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Notes from Breastfeeding class: 

At 6 weeks it is usual for a baby to feed often during the day, more in the evening, and to wake for some feeds during the night. Ignoring the baby's cues will lead to a reduced milk supply, and paradoxically cause him/her to feed even more. Giving formula will also decrease breast milk output. 
Milk is produced via a positive feedback loop: the more frequently and efficiently milk is removed, the more milk will be produced. A healthy infant, feeding comfortably and frequently, is the most effective way to ensure an adequate milk supply. 
Breast milk contains a protein called the feedback inhibitor of lactation (FIL). It is present in small amounts when the breast is being emptied regularly. When feeding is restricted the protein builds up in quantity and leads to a reduction in milk production by the breast. 
Normal babies have periodic episodes when they try to feed extremely frequently, day and night. This is an attempt to upregulate and increase the milk supply, and is particularly common at 6 weeks. It is often called a "growth spurt". 
Giving formula or following a schedule prolongs the episode by blocking the positive feedback loop. Following the baby's cues will usually increase supply within 1-2 days, and feed frequency will return to normal. 
A healthy baby will keep suckling until his hunger, thirst and need for comfort are satisfied. This ensures he gets the optimum balance of protein-rich foremilk, and lipid-rich hindmilk. He will come off the breast spontaneously when he is ready, and look content. 
If he needs more milk he will take the second breast when it is offered. Routinely changing breasts before the baby is ready will disrupt milk production. A baby may fall asleep at the breast. The mother can break the suction by gently inserting a clean finger in the corner of his mouth, and offer him the other side. 
All mothers are supposed to be taught how to express milk by hand in the immediate postnatal period. 

To qualify as a contraceptive method: 
-Breastfeeding must be full (that is, no formula, no solids, no extra fluids and no expressing by pump or hand; prolactin levels may drop if the mother is expressing) 
-The baby should be under 6 months old 
-Menstruation must be absent 
-There should be no long intervals between feeds 
-The mother should not use a pacifier to satisfy the baby's suckling needs 
When these criteria are fulfilled, the lactational amenorrhoea method (LAM) is over 98% effective in preventing pregnancy (Faculty of Sexual and Reproductive Healthcare (FSRH), 2009. 
Average duration of lactational amenorrhoea in breastfeeding mothers is up to 15 months. 
The copper IUD is licensed for emergency contraception up to 5 days after intercourse (FSRH, 2012). 

Department of Health (DH), 2011, and World Health Organization guidance (WHO, 2013) is that solids should be started around 6 months of age. This balances the infant’s need for extra nutrients (especially iron) against the risks of infection and allergy. Breastfeeding can and should be continued alongside his solids once he is 6 months old. This provides optimum nutrition, and offers continued protection from allergy and infection. 

She may need to express her milk to maintain supply. Most babies will take the breast when sleepy, for example at night and for pre-nap feeds. She may wish to avoid bottles and feed with a cup, to prevent teat preference developing. 

Suckling and breast milk both have analgesic properties, and breastfeeding reduced infant pain responses in a randomised controlled trial (Carbajal et al, 2003). 

Breastfeeding reduces the risk of gastrointestinal infection, respiratory illness and atopic disease (NICE, 2006) in infants. Teenagers and adults who have been breastfed are at less risk of high blood pressure, obesity and type 2 diabetes (Horta et al, 2007 Chivers et al, 2010). 
Mothers who have a history of breastfeeding have a decreased chance of developing postmenopausal osteoporosis (Schnatz et al, 2010). Breastfeeding also helps to protect against maternal ovarian and breast cancer. Breastfeeding may also reduce the risk of maternal type 2 diabetes (Liu et al, 2010). 

Mastitis begins as a sterile inflammatory reaction to milk stasis. Resting the affected breast will exacerbate this, and hasten the development of secondary bacterial infection. The key to effective mastitis treatment is frequent feeding from the affected breast. Pain relief (paracetamol, possibly supplemented by NSAIDs and/or codeine) may well be needed. Local heat, massage and milk expression should also help. 
As the mastitis develops, the area becomes harder, more tender and very red. Flu-like symptoms, including fever, occur. Without prompt treatment to drain the milk, there will then be secondary infection. This may progress to abscess formation, and surgical drainage or aspiration will be needed. 
The usual pathogens are Staphylococcus or Streptococcus, often finding entry through a cracked nipple. 

Recommended treatment for mastitis (WHO, 2000; NICE Clinical Knowledge Summaries (CKS), 2010) 

Penicillin OK 
Flucloxacillin 250-500 mg four times a day 
Amoxycillin 250-500 mg three times a day 

Penicillin allergy 
Erythromycin 250-500 mg four times a day 
Cefalexin 250-500 mg four times a day 

Alcohol ingested by a breastfed neonate has been shown to have effects on the infant even in small quantities (Mennella and Beauchamp, 1991). 

Breast milk has a lower level of electrolytes than formula, it is rapidly absorbed, of high nutritional value and hastens a return to normal gut flora. Unlike oral rehydration therapy, it is a familiar tasting fluid which is highly acceptable to sick infants. 
If the baby is given unrestricted access to the breast, supply will increase to compensate for mild to moderate GI losses. Should losses be more than this, oral rehydration fluids can be used to supplement breastfeeding until dehydration is corrected. 
Secondary lactose intolerance can follow a bout of gastroenteritis, but is rarely a cause of anything more than nuisance diarrhoea. It nearly always settles spontaneously within a week or two. Withholding breast milk is unnecessary and potentially dangerous. 
Breastfeeding offers a great deal of protection from gastrointestinal infections through a variety of mechanisms. 

