The Miracle of Peace

As I was starting to fall asleep, I was counting my blessings. I couldn't believe what a wonderful day it had been!

I was off from work. This is huge. To have Anthony with me, and no call the entire weekend is huge, huge, huge!  I requested this holiday off.  When you are in a profession that is of service, like police, medicine, or other fields...this sacrifice is understood and part of the culture. But when you get a break? It's REALLY nice not to be wearing the beeper and taking those emergencies, or eating the meal the hospital makes or the department pot luck. You're with family like always.

Our house is tidy!  We are busy, and things 'pile up'.  On tables, chairs, and just about any horizontal surface of the home.  Anthony helped me and we 'moved things out of the way'. Our carpet, and furnishings are definitely 'wabi sabi' LOL--but at least we could see everything, and everyone had a place to sit.

The family came, and the day was Drama-free.

It was. It most definitely was. This is rare for my family, and I am grateful.

I cooked.

I absolutely love to entertain guests. I made a turkey (a kosher one), and had a Honey-baked ham (I know, I know, I know, I've seen the movies, and I'm sorry. People like it...). I peeled so many things today! I spent hours and hours preparing. I peeled apples, butternut squash, potatoes, beets, turnips, and tangerines...I trimmed green beans. I made salad. I was in Heaven, and enjoyed blessing the food as I prepared it for our guests.

Anthony was the quintessential host!

He not only prepared the rabbit for the new experience of meeting our guests, he proudly showed her,  then he also took care of music, and entertainment, even choosing a game for the family to play after we ate. It was Scattergories.

I had just enough help in the kitchen, but not too much to be obtrusive.

I had blessings on top of blessings, and then more!

But wait!

Online, and also, on my phone, there were SO many greetings and wishes for a Happy Thanksgiving. I felt the warmth and the love from the hearts and homes of so many people!!! It's a whole other world out there, guys! A really happy one, with nurturing, warmth, love and compassion.

I love it so!

Today, we did a first, and I'd like to call you attention to it.   For the very first time, our soul family of readers, is gathering together in a post I have pinned at the top of the page, Doctors With Reiki on Facebook. People are showing their love and support and their smiling faces too!--to those who are feeling overwhelmed and alone this holiday season. It will stay up there, pinned, the whole time.

I remember feeling dread this time of year, when I was single, and in training. I was divorced, and everyone seemed to be happy and paired up.

It was as if I had forgotten all the miserable holidays I had ever had when married--not once but TWICE with all sorts of fights and bullshit in the relationship, even to the point of going to midnight mass by myself while he was in the car stewing over some ridiculous slight...

I simply didn't understand the beauty of being alone--able to experience my OWN Christmas...it wasn't until later I bought my own tiny tree, and little ornaments, and made my traditions by myself, that it started to get better...

Even now, with Anthony going back and forth, I am thankful he HAS a father who invites him to their family gatherings. And after solid years of isolation, I am now being invited to their family events too...because after all, family is family, and love is stronger than all those other feelings that sometimes happen when couples raise a child in separate homes.

I am starting to see the changes in everyone, everywhere around me--people in my family, in my community, at my work, and online--changes for the better, changes of the heart, changes of the soul. This encourages me greatly.

But most of all, none of these changes would have ever been appreciated, or noticed, if I had not done my own work at getting to know myself, to love myself, and to acknowledge and release all my feelings that have come up in my clearing for the Ascension process.  All the meditation, all the tears, all the re-living horrible and painful experiences in many lifetimes--has helped to create a cohesive 'sense' of what is 'me', and more important, 'what ISN'T'.

All the fear, all the pain, all the hardship, all the conflict, all the struggle--are behind me.

The only thing that matters is LOVE.

Ross and I, if you've read this blog for some length of time, have had our tests, and I have been shaken to the core over things I needed to forgive him.  Our relationship is strong, and believe it or not, we have taken it to the next level!  How can I explain it? Um, let me try...I understand his love for me, and his precise skill as my guide...to the point where my lessons make sense, and I see where he is leading me with his expert guidance and teaching. And I WANT to go where he is guiding me to go. It's mind-blowing, the things of the soul, I have yet to experience! I have begun the steps to train for immortality with a physical body. It is a skill, a highly esoteric one. And the energies are right for everyone else who is ready, to assume their lessons too, with their guides, when it is for them like it is for Ross and me. All the pieces are in place. I don't know how long the process is, nor do I mind. It's fun, it's exciting, and it's a chance to explore something new which thrills me so much to learn...

Ross is permitting me to share this with you. All of it. I never would explain or say if he felt you were not ready for it.

He feels you are ready to have a 'sneak peek' at what is possible in the future for everyone on Surface Gaia.





