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By: Q. Mazin, M.B.A., M.B.B.S., M.H.S.

Co-Director, Stanford University School of Medicine

With this in mind, we placed exploring electrodes on both anterior thighs of subjects, three inches above Upledger Institute International (upledger. Karni used his creative expertise in physics and engineering to get his Modified Wheats to ne Bridge to algebraically add the noise deflections. We then began to see patterns of electrical potential change within patients that correlated to specific craniosacral techniques that I was using at the time. We placed a screen between Karni and his polygraph, on which all of the data was being recorded, and myself with the patient. Soon, from his polygraph tracings, Karni was able to tell me what I was doing with the patient. We saw that breathing was not consistently related to craniosacral system activity. We saw that at the onset of a still point the heart quite often gave a premature ventricular contraction. We definitely saw that electrical phenomena were related somehow to craniosacral system phenomena in the same body. The most exciting thing for me was the observation that, when I found a point of release in the craniosacral system, the craniosacral rhythmical activity s to pped simultaneously with a cessation of patient in-body electrical potential fluctuation. The electrical potential baseline also dropped during this period of "release" within the craniosacral system. I still believe this is probably our most important finding, although we still do not understand the mechanics of this relationship. Karni and I continued through 1978, when he was forced to return to the Technion Institute in Israel. We placed sensitive strain gauges at the mid-forearms and the wrists of patients, which would measure and record on the polygraph circumferential changes in the arm and wrist. This pulse moved from mid-forearms to wrists, usually over a period of about four-tenths of a second. Karni and I also did a lot of other exploration related to Kirlian pho to graphy, acupuncture points and meridians, and so on. This was reported in 1978 to the International Kirlian Society Convention in New York City. We also saw changes in electrical activity in acupuncture meridians resultant to CranioSacral Therapy. Since then, I have often had acupuncturists evaluate the pulses and moni to r the changes that occur as I do CranioSacral Therapy. Clearly, the system of acupuncture meridians and energies are often favorably influenced by CranioSacral Therapy. He then arranged a visiting professorship for me in the summer of 1979 at the Technion Institute in Haifa. At Technion, we did more strain plethysmography work along with Joseph Mizrahi, Ph. This work was published in a journal produced by the Julius Silver Institute of Biomedical Engineering Sciences at the Technion Institute in Haifa, Israel, in April 1980. Four cases of long-standing coma secondary to anoxia displayed craniosacral rhythms of 3-4 cycles per minute all over the body. Two cases of long-standing coma due to drug overdose displayed rhythms of 10-25 cycles per minute all over the body. One case of poliomyelitis with secondary residual paraplegia displayed palpable craniosacral rhythms of 24 cycles per minute in the paralyzed limbs and 10 cycles per minute in the rest of the body. One case of Guillian Barre Disease displayed craniosacral rhythms of low amplitude 24 cycles per minute in paralyzed lower extremities, and low amplitude 6 cycles per minute above the paralysis. Seven cases of spinal-cord injury displayed craniosacral rhythm of 7-10 cycles per minute on the head and body above the cord injury, and 18-26 cycles per minute below the cord injury. I was able to accurately localize the level of the spinal-cord injury in this way with no knowledge of this level of injury from other sources. One case of long-standing coma due to cerebral hemorrhage with secondary left sided hemiplegia displayed a craniosacral rhythm on the hemiplegic side of 25 cycles per minute.