At work the mother could send expressed milk to the child's carer. Then she could maximise breastfeeding when she is at home. 
Or she could allow the carer to use formula milk but continue to breastfeed as normal when at home. 
A study comparing breastfed with formula fed babies found that the formula fed babies developed more minor illnesses and their mothers had higher levels of absence due to their child's sickness compared with the breastfed group (Cohen et al, 1995). 

Less than 1% of UK babies are exclusively breastfed until 6 months (HSCIC, 2012). 

One of the main reasons mothers stop feeding in the early days is nipple soreness. Bottle-feeding is so dominant in the UK that most women instinctively hold the baby in the crook of their arm. 
For a breastfed baby, this means it is very difficult to reach the breast, and the nipple becomes stretched and distorted. It is common for the breast to be held between two fingers and offered to the baby as though it were the teat of a bottle, with similar results. 
If nipple injury has already occurred, the first few seconds of a feed can be sore. Pain that persists is a problem, probably because of poor positioning, causing further nipple pressure and damage. 

Teenager and socioeconomically disadvantaged mothers are risk factors for breastfeeding failure (Brand et al, 2011). 
Other reasons for women stopping breastfeeding include milk supply issues, the baby rejecting the breast, and returning to work (Brand et al, 2011). 

Paracetamol may safely be taken by lactating mothers. NSAIDs are sometimes found in breast milk but quantities are thought too small to be harmful. Codeine is also found in breast milk, and particularly in larger doses has been associated with infant drowsiness or sedation. 

Physiological jaundice starting after 24 hours of life and persisting for the first week or two is normal. When jaundice is mild, the baby is well hydrated and showing no sign of illness, there is no need for a blood test. Jaundiced babies can be sleepy, so it may be necessary to actively encourage mothers to feed frequently. This usually avoids the need for supplementary non-breast milk fluids. 

Principles when feeding a baby: 
-See that she is sitting upright, with good support for her back and baby. 
-Look for slow deep sucks and rounded cheeks full of milk; listen for swallowing and breathing pauses. 
-Mother and baby should seem serene. 
-Baby’s tummy should face mummy, so she is tucked in close to Leanne’s body and can reach the breast without turning his head. 
-The nipple should point to the baby's nose, one hand supporting the breast if needed. 
-Baby should be held by the shoulders and neck, so his head is partly free. 
-Mothers should then wait for his mouth to open really wide, in a full-size gape. Then quite quickly she needs to bring him to the breast. 

Nicotine and other toxins do enter breast milk. But smokers’ babies are invariably exposed to second or third-hand smoke from their parents’ clothes and skin even if smoking within the house is avoided. Stopping breastfeeding will not avoid baby’s exposure to tobacco, with the consequent risks of asthma, respiratory infection, otitis media, SIDS, etc. 
Many of these risks are raised further by bottle-feeding, so avoiding milk formula feeding is especially sensible when a mother smokes. 
Nicotine enters the milk in parallel with blood levels, and reaches a peak soon after having a cigarette. You may wish to advise mothers to delay smoking until just after a feed, in order to minimise baby's exposure. 
NICE guidance on NRT(nicotine replacement therapy) suggests that when a breastfeeding mother is unable to stop smoking unaided she should be offered NRT (NICE, 2008). 
The intermittent release methods (spray, gum, lozenges, etc) may be preferred to patches as the baby’s exposure can be lowered by careful timing of their use. 
She should be strongly advised that she must not smoke whilst using NRT since that would expose her baby to a very high nicotine level. 

Parents should never share their bed with their baby if one or both of them has had any alcohol or misused drugs. A smoker’s bed is always hazardous for an infant (WHO, 2009). 
The Department of Health advises that the safest place for a baby to sleep, particularly in the first weeks of life, is in a cot in the parents’ bedroom (DH, 2009). 

Formula feeding is advised for mothers with HIV in the UK. 

The Faculty of Sexual and Reproductive Healthcare has endorsed the combined oral contraceptive pill (COCP) as broadly suitable for some breastfeeding mothers. This includes mothers who are mixed feeding or those who have older babies (over 6 months) (FSRH, 2009).
The available evidence suggests that the progesterone-only pill (POP) has no effect on milk supply or composition, and so is suitable for breastfeeding mothers (FSRH, 2009). Although its effectiveness when used alone is lower than the combined pill, it is very reliable when used in combination with breastfeeding. 
Progestogen-only injectable contraception (Depo-Provera), progestogen-only implants (Implanon), the copper IUCD and the levonorgestrel-releasing intrauterine system (IUS) (Mirena) are all suitable for use by breastfeeding women (FSRH, 2009). 

Nystatin drops are traditionally used to treat babies with thrush, it is the drug of choice (NICE, 2006). 
Treatment must be continued for several days after symptoms have resolved. Mother and baby should both be treated. 
Some women get severe, deep breast pain lasting for a long time after a feed. It is often attributed to thrush and anecdotally does seem to respond to fluconazole, but causation has not been proven. Breast "thrush" presents with a very different clinical picture from mastitis. The breasts usually look normal apart from a flaky nipple and the name comes from the association with oral thrush in the baby. 
Fluconazole is considered safe in breastfeeding as it is widely used in neonates. 

