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Were symptoms initiated or contrast buy finax online pills alternative medicine, large sheets of epithelial cells are seen in made worse by any local medications best 1mg finax medicine x stanford, a new sexual microscopic examinations of saline preparations partner generic 1mg finax with amex medicine upset stomach, or associated with a different method of (Figures 11. Inquiry should also be made about these patients, it is important to obtain a culture to the patient’s general history of allergy, whether the rule out a Candida infection, for occasionally the intensity of symptoms varies with the seasons, or culture is positive despite the lack of yeast forms whether the ingestion of a specifc food or class of on microscopic examination. A sample of vaginal secretions, obtained with a local vaginal allergy is the presence of IgE in the a plastic spatula, is placed on a drop of saline for vaginal fuid. Cultures for bacteria and have equated allergic vaginitis with the presence fungi should be obtained at this time. There are no of excessive number of eosinophiles detected by distinguishing fndings on initial physical exami- eosin staining of a smear of vaginal fuid. These women test should be readily available on physician request can have some vulvar infammation, no vestibular to clinical laboratories. In nearly every one of these gland tenderness, and no distinguishing quality of cases, the initial microbiologic cultures show no the vaginal discharge. The vaginal pH is usually within the done if the history reveals that the patient’s vagi- normal acidic range, the whiff test is negative, and nal symptoms are exacerbated with intercourse the microscopic examination often shows moderate and exposure to ejaculated seminal fluid. Studies to increased numbers of white cells and no yeast should be initiated to see if the woman is aller- forms, and lactobacilli are present. Physicians who fnding on microscopic examination that supports order these tests should do so with the awareness this diagnosis is the presence of sheets of squa- that these tests are different from the more com- mous epithelial cells. In bined with allergens also present in the ejaculate contrast, in the woman with a suspected allergic causes an immediate hypersensitivity reaction vulvovaginitis, we are looking for her reaction to when these components bind to mast cells and/or the seminal fluid not spermatozoa. There is another Treatment interventions for this complex clinical unique group of patients in whom the woman’s problem are diverse. A starting point is to redirect reaction to the ejaculate is not associated with the personal hygienic attitudes of these patients. Instead, it is these women is that these chronic local symptoms an instantaneous infammatory response manifested are equated with genital uncleanliness that will be by extreme vaginal burning that follows the vaginal relieved by thorough and frequent washing of the insertion of an antifungal or antibiotic cream, gel, lower genital tract. An awareness of this phenomenon is tive applications of soap, a skin and mucosal irri- important. No matter how thoroughly a patient rinses the some patients report a prior experience that is a soaped genital area in the shower, a residue is left response to their call of distress to a physician’s offce on the skin and mucous membranes that continues when this reaction occurs. Patients often resist suggestions erroneously advised them that this response means to avoid the use of soap when they shower until the the medication is working and they should continue infammation is brought under control. When this advice was followed, it markedly trary to a lifetime of personal care axioms. A similar history of an immediate deleterious of symptomatic vulvar infammation, periodic use response can be obtained from women reacting to a of the local application of the solid white cooking cream, gel, or ointment locally applied to the mucosa fat—Crisco® in the United States—can be helpful. Both of these two agents are prescribing any local vaginal or vulvar medications, soothing and protect the mucosa from any irritation the patient should be advised that an instant intense from urine. They are not as occlusive as Vaseline® burning reaction that persists is abnormal, and if and are less likely to macerate the mucosa or the skin. This is particularly true when the highly con- medication is usually better than more. However, exposure to local medications containing substances by far, the most common source of a local infam- that exacerbate the patient’s symptomatology delays matory reaction is due to the chemical preservative the elimination of symptoms. It is present in This physician’s initial focus, obtaining a history, is nearly all local vaginal antifungal creams. It is also to determine if the patient had an untoward reaction present in the vaginal antibacterial medications, to prior local medications. Allergic Vulvovaginitis 123 Most adrenocorticoid creams and some ointments male ejaculate. It is also present in the male ejaculates, there are two quick physician some locally applied lidocaine products. The locally applied adreno- should use a condom to see if the lack of exposure corticoids to reduce infammation instead produce an to the ejaculate eliminates the symptoms, and the accentuated infammatory response, because of the patient should provide detailed information about local tissue reaction to the propylene glycol. Estrogen her history