Ross

(his hands are interlaced, and he is twiddling his thumbs)  I am not knitting.  (he laughs, and is pleased with his own joke--ed).

Nothing could be further from the truth!

I have been very busy guiding Carla up to the point where (points to his eyes--ed) she can SEE!  Where she can decide, 'yes I want to take up this program with my husband' and be completely awake enough to make the decision.

Carla appreciates everything that she has learned!

All of it!

ALL OF IT!

Even the pain.

For it has gotten her--energetically--to where she is Here and Now so she can enjoy it.

Now let the fun begin!


(clap clap--ed--it's that thing he does when he is done talking and it's time to move on to something else)

(he also wants me to sneak a piece of pumpkin pie before I go to sleep--lol--he is so good at 'reading' me...ed)




Aloha and Mahalos,
Namaste,
Peace,

Ross and Carla
The Reiki Doc Couple

Focus On You Treatment

This woman is giving herself Reiki on her feet. 

Self care is important. Energy self-care is right up there with meditation for your wellness.

Even more, it is the meditation which is going to help you grow, and to lead you up and out of the third dimension, and back to home.

Eventually you will reach a point where everything is from Source, and you know it, and you feel it, and deep down in your soul, you will know everything in your 'waking life 's Illusion, and everything is going to be okay.

This is the building block for life in the Higher Realms.

What I wish to talk about briefly, as there is no limit on this subject, is the topic of VASTNESS.

Everything that is from Home and Source is limitless, endless, in total peace and harmony, and JOYFUL.

This is your 'vitamin'.

You need a little 'taste' of this every day, while you are awake, to strengthen you on the road ahead.

It is not easy being incarnate. There is much that carries over from our past lives. There is a lot of 'sorting things out' as our memories return.  No past life is 'unthinkable', for all of it is a 'lesson' and everyone at one time or another takes their coursework in one of the 'darker lives'.

That being said, there is no need to dwell on it. Acknowledge these memories from the past--good, bad or indifferent--and let them go.

Know that YOU are YOU, who you are here today, and as your Higher Self becomes more known to you, it will be seamless working together and you will not give it much time for thought. It will feel NORMAL and RIGHT.

Wherever you 'go' when you are asleep, is your Higher Self at meetings and other things you may or may not recall. Sleep time is when the consciousness returns back for guidance and planning for the next day's events.  That place we go every night IS Home! Believe it or not! LOL

As the Higher Self incorporates--as an aside, I have Full Consciousness but still suffer from the Veil a little, as these plans and lessons appear to still be just that--lessons!--there is an increased sense of Purpose, and Patience with one's trials.

Many of you who read these words once have known us, Ross and me, as your teachers and guides. It is our vibration which is both familiar and comforting to you. This is why you enjoy the connection (we do too!).  And this is why as your teachers, it is our solemn duty from our souls to yours, to keep you focused on your growth and your development as a soul.

Why incarnate again when this time you may master the lessons? 

Ross

I give myself Reiki too. (no that is not a picture of me--I have a beard and the couch would be a lot more messy if it was me! --he laughs--ed)

All of us do.

Every single one of us. It is like how you brush your teeth when you are incarnate--and don't even stop to think about it. It's just something that needs to be done. It's like shaving, for those who shave their beards--though I couldn't possibly know why! (he smiles--ed)--something every morning that is routine.

Every day, at the same time, all of us where I am, meditate.

Yesterday I had a small gift for Carla. It was a Lemurian Citrine crystal point.

Carla went and meditated with it, in her favorite chair, at her  favorite place.

It brought Carla memories of our life together in India, where she was happy with me. She saw, in her mind's eye, like a movie, from one scene to the next. She saw how she once almost lost me to illness, and how she kept her watch over me, and helped me to heal. She saw the house, the neighbors, the friends and she was filled with the love and happiness and PEACE which was with her in that life.

We had our teachers, our learning, and together we enjoyed ourselves very much.

In Berkeley, in her late teens, Carla discovered her love for Indian food, and also, had a wall decoration of hand-painted elephants on cloth along with Indian designs from her friend Khaver who went there the summer after freshman year. It was her TREASURE! At the time, she didn't make the connection as to why she loved Mother India so much...now she knows! This is the meaning of Full Consciousness. Nothing is hidden, but it can take time to awaken and sort things out.

As Carla meditated, her energies got so high up that SaLuSa presented himself to her, face to face. Carla was both delighted and honored.

SaLuSa himself shared that at our meeting, mine and Carla's, when we first meet, he will be present as the chaperone--a trusted one who knows both of our hearts, to make sure once we reacquaint we are off to the best possible start as a couple.