Diclofenac is usually considered safe in lactation. 
Anaesthetic gases may affect milk production, so women who have had a general anaesthetic may need extra support in the first few days. 

Mothers and babies can experience psychological symptoms for years after early separation. It is nearly always better that there is immediate contact after birth.Early contact with a newborn enhances bonding, and facilitates later breastfeeding. 
Skin-to-skin contact, is as effective as an incubator in regulating a premature baby's temperature, and preventing hypoglycaemia. It regulates the baby's heart rate and breathing pattern. It aids maternal milk production and facilitates the establishment of breastfeeding (Anderson, 1999). 

Necrotising enterocolitis and infection are leading causes of death for infants needing specialist neonatal care. Premature babies fed on formula have 20 times the rate of necrotising enterocolitis (Lucas and Cole, 1990) and marked increases in urinary tract and lower respiratory tract infections (Lucas, 1992). Decreases in IQ at age 7 have been documented for babies who are formula fed (Lucas et al, 1992; Quigley et al, 2009). 
Rates of infection are much higher in SCBU occupants who are deprived of breast milk. 

To express, the breast is gently squeezed proximal to the nipple, using the thumb and fingers. The colostrum or milk is collected in a sterile container. 
Milk may be kept at room temperature for 6 hours, or refrigerated or frozen for later use. 

Galactagogue metoclopramide 10mg is occasionally recommended for mothers of babies on SCBU. In general, breast milk containing a small amount of medication is preferable to formula milk. 

Pumping both breasts simultaneously is quicker, which is important for mothers. It helps increase milk yield because it mimics the physiological action of feeding both twins simultaneously. 
She will need to pump both breasts around eight times a day, so a manual pump will risk carpal tunnel syndrome, electric pumps are better. 

Tongue-tie as a possible cause of failure to latch. The baby’s tongue needs to be able to protrude beyond the lower lip. If present, it should be possible to have it corrected right away, usually in the paediatric surgical outpatients. It has an immediate effect on the baby’s ability to latch and breastfeed.



Σωστή κι αποτελεσματική τεχνική για την εξαγωγή κι αποθήκευση μητρικού γάλακτος κατά το θηλασμό. 


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Η Μαρια μπορει να σου κανει μηνυση για αυτο το ποστ. Ειναι εμμεση απειλη ανθρωποκτονιας. Εδω στην Αγγλια θα σε ειχαν παει σηκωτο στο συλλογο/αστυνομια. Το εκανα ρεπορτ στους μοντερειτορς

Να σου κλέψω λίγο το νήμα, Χριστός Ανέστη να σε έχει καλά όπως κι όλα τα παιδιά του φόρουμ και να μην είσαι σκληρή με τους άλλους ακόμη κι αν έχεις δίκιο.

Φορολογικοί παράδεισοι τρισεκατομμυρίων ευρώ η Ολλανδία και το Λουξεμβούργο! http://rt.com/business/202715-luxembourg-biggest-tax-haven-eu/ http://www.taxjustice.net/2014/05/20/netherlands-

Notes from Chronic Pelvic Pain Course: 

Inflammatory bowel disease is a differential diagnosis in a teenager with chronic abdominal/ pelvic pain. A detailed bowel history should be taken and referral made to gastroenterology, if appropriate. 
If her symptoms are suggestive of Irritable bowel syndrome, she should be offered dietary advice and a trial of an antispasmodic drug. 
Chronic constipation can present with recurrent abdominal/ pelvic pain and can occasionally present with acute abdominal/ pelvic pain. 
Congenital genital tract abnormalities may present at birth, at menarche or at the beginning of sexual activity. Lower vaginal atresia results in abdominal pain as blood accumulates in the upper vagina during menses (concealed). The diagnosis is confirmed by transabdominal pelvic ultrasound scan. 
Psychological or social problems (abuse) at school (bullying) or at home may be relevant. 
A history of physical, sexual and psychological abuse is more common in women with CPP (Latthe et al, 2006). 
Although endometriosis may occur in teenagers, it is uncommon. 

Primary dysmenorrhoea (related to prostaglandin production in the uterus) is the most likely diagnosis. NSAIDs (eg mefenamic acid) are therefore likely to be effective. 
There is no contraindication to the use of the COCP on a continuous basis in a 15 year old by virtue of her age. As her symptoms are related to menstruation it is highly likely that use of the COCP on a continuous basis would result in symptomatic relief. 
Use of progestogens on a continuous basis is an alternative in women in whom the COCP/ NSAIDs are ineffective or unsuitable. 

Irritable bowel syndrome can be diagnosed using Rome III criteria (Longstreth et al, 2006): at least 3 months of intermittent or constant pain that is relieved by defaecation and associated with at least two of the following: 
-altered stool frequency 
-altered stool passage - straining, urgency 
-altered stool form - diarrhoea, "rabbit pellets" 

Rectal bleeding is commonly associated with haemorrhoids or an anal fissure. 
One-third of healthy women (with no underlying pathology) experience an alteration in bowel habit during menstruation. 
Deep dyspareunia may occur in women with IBS but typically occurs after rather than during intercourse due to postcoital bowel spasm. 