of allergies and the male sexual partner’s creams, given to decrease local tissue infammation medication and dietary history. Similar questions and to build up the integrity of the vulvar or vagi- should be directed toward women in a female– nal mucosa, can also cause an acute local infamma- female relationship. Occasionally, this exposes a tory reaction due to the presence of this preservative. Two uncommon examples Some lidocaine preparations applied to the vulvar from the Weill Cornell vulvovaginal clinic demon- vestibule to decrease pain unfortunately increase it, strate this. One patient, allergic to tetracycline, was because of this reaction to propylene glycol. When burning with the application of the medicine that the antibiotic was discontinued, the symptoms less- persists and often intensifes. When the beer-drink- ene glycol–containing preparation in the future for ing stopped, so did the vaginal symptoms. Most subsequently needs a local vaginal antifungal agent, women require continued use of the condom to alternatives are nystatin capsules vaginally or boric avoid recurrence of symptoms. If topical adrenocortical diagnostic trial and can be a short-term solution for steroids are to be prescribed, ointments that do not the couple. When testing reveals this incompatibil- contain propylene glycol are readily available using ity to seminal fuid, however, immunotherapy with the Physicians’ Desk Reference as an information the male’s purifed seminal plasma protein fraction, source. If local estrogen treatment is appropriate, a although still experimental and not standardized, has been reported to help some patients. There are other potential sources of diffculty In addition to the future avoidance of local expo- for coitus-related vaginitis. Some women suspected sure to allergens, the use of antihistamines usually of having an infection are advised to have the male has an immediate impact on symptomatology. An unrecognized latex allergy causes orally, these histamine H1 receptor antagonists symptoms related to the use of a latex condom. After block with varying degrees of effectiveness the del- eliminating the patient’s exposure to latex and see- eterious effects of histamine released by the vaginal ing symptoms diminish, the physician can refer the or vulvar mucosal membrane in response to aller- patient to an allergist for skin testing and serologic gens or irritants. This is an important diagnostic exercise and dine 60 mg at bedtime can be prescribed and usually provides support for the plan of avoidance of latex helps reduce tissue swelling due to infammation and products. To date, no desensitization protocols for lessens the symptoms of itching and burning associ- latex has been reported in this group of patients. If this is not effective, cromoglycate This detergent is used to coat most latex condoms preparations have been employed in a few patients. They must be prepared in a compounding IgE present in their ejaculate, and it is theorized that pharmacy. These same compounds were also evalu- the presence of IgE and an allergen in the ejacu- ated in a trial led by Nyirjesy and Sobel in patients late triggers the acute infammatory reaction when with vulvar vestibulitis. If the answer in which exact clinical information does not elicit is affrmative and the partner is male, the physi- a warm patient response. The physician monologue cian should ask if the patient was exposed to the usually follows this pattern: “We have discovered Vulvovaginal Infections 124 the source of your problem. The solution is simple: wear a Evaluation and treatment of localized vaginal condom.

This suggests the importance of primordial prevention in children and adolescents cheap 1mg finax amex treatment 3rd degree burns. It is maintaining this low-risk status over time through healthful behaviors that is quite important best buy for finax medications hyperkalemia, but difficult discount finax online amex medications 319. This means that the very valuable commodity of low risk for cardiovascular disease, which is present at birth, is lost over time due to unhealthy behaviors and accumulation of risk factors starting in childhood and adolescence. Dyslipidemia and hypertension are reviewed in detail in sections “Lipids and Lipoproteins” and “Hypertension. Diabetes Diabetes is well established as a major risk factor for cardiovascular disease in adults (31). This was different from the experience with adults in whom the prevalence of type 2 diabetes mellitus was much higher. However, with the increasing prevalence and severity of obesity in the pediatric population, the prevalence of type 2 diabetes has increased dramatically (32). This is of critical importance from the standpoint of cardiovascular disease development. In adults, type 2 diabetes is responsible for more cases of renal failure and peripheral vascular disease than any other disease process (33). The risk of cardiovascular disease in patients with diabetes is increased by as much as fivefold compared with individuals without diabetes (33). It has been estimated that 70% of adult patients with type 2 diabetes die of cardiovascular disease (34), and the 10-year mortality rate for patients with type 2 diabetes is approximately 10 times higher than in a nondiabetic comparison group, with most deaths occurring as a result of coronary artery disease (35,36). The predisposition to cardiovascular disease in patients with diabetes cannot be overemphasized. This means that patients with diabetes should be treated with the