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These findings suggest that alterations in fetal hemodynamics may result in structural cardiac abnormality and may be the precursors of some forms of congenital heart disease. Intertwin comparisons were made for the following cardiac parameters: cardiothoracic index, end-diastolic thickness of the ventricular walls and septum, aortic and pulmonary artery Doppler peak velocities, ejection and acceleration times, left ventricular shortening fraction, and combined cardiac output and output indexed to fetal weight. The left ventricular shortening fractions and outputs were significantly increased in the donor twin with twin-to-twin transfusion syndrome and normal in placental insufficiency. It was concluded that, in twin-to-twin transfusion syndrome, the donor twin shows evidence of a hyperdynamic cardiac state. Intertwin comparison of cardiac parameters, especially the left ventricular shortening fraction, can be considered a useful tool in diagnosing the different etiologies of the polyhydramnios oligohydraminos sequence. Serial Doppler echocardiographic sudies showed no specific cardiac involvement in the donor twins, either in utero or after birth. In contrast, all recipient twin fetuses showed variable degrees of biventricular hypertrophy and dilatation with tricuspid regurgitation. Deterioration in the fetal condition is associated with a breakdown of hemodynamic compensatory mechanisms, with a decline in cardiac output and the development of abnormal venous flow with increase in pulsatility of ductus venosus waveforms and loss of forward flow velocity during atrial contraction. In monochorionic twins with no twin-to-twin transfusion syndrome, the incidence of vascular anastomoses is much higher than in those with the syndrome. Additionally, there is decreased blood flow velocity and increased impedance to flow in the ductus venosus of both the donor and recipient fetuses. In donor fetuses, flow velocities across the atrioventricular valves are decreased. In the recipient, there is evidence of hypervolemia with congestive heart failure; hypervolemia may cause compensatory cardiac hypertrophy, but eventually the pumping capabilities of the enlarged heart are exceeded and cardiac failure occurs. The lambda sign at 10?14 weeks of gestation as a predictor of chorionicity in twin pregnancies. The contribution of singletons, twins and triplets to low birth weight, infant mortality and handicap in the United States. Therapeutic amniocentesis in twin?twin transfusion syndrome appearing in the second trimester of pregnancy. Monoamniotic twins: improved perinatal survival with accurate prenatal diagnosis and antenatal fetal surveillance. Early prenatal diagnosis of cord entanglement in monoamniotic multiple pregnancies. Abundant vascular anastamoses in monoamniotic versus diamniotic monochorionic placentas. Discordant twins a prospective study of the diagnostic value of real-time ultrasonography combined with umbilical artery velocimetry. Prediction of the small for gestational age twin fetus by Doppler umbilical artery waveform analysis. Is pulsed Doppler velocimetry useful in the management of multiple-gestation pregnancies? Doppler flow velocity waveforms in fetal surveillance of twins: a prospective longitudinal study. Placental microvascular changes in twin pregnancies with abnormal umbilical artery waveforms. Color Doppler ultrasonography in the identification of communicating vessels in twin?twin transfusion syndrome and acardiac twins. Colour Doppler energy insonation of placental vasculature in monochorionic twins: absent arterio?arterial anastomoses in association with twin-to-twin transfusion syndrome. The value of Doppler ultrasound in the diagnosis and management of twin-to-twin transfusion syndrome. Doppler velocimetry determined redistribution of fetal blood flow: correlation with growth restriction in diamniotic monochorionic and dizygotic twins. Clinical and echographic features of in utero cardiac dysfunction in the recipient twin in twin?twin transfusion syndrome. Temporary iatrogenic fetal tricuspid valve atresia in a case of twin to twin transfusion syndrome. Potential value of fetal echocardiography in the differential diagnosis of twin pregnancy with presence of polyhydramnios oligohydramnios syndrome. The two methods are complementary to each other, with color Doppler being used for general assessment of flow in the region of interest and pulsed Doppler for targeted examination of flow in a vessel or across a valve 1-10.