Varicella vaccination alters the chronological trends of herpes zoster and varicella. A fi Positive heterophile agglutination test maculopapular or occasionally petechial rash occurs in less (Monospot). Airway more than 95% of the adult population worldwide and obstruction from lymph node enlargement, pericarditis, persisting for the lifetime of the host. Labora to ry Findings tious mononucleosis occurs at younger ages and tends to An initial phase of granulocy to penia is followed within beless symp to matic. Rare cases in the elderly occur usually 1 week by lymphocytic leukocy to sis (greater than 50% of without the full symp to ma to logy. Saliva may remain infectious during convalescence, ing vacuolated, foamy cy to plasm and dark nuclear for 6 months or longer after symp to m onset. Hemolytic anemia, with anti-i antibodies, occurs occasionally as does thrombocy to penia (at times marked). Prognosis & Prevention ation are common but atypical lymphocy to sis is much less In uncomplicated cases, fever disappears in lO days and common. Heterophile-negative infectious mononucleosis lymphadenopathy and splenomegaly in 4 weeks. Treatment (Duncan disease), lymphoma to id granuloma to sis, and a fatal T cell lymphoproliferative disorder in children. After primary infection, the virus remains latent in treating more than two-thirds of cases. Transmission occurs through sexual contact, while peripheral T cell lymphomas and diffse large B cell breastfeeding, blood products, or transplantation; it may lymphomas are more common in the elderly due to waning also occur person- to -person (eg, day care centers) or be immunity. Transmission is much higher from mothers with primary Severe thrombocy to penia; significant hemolysis. About l0% ofinfected newborns will be symp to matic with Airway obstruction from severe adenitis. Age-specifc prevalence of Epstein-Barr In immunocompromised persons, solid organ and virus infection among individuals aged 6-19 years in the United States and fac to rs affecting its acquisition. Epstein-Barr virus infection and posttransplant on the serostatus of the donor and recipient, disease may lymphoproliferative disorder. Symp to ms and Signs ventriculoencephalitis (suspected with ependymitis), and focal encephalitis. Abnormal liver function postsplenec to my, often years later and associated with a tests are common in the first 2 weeks of the disease protracted fever, marked lymphocy to sis, and impaired (often 2 weeks after the fever).

Chlamydia psittaci Rare Exposure to birds, including parrots, pigeons, and chickens; headache; temperature-pulse dissociation. A prediction rule to identify low-risk patients with community-acquired pneumonia. Appropriate choices include the following: Extended-spectrum fiuoroquinolones. Limited eficacy; rewarming of the rewarming air blankets over the to rso only); extremities can cause paradoxical warmed baths. Extracorporeal blood rewarming Moderate and severe the most effective technique, via cardiopulmonary, hypothermia; cardiac but invasive, and requires the arteriovenous, or venovenous arrest. Peri to neal/pleural lavage with Moderate and severe Useful when extracorporeal warmed fiuids. Noninvasive mechanical ventilation Mucolytic agents Magnesium 416 Inhaled bronchodila to r therapy: Combination therapy (fi2-agonists and ipratropium bromide) should be given to all patients with moderate to severe exacerbations. Indications for mechanical ventilation in clude the following: Persistent hypercapnia Altered mental status Progressive and persistent acidemia (pH < 7. A diligent search for exacerbating or con comitant processes should be completed in all patients. Includes a fi2 agonist (most commonly albuterol) and/or the anticholinergic agent ipra tropium bromide. Chest physiotherapy and mucolytic therapy are inef fective as acute interventions. Postsplenec to my sepsis has a short viral-like prodrome followed by abrupt de terioration and shock. Encapsulated organisms involved include Strep to coccus pneumoniae (> 50%), Neisseria meningitidis, and Haemophilus infiuenzae. Other organisms include Capnocy to phaga (dog or cat contact), Salmonella (sickle cell anemia), Babesia, and malaria (more fulminant). Found in coastal New England and Long Island and, to a lesser extent, in the upper Midwest and the West Coast. Deaths in the United States have occurred in patients both with and without spleens. Bar to nella henselae is transmitted by kittens or feral cats, Bar to nella quintana by body lice. Clinical manifestations vary de pending on (1) the transmitted species and (2) the immune status of the host. Peliosis hepatis produces fever, weight loss, abdominal pain, and hepa to splenomegaly; imaging shows hypodense, cystic, blood-filled structures in the liver, spleen, or lymph nodes. Smallpox Severe fiulike Acute rash Varicella Clinical Standard, Supportive prodrome followed by with fever. Viral Fever with mucosal Acute rash Meningococcemia, Clinical Standard and Supportive hemorrhagic bleeding, petechiae, with fever. Adapted from the California State Department of Health and the Centers for Disease Control and Prevention. Infiammation and purulence around the catheter and catheter necessitates catheter bloodstream infection are specific but not sensitive.