same aggressive approach to risk factor management that would be recommended in a patient who already has established coronary artery disease or who has had a myocardial infarction. The risk status for cardiovascular disease in adolescents with type 2 diabetes is not well understood. However, if the progression of atherosclerosis is similar to that seen in adults, it can be anticipated that these patients may develop clinically apparent cardiovascular disease as early as their late thirties and early forties. Unfortunately, because so little is known about the progression of cardiovascular disease in young patients with type 2 diabetes, it is difficult to make evidence-based decisions regarding the optimum clinical strategies to prevent cardiovascular disease. A study from Australia documents greater risk of early mortality in those who have onset of type 2 diabetes in youth compared to those with type 1 diabetes (40). Some results regarding the relationship of diabetes and cardiovascular abnormalities have begun to emerge. They found that adolescents with obesity and with obesity-related type 2 diabetes had changes in cardiac geometry consistent with cardiac remodeling. Both groups also had decreased diastolic function when compared to lean controls with the greatest decrease in those with type 2 diabetes. They found that youth with type 2 diabetes had increased arterial stiffness compared to those with type 1 diabetes. In their study, increased central adiposity and blood pressure were associated with increased arterial stiffness independent of the type of diabetes. This suggests that more research is needed to understand additional factors that may be related to this process. These results emphasize the need for improved blood glucose control to prevent the progression of cardiovascular disease in patients with type 2 diabetes. Additional research will be needed to better define the optimum clinical approaches to young patients with type 2 diabetes. Nevertheless, it is important to manage the diabetes with appropriate weight management and blood glucose control methods. It is also important to evaluate cardiovascular risk factors in patients with diabetes and treat those risk factors when present. Cigarette Smoking Cigarette smoking is a major independent risk factor for cardiovascular disease (46). Although prevention of cigarette smoking is of the greatest importance, it has also been shown that cessation of smoking can provide a benefit by reducing risk of cardiovascular and lung disease. This reduction of risk begins in the first year after cessation and continues to further reduction as long as 3 years after cessation. In adolescents, atherosclerotic lesions have been seen with increased prevalence in cigarette smokers as young as 15 years of P. Chronic cigarette smoking may lead to injury of the endothelium, which serves as the nidus for the development of atherosclerosis. It has been estimated that of smoking-related deaths, cardiovascular disease is involved in over one-third, and this process often begins early in life (49). Most individuals who become regular smokers initiate cigarette smoking in childhood and adolescence. Many adolescents, while experimenting with smoking, believe that they can control their use of cigarettes. Unfortunately, this is not the case as many cannot quit smoking and continue to smoke on a regular basis. During the period from 1997 to 2003, overall smoking prevalence declined in high school students from >27% to 22% (50). Unfortunately, the prevalence of smoking in girls has increased over time, so now the prevalence is closer to equal for boys and girls (51). In 2009, the prevalence of cigarette smoking in adolescent high school students was 17. The major influences on initiation of smoking appear to be parents and peers smoking regularly (52,53). It has been shown that parent discussion of smoking, rules against smoking, and punishment for use of cigarettes all have a beneficial effect on decreasing adolescent smoking (54,55). Of greatest importance is that adolescents are significantly less likely to initiate smoking when parents quit smoking (56). Studies have also demonstrated an inverse association between physical activity and smoking, suggesting that an increased level of physical activity may protect against smoking initiation (57). These epidemiologic study results suggest important approaches to the prevention of the onset of cigarette smoking. Efforts of prevention should begin in elementary and middle school students because many children are already experimenting with cigarette smoking by age 10 years (58). Exposure to environmental tobacco smoke may also be associated with increased risk of cardiovascular disease. These results emphasize that elimination of cigarette smoking in the household may have a dual benefit by directly reducing cardiovascular risk and by decreasing the risk for initiating active smoking. One of the most striking public health results comes from studies that show that banning smoking in public places, such as restaurants and bars, resulted in a dramatic decline in cardiovascular disease mortality (61,62). These results suggest that exposure to environmental tobacco smoke has a substantial deleterious effect. These are battery powered devices that, upon inhalation, activate a pressure sensitive circuit that heats an atomizer and turns liquid, including nicotine, into an aerosol that is inhaled. In general, the health effects of electronic cigarettes have not been well studied.

