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  • Director, Infectious Diseases Training Program, NIH Office of Clinical Research Training and Medical Education, Bethesda, Maryland

https://www.niaid.nih.gov/research/john-e-bennett-md

The effect of the over-use of aloes combined with systemic corticosteroids is not known erectile dysfunction in diabetes ppt generic 50mg kamagra with visa, but impotence grounds for divorce purchase generic kamagra online, theoretically at least erectile dysfunction treatment fruits effective 50 mg kamagra, the risk of hypokalaemia might be increased erectile dysfunction pump for sale cheap kamagra 100 mg with mastercard. Importance and management the interaction between aloes and corticosteroids is theoretical, but be aware of the potential in patients who regularly use, or abuse, anthraquinone-containing substances such as aloes. Chronic diarrhoea caused by long-term use, or abuse, of stimulant laxatives such as aloes, may also lead to excessive water loss and potassium deficiency. This interaction is sometimes mentioned in reviews;1,2 nevertheless, there is little, if any, direct evidence. However, even this case may not have occurred as a result of an interaction as the patient also had gastroenteritis, causing profuse diarrhoea. Aloes + Digitalis glycosides Theoretically, digitalis toxicity could develop if patients regularly use, or abuse, anthraquinone-containing substances such as aloes. Although this is often mentioned in reviews1,2 there do not appear to be any reports describing clinical cases of this effect. Importance and management this is a theoretical interaction, but it may be prudent to exercise Mechanism Possible pharmacodynamic interaction involving additive loss of potassium and water by anthraquinone-containing substances and potassium-depleting diuretics. However, note that, if anthraquinone laxatives are used as recommended (at a dose producing a comfortable soft-formed motion), then this interaction is not clinically relevant. See also Senna + Diuretics; Potassium-depleting, page 350, for the effects of anthraquinones on furosemide absorption. Andrographis may also have antiplatelet effects, and so it may interact with conventional antiplatelet drugs and anticoagulants, although evidence is sparse. Impact of Andrographis paniculata crude extract on mouse hepatic cytochrome P450 enzymes. Use and indications Used in Ayurvedic medicine particularly for jaundice as a general liver and digestive system tonic, and as an immune system stimulant for treatment and prevention of infections. One group of animals was given an aqueous solution of Kan Jang orally for 5 days, at a dose of 17 mg/kg daily of the active principle andrographolide (a dose about 17-fold higher than that recommended for humans). Sixty minutes after the final daily dose of Kan Jang or water, an aqueous solution of warfarin was given orally, at a dose of 2 mg/kg. This may increase the risk or severity of bleeding if over-anticoagulation with warfarin occurs. Importance and management A very high dose of andrographis does not appear to directly affect prothrombin time, but may modestly increase warfarin exposure. As this study suggested that the pharmacodynamic effects of warfarin were not altered, any pharmacokinetic interaction would not be expected to be clinically relevant. Therefore, until more is known, some caution is appropriate if andrographis is given in high doses for a long period of time with any anticoagulant. Anti-diabetic potentials of Momordica charantia and Andrographis paniculata and their effects on estrous cyclicity of alloxan-induced diabetic rats. A Andrographis + Antihypertensives Limited evidence suggests that andrographis may have hypotensive properties that may be additive if given with conventional antihypertensives. Andrographis may have antihypertensive effects, and a slight additive reduction in blood pressure is possible if it is given with conventional antihypertensives. Importance and management these experimental studies provide limited evidence of the possible hypotensive properties of andrographis. Mechanisms of cardiovascular activity of Andrographis paniculata in the anaesthetized rat. Experimental evidence Andrographolide1 and an andrographis decoction2 lowered bloodglucose levels in animal models of diabetes. Experimental evidence In an in vitro study, aqueous extracts of andrographis, and two of three individual diterpenoid constituents (all andrographolides), inhibited thrombin-induced platelet aggregation. See also willow, page 399, for more information on herbs that possess antiplatelet properties. Thisoda