Frankly, Carla is still blown away by the experience of being in the Now moment with both of us, but SaLuSa, who has always been rather 'fuzzy'--was crystal clear in both form and energy signature and intent.

See all the way you can go, once you meditate? It helps to have a crystal you resonate with from time to time, but it is not a necessity, It is an option. And even a stone you have found on your travels, for you, might do the very same energy 'boost' assistance as the fancy orb or sphere or crystal point.  Size doesn't matter, when it comes to spirit. Just go with what 'feels right' and you will be blessed.

Aloha and Mahalos

Namaste,

Peace,

Ross and Carla

The Reiki Doc Couple

After Eye Surgery

When my doctor recommended them, I did not consider all of the side effects of the surgery, but my life has changed quite profoundly. My confidence is much greater than before. I find it easier to look people directly in the eyes.

I think any man or woman who has this procedure recommended by his or her doctor should not hesitate to get implants.

Say what?

Let me explain.
I’m descended from the nearsighted tribe branch of Darwin’s tree.
We’re talking negative double digits.
You know who you are. Add a dash of astigmatism, and progression for reading. Grind finely till done.

January, 2006, I visited my eye doctor, ophthalmologist Dr. Albert Cheskes, on my bi-annual visit for a prescription, for yet stronger, and yet higher quality high refraction lenses for my eyeglasses. It was time to get my eyes re-tested, and I’d even get to pay for the eye test, as the Ontario government no longer feels this to be a medical right.

However, rather than being handed a new prescription, I was matter-of-factly informed that I needed new lenses alright, but they’d be the more recently designed acrylic foldable intraocular lens (IOL), and they would replace the originals that came with this body at birth.

My apologies for calling them silicone above, but I find it reads better.
There are in fact intraocular lenses made of silicone.

My eyes had cataracts, and my option for better vision was the surgical route. To get rid of the cataract, you get rid of the lens that was in your eye at birth.
Cataracts obscure and cloud the vision. They scatter light, creating halos. They interfere with good vision.

Len’s lenses were to be replaced.

Well, that’s good. I wouldn’t have to choose new frames.

And guess what? OHIP covers this visit, because cataracts are on its list of covered medical services.
Both surgeries would also be covered by OHIP.

A date was set for the first eye surgery, with a wait of a couple of months. This was no emergency.
Time passed all too quickly.

I’m a fifty-something person. A bit of nervousness about commencing with the replacement of body parts accompanied the news. I'll be turning into a cyborg. I may as well accept my fate.

Before a couple of weeks have gone by I am pointed to a New York Times article

http://www.nytimes.com/2006/02/07/health/07case.html?ex=1145937600&en=41a5e3b5d6c6c2ec&ei=

and I’m feeling a little better, once I read of the author’s experience.

Dr. Leary might be there to hold my hand. That would temper it.

A few weeks prior to surgery I get my eyes measured by the latest computerized laser-using ophthalmologic device that measure all kinds of parameters about each of my eyes. The curvatures, and distances and thicknesses and every measurement possible about my eyes are done, to enable Dr. Cheskes to make the best choice in lens implants.
I have paid a premium of $280 to get the measurement done by the non-invasive laser machine. It does not even care if I blink. OHIP covers measurement by a more primitive device that actually touches the eyes. I buy myself this luxury service.
I sit for a few minutes till the laser has done its readings.
My eyes are even given ultrasounds that reveal images of the back of the eye.
This information all goes back to Dr. Cheskes.

The day arrives. No liquids, no food, and drops in the one eye, the second of two to be instilled on the way out the door.
I have instilled into my eye an extremely effective drop at dilating it. This must be near the maximum dilation an eye can dilate. My doctor is delighted an hour later to see such a good pupil. (Sorry, that’s his joke.)

Nurse, still more drops in the eye please.

Dr. Tam, I’m pleased to meet you.

I’ve yet to meet an anaesthesiologist I don’t like.

He relaxes me with a needle in the back of my hand, and a dose of something.
(Note to Director, fade out here.)
Various things are placed in and over my eye and taped in place. There is a slight pressure on my eye from all that covers it.

Soon I am escorted to the next waiting chair, as my spot is shortly taken by the next patient in line, and as I wait my turn for fifteen or twenty minutes of surgery, in the adjacent operating room. At this point I, as promised by Dr. Cheskes, I am not having a bad time. I am quite relaxed indeed. Dr. Tam has begun well.

I find myself in conversation with one of the nursing assistants. Because I see that post-operative patients are offered coffee, tea and the same cookie selection offered when donating blood, we’re soon discussing blood donations, and the paperwork involved, and the many questions to be answered…

I hear a woman say to me, “and have you ever paid for sex?”