His to pathology Clinical Features The branchial cyst is lined with stratifed squamous epi Clinically, these cysts, when located above the mylohy thelium, pseudostratifed columnar epithelium, or both oid muscle, displace the to ngue superiorly and posteri (Figure 10-54). Tese cysts are painless and slow grow Diferential Diagnosis ing; no gender predilection has been noted. Lesions are Preoperative diagnoses may include cervical lymphadenitis, generally smaller than 2 cm in diameter; however, skin inclusion cyst, lymphangioma, and tumor of the tail of extreme examples may range up to 8 to 12 cm. Laterally displaced thyroglossal tract cyst and palpation, the cysts are soft and doughy because of dermoid cyst might also be considered. Fine-needle aspiration Microscopically, the dermoid cyst is lined by stratifed squa biopsy of the neck mass and advanced imaging are helpful mous epithelium supported by a fbrous connective tissue in excluding this possibility. Dermoid Cyst Dermoid cysts are developmental lesions that may occur in many areas of the body (Box 10-16). Numerous secondary skin structures, including hair follicles, sebaceous glands, and sweat glands (and occasionally teeth) may be found. Thyroglossal Tract Cyst Tyroglossal tract cysts are the most common developmen tal cysts of the neck, accounting for nearly three fourths of such lesions (Box 10-17). The thyroid anlage grows downward from the fora men caecum area to its permanent location in the neck. Residual epithelial elements along this pathway that do not completely atrophy may give rise to cysts in later life from occurring in the thyrohyoid membrane and only 2% within the posterior portion of the to ngue (lingual thyroid) to the the to ngue itself. When attached to the hyoid Clinical Features bone and to ngue, they may retract on swallowing or on Approximately 30% of cases are found in patients older extension of the to ngue. If infected, drainage through a than 30 years, with a similar percentage in patients younger sinus tract may occur. A ciliated or columnar Lingual thyroid type of epithelium is usually found in cysts that occur Mass in to ngue base caused by failed descent of thyroid tissue below the hyoid bone. However, wide variation may be May be only functional thyroid tissue in patient Treatment by excision; may recur because of to rtuous seen within a single cyst. Rare malignancies aris Rare cases of thyroid cancer develop along the cyst tract. Kolar Z, Geierova M, Bouchal J et al: Immunohis to chemical analysis Because the lesion may be rather to rtuous in confguration, of the biological potential of odon to genic kera to cyst, J Oral Pathol recurrence may be seen. They may be found within the maxillofacial Ameloblas to ma skele to n (central) or may be located in the soft tissue overly Calcifying Epithelial Odon to genic Tumor (Pindborg ing the to oth-bearing regions and in the alveolar mucosa of Tumor) edentulous segments of the jaws (peripheral). An under Adenoma to id Odon to genic Tumor standing of the biological behavior of the various odon to Squamous Odon to genic Tumor genic tumors is fundamentally important to the overall Clear Cell Odon to genic Tumor (Carcinoma) treatment of patients. Kera to cystic Odon to genic Tumor (See Odon to genic Several classifcation schemes based on his to logic pat Kera to cyst/Kera to cystic Odon to genic Tumor in terns have been devised for this complex group of lesions. Chapter 10) Common to all is the division of tumors in to those com Dentinogenic Ghost Cell Tumor (Calcifying Odon to genic Cyst) posed of odon to genic epithelial elements, those composed of odon to genic mesenchyme, and those that are prolifera Mesenchymal Tumors tions of both epithelium and mesenchyme (ec to mesen Odon to genic Myxoma chyme). As classifed on the basis of biological behavior, Central Odon to genic Fibroma they range from clinically trivial. Cemen to blas to ma Periapical Cemen to -osseous Dysplasia Epithelial Tumors Mixed (Epithelial and Mesenchymal) Tumors Ameloblas to ma Ameloblastic Fibroma and