Ectopic endometrial tissue may be present in unusual sites such as the rectum and umbilicus, and associated with bleeding from these sites during menstruation. 
Endometriosis is found in 35-50% women with CPP. Cyclical pelvic pain (often associated with dysmenorrhoea and dyspareunia) in women of reproductive age is the most common symptom associated with the condition and merits referral to secondary care for investigation. 

Red flag symptoms of endometriosis (RCOG, 2006): 
-severe dysmenorrhoea 
-deep dyspareunia 
-ovulation pain 
-other cyclical or perimenstrual symptoms, eg bowel or bladder 
-dyschezia (pain on defaecation) 

The gold standard for diagnosing endometriosis is laparoscopy. There are no serum or urinary biomarkers of endometriosis. However, treatment of endometriosis, using drugs that cause ovarian suppression (eg combined oral contraceptive pill, continuous oral or intramuscular depot progestogens, GnRH agonists with "add-back" HRT for bone protection), may be started prior to laparoscopy. If these drugs successfully alleviate symptoms, a laparoscopy is not always necessary. The Mirena intrauterine system is also a recognised treatment for endometriosis-associated pain. 

Adenomyosis is characterised by the same symptoms as endometriosis. It is more often diagnosed histologically following a hysterectomy but can be diagnosed by pelvic magnetic resonance imaging (MRI). 

Adhesions due to previous surgery, pelvic infection ("chronic pelvic inflammatory disease (PID)") or endometriosis are also associated with CPP but there is little evidence that division of adhesions reduces pelvic pain symptoms. 

Pelvic congestion syndrome is the association of pelvic varicosities seen on MRI with pelvic pain. Ovarian suppression has been shown to be helpful. 

Bowel symptoms are very common in women with CPP, occurring in 50% of women with pain attending a gynaecology clinic (Latthe et al, 2006). Bladder problems, including bladder pain syndrome (interstitial cystitis) or overactive bladder, are also common in this setting, being present in 38-84% of women with pain (Latthe et al, 2006). Musculoskeletal problems cause or exacerbate pelvic pain in up to 75% of women. 

In endometriotic women with persistent symptoms or symptoms particularly during menstruation, oral progestogens, Depo-Provera and the COCP may be used long term. GnRH agonists, if given long term, must be prescribed with "add-back" HRT for bone protection. GnRH agonists cause menopausal-like symptoms (eg hot flushes, increased sweating, vaginal dryness, dyspareunia and loss of libido) and a decrease in bone density without HRT. 
GnRH agonist therapy given for 3 months may be as effective as treatment given for 6 months in relieving endometriosis-associated pain. 

Hysterectomy on its own is very unlikely to relieve CPP in women with endometriosis. Bilateral salpingo-oophorectomy is also required and even this is not guaranteed to cure all symptoms. She will subsequently require long-term HRT. 

Pain control 

Analgesic drugs should be used in a stepwise fashion similar to the WHO analgesic ladder. The ladder advocates a stepped approach to the use of painkillers from the following analgesia groups: 
-simple analgesics, ie paracetamol and NSAIDs 
-weak opioids, ie tramadol, codeine 
-strong opioids, ie morphine, fentanyl, oxycodone (in conjunction with specialist care) 
-adjuvants such as antidepressant or anticonvulsant drugs, eg amitriptyline, gabapentin 

Non-opioid analgesics form the basis of pain management at every step of the analgesic ladder (paracetamol and NSAIDs should always be prescribed with opioid analgesia). This approach is known as multi-modal analgesia first established to treat cancer pain. This introduced the concept that pain is best managed not by a single drug or therapy but by combinations, which maximise efficacy whilst keeping side effects low. The NSAID mefenamic acid is useful for the management of cyclical pelvic pain in adolescents. 

Tricyclic antidepressants (TCAs) and antiepileptic drugs such as the gabapentinoids are commonly used in the management of chronic pain and in particular neuropathic pain. If, as is postulated, CPP has a neuropathic component, then it is rational to try them in this setting (Engeler et al, 2012). 

The usual first-line drug is amitriptyline (WHO analgesic ladder). Amitriptyline should be started at a low dose, typically 10-25 mg. The drug should be slowly titrated up to effect over a period of several weeks, the aim being to use the lowest effective dose. The target dose will be in the region of 75 mg, though many patients will not tolerate the drug side effects. The substitution of nortriptyline or imipramine in similar dosage may reduce the side effects, particularly sedation. 

With gabapentin, patients are typically started on 300 mg daily and slowly titrated up (over a few weeks) to an initial target dose of 600 mg three times a day. Side effects of gabapentin experienced by patients can include somnolence and dizziness, but in general it tends to be well tolerated, has little interaction with other drugs and has a safe side-effect profile. The efficacy and side effects are probably similar to amitriptyline. Pregabalin has a similar side-effect profile to gabapentin but may be better suited to individual patients. The starting dose is 75 mg twice a day titrating up to a target dose of 300 mg twice a day. 

Addressing psychological and social issues that commonly occur in association with CPP is important. Depression, relationship breakdown and sleep disorders are common in women with chronic pain. This may be a consequence rather than a cause of their pain but specific treatment may improve the woman’s ability to function. It is important that the multifactorial nature of pain is discussed and explored from the start. The aim is to develop a partnership between clinician and patient to plan a management programme. 

Persistent haematuria may indicate urinary tract calculi, painful bladder syndrome (interstitial cystitis) or a bladder tumour. A UTI should be excluded and a referral made to a urologist or urogynaecologist. 
Diverticular disease should always be considered. 
Painful bladder syndrome (interstitial cystitis). 