P, Rangkadilok N, Pholphana N, Worasuttayangkurn L, Ruchirawat S, Satayavivad J. Constituents Aniseed fruit contains 2 to 6% of a volatile oil composed mostly of trans-anethole (80 to 95%), with smaller amounts of estragole (methyl chavicol), -caryophyllene and anise ketone (p-methoxyphenylacetone). Aniseed appears to have some oestrogenic effects, but the clinical relevance of this is unclear. Effects of the naturally occurring alkenylbenzenes eugenol and trans-anethole on drug-metabolizing enzymes in the rat liver. Use and indications Aniseed dried fruit, or oil distilled from the fruit, are used mainly for their antispasmodic, carminative and parasiticide effects. Pharmacokinetics Studies in rats suggested that trans-anethole did not alter 33 34 Aniseed oestrogenic. Because of the nature of the evidence, applying these results in a clinical setting is extremely difficult and, until more is known, it would be unwise to advise anything other than general caution. Estrogenic activity of isolated compounds and essential oils of Pimpinella species from Turkey, evaluated using a recombinant yeast screen. Aniseed + Oestrogens the interaction between aniseed and oestrogens is based on experimental evidence only. Experimental evidence In a yeast oestrogen screen assay, the fruit oil from aniseed was Aristolochia Aristolochia species (Aristolochiaceae) A Synonym(s) and related species the nomenclature of these and related plants has given rise to confusion with other, non-toxic plants. This has been exacerbated by the fact that different Chinese names have been used for each species. Birthwort has been used as a collective name for the Aristolochia species, but it has also been used for one of the species, Aristolochia clematitis L. The Chinese name Mu Tong has been used to refer to some of the Aristolochia species. Numerous deaths have resulted from aristolochic acid nephropathy and associated urothelial cancer, caused by ingestion of aristolochia both medicinally and from contamination of food. All plants of the family Aristolochiaceae are banned in Europe and elsewhere, and should be avoided. Constituents the main constituents of the bark are triterpenoid saponins including arjunic acid, arjunolic acid, arjungenin and arjunglycosides, and high levels of flavonoids, such as arjunone, arjunolone, luteolin and quercetin. Interactions overview Arjuna appears to have some effects on cardiovascular function, which may lead to interactions with conventional drugs used for similar indications. Arjuna may also affect thyroid function, which could alter the control of both hyperand hypothyroidism. For information on the interactions of individual flavonoids present in arjuna, see under flavonoids, page 186. Use and indications Arjuna is widely used in Ayurvedic medicine for the 36 Arjuna 37 Arjuna + Cardiovascular drugs Arjuna appears to have some effects on cardiovascular function that may be of benefit when given with conventional cardiovascular drugs. Clinical evidence the effect of arjuna on angina pectoris, congestive heart failure, left ventricular mass and hyperlipidaemia has been investigated in a number of small studies in patients with various cardiovascular disorders (these have been the subject of a review1). See Arjuna + Thyroid and Antithyroid drugs below for the possibility that some of the cardiovascular effects of arjuna might occur via an antithyroid action. Salutary effect of Terminalia Arjuna in patients with severe refractory heart failure. Experimental evidence In a study in animals, arjuna bark extract appeared to inhibit thyroid function. Giving levothyroxine increased the level of thyroid hormones, increased the heart to body weight ratio, as well as increasing cardiac and hepatic lipid peroxidation. When the plant extract was given simultaneously, the level of thyroid hormones, and also the cardiac lipid peroxidation, were decreased. These effects were comparable to those of a standard antithyroid drug, propylthiouracil. When arjuna bark extract was given to euthyroid animals, thyroid hormone levels were decreased, whereas the hepatic lipid peroxidation increased, indicating drug-induced liver toxicity. Importance and management Although the evidence is experimental, until more is known, it might be prudent to avoid the use of arjuna in patients requiring levothyroxine (or any thyroid hormone), because of the possibility of reduced efficacy. If patients want to try arjuna, their thyroid function should be monitored more frequently. An additive effect with antithyroid drugs such as propylthiouracil might also occur, and therefore similar caution would seem advisable.