I’m thinking that this two-tiered medicine thing isn’t bad at all, when I realize I am discussing questions on the blood donation questionnaire with someone in Dr. Cheskes’ office and I burst out laughing at the weirdness (the wiredness?) of it all. The nurse realizes the course of my train of thought, and laughs along with me.

A few minutes go by and I’m walked into the operating room and my next chair.
After some preparations, I am draped with a surgical sheet which covers all of me, except the opening that is revealed to the doctor around my eye. The sheet itself adheres to the area surrounding my eye.
I’m given an injection somewhere behind the ear, it seemed.
Next I am told to look upwards and back, and I really am unaware of whether my eye is open or closed. I know it is open. An injection was then made into some part of my eye, or behind it.
I’m later told that my optic nerve had been frozen.

My doctor does his stuff, which is a slit in the cornea to remove the clouded lens in my eye, with ultrasonic tool and machines that when reset to a new setting on his instructions, speak back the new setting to confirm it. I can hear everything going on on the other side of the sheet.
Once in a while water or something like it washes down my cheek as the eye is kept clean and lubricated.
Then it is over.
The sheet is removed, the eye covered and protected.
A lens made of acrylic plastic manufactured by a company now owned by the food giant Nestle, has been inserted behind my iris.
A follow-up visit the next morning sees the covering removed, and a pleased doctor.
I follow a rigorous drop in the eye schedule for the next few weeks. One set of drops 4 times a day, one three times a day, one twice. I figure out a system, and take good care of my eye.
The first couple of days with the new input device, my right eye, are much closer to Dr. Leary than had been the surgery itself. I am able to walk in Kensington Market, and on the busy streets of Toronto, without my prescription glasses on that I have worn for the past 50 years. A fabulous side effect of cataract surgery, in my case, is that I now have a prescription lens right in my eye. It is of fixed focus, as the lens one is born with is adjustable with muscles in the eye. What has been gained however outweighs by far what has been lost.
Protective sunglasses are very necessary in daylight, and at times indoors, as my brain adapts to my upgraded eye.

Dr. Cheskes is delighted with the result at my one month check-up.
I tell him I have a joke for him. But first I speak about an unusual side effect of the surgery that I am quite happy about. My penis appears to be larger.

Those who laughed already, move to the head of the class. Ophthalmologists and optometrists should all be laughing.
The near-sighted person who has vision corrected by prescription glasses sees a smaller than real view of the world through those glasses.
Look a myopic in the eye through their glasses and you see a smaller than real eye.
That is the same effect, observed in the opposite direction.
So with the correction for vision directly in the new lens, the world is back to its real size.
Things appear to be larger, because they have seemed smaller for so long.

We schedule the second surgery in a couple of months.

I am so much more relaxed for the second surgery prior to any sedation that I am asked if I am on blood pressure medication. I’m not.
Certain details seem different for the second surgery.
No pressure on the eye prior to surgery, and drops rather than needles for the anaesthetic.
But a new lens with optical correction is inserted in my left eye.

It is now almost a year since the first surgery. I no longer wear prescription eyeglasses.
I can read, use the computer, work with the tools that are part of my life, and am able to drive, and do anything I want in fact.
I had purchased glasses to correct my vision to nearer 20-20 if that should become necessary, for night driving, for example.
In the end I have required them once or twice only.
I am very happy not to have to wear glasses any more.
And I have almost completely stopped reaching to my eyes to push my (non-existant) glasses up my nose.
Some habits are hard to let go of.

I should add, that a few weeks ago I spoke to an acquaintance whose father had had cataract surgery done, not at the same clinic as I did, and by a different surgeon.
The result of his first surgery was corneal damage that left him with permanent blurred vision in the eye.
So this very common surgery does have a risk factor, as I had always been aware, and was certainly informed about.

Authored by Len Micay,
in Toronto, Canada

Simple and Complex Seizures Fever

Simple febrile seizuresBasic diagnosis:Febrile seizures with no seizure frequency of more than 1 time in 24 hours, seizures are common, long seizure <15 minutes and no neurological abnormalities before and after seizures.Treatment and follow-up:- All patients who come in a state of seizure overcome with diazepam- Administration of antipyretics and appropriate causal therapy causes heat- Rectal temperature ³ 39,50C- Recurrent seizures- If the rectal temperature <39,50C, the patient returned with equipped antipyretic drugs and anticonvulsants diazepam oral / rectal intermittent treatment- Advice: when a seizure again, back to the hospital
Complex febrile seizuresBasic diagnosis:Long febrile seizure with convulsions> 15 minutes, focal seizures or generalized seizures with a frequency of> 1 times in 24 hours.Treatment and follow-up after the seizure could be addressed:Determine whether it is necessary or intermittent treatment rumat- When a child with a long spasm given corticosteroids to 12 hours free of seizures- Give antipyretics and antibiotics according to the cause of the rise in body temperature

    when heat antipyretic (paracetamol / ibuprofen)
- Paracetamol: 10-15 mg / kg / times (4 doses)- Ibuprofen: 10 mg / kg / times (3 doses)