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The lacrimal sac may be in- Cutting down on the probe discount finax 1mg on-line medications 247, if it is not in the sac lumen order discount finax treatment yellow jacket sting, can advertently grasped as the punch is closed generic 1mg finax with amex treatment wrist tendonitis. Once the width of fap is determined, the fap is trimmed with a pediatric through-biting Blakesley forceps leaving the upper and lower limb of this fap the same thickness as the exposed bone above and below the marsupialized sac (Fig. Most of the middle sec- tion of the original fap is removed to allow the posterior wall of the fap and mucosal edge of the mucosal fap to be approximated. The posterosuperior region of lacrimal and nasal mucosa is difcult to approximate because the middle turbinate holds the nasal mucosal fap away from the sidewall. In this region the agger nasi cell is opened and the mucosa from this cell approximated to this region of the lacrimal mucosa. This results in a U-shaped fap and the surgeon should aim to achieve approximation of lac- rimal and nasal mucosa superiorly, posteriorly, and infe- riorly. This mucosal fap can be difcult to fashion with standard through-biting Blakesley forceps so the pediatric Fig. Approximating the lacrimal and nasal mucosa should result in a frst intention healing rather than a sec- posteriorly as possible through the sac wall (Fig. This ondary intention healing and should reduce the formation results in the largest possible anterior fap. The tip of the spear of granulation tissue and scarring and therefore lessen the knife is pushed into the tented sac wall just underneath the potential risk of closure of the sac and failure of the sur- region of the probe and the sac wall is opened using a rotating gery (Fig. Do not place the entire blade of the spear Next the tightness of the common canaliculus is evalu- knife into the sac but rather cut with the anterior two-thirds ated by placing a Bowman’s canalicular probe through the of the blade. If the common cana- lower releasing incisions in the anterior fap so that the fap liculus holds the probe tightly then lacrimal tubes should can be rolled out on the lateral nasal wall (Fig. If the gripping of incisions in the posterior fap and this fap is also rolled out the probe is equivocal then tubes are placed in patients with (Fig. For placement of tubes the puncta are dilated and To determine the width of the mucosal faps, the amount silastic lacrimal intubation tubes (O’Donoghue tubes) are of raw bone above and below the sac is estimated. Cadaveric dissection demonstrating the to ensure the largest possible anterior fap. Otolaryngol Clin N Am incision (C) posteriorly to allow for the largest anterior lacrimal fap. This allows mucosal apposition between the posterior raw bone above and below the opened lacrimal sac (block arrows). A spacer of loop of tubing is pulled in the medial canthus of the eye so silastic tubing is slid over the tubes and used to push the that the tubes are not tight (Fig. The silastic tubing is cut and the Gelfoam/MeroGel gently lifted of the faps and the posi- tion of the faps checked before it is replaced (Fig. This aids in clearing any residual blood clots and keeping the nasal cavity moist and clear of secretions. The patient is placed on broad-spectrum antibiotics for 5 days and antibiotic eye drops are used for 3 weeks. If O’Donoghue tubes were placed, they are removed in the clinic after 4 weeks and the patency of the nasolacrimal system checked by placing a drop of fuorescein in the conjunctiva and en- doscopically monitoring the fow of fuorescein from the conjunctiva to the nose. It is rare to see any granulations but if they are present they should be removed. Once fuorescein tomatic improvement, a complete absence of symptoms, or has been placed in the conjunctiva it should be visualized im- as an anatomically patent nasolacrimal system after surgery. The lac- suggest a common canaliculus problem but had otherwise rimal sac should be marsupialized and well healed forming normal canaliculi were included. Care is taken to ensure that tubes are not positioned too tight, making eye opening difcult. Of the 11 patients considered failures, six had an anatomically patent nasolacrimal system with a free fow of fuorescein from the conjunctiva to the nose (such as demonstrated in Fig. However, symp- tomatic patients are still classifed as failures even if the surgery was technically successful. In the anatomically obstructed group the success rate was 95% whereas in the functional group it was 81%. This functional group still had a 95% ana- tomical patency but a few patients with a patent system still had symptoms and were therefore classifed as failures. If success is defned as complete absence of symptoms with anatomical patency, functional obstruction of the lacrimal system does not have as good a prognosis as anatomical ob- struction and this should be kept in mind when consenting patients with functional obstruction. Results and Technique Modifcations in Revision group were under the age of 14 years. The nasal vestibule is much cess rate was 83% but increased to 89% with a second revision smaller and there can be some initial difculty getting a operation. However, as surgery creation of nasal mucosa and lacrimal sac mucosa apposition continues, the nasal vestibule stretches and its narrowness more difcult. The initial mucosal incisions are