introduction: It is suggested that hypoplastic and/or scarred kidneys may Blood analysis revealed increased pancreatic enzymes levels. However to our knowledge this 1 Division of Pediatric Nephrology, Hacettepe University Faculty of is the only reported case of disease recurrence only in a second Medicine, Ankara Turkey, 2 Division of Pediatric Intensive Care, graft having not developed antibodies in the first. Hacettepe University Faculty of Medicine, Ankara Turkey References: 1Holmberg C and Jalanko H. Factors contributing to Results: Out of 101 patients; 16 patients with incomplete information, 21 poor access to pediatric renal transplant are unclear. Emergent themes were identified, Logistic regression analysis revealed chloride alteration fi10 mEq/L within discussed, and organized into major themes. Family/ school/health care providers support was reported as essential to deal with dialysis.

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Treatment with a statin is a reasonable option for patients with aortic arch atheroma to arrhythmia event monitor cheap 50mg metoprolol visa reduce the risk of stroke heart attack 27 generic 50mg metoprolol with visa. Recommendations for Brain Protection During Ascending Aortic and Transverse Aortic Arch Surgery Class I 1 heart attack at 25 purchase 12.5mg metoprolol amex. A brain protection strategy to blood pressure 8660 cheap metoprolol 50mg amex prevent stroke and preserve cognitive function should be a key element of the surgical, anesthetic, and perfusion techniques used to accomplish repairs of the ascending aorta and transverse aortic arch. Deep hypothermic circulatory arrest, selective antegrade brain perfusion, and retrograde brain perfusion are techniques that alone or in combination are reasonable to minimize brain injury during surgical repairs of the ascending aorta and transverse aortic arch. Perioperative brain hyperthermia is not recommended in repairs of the ascending aortic and transverse aortic arch as it is probably injurious to the brain. Recommendations for Spinal Cord Protection During Descending Aortic Open Surgical and Endovascular Repairs Class I 1. Cerebrospinal fluid drainage is recommended as a spinal cord protective strategy in open and endovascular thoracic aortic repair for patients at high risk of spinal cord ischemic injury. Spinal cord perfusion pressure optimization using techniques, such as proximal aortic pressure maintenance and distal aortic perfusion, is reasonable as an integral part of the surgical, anesthetic, and perfusion strategy in open and endovascular thoracic aortic repair patients at high risk of spinal cord ischemic injury. Moderate systemic hypothermia is reasonable for protection of the spinal cord during open repairs of the descending thoracic aorta. Adjunctive techniques to increase the tolerance of the spinal cord to impaired perfusion may be considered during open and endovascular thoracic aortic repair for patients at high risk of spinal cord injury. These include distal perfusion, epidural irrigation with hypothermic solutions, high-dose systemic glucocorticoids, osmotic diuresis with mannitol, intrathecal papaverine, and cellular metabolic suppression with anesthetic agents. Neurophysiological monitoring of the spinal cord (somatosensory evoked potentials or motor evoked potentials) may be considered as a strategy to detect spinal cord ischemia and to guide reimplantation of intercostal arteries and/or hemodynamic optimization to prevent or treat spinal cord ischemia. Computed tomographic imaging or magnetic resonance imaging of the thoracic aorta is reasonable after a Type A or B aortic dissection or after prophylactic repair of the aortic root/ascending aorta. Computed tomographic imaging or magnetic resonance imaging of the aorta is reasonable at 1, 3, 6, and 12 months postdissection and, if stable, annually thereafter so that any threatening enlargement can be detected in a timely fashion. When following patients with imaging, utilization of the same modality at the same institution is reasonable, so that similar images of matching anatomic segments can be compared side by side. If a thoracic aortic aneurysm is only moderate in size and remains relatively stable over time, magnetic resonance imaging instead of computed tomographic imaging is reasonable to minimize the patient’s radiation exposure. Surveillance imaging similar to classic aortic dissection is reasonable in patients with intramural hematoma. If there is concern about a leak, a predischarge study is recommended; however, the risk of renal injury should be borne in mind. All patients should be receiving beta blockers after surgery or medically managed aortic dissection, if tolerated. For patients with a current thoracic aortic aneurysm or dissection, or previously repaired aortic dissection, employment and lifestyle restrictions are reasonable, including the avoidance of strenuous lifting, pushing or straining that would require a Valsalva maneuver. Such fevers do not all have an infectious cause, but they all require thorough investigation to rule out life-threatening conditions. This article summarizes the principles of diagnosis and management of postprocedure fevers for the emergency care provider. Infectious causes should be considered mainly for fever presenting later than 48 hours after surgery, whereas early postoperative fever is 2 most commonly