    Canal drug phenobarbital (3 -5 mg / kg / day) or valproic acid (10-40 mg / kg / day) is given when there is a risk factor below:
- There is a history of febrile seizures without parents or siblings- There is a neurological deficits before and after seizures are transient or permanent (serebralis palsy, mental retardation, and microcephaly)- There is a focal seizures- Long seizure of more than 15 minutes- Recurrent seizures
Intermittent drug:
- Oral diazepam: 0.3 -0.5 mg / kg / day every 8 hours during fever- Diazepam rectal: 0.5 mg / kg / times (3 doses)
- The use of phenobarbital every day can cause behavioral disorders and learning difficulties.The use of valproic acid in less than 2 years of age may lead to impaired liver function, if necessary, examination SGOT and SGPT after 2 weeks, 1 month and then 3 months.Febrile convulsion11 September 2012 16:24
Limitation:Febrile seizures are seizures that occur in the increase in body temperature (rectal temperature above 380C), which is caused by an extracranial process.
TREATMENT AT THE MOMENT Seizures

 Diazepam rectal can be given at home. Diazepam rectal dose is:· 5 mg for children under the age of 3 years or a dose of 7.5 mg for children over the age of 3 years, or

    5 mg to weigh less than 10 kg and 10 mg for body weight over 10 kg, or 0.5 to 0.75 mg / kg / times
At home, given a maximum of two times in a row with a distance of 5 minutes. Careful respiratory depression can occur.Diazepam may also be given by intravenous suntukan as much as 0.2 to 0.5 mg / kg. Give slowly, at a rate of 0.5 -1 mg per minute. When the seizures stopped before the dose runs out, stop the injection. Diazepam can be administered 2 times the distance of 5 minutes if the child seizures. Diazepam should not be given intramuscularly because it is not well absorbed.When still a seizure, give phenytoin intravenously as much as 15 mg / kg slowly. If still seizures, hospitalization in the intensive care unit, give penobarbital and attach a ventilator if necessary.
After Seizures Stop
If the seizure has stopped, determine whether the child is included in febrile seizures requiring rumat treatment or intermittent treatment enough when the fever.
TREATMENT RUMAT
Rumat treatment is a treatment administered continuously for a long time.1. rumat Drugs that may decrease the risk of recurrence of febrile seizures only phenobarbital or valproic acid. All other anticonvulsant drugs are not useful for preventing recurrence of febrile seizures.2. valproate dose is 10-40 mg / kg / day divided 2-3 doses while phenobarbital 3-5 mg / kg / day divided into 2 doses.3. Treatment granted rumat enough for one year, except in the case of very selective (recommendation D)4. The use of phenobarbital every day can cause behavioral disorders and learning difficulties. While the use of valproic acid in less than 2 years of age can cause liver dysfunction. When giving valproate, check SGOT and SGPT after 2 weeks, one month, and then every 3 months.5. Treatment rumat only given when a febrile seizure showed one or more of the following symptoms:1. Seizures time> 15 minutes.2. Children with neurologic abnormalities were apparent before or after the seizure, for example hemparesis, Todd paresis, cerebral palsy, mental retardation, hydrocephalus.3. The focal seizures.4. If there is a sibling or parent families who have epilepsy.
Rumat treatment should not be given but can be considered in the circumstances:

    Seizures repeated two or more times in 24 hours.
    When febrile seizures in infants aged less than 12 months.