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The nodule concentrates the radiotracer avidly with suppression of the remainder of the gland and low background activity (Figure 3). This book chapter is open access distributed under the Creative Commons Attribution mercial purposes, as long as the author and publisher are properly credited. The decreased uptake that occurs initially with subacute thyroiditis during the thyrotoxic stage (Figure 2d) is the result of an intact pituitary feedback mechanism, not damage or dysfunction of the gland. Uptake is suppressed in the entire gland although the disease may be patchy or regional [1,3]. During recovery, the appearance is variable depending on the severity of the thyroid damage. Scan may show in homogeneity of uptake or regional or focal areas of hypofunction in figure 7. Hashimoto thyroiditis, also known as chronic autoimmune thyroiditis, is an autoimmune destruction of the thyroid characterized by goiter, autoimmunity to thyroid antigens, and lymphocyte infiltration. This condition is the most common of all thyroid disorders and affects people of all ages [6-8]. The autoimmune reaction results in lymphocytic and plasma cell infiltration with formation of lymphoid follicles, which in turn leads to thyroid follicle deterioration. As a result of the ongoing replacement of the normal thyroid follicles by lymphocytes and fibrous tissue, there is eventual reduction in thyroid function because thyroid hormone production by the gland is impaired leading to goiter and hypothyroidism [6]. The most common thyroid scan appearances are that of an enlarged gland with diffusely increased tracer uptake, a pattern identical to that found in Graves disease (Figure 4). It manifests in the postpartum period when there are fluctuations in immune function as thyrotoxicosis followed by hypothyroidism [6,8]. Functional Assessment of Thyroid Nodules Identified on Clinical Examination or Ultrasound or by other Diagnostic Imaging Radionuclide scanning can functionally evaluate a focal thyroid nodule as hot, warm, or cold on the basis of relative uptake of the radiotracer by the nodule. A thyroid nodule is cold (hypofunctional) if there is a focal photopenic defect devoid of the tracer uptake (Figure 5a), hot (hyperfunctional) if there is focal increased accumulation of the radiotracer (Figure 5b) or warm (indeterminate) if the uptake is similar to the surrounding normal parenchyma. This book chapter is open access distributed under the Creative Commons Attribution mercial purposes, as long as the author and publisher are properly credited. Figure 5a: Cold or hypofunctional thyroid nodule appearing as a photopenic defect in the right lobe. This book chapter is open access distributed under the Creative Commons Attribution mercial purposes, as long as the author and publisher are properly credited. About 80 to 85% of thyroid nodules are cold, with only 10% of these representing malignancies. The potential of malignancy in hot nodules is extremely rare (less than 1% incidence). The current role of nuclear scintigraphy using 123/131I or 99mTc-pertechnetate is therefore adjunctive rather than as a first-line diagnostic test. Figure 5c: Multinodular goitre with a dominant cold nodule appearing as a large photopenic defect in the right lobe. Retrosternal goitres are associated with palpable enlargement of the cervical thyroid and diagnosed clinically if the lower border of the goitre cannot be felt. To confirm, a radiograph of the thoracic inlet and a thyroid scan with 123/131I should be performed to evaluate the extent when ultrasound is not able to visualize the lower pole of the thyroid gland (Figure 5d). This book chapter is open access distributed under the Creative Commons Attribution mercial purposes, as long as the author and publisher are properly credited. Figure 5d: 99mTc-pertechnetate scan showing a large goiter with retrosternal extension. It is unable to characterize follicular neoplasms because of its inability to detect capsular invasion and vessel infiltration of the tumor. At present, there is no radiopharmaceutical that has satisfactory specificity in the detection of thyroid cancer. The cellular accumulation of Sestamibi depends on the tumour size, its vascularity and richness of mitochondria in the tumor cells and is concentrated across a potential gradient [9]. This book chapter is open access distributed under the Creative Commons Attribution mercial purposes, as long as the author and publisher are properly credited. In several prospective studies image of a metabolically active thyroid nodule was characterized by relatively low positive predictive value (33 to 50%). This book chapter is open access distributed under the Creative Commons Attribution mercial purposes, as long as the author and publisher are properly credited. In some centres positron-emitting iodine isotope 124I is available with a half-life of 4.