attributed to noninfectious causes. Others have stated that noninfectious causes appear to cause lower-temperature fevers (<38. Despite these claims, the cause of postprocedure fever is often not identified despite the rigorous efforts of clinicians. The classic “Ws” of postoperative fever (Table 1), long taught 4 to medical students as mantra, have been challenged recently. As with all medical diagnoses, a thorough history and physical examination should serve as the diagnostic starting point in ascertaining relevant information in terms of exposure to infectious pathogens. In addition, the timing of fever after a procedure can help differentiate potential causes. It is therefore useful to divide the time frame of postprocedure fever into 4 categories: immediate, acute, subacute, and delayed. Fevers that occur in the first 4 days after surgery are less likely to represent infectious complications than are fevers occurring on the fifth and subsequent days (Fig. Fever can also accompany the continuum of systemic inflammatory response, sepsis, severe sepsis, and septic shock (Table 2). The time of emergence of postprocedure fever can guide the provider’s differential diagnosis and, thus, management decisions. In a prospective study of 81 patients with 2 idiopathic postoperative fever, Garibaldi and colleagues found that 80% of those with fever on the first postoperative day had no infection. However, a fever that begins on or after postprocedure day 5 is much more likely to represent a clinically significant infection, so appropriate diagnostics to look for an infectious source may be useful. These tests can include laboratory investigations (blood culture, urine cultures, complete blood counts) and images (plain Fig. Percentage of postoperative fevers occurring on the indicated day following an operative procedure. Lines indicate the percentage of fevers occurring on each day attributable to the cause indicated. These mediators increase capillary permeability and are central elements of 8 the inflammatory response and, thus, healing. The cytokines act directly on the anterior hypothalamus and cause a release of prostaglandins, which mediate the febrile 5 response. The severity of the procedure, in terms of the extent of tissue trauma, can also influence the fever curve. For example, laparoscopic cholecystectomy is associated with fewer episodes 11 of postoperative fever than an open approach. Inflammation secondary to cytokine release is now thought to be the most common cause of immediate postprocedure fever. For most patients, the fever resolves 2,5,12–14 and a benign course can be expected. In the immediate postprocedure period, routine measurement of temperature followed by a detailed laboratory or diagnostic workup is not warranted as long as the patient is hemodynamically stable. Diagnostic tests, such as blood or urine cultures, should not be ordered routinely during this period. A prospective triple-blind study involving 308 consecutive patients found that measuring postoperative body temperature was of limited value in the detection of infection after elective surgery for noninfectious 15 conditions. In the past, atelectasis was thought to be a common cause of postprocedure fever; however, numerous studies have shown that it is not clearly related to fever. Roberts 16 and colleagues evaluated 270 patients who had undergone elective abdominal surgery, and reported the presence of fever in 40%. Atelectasis was associated 15 with neither the presence nor the severity of fever. Vermeulen and colleagues reviewed the records of 284 general surgery patients, who had 2282 temperatures taken. As a predictor of infection, a temperature of 38 C had sensitivity of only 37% and specificity of 80%, a likelihood ratio of a positive test of 1. Other common causes of immediate postprocedural fever include reactions to medication and transfusions, the presence of infection before the procedure, fulminant surgical-site infection, trauma, and adrenal insufficiency. These potentially life-threatening conditions mandate early diagnosis followed by prompt intervention. Presentations might occur particularly early, often within hours to 18 days of the initial procedure. The pathogen can be introduced from hematogenous spread from distant sites of 18,19 infection, minor trauma, or surgical incisions. Fournier gangrene can be caused by colorectal or genitourinary surgical intervention. Other potential sources include 20,21 intramuscular injections, odontogenic infections, or surgery. Commonly cultured organisms include Group A hemolytic streptococci, enterococci, coagulase-negative staphylococci, Staphylococcus aureus, Staphylococcus 18 epidermidis, and clostridial species. In the emergency setting, particularly severe cases can present with signs of systemic inflammation (tachycardia and fever) and even with evidence of end-organ dysfunction (eg, confusion, hypotension). Early consultation with a surgical service is necessary, given that definitive diagnosis and treatment both require operative interventions (debridement, collection samples for pathologic evaluation, and confirmatory diag23 nosis). Prompt surgical consultation, in addition to administration of appropriate antibiotics 25,26 and intravascular volume resuscitation, is imperative. Broad antibiotic coverage should be initiated, covering gram-positive, gram-negative, and anaerobic organisms.