  Note:
· All the researchers agree that febrile seizures> 15 minutes is indicative rumat treatment.· What is meant by a real neurological disorder for example paralysis, microcephaly. No real neurological disorder eg mild developmental delay is not an indication.· Focal seizures or focal became common shows that children have the organic focus on the contralateral side of the brain.· Not all agree that the seizure 2 times or more in one day is an indication rumat treatment.
Intermittent Treatment
What is meant by intermittent treatment is treatment that is given when the child has a fever, to prevent febrile seizures. Consists of administering antipyretics and anticonvulsants.
Antipyretic
There was no evidence that the use of antipyretics to reduce the risk of febrile seizures. However the Child Neurology agreement states that experience shows that antipirtetik still useful.
Antipyretic can be used are:
    Paracetamol or acetaminophen 10-15 mg / kg / times given 4 times.
    Ibuprofen 10 mg / kg / time, given 3 times.
Anticonvulsants when fever
    The use of diazepam oaral doses from 0.3 to 0.5 mg / kg every 8 hours during the lower the risk of recurrent febrile seizures.
    Rectal diazepam can also be given at a dose of 0.5 mg / Kabb / time, given 3 times per day.
Note:
        In Indonesia, a dose of from 0.3 to 0.5 mg / kg / 8 hours it often causes sedation is quite heavy. The recommended dose is 0.5 mg / kg / day divided by 4 doses.
Phenobarbital, carbamazepine, phenytoin useless to prevent febrile seizures when given intermten. New small doses of Phenobarbital anticonvulsant effects with stable levels in the blood when it has been given for 2 weeks.Media filesindex.jpgManagement of Seizures11 September 2012 16:24
Seizure management objectives:1. Ensuring oxygenation of brain tissue, as well as heart and lung function.2. Overcoming the seizure as soon as possible and prevent the recurrence of seizures.3. Improving metabolic disorders and water and electrolyte balance.4. Prevent systemic complications.5. Identify and treat the cause of the temperature rise.
To achieve the above objective, the aid measures undertaken are:1. Addressing and preventing the recurrence of seizures. All the children were in a state of convulsions during the examination, whatever the cause, the drug of choice is diazepam, either parenteral or perrektal.2. Common TreatmentWhile seizures, were given help to improve and ensure oxygenation of the brain by way of:a. Giving oxygenb. Loosen tight clothingc. Clear the airway, sucking fluids from the oral cavity and respiratory tractd. The child is placed in a position of semi trendelenberge. To prevent aspiration should position the child's head is tiltedf. Lowering the temperature when the heat by means of:- Blowing cold air- Cool the surrounding air- Compress with ice or alcohol- Antipyretics: paracetamol 30-50 mg / kg / day divided into 3 doses or aspirin 60 mg / years of age / time, 3 times per day
3. When the seizure of more than 30 minutes, then to cope with brain edema that may occur Corticosteroids: Dexamethasone 0.2-0.3 mg / kg / time, 3 times a day, 4-5 days old administration. If there are signs of herniation: irregular breathing, bradipnoe, diminishing consciousness, given mannitol 20% at a dose of 0.25 to 1 g / kg / times intravenously. Given within ½ hour can be repeated every 8 hours. Give fluids with low sodium levels, namely liquid 2: 1 and the amount of fluid on the first day 70% of maintenance needs. If not available mannitol may also be glycerol 10% with a dose of 0.5-1 g / kg / day orally given 4 doses.4. Finding and treating the cause of heat.

Role tonsillectomy in PFAPA syndrome

ROLE tonsillectomy in PFAPA syndrome
Kevin K. Wong, MD; Jane C. Finlay, MD, FRCPC; J. Paul Moxham, MD, FRCSC

Objective: To test the efficacy (potency) tonsillectomy in improving symptoms and preventing episode recurrence in children with PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis).
Design: Retrospective case series.
Background: a tertiary care hospital of children.
Patients: Patients treated in teaching hospitals in Vancouver, British Columbia, Canada between 2000 and 2004 with a diagnosis of PFAPA syndrome or patients who have been diagnosed earlier in the consultation.
Intervention: Tonsillectomy.
Main Outcome Measurements: Resolution of symptoms in the 3rd, 12th, and 24th after tonsillectomy.
Results: Eight of the nine patients achieved complete remission within 3 months. The rest, the frequency of episodes of recurrence was reduced from every two weeks to once every 3 to 4 months. This patient ultimately had resolution of symptoms at 2 years after tonsillectomy. There are no complications caused by tonsillectomy.
Conclusion: Tonsillectomy is a good treatment for patients with PFAPA syndrome.

PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis) was first described in 1987 by Marshall et al. This clinical syndrome usually affects children less than 5 years. Periodic fevers (temperature> 39 ° C) lasts 3 to 6 days and occur at intervals of 3 to 6 weeks. In addition aphtosa stomatitis, pharyngitis and cervical adenitis, less common symptoms may be found, such as malaise, headache, abdominal pain, vomiting, hepatosplenomegaly, and arthralgia. Usually improves the situation of children in between episodes of recurrence. The condition of an average of 4.5 years.
The exact cause of PFAPA syndrome remains unknown. Causes of infection (bacterial and viral) is the cause of most can be removed by culture, serology and skin tests. Theory of autoimmune and rheumatologic disorders are also not agreed. Plus also no geographic or ethnic predilection for patients. Diagnosis of clinical circumstances because there is no definitive laboratory test that can yield positive results in the PFAPA syndrome. During an acute episode, WBC and ESR has consistently increased.
PFAPA syndrome treatment is based on case series or retrospective review of medical. Treatment is usually given oral kortikoseroid. In one study found that there was a 76% improvement in symptoms on corticosteroids for patients with PFAPA syndrome. However, prednisolone can not prevent further episodes and short intervals antarepisode usually results in some patients. Cimetidine is also used to prevent relapse and reduce the severity of the case, although keberhasilaanya still limited. Several case reports have been published in the last decade is to explain patients PFAPA syndrome. Based on these limited data, tonsillectomy may improve symptoms. Herein, has described 9 patients with PFAPA syndrome who ditonsilektomi.