CPP can be associated with gynaecological conditions such as endometriosis, and non-gynaecological conditions such as inflammatory bowel disease and irritable bowel syndrome (and diverticular disease), painful bladder syndrome (interstitial cystitis) and musculoskeletal pain (including osteoarthritis). A history of physical, sexual and psychological abuse is more common in women with CPP. In more than 50% of patients, no cause for the painful symptoms can be found.

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Notes from CXR diagnosis course: 

Unexplained shortness of breath is a justifiable indication for a CXR, whereas for example, preoperatively as a routine examination, upper respiratory tract infection, and costochondritis are not justifiable indications. 

First, you should check technical factors: 

patient’s details 
degree of any rotation 
degree of inspiration 
exposure (lower thoracic spine and disc spaces should be just visible) 

Then assess: 

mediastinum and hila 
soft tissues 

The cardiothoracic ratio is equal to the maximum cardiac diameter divided by the maximum internal diameter of the thorax. On a standard adult PA CXR, this should not be greater than 50% (two standard deviations above the mean). However, it may be increased in the elderly due to infolding of the ribs. 
Basal septal lines (Kerley B lines) can be seen on the CXR; these arise due to visible interlobular lymphatics and their surrounding connective tissue. These are typically 1-3 cm long, less than 1 mm thick, extend from and perpendicular to the pleural surface and are best seen in the costophrenic angles. 
Cardiac enlargement, prominent upper lobe blood vessels, basal septal lines, pleural effusions and alveolar pulmonary oedema “bat’s wing” shadowing are all features of heart failure. 

In right lower lobe consolidation, the outline of the right hemidiaphragm is lost. 
The right middle lobe is bounded superiorly by the horizontal fissure and inferiorly by the oblique fissure. 
An air bronchogram may be seen, whereby air in the bronchi is contrasted against the surrounding consolidated lung. 
Consolidation of the right middle lobe obscures the right heart border. This is referred to as the “silhouette sign”. 
The right atrium forms the right heart border. 
The lingula of the left lung forms part of the upper lobe and is equivalent to the middle lobe of the right lung. Consolidation of the lingula lobe obscures the left heart border. 
In the AP projection, the heart and mediastinum appear magnified, the scapulae are superimposed on the lungs and the clavicles may be projected above the lung apices. 

On a straight CXR: 
-distances between the spinous process of the vertebra and the medial ends of the clavicles are equal 

On a rotated CXR: 
-apparent sizes of the hemithoraces may appear different 
-lungs may show different densities 
-relative sizes of the hila may be distorted 

Being steeper than the left lower lobe bronchus, foreign bodies in the lung are more likely to pass into the right lower lobe. 
Recommend the use of pH indicator strips to measure the acidity of the aspirate. 
Auscultation of injected air (the “whoosh” test) is not advised as a safe testing procedure. 
When a satisfactory position has been confirmed, the external length of the nasogastric tube should be measured and the tube marked with permanent marker pen. 

During a normal inspiration, the diaphragm usually lies between the fifth and seventh ribs anteriorly. On David’s CXR, the anterior ends of the upper eight ribs are visible, the hemidiaphragms appear flat and the heart appears long and thin. These are features of hyperinflation. 
A pneumothorax may be classified as “simple” if there is no associated mediastinal shift or as “tension” if there is associated mediastinal shift away from the side of the pneumothorax. 
It is particularly important to recognise a tension pneumothorax because the mediastinal structures become distorted and compromise venous return to the heart. 
A tension pneumothorax is a clinical diagnosis and a medical emergency requiring immediate decompression that should not be delayed by waiting for a CXR. 
On a supine CXR, the pneumothorax is more difficult to identify because the air in the pneumothorax rises anteriorly to lie in the anterior costophrenic angle. This accounts for the lucency seen overlying the liver. 
A pneumothorax is more easily seen on a CXR in expiration, where its size relative to the underlying lung is greater than during inspiration. 

Chilaiditi’s sign, is a normal variant in which the colon is interposed between the liver and the diaphragm. The haustra of the colon are clearly seen. 
Using a careful radiographic technique, it is possible to detect small quantities of free air, even as little as 1 mL, on an erect CXR. 
On a PA CXR, the mediastinum is usually no wider than a vertebral body. 

As the carcinoma outgrows its blood supply, the centre becomes necrotic. The carcinoma is connected to the airway and the necrotic centre is expectorated. This leads to a thick-walled, irregular cavity. 
Other than malignancy, one of the most important groups is cavitating infections, which include pulmonary tuberculosis and staphylococcal pneumonia. 
Less common causes include Caplan’s syndrome, in which peripheral nodules may cavitate. This is seen in patients with pneumoconiosis and rheumatoid disease. 

Anterior mediastinal masses include thyroid masses, thymic tumours and germinal cell neoplasms (eg a teratoma). 
Posterior mediastinal masses include neural tumours and oesophageal abnormalities. 

Lucency in the soft tissues of the chest wall indicates the presence of gas, which is seen in surgical emphysema. 
Syndrome of spontaneous rupture of the oesophagus typically affects the left side of the lower oesophagus. Other radiological features include a pleural effusion and a pneumothorax.