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Ejection Fraction Ejection fraction (Ef) is the stroke volume divided by enddiastolic volume erectile dysfunction at age 20 cheap kamagra american express, expressed in percentage erectile dysfunction treatment options exercise cheap kamagra 100mg amex. Actually impotence by smoking order kamagra 100 mg amex, the ventricular Chapter 91 t Cardiac Cycle 543 volume is not altered during isometric contraction erectile dysfunction drugs in the philippines order genuine kamagra line. It is because the heart thrusts itself into the cardiometer during isometric contraction. It is because of the entrance of blood into coronary artery from aorta during this period. Rapid rise in ventricular volume is due to sudden rush of blood after the opening of atrioventricular valves. Heart sounds are heard by placing the ear over the chest or by using a stethoscope or microphone. First and second heart sounds are called classical heart sounds and are heard by using the stethoscope. Third heart sound is a mild sound and it is not heard by using stethoscope in normal conditions. Four types of factors are responsible for the production of the first heart sound. Valvular factor Synchronous closure of atrioventricular valves set up the vibrations in the valvular leaflets and chordae tendineae. These vibrations are mainly responsible for the production of the first heart sound. Vascular factor Rush of blood from the ventricles into aorta and Applied Physiology 1. Reduplication of first heart sound Reduplication means splitting of the heart sound. First heart sound is split when the atrioventricular valves do not close simultaneously (asynchronous closure). Splitting of first heart sound in normal conditions (physiological splitting) is rare. Pathological splitting of first heart sound occurs in stenosis of atrioventricular valves and atrial septal defect. Soft first heart sound Heart sound becomes soft when the intensity of sound decreases. A soft first heart sound is heard in low blood pressure, severe heart failure, myocardial infarction and myxedema. Loud or accentuated first heart sound First heart sound becomes louder or accentuated (becoming prominent) in conditions like mitral stenosis, Wolff-Parkinson-White syndrome and acute rheumatic fever. Cannon sound Cannon sound refers to the loud first heart sound that is heard intermittently. Muscular factor Myocardial tension and the contraction of ventricular muscle during isometric contraction and the ejection periods also add to the production of the first heart sound. Atrial factor Vibrations produced by the atrial systole also play a role in the production of the first heart sound. It is also called ventricular gallop or protodiastolic gallop, as it is produced during earlier part of diastole. Usually, the third heart sound is inaudible by stethoscope and it can be heard only by using microphone. Causes Third heart sound is produced by the rushing of blood into ventricles and vibrations set up in the ventricular wall during rapid filling phase. Conditions when Third Heart Sound becomes Audible by Stethoscope Third heart sound can be heard by stethoscope in children and athletes. Pathological conditions when third heart sound becomes loud and audible by stethoscope are aortic regurgitation, cardiac failure and cardiomyopathy with dilated ventricles. When third heart sound is heard by stethoscope, the condition is called triple heart sound (see below). Third heart sound is usually heard best with the bell of stethoscope placed at the apex beat area, when the patient is in left lateral decubitus (lying on left side) position. Cause Second heart sound is produced due to the sudden and synchronous closure of the semilunar valves. Reduplication of second heart sound Splitting of second heart sound occurs due to asynchronous closure of semilunar valves. Interval between the two valves widens during inspiration and narrows during expiration. Increased negative intrathoracic pressure during deep inspiration increases lung expansion and venous return into right atrium. However, the venous return from lungs to left atrium is reduced during this condition. Because of increased venous return in right atrium and subsequent increase in blood volume in right ventricle, pulmonary valve is kept open for slightly longer time than the aortic valve. So, the pulmonary valve closes little later than the aortic valve causing splitting of second heart sound. Pathological splitting: the splitting of second heart sound occurs during pulmonary stenosis, right bundle branch block and right ventricular hypertrophy. Reverse splitting: It is the splitting of second heart sound, in which aortic valve closes after the closure