METHOD
We have conducted a retrospective case series analysis on all patients admitted to the British Columbia Children's Hospital between January 1 2000-31 December 2004 with the diagnosis of PFAPA syndrome or patients who have been previously diagnosed at the initial consultation. Patients included in the above criteria tonsillectomy performed by 1 surgeon. The patient's parents agreed and granted penjelasanmengenai procedure to be performed. All patients were observed at least 24 months after tonsillectomy. Do records of disease recurrence in the interval between episodes (if there is no complete remission), and some complications from the surgical procedure. Ethics approval for this study was obtained from the study of ethics University of British Columbia.

RESULTS
Total patients with PFAPA syndrome is 9 patients, 5 men and 4 women. The mean age of 4.1 years (range 3-5 years of age). The mean fever indicated in patients was 4.1 weeks and occurs within 2-6 weeks of the onset of illness. No patients who received previous treatment. The nine patients minmal observed 24 months after tonsillectomy. Obtained complete remission in 8 of 9 patients in 3 months after tonsillectomy. The patient's symptoms usually disappear at 24 months postoperatively. No complications (minor or major) caused by tonsillectomy.

Opinion
PFAPA syndrome symptoms, particularly fever and pharyngitis observed with the background of otolaryngology. Marshal et al noted that periodic fever was first explained at the beginning of the 1940s, but new PFAPA syndrome is found at the end of the second decade. As a result, the introduction of PFAPA syndrome cases also experienced misdiagnosis as a syndrome or other disease symptoms and signs is almost the same. For sindom PFAPA diagnosis, a physician must have knowledge and a clear understanding of the differential diagnosis of PFAPA syndrome, ie cyclic neutropenia, fever hereditary and Behcet's disease. These diseases should be ruled out before the establishment of the diagnosis of PFAPA syndrome correctly. How to make the diagnosis sidrom PFAPA is the exclusion dagnosis way.
Cases of cyclic neutropenia is less common than PFAPA syndrome, but the two conditions are indistinguishable. At cyclic neutropenia, the episode raised approximately every 21 days (range 14-35 days) and are often associated with aphthous ulcers, gingivitis, cervical lymphadenopathy, and fever. Neutropenia occurs due to oscillation neutrophil production in the bone marrow. During the period of neutropenia, generally decreased PMN <200 cells / microliters for 3-5 days but it can be returned to normal levels quickly. During the symptomatic period, the number of PMN may have on the level of the norm. So as to establish the diagnosis of blood needed hiting checks twice a week for 6 weeks or at least 2 weeks before the expected febrile episode. On histopathologic examination of bone maturation obtained mielosit stop on the stage. Treatment is usually given granulocyte colony stimulating factor.
Hereditary periodic fever is generally classified in familial Mediterranean fever (FMF), with hyper-IgD syndrome and Hibernian fever. FMF is autoimflamasi disease characterized by periodic attacks of fever and serositis. FMF is an autosomal recessive disease that occurs mainly in the Turkish, Armenian, Arab, and Jewish descent. The incidence of febrile attacks associated with the severity of abdominal pain, arthritis, and pleurisy or chest pain that is characterized by an increased acute phase reactants. FMF diagnosis can be considered in individuals with different ethnic backgrounds who have experienced episodes of febrile illness. Colchicine merupaka primary treatment, because it can control the attack and prevent progression to amloidosis.
Same with PFAPA syndrome, hyper-IgD syndrome usually first arises at a very young age (median onset age: 6 months) and includes periodic fever. Characteristics fever is for 3-7 days, and the attacks usually occur every 4-8 weeks. Berkuang frequency and severity of attacks in line with the increasing age of the patient. However, in contrast to the fever episode PFAPA syndrome. PFAPA syndrome, fever occurs in the whole life of the patient. Other symptoms include chills, lymphadenopathy, abdominal pain, vomiting, diarrhea and headache. During the attack, the acute response phase that occurs leukocytosis, Neutrophilia, and increased ESR. Increased serum IgD and IgA (> 100U / mL) is a distinctive sign, but not all there. It takes a retrial during this period. Causes of this disease are believed MVK gene mutation that encodes mevalonate kinase. The main treatment is only with supportive therapy. Recent studies are testing the drugs etanercep, TNF receptor Fc fusion protein, which is expected to generate a combined effective results.
Behcet's disease is a disease multiorgan characterized by oral apthae and at least 2 of the following: (1) genital apthae, (2) synovitis, (3) posterior uveitis, (4) vasculitis pustulasn cutaneous, (5) meningoencephalitis, (6) ulcer recurrence genital, and (7) uveitis in the absence of inflammatory bowel disease and collagen vascular disease. Same with PFAPA syndrome, there is no specific laboratory tests, but the clinical krieia can be helpful in diagnosis. Behccet disease usually no febrile episodes, and oral ulcers are usually more severe than PFAPA syndrome. Characteristics of these symptoms can help in memmbedakannya with PFAPA syndrome.
The literature that uses tonslektomi in the treatment of patients with PFAPA syndrome showed explanation article 6 of 41 cases. A substantial decrease episodes of PFAPA syndrome occurs more than 84% of patients (37 of 44). Most authors who examine tonsillectomy in PFAPA syndrome concluded that tonsillectomy is one treatment option that can be considered. Hereditary problems with the current literature solely based on retrospective case series study (EBM fifth level). Leong et al found PFAPA syndrome patients may have recurrent infections and will complete resolution after the procedure, tonsillectomy. Paa our case, 89% of patients experienced resolution of symptoms (8 of 9) similar to the literature. There is one patient in our series of cases which did not experience resolution of symptoms completely, but reduced the frequency of relapse episodes. Just after 2 years after tonsillectomy, these patients experienced resolution of symptoms perfectly. Is this resolution is due to the direct influence of tonsillectomy or for healing itself naturally disease, is still unknown.
Although the PFAPA syndrome can eventually heal itself, many authors recommend the treatment to be done properly at the time of diagnosis. Medical management (such as steroids and cimetidine) are the most widely prescribed treatment. Tonsillectomy is still not considered in the flow of treatment, but both medical and surgical treatment, both demonstrated success in meresolusi symptoms. Current management support the delivery of steroid treatment. A wide variety of oral prednisone dose has been proposed, with a dose of 1-2 mg / kg single doses is the most common dose is given. Another approach to expand doses for 7 days or replace potency steroid (eg, prednisone given every day administration of 2 mg / kg / day and betamethasone 0.3 mg / kg / day on other days). Two kai cimetidine dose of 150 mg daily for 6 months pral yelah also used successfully. The H2 antagonist cimetidine is meninhibisi chemotaxis and activation of T cells Thomas and Edwards found 8 of 28 patients treated with cimetidine remission of symptoms perfectly.
NSAID use showed results that failed to satisfy in controlling the symptoms of PFAPA syndrome. Acetaminophen and ibuprofen reduce fever as much as 6% and 33% of patients (respectively), but when the drug's effect is lost once the fever again. Other medical drugs such as antibiotics, acyclovir, and colchicine have minimal effect in relieving symptoms. Complications administration of a single dose of steroids is very rare in children, naumn risks that arise must be described in oang parents.