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Notes from Emergency Contraception Course:

Levonorgestrel 1.5 mg should be taken as soon as possible and within 72 hours of the first episode of UPSI or contraceptive failure in the cycle. Ulipristal 30 mg should also be taken as soon as possible, but is effective up to 120 hours after UPSI.
A copper intrauterine device (IUD) can be inserted up to 5 days after UPSI.

There is no time in the menstrual cycle when the risk of pregnancy following UPSI can be considered to be zero. However, there is no risk of conception within 21 days of childbirth; thus, emergency contraception is not required for UPSI during this time.
The overall risk of pregnancy after one act of UPSI at any time in the cycle is 2-4%, but mid-cycle (days 10-17) the risk is as high as 20-30%.
Levonelle® One Step prevents 95% of expected pregnancies when taken within 24 hours of UPSI. Its effectiveness declines to 85% between 24 and 48 hours and to 58% between 48 and 72 hours after UPSI.
ellaOne® is a new product, a progesterone receptor modulator, and can be taken within 120 hours (5 days) after UPSI. It is as effective as Levonelle® One Step within 24 hours of UPSI, but its efficacy does not diminish significantly over 120 hours.
However, it is three times as expensive as Levonelle® One Step and experience outside clinical trials is presently limited.
Because it blocks the action of progestogens, it may reduce the efficacy of hormonal contraceptives (all of which contain progestogen).

There are no age limits to the use of EHC and there is no evidence that the efficacy of either Levonelle® One Step or ellaOne® is affected by body mass index.
There are no absolute medical contraindications to the use of Levonelle® One Step (apart from allergy to progestogens). However, it should be used with caution in women with severe liver disease or active acute porphyria. Effectiveness may be reduced by severe malabsorption.
ellaOne® is contraindicated in severe hepatic impairment or poorly controlled asthma.
Lactating women can take Levonelle® One Step safely, but should avoid breastfeeding for 36 hours after taking ellaOne®.
There is little research evidence regarding the effect of liver enzyme-inducing drugs (including St John's Wort and many antiretroviral drugs) on the effectiveness of EHC. Advice is to take two tablets (3 mg) of Levonelle® One Step (this is outside the product licence); this advice also applies to women starting post-exposure HIV prophylaxis. The use of ellaOne® is not recommended. Insertion of an emergency IUD should always be recommended where possible.
Rifampicin and rifabutin have powerful enzyme-inducing properties. An emergency IUD should be offered first line to women taking these preparations.
Drugs that reduce gastric pH (antacids, histamine H2-receptor antagonists and proton pump inhibitors) may inhibit absorption of ellaOne®.
Warfarin does not affect EHC, but EHC may interfere with warfarin. The anticoagulant effects may be increased or decreased. Advise repeat INR 48 hours after treatment.

IUD should be offered to all women requesting emergency contraception even if they present within 72 hours of UPSI.
The emergency IUD will prevent over 99% of expected pregnancies. It can be safely offered to women who have never had a full-term pregnancy. The risks are equivalent to IUD insertion in any circumstance. The risk of ## no greeklish please! ## - oxi fragolevantika grapste kalytera sta agglika - must be adequately addressed.
An IUD containing over 380 mm2 of copper should be used if technically possible.
If the IUD cannot be fitted immediately, the woman should also be given EHC (if within 120 hours of UPSI) in case she fails to re-attend.
The IUD may be removed after the next period (if there has been no UPSI since menstruation) or left in situ for long-term contraception.
An IUD inserted postcoitally acts principally by preventing implantation.
It does not dislodge an implanted blastocyst and so does not cause abortion.
There is a significantly increased risk of pelvic infection in the 21 days following insertion of an IUD. If a woman accepts an IUD she should be told how to recognise symptoms and when to seek medical advice.
Women should be tested for Chlamydia trachomatis infection and given prophylactic antibiotic treatment if needed.
A copper IUD can be inserted up to 5 days after the first episode of UPSI.
Its principal mode of action in routine use is to disrupt sperm viability and prevent fertilisation. However, because it also prevents implantation when inserted postcoitally, it can be inserted up to 5 days after the earliest expected date of ovulation, when it will protect against all previous episodes of UPSI in that cycle.
It is over 99% effective at preventing pregnancy.
In a woman with a 28-day cycle, ovulation will occur around day 14 and implantation of a fertilised ovum 5 days later (day 19).
There is no evidence that MIRENA is effective as emergency contraception, and it is not licensed or recommended for this purpose.

Inhibition or postponement of ovulation is believed to be the primary mode of action of both Levonelle® One Step and ellaOne®. Levonelle® One Step is effective only up to the beginning of the luteinising hormone surge that triggers ovulation.
Disruption of the luteal phase (causing alteration of the endometrium and thus preventing implantation) is an important secondary effect of ellaOne®. The rapid decline in efficacy of Levonelle® One Step after 24 hours suggests that it has very little effect on the endometrium. It is not effective when taken after ovulation (even within the 72-hour window).
EHC does not interfere with an implanted blastocyst and therefore does not cause an abortion.

23% of women report nausea after taking Levonelle® One Step, but only 5% vomit.
Taking the tablets with food will help.
If a woman vomits within 2 hours of taking EHC, she should take it again as soon as possible. Some women need antiemetics (domperidone maleate is recommended).
ellaOne® can cause abdominal pain. Nausea, vomiting, headache and mood disturbance may also occur.
Menstrual irregularities are common during the next cycle with either drug.