still placed as was never more than an initial concern. The other anatomi- previously described with the reservation that the anterior cal variation is the underdevelopment of the turbinates with vertical incision must be placed anterior to the previously cre- a relatively small vertical height of the nasal cavity. In other words the anterior vertical incision the axilla of the middle turbinate in relative close proximity must be placed onto bone. If you are unsure of the anterior to the skull base and increases the risk to the skull base. The limit of the previous bony ostium, palpate the frontal process initial mucosal incisions remain similar to those described of the maxilla. Start anteriorly on the frontal process and move in adults and the superior incision is still placed ,8 mm posteriorly until the junction of the hard bone and soft ostium above the axilla. Once the initial mucosal incisions have been 2-year-old so the surgeon must be aware of this proximity made, use the suction Freer elevator to elevate the mucosal while removing bone from over the sac. The remainder of the fap from the bone anteriorly, above and below the previous procedure is the same as was previously described. Sharp dissection is success rate in our series20 (patency of the lacrimal ostium necessary as the mucosa is attached to the underlying sac by on endoscopy). We electively do a postoperative evalu- ation under general anesthesia after 4 weeks. The intrana- Results and Technique Modifcations in sal lacrimal ostium is evaluated and the O’Donoghue tubes 14,17–23 are removed. Patients included in this and there is often a little exposed bone after draping of all 160 Endoscopic Sinus Surgery A B Fig. In do not have penetration of the dye into the sac but on scin- some patients there may be minor adhesions between the tigraphy have penetration of the radioisotope into the sac. We also found that in functional nasolacrimal obstruction This occurs because the nasal cavity is small and we do not we have a lower threshold for placing tubes as these patients perform a septoplasty unless there is signifcant septal de- have a lower success rate and the common canaliculus may viation. The radioisotope has more time to a Killian’s incision is performed and the septum mobilized slowly penetrate the valve then the dye does and may indi- from the maxillary crest and from the bony septum. This mobilization is usually sufcient present two examples of tight valves of Rosenmüller and it and allows surgery to proceed in the previously obstructed can clearly be seen how the mucosal fold grips the end of nasal cavity. This was done Rationale for the Insertion of endoscopically through a Killian’s incision. The tubes are not placed in an attempt to keep the sac open as the sac is so widely marsupialized with lacrimal and nasal mucosa apposition it would be unnecessary.


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In contrast discount finax 1mg otc treatment 3 cm ovarian cyst, in the setting of polysplenia and left isomerism purchase finax no prescription symptoms webmd, the sinus node can be congenitally absent or malpositioned order finax with american express medications 122. During surgical operations such as the Mustard and Fontan procedures, the sinus node and its artery are susceptible to injury. Electrophysiologic studies support the concept of preferential pathways, but morphologic studies do not. The three internodal tracts identified electrophysiologically correspond to those regions of the atrial septum and right atrial free wall, such as the crista terminalis, that contain the greatest concentration of myocytes. Thus, microscopically, these regions consist of working atrial myocytes rather than specialized P, transitional, or Purkinje cells. Because the septal preferential pathways near the fossa ovalis travel anterosuperiorly in its limbus, internodal conduction disturbances would not be expected following a Rashkind balloon atrial septostomy, in which the valve of the fossa ovalis is torn, or a Blalock–Hanlon posterior atrial septectomy. However, for operations in which the atrial septum is resected, as in the Mustard and Fontan procedures, such disturbances can occur. Similarly, disruption of the crista terminalis may interfere with normal internodal conduction. In contrast, it is located subendocardially, rather than subepicardially, within the triangle of Koch and adjacent to the right fibrous trigone (or central fibrous body). Centrally, the node is more compact and is characterized by an interlacing arrangement of P cells. A: The sinus node lies subepicardially in the terminal groove of the right atrium (right lateral view). C: The right bundle branch is a small cordlike structure that courses along the septal and moderator bands (opened right ventricle). D: In contrast, the left bundle branch represents a broad sheet of fibers that travels subendocardially along the left side of the ventricular septum. It thereby represents the only normal avenue for electrical conduction between the atrial and ventricular myocardium. Thus, during operative procedures involving these valves or a membranous ventricular septal defect, care must be taken to avoid injury to the His bundle. Both regions are characterized by numerous parallel bundles of Purkinje cells and working ventricular myocytes, separated by delicate fibrous tissue (28). During fetal and neonatal life, these conduction bundles are often dispersed or separated