Ameloblastic Fibro-odon to ma Odon to ma His to rically, ameloblas to ma has been recognized for over a century and a half. Its frequency, persistent local growth, and ability to produce marked deformity before leading to serious debilitation probably account for its early recogni tion. Recurrence, especially after conservative treatment, Odon to genic tumors are derived from the epithelial and/or has also contributed to awareness of this lesion. Terefore, they are found exclusively in the mandible and Pathogenesis maxilla (and occasionally in the gingiva). The origin and this neoplasm originates within the mandible or maxilla pathogenesis of this group of tumors are unknown. Less cally, odon to genic tumors are typically asymp to matic, commonly, the ameloblas to ma may arise at a soft tissue loca although they may cause jaw expansion, movement of teeth, tion within the gingiva of to oth-bearing areas.

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The primary indication for periodontal fap surgery is to gain access to the root surface and remove bacterial deposits and calculus that may have re mained following nonsurgical therapy. First outlined by Schluger in 1949,3 osseous surgery was defned as the pro cedures to modify bone support altered by periodontal disease either by reshaping the alveolar process to achieve physiologic form without removal of alveolar bone or by removing some alveolar bone, thus changing the posi tion of crestal bone relative to the to oth roots. In this surgery, the bone that is reshaped is not part of the attachment apparatus, thus no bony support of the to oth or teeth is lost. Friedman defned ostec to my as an operative procedure in which bone that is part of the attachment apparatus is removed to eliminate a periodontal pocket and establish gingival con to urs that will be maintained. The full-thickness fap includes the epithelium, connective tissue, and perios teum. In a partial-thickness fap, the mucosa is separated from the periosteum (which is attached to the alveolar bone). The modifed Widman fap, frst described by Ramfjord and Nissle in 1974,5 is a fap used to provide access for root planing. Osteoplasty for fap adaptation purposes Q: Describe the apically repositioned fap. First described by Nabers in 1954,6 the apically repositioned fap is a full thickness reverse-beveled scalloped incision with vertical releasing incisions to the mucogingival junction. With a distal wedge excision, excessive tissue distal to the last remaining to oth in the mouth can be excised to reduce the pocket. In an envelope fap, the horizontal incision is made at the gingival margin with out any vertical incisions. Q: Describe the palatal approach to osseous surgery according to Ochsenbein and Bohannan. However, adequate width (greater than 2 mm) of the papilla is necessary as well as a suffcient embrasure space. Positive architecture (interproximal bone coronal to the facial or lingual bone) as opposed to negative architecture (interproximal bone apical to the facial or lingual bone) allows close adaptation of the gingival tissues to the bone, which results in minimum sulcus depth. Papapanou and Wennstrom14 found that angular defects do worsen and can be more challenging to treat if not detected early. An increased possibility of to oth loss was associated with teeth showing initial signs of angular defects. The interproximal areas are leveled or ramped (if defect is on the lingual, ramping is performed to ward the lingual) frst because they will be the highest point (positive architecture). Wound Healing Q: What is the difference between primary, secondary, and tertiary wound healingfi Table 10-2 presents results from studies of wound healing following osseous surgery. Table 10-2 Wound healing following osseous surgery Study Subject Results Wood et al15 Alveolar crest reduction follow 0. See Table 9-2 in chapter 9 for a synopsis of studies comparing surgical and nonsurgical therapy. Open Flap Curettage Versus Osseous Recon to uring Q: Compare open fap curettage and osseous recon to uring.