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Direct obstetric deaths Direct obstetric deaths are those resulting from obstetric complications of the Regulations regarding nomenclature pregnant state (pregnancy, labour and puerperium), from interventions, omissions or incorrect treatment, or from a chain of events resulting from any of the above. Indirect obstetric deaths Indirect obstetric deaths are those resulting from previous existing disease or disease that developed during pregnancy and that was not due to direct obstetric causes, but which was aggravated by physiologic effects of pregnancy. Article 1 Members of the World Health Organization for whom these Regulations shall come into force under Article 7 below shall be referred to hereinafter as Members. Article 2 Members compiling mortality and morbidity statistics shall do so in accordance with the current revision of the International Statistical Classifcation of Diseases, Injuries and Causes of Death as adopted from time to time by the World Health Assembly. Article 3 In compiling and publishing mortality and morbidity statistics, Members shall comply as far as possible with recommendations made by the World Health Assembly as to classifcation, coding procedure, age-grouping, territorial areas to be identifed, and other relevant defnitions and standards. Article 4 Members shall compile and publish annually for each calendar year statistics of causes of death for the metropolitan (home) territory as a whole or for such part thereof as information is available, and shall indicate the area covered by the statistics. Article 6 Each member shall, under Article 64 of the Constitution, provide the Organization on request with statistics prepared in accordance with these Regulations and not communicated under Article 63 of the Constitution. Upon their entry into force these Regulations shall, subject to the exceptions hereinafter provided, replace as between the Members bound by these Regulations and as between these Members and the Organization, the provisions of the Nomenclature Regulations 1948 and subsequent revisions thereof. Any revisions of the International Classifcation of Diseases adopted by the World Health Assembly pursuant to Article 2 of these Regulations shall enter into force on such date as is prescribed by the World Health Assembly and shall, subject to the exceptions hereinafter provided, replace any earlier classifcations. The period provided in execution of Article 22 of the Constitution of the Organization for rejection or reservation shall be six months from the date of the notifcation by the Director-General of the adoption of these Regulations by the World Health Assembly. Any rejection or reservation received by the Director General after the expiry of this period shall have no effect. The provisions of paragraph 1 of this Article shall likewise apply in respect of any subsequent revision of the International Classifcation of Diseases adopted by the World Health Assembly pursuant to Article 2 of these Regulations. Article 9 A rejection, or the whole or part of any reservation, whether to these Regulations or to the International Classifcation of Diseases or any revision thereof, may at any time be withdrawn by notifying the Director-General. Article 11 the original texts of these Regulations shall be deposited in the Archives of the Organization. Upon the entry into force of these Regulations, certifed true copies shall be delivered by the Director-General to the Secretary-General of the United Nations for registration in cccordance with Article 102 of the Charter of the United Nations. In faith whereof, we have set our hands at Geneva this twenty-second day of May 1967. Ileostomy surgery is a lifesaving surgery that enables a person to enjoy a full range of activities, including traveling, sports, family life and work. Thousands of people annually undergo ostomy surgery for various reasons and return to a healthy, functioning lifestyle. Give new things a fair trial, but do not insist on them if they fail to make you more comfortable. When an individual can independently perform their own ostomy care, they feel much better about themselves and will enjoy a much better quality of life. The sooner you learn to take care of your ileostomy, the better you are likely to feel about yourself. There are many ways to gain a greater understanding of your life with an ileostomy. Taking part in an ostomy support group allows you to share your feelings and ask questions as you make progress with your adjustment. It also allows you to share your successful adjustment with others who may need the benefit of your experience. If you would like a visitor or to take part in a support group, ask your physician, ostomy nurse, or other nurses to make a referral. The end of the ileum (the lowest portion of the small intestine) is brought through the abdominal wall to form a stoma, usually on the lower right side of the abdomen. When you look at your stoma, you are actually looking at the lining (or mucosa) of the intestine, which is like the lining of your cheek. The entire colon, rectum, and anus are removed or bypassed with a permanent ileostomy and normal colon and rectal functions are no longer present. With a temporary ileostomy, all or part of the colon is removed, but part or all of the rectum is left intact, and may eventually be reversed. Enzymes released into the small intestine break food into small particles so that vitally needed proteins, carbohydrates, fats, vitamins and minerals can be absorbed. These enzymes will also be present in ileostomy discharge, and they can cause skin breakdown.

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