EHC does not provide contraceptive cover for the remainder of the cycle. Women must abstain from sex or use an effective alternative contraceptive method.
ellaOne® may interact with progestogen-containing contraceptives, and women using these methods should also use condoms for 7 days plus an additional 7 days for combined hormonal contraceptives (9 days for Qlaira®) or 2 days for progestogen-only contraceptives.
After taking Levonelle® One Step, 87% of women menstruate within 7 days of their expected date. If her period is more than 7 days late, or lighter than usual, Tracey should return for a pregnancy test.
If EHC fails, the possibility of ectopic pregnancy should be considered. Ectopic pregnancies have been identified following administration of Levonelle® One Step in case series; however, the overall risk does not appear to be increased following EHC use. There are insufficient post-marketing data to allow accurate assessment of risk. Clinicians and women should be alert to the possibility of an ectopic pregnancy, but the risk is likely to be small. A previous history of ectopic pregnancy does not contraindicate use of EHC.
There is no increased risk of fetal abnormality if pregnancy occurs following Levonelle® One Step. There is as yet only limited experience with ellaOne®, but so far no excess numbers of congenital abnormalities have been reported. 

All women requesting emergency contraception should be offered screening for STIs.
This is best done at least 1 week after the risk event. Testing too early in the incubation period of STIs can give false-negative results. If women are found to have chlamydia it is important that their partner is also treated to prevent reinfection.
The prevalence of chlamydial infection in sexually active teenage girls is over 10%.
The risk of pelvic infection is increased 6-fold in the 21 days following IUD insertion. This is related to the presence of pre-existing STIs.
Best practice guidance suggests that prophylactic antibiotics to treat Chlamydia trachomatis (azithromycin 1 g immediately or doxycycline 100 mg twice daily for 7 days) should be given to women at risk of STIs who are having an emergency IUD inserted.

Levonelle® One Step is not licensed for use more than once in a menstrual cycle, but can be given if clinically indicated. UPSI earlier in the cycle can be regarded as "protected" in terms of pregnancy risk if EHC was used.
ellaOne® should not be used more than once in a menstrual cycle as neither efficacy nor safety can be assumed.
If a second risk does occur, an emergency IUD is recommended, but if this is refused then Levonelle® One Step may be given (outside the product licence). Theoretically, the efficacy of Levonelle® One Step may be reduced by prior administration of ellaOne®.

Research has shown that most women use EHC correctly and that UPSI is not increased.
However, it would be better to persuade her to start a regular method of contraception. Repeated use of EHC is less effective than a regular method of contraception, in particular non-intercourse-related methods like the combined oral contraceptive or injectable contraception (Depo-Provera®).
If a woman is likely to continue to be at risk of unwanted pregnancy, she may "quick start" combined hormonal contraception (with the exception of co-cyprindiol), the progestogen-only pill (POP) or the implant. A pregnancy test after 3 weeks is recommended.
Additional contraceptive precautions must be taken for the first 7 days of combined hormonal contraception or the implant, or for the first 2 days of the POP. If ellaOne® has been used for emergency contraception, extra precautions must be taken for an additional 7 days (ie 14 days or 9 days in total).

Emergency contraception (including the IUD) can be prescribed safely and legally to women under the age of 16 years providing they are considered competent to consent.
Young people are entitled to confidentiality and may need to be specifically reassured on this point. However, young persons under the age of 16 years should always be encouraged to discuss the situation with their parents or guardians if at all possible.

If a pill pack is started 2 or more days late and the woman has had UPSI during the pill-free week (or in the first 7 days of the new pack), emergency contraception is indicated.
All methods should be discussed.
Seven consecutive pills are required to ensure that the ovaries are fully suppressed and ovulation is inhibited. A break of seven consecutive pills is then safe, and ovulation will not occur if regular pill taking resumes on the eighth day.
Emergency contraception is indicated if a woman has missed two or more pills in the first seven pills of the packet and had UPSI during the pill-free interval or during the first 7 days of the pack. Women should be advised to start the new packet straight away and continue to take her pills in the normal way. She must abstain from sexual intercourse or use additional barrier contraception for the next 7 days, until their ovaries are fully suppressed.
If she takes ellaOne®, she will need to use additional protection for a further 7 days, to allow for the inhibitory effect of ellaOne® on hormonal contraception.

Emergency contraception is indicated if UPSI occurs within 2 days of a missed or late POP. "Late" means 3 hours late for most POPs, but 12 hours late for Cerazette®.

The contraceptive efficacy of medroxyprogesterone acetate is maintained for up to 14 weeks after the last injection, and additional contraception is not required during this time.
The next injection can be given up to 2 weeks late (ie 14 weeks after the last injection) without any additional precautions.
After 14 weeks, emergency contraception should be given if indicated. The next injection of Depo-Provera® may be given immediately and a pregnancy test done 3 weeks later.

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Progestogen Only Pill


Migraine with aura is a significant and serious side effect of taking the COCP and its presence indicates that it is no longer safe for women to take it because they are at increased risk of stroke. However, they can consider changing to the POP which can be safely used by women of any age with a history of migraine or migraine with aura.