of pulmonary valve. It is also called paradoxical splitting (paradoxical = contradictory or opposite). Reverse splitting is common in left bundle-branch block, aortic stenosis and left ventricular hypertrophy. Loud or accentuated second heart sound Loud or accentuated second heart sound is produced by the closure of either aortic valve or pulmonary valve. Aortic valve produces loud sound during systemic hypertension and coarctation (narrowing) of aorta. This sound is produced during atrial systole (late diastole) and it is considered as the physiologic atrial sound. Conditions when Triple Heart Sound is Produced Triple heart sound is produced in conditions like myocardial infarction and severe hypertension. It is due to third and fourth heart sounds that are heard besides first and second heart sounds. Causes Fourth heart sound is produced by contraction of atrial musculature and vibrations are set up in atrial musculature, flaps of the atrioventricular valves during systole. It is also due to the vibrations set up in the ventricular myocardium because of ventricular distention during atrial systole. Conditions when Fourth Heart Sound becomes Audible Fourth heart sound becomes audible by stethoscope when the ventricles become stiff. Ventricular stiffness occurs in conditions like ventricular hypertrophy, long standing hypertension and aortic stenosis. To overcome the ventricular stiffness, the atria contract forcefully, producing audible fourth heart sound. When fourth heart sound is heard by stethoscope, the condition is called triple heart sound (see below). It is usually heard best with the bell of stethoscope placed at the apex beat area, when the patient is in supine or left semilateral position. Conditions when Quadruple Heart Sound is Produced Quadruple heart sound is produced in patients with congestive heart failure. Summation Gallop Whenever there is tachycardia in patients with quadruple heart sound, the third and fourth heart sounds merge together and give rise to a single sound. The chest piece of the stethoscope is placed over four areas on the chest, which are called auscultation areas. Mitral area (Bicuspid area) Mitral area is in the left 5th intercostal space, about 10 cm away from the midline (midclavicular line). It is due to an abnormal third or fourth heart sound that is heard besides first and 548 Section 8 t Cardiovascular System sound) is transmitted well into this area. Apex beat Apex beat is the thrust of the apex of ventricles, against the chest wall during systole. Sound produced by the closure of tricuspid valve (first heart sound) is transmitted well into this area.

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Reduce oral dosing in the presence of mild hepatic insufficiency (Child-Pugh score of 5­6); avoid use in severe hepatic insufficiency what age can erectile dysfunction occur generic kamagra 50 mg online. Do not use in children < 2 yr (higher rate of upper respiratory infections) erectile dysfunction medication cheap purchase 50 mg kamagra with mastercard, immunocompromised patients l-arginine erectile dysfunction treatment trusted 50mg kamagra, or with occlusive dressings (promotes systemic absorption) erectile dysfunction funny images discount 50 mg kamagra mastercard. Use medication for short periods of time by using the minimum amounts to control symptoms; long-term safety is unknown. Most common side effects include burning at the application site, headache, viral infections, and pyrexia. Skin discoloration, skin flushing associated with alcohol use, anaphylactic reactions, ocular irritation after application to the eye lids or near the eyes, angioneurotic edema, and facial edema have been reported. May falsely decrease aminoglycoside serum levels if the drugs are infused close to one another; allow a minimum of 2 hr between infusions to prevent this interaction. Child: Dilute powder using the ratio of 17 g powder to 240 mL of water, juice, or milk. Side effects reported in this trial included diarrhea, flatulence, and mild abdominal pain. Local irritation consisting of redness, burning, stinging, and/or itching is common. Hypersensitivity reactions consisting of lid edema, itching, increased redness, tearing, and/or circumocular rash have been reported. Apply finger pressure to lacrimal sac during and for 1­2 min after dose application. Metabisulfite containing products may cause allergic reactions to susceptible individuals. Prolonged treatment may result in overgrowth of nonsusceptible organisms and fungi. Contraindicated in pregnancy, hyperkalemia, iodine-induced goiter, and hypothyroidism. Lithium carbonate and iodide-containing medications may have synergistic hypothyroid activity. Total dosage not to exceed 200 mEq/24 