Tonsillectomy is a surgical option that can improve the symptoms of patients with PFAPA syndrome. Based on our knowledge, no studies using neoadjuvant or adjuvant medical treatment for tonsillectomy in patients with PFAPA syndrome. A definite role that the tonsillectomy role in resolution of symptoms remains unclear, but the syndrome may be caused by a general immune response in tonsil parenchyma. There is no difference in the appearance of the patient is done or not done adennoidektomi on tonsillectomy. However, adenoidectomy alone can not meresolusi symptoms. In our study, no complications arise. Based on the literature, we did not encounter complications were reported on the actions of tonsillectomy in patients with PFAPA syndrome. No reason was stated that the complications of tonsillectomy in PFAPA syndrome is higher than in other patients.
In conclusion, the PFAPA syndrome is a condition that is not fair and pendiagnosisnya way is with a diagnosis of exclusion. In addition to tonsillectomy, the other main therapy is steroid therapy. Treatment options that can be used is prednisone, cimetidine, or tonsillectomy who have demonstrated success in reducing or eliminating the symptoms completely. PFAPA syndrome treatment is based on the theory that the cause of PFAPA syndrome is a dysregulation of the immune response. Based on this theory, if the deviation of immune response is reduced, then the symptoms will disappear. We get good observations with tonsillectomy. There are 8 of 9 patients in our study who showed complete remission of their symptoms after tonsillectomy. The remaining patients experienced a decrease in the frequency of attacks is farcical and experienced resolution of symptoms after 24 months.
Because PFAPA syndrome is a relatively newly recognized in the clinic, it takes more research was done to determine the maximum treatment. Based on our experience, we found that the children who qualify for surgery, tonsillectomy is a good treatment option for PFAPA syndrome.