within the central fibrous body. The final destination of each bundle within the right or left ventricle is probably determined by its position proximally within the penetrating portion of the His bundle. These accessory pathways are apparently nonfunctional in most individuals, although they may produce ventricular preexcitation in some. Such bypass tracts can be single or multiple and may be identified by electrophysiologic mapping. In contrast, the left bundle branch represents a broad fenestrated sheet of subendocardial conduction fibers that spreads along the septal surface of the left ventricle. As it courses toward the ventricular apex and both mitral papillary muscles, the left bundle branch may separate into two or three indistinct fascicles. Left ventricular pseudotendons also may contain conduction tissue from the left bundle branch (29). Microscopically, the bundle branches consist of Purkinje cells and ventricular myocytes (28). Interestingly, following a right ventriculotomy for reconstruction of the right ventricular outflow tract, the electrocardiogram characteristically exhibits a pattern of right bundle branch block, even though the right bundle has not been disrupted. Cardiac Innervation Because the embryonic heart tube first forms in the future neck region, its autonomic innervation also originates from this level. From the cervical ganglia arise three pairs of cervical sympathetic cardiac nerves, which intertwine as they join the cardiac plexus between the great arteries and the tracheal bifurcation. Several thoracic sympathetic cardiac nerves arise from the upper thoracic ganglia and also join the cardiac plexus. From the parasympathetic vagus nerves emanate the superior and inferior cervical vagal cardiac nerves and the thoracic vagal cardiac nerves, which also enter the cardiac plexus. These nerves then descend from the cardiac plexus onto the heart and innervate the coronary arteries, conduction system, and myocardium. In addition, afferent nerves concerned with pain and various reflexes ascend from the heart toward the cardiac plexus. Transplanted hearts are completely denervated early after transplantation and can respond only to circulating substances, such as catecholamines, but usually not to autonomic impulses. Moreover, because afferent pathways are also lost, coronary obstruction owing to chronic transplant vasculopathy may be associated with undetected myocardial ischemia, because chest pain cannot develop. Examination of Cardiac Specimens General Features Evaluation of cardiopulmonary specimens from patients with congenital heart disease entails more than documentation of the underlying anomalies, although this is certainly important. The recognition of malformations in other organ systems is necessary for the identification of various syndromes, which can have implications for genetic counseling. In addition, the presence of secondary obstructive lesions in the pulmonary vasculature may be more significant in explaining the death of a patient than the underlying cardiac anomalies. Other processes, such as infections or protein-losing enteropathy, also may be important. In the 21st century, it is distinctly uncommon for subjects with congenital heart disease to have received no interventional therapy, either in the operating room or in the cardiac catheterization laboratory. Hence, the investigation of cardiopulmonary specimens also entails an evaluation of old and recent procedures, addressing not only their effectiveness but also their secondary effects on the heart and the pulmonary circulation. This includes recognition not only of the complications of therapy but also of the beneficial effects, such as the regression of obstructive pulmonary vascular disease. Pathologists who evaluate treated forms of congenital heart disease often act in the capacity of a medical archeologist, searching for the telltale results of procedures performed at various times in the past. In complex cases, accurate conclusions can be reached only if accurate and complete historical information is available concerning clinical diagnoses and previous procedures. For example, in patients with multiple interventions, the results of reconstruction and takedown procedures may so alter the underlying morphology that identification of the original anomalies or even previous procedures becomes difficult or impossible. Such reviews may represent informal sessions, formal conferences, or publications, and therefore can involve the specimen itself or its photographs. In this regard, methods of dissection and photography should be chosen that display the lesions most clearly and accurately. If one does not have the time, training, or interest to dissect operated hearts with congenital anomalies, referral to a pathologist who does represents a reasonable option. In the past, for the dissection of congenitally malformed hearts, it was recommended that the heart and lungs be maintained as one intact specimen. Based on personal experience, however, if the pulmonary arterial and venous connections are normal, then the lungs can be removed from the heart without compromising the accuracy of the evaluation. In fact, both the inspection and photography of the heart are generally easier if the lungs and tracheobronchial tree are removed (but not discarded). In contrast, the entire thoracic aorta with appreciable lengths of its brachiocephalic branches should remain attached to the cardiac specimen.