With the POP, 20% of women will be amenorrhoeic, 40% will have regular periods and 40% will have irregular bleeding. There is little evidence that changing the type of progestogen will improve bleeding patterns. Remember to check for other possible causes of bleeding; if amenorrhoea occurs, the woman can be reassured to continue the POP, but only after pregnancy has been excluded.
Other side effects reported while on the POP include nausea, vomiting, headache, dizziness, depression, breast discomfort and changes in libido. Many of these are temporary side effects that settle after the first few months.
If started on day 1-5 of the menstrual cycle, the POP is immediately effective and no alternative contraception is required at initiation. The exception to this is if a woman has a cycle of less than 23 days, in which case she should start the POP on day 1 or 2 because she could possibly ovulate quite early in her cycle. She may also need to use additional contraception for 48 hours.
In all women, if the POP is started at any other time of the cycle, pregnancy must be excluded and alternative forms of contraception must be used for 48 hours.
Additionally, the POP must be taken at the same time each day with no pill-free interval. If using a traditional POP (eg levonorgestrel (Norgeston®), norethisterone (Micronor®, Noriday®) or etynodiol (Femulen®)), it must be taken within 3 hours of the same time each day. With the newer desogestrel-based POP (Cerazette®), it must be taken within 12 hours of the same time each day.
With the traditional POPs, 60% of cycles will be anovulatory, but this number increases to 97% with the newer desogestrel POP.
The other mode of action for POPs is to make the cervical mucus impenetrable to sperm.
It also has the effect of making the lining of the uterus thin so that it is less likely to accept a fertilised egg.
If changing from a COCP, the POP can be commenced immediately. Providing that no pills have been missed and you are both confident that she is not pregnant, she will be protected from pregnancy.
If changing from another POP, the same rule applies.
If changing from the progestogen-only implant or the progestogen-only intrauterine system (IUS; ie Mirena®), the POP can be commenced immediately with no need for additional contraception.
If changing from the progestogen-only injection, the POP can be commenced when the next injection would be due and protection is immediate.
If changing from a copper IUD, the POP needs to be commenced 2 days before removal of the IUD, in which case no additional contraception will be needed once the IUD is removed. However, if the POP is commenced at the same time as IUD removal, alternative forms of contraception are needed for 7 days before and 48 hours after IUD removal.
By extension, if changing from barrier methods, the POP should be started on day 1-5 of the cycle or other forms of contraception will be required for 48 hours after initiation of the POP.
The rules for missed pills are as follows:
If it is within 3 hours (12 hours for desogestrel) since the pill should have been taken, then the pill should be taken when remembered and she should continue taking her pill at the normal time. She will be protected from pregnancy.
If the pill is more than 3 hours (12 hours for desogestrel) late, a pill should be taken as soon as she remembers and she should then continue taking the pill at the usual time. This may mean that she takes two pills in the same day or close together, which is harmless. Sex occurring before a missed or late pill is protected due to the effect on cervical mucus, but she is not protected from pregnancy due to sex occurring after a missed pill unless she abstains from sex or uses other forms of contraception for 48 hours after the POP is taken. Emergency contraception should be considered if sex has occurred during the time when protection from the POP is questionable.
The same rules apply if she vomits within 2 hours of taking the pill (ie she should take another pill as soon as she is able). If it is then 3 hours (12 hours) from when she should have taken the pill, or if she continues to vomit or has severe diarrhoea, she needs to use other forms of contraception throughout the illness and for 48 hours afterwards, ie until she has taken 2 pills when well.
Lactational amenorrhea is only effective as a form of contraception provided that the woman is amenorrhoeic and the child is less than 6 months of age and is exclusively breastfed, with no more than 4 hours between day feeds and 6 hours between night feeds.
Current breast cancer is the only absolute contraindication to commencing the POP. 
There has been no causal link established between use of the POP and DVT, cardiovascular disease and breast cancer, and although mood changes and weight gain have been reported on the POP, there is also no established causal association.
With regard to weight, there is no direct evidence to show any reduced efficacy with increasing weight and it is not recommended to prescribe two pills to a woman over 70 kg, as some doctors have been doing. Moreover, there is no effect on the efficacy of the desogestrel pill with increasing weight.
The POP can be safely taken up to the age of 55 years when it is assumed that natural loss of fertility has occurred. Alternatively, follicle-stimulating hormone levels can be measured on two occasions (at least 1 month apart), and if both readings are over 30 IU/L, this suggests likely ovarian failure. The woman should continue with the POP at that point for 1 more year (or use a barrier method) or for 2 years if she is aged under 50 years.
Progestogens are not affected by non-liver-enzyme-inducing drugs.
However, their metabolism is increased by liver-enzyme-inducing drugs and alternative forms of contraception should therefore be recommended for women who need to be on such drugs.
If a liver-enzyme-inducing drug is stopped, it will take 4 weeks before the enzymes return to normal. Thus, if a POP is commenced, alternative contraception should be used until 4 weeks after the enzyme inducer was stopped.
Enzyme-inducing drugs include carbamazepine, eslicarbazepine, nelfinavir, nevirapine, oxcarbazepine, phenytoin, phenobarbital, primidone, ritonavir, St John’s wort, topiramate, rifabutin and rifampicin.
The advantages of the POP are as follows:
-It can be taken by women who smoke, have cardiovascular risk factors and other conditions which exclude them from the COCP.
-It is 99% effective if taken correctly.
-It can be used when breastfeeding.
-It is cheap.
-It may help with premenstrual symptoms and painful periods.

Weight change, mood change and headache may occur in some women taking the POP but there is no evidence of a causal association between the POP and these effects.


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