hr Serum K <2 mEq/L: Replete at rates up to 40 mEq/hr. Oral liquid supplements should be diluted in water or fruit juice prior to administration. Reduce dosage in renal impairment because 80%­90% of the drug is excreted unchanged in the urine 12 hr after administration. Ophthalmic (consult ophthalmologist before use): Child and adult: Start with 1­2 drops Q1 hr during the day and Q2 hr during the night until favorable response, then reduce dose to 1 drop Q4 hr. Increase in intraocular pressure, cataract formation, and delayed wound healing may occur. Consult a nephrologist See Chapter 10 for physiologic replacement, relative steroid potencies, and doses based on body surface area. Methylprednisolone is preferable in hepatic disease because prednisone must be converted to methylprednisolone in the liver. Avoid use with quinacrine and with other drugs that have a potential for causing hemolysis or bone marrow suppression. Primidone is metabolized to phenobarbital and has the same drug interactions and toxicities (see Phenobarbital). Additionally, primidone may cause vertigo, nausea, leukopenia, malignant lymphoma-like syndrome, diplopia, nystagmus, systemic lupus-like syndrome. Extrapyramidal reactions (reversed by diphenhydramine) or orthostatic hypotension may occur. Use with caution in presence of obstructive lung disease, diabetes mellitus, and renal or hepatic disease. May cause hypoglycemia, hypotension, nausea, vomiting, depression, weakness, impotence, bronchospasm, and heart block. Acute hypertension has occurred after insulin-induced hypoglycemia in patients on propranolol. Concurrent administration with barbiturates, indomethacin, or rifampin may cause decreased activity of propranolol. Glomerulonephritis, severe liver injury/failure, agranulocytosis, interstitial pneumonitis, exfoliative dermatitis, and erythema nodosum have also been reported. A dose reduction of -blocker may be necessary when the hyperthyroid patient becomes euthyroid. Use with caution in patients with renal failure (dosage reduction has been recommended), gout or diabetes mellitus. Contraindicated in ragweed hypersensitivity; drug is derived from chrysanthemum flowers. Local irritation including erythema, pruritis, urticaria, edema, and eczema may occur. Use with caution in patients with epilepsy, asthma, bradycardia, hyperthyroidism, arrhythmias, or peptic ulcer. Pyrimethamine can cause glossitis, bone marrow suppression, seizures, rash, and photosensitivity. Aurothioglucose, trimethoprim, and sulfamethoxazole may increase risk for blood dyscrasias. Most cases of acquired toxoplasmosis do not require specific antimicrobial therapy. Dose Titration Day 1: 50 mg once daily Day 2: 100 mg once daily Day 3­5: increase by 100 mg/24 hr increments each day until 400 mg once daily is achieved on day 5. Day 1: 300 mg once daily Day 2: 600 mg once daily Day 3: Adjust dose to 400­800 mg once daily based on efficacy and tolerance Recommended Dose 400­600 mg/24 hr 1041 Q Maximum Dose 600 mg/24 hr Adult 400­800 mg/24 hr 800 mg/24 hr Age Child 10 yr and adolescent Recommended Dose 400­600 mg once daily Maximum Dose 600 mg/24 hr Adult 400­800 mg once daily 800 mg/24 hr Continued For explanation of icons, see p. Dose Titration Day 1: 50 mg once daily Day 2: 100 mg once daily Day 3: 200 mg once daily Day 4: 300 mg once daily Day 5: 400 mg once daily Day 1: 300 mg once daily If needed, increase dose in increments of up to 300 mg/24 hr. Extended-release tabs must be swallowed whole and administered preferably in the evening without food (a light meal of 300 calories is allowed). Patients may get idiosyncratic ventricular tachycardia with low levels, especially when initiating therapy. Quinidine potentiates the effect of neuromuscular blocking agents, -blockers, anticholinergics, and warfarin. Recommended serum sampling times at steady state: trough level obtained within 30 min prior to the next scheduled dose after 1­2 days of continuous dosing (steady-state). Dose frequency reductions (Q8 hr to Q12 hr) or discontinuation can improve severe cases of arthralgia and myalgia. May increase the effects/toxicity of cyclosporine, tacrolimus, sirolimus, delavirdine, nevirapine, indinavir, ritonavir, diazepam, midazolam, carbamazepine, methylprednisolone, vinca alkaloids, docetaxel, paclitaxel, quinidine, and some calcium channel blockers. Duodenal/gastric ulcer doses for 1 mo­16 yr are extrapolated from clinical adult trials and pharmacokinetic data in children. Extemporaneously compounded carbohydrate-free oral solution dosage form is useful for patients receiving the ketogenic diet. Patients generally respond to 1 dose, but if needed, dose may be repeated Q24 hr for up to four additional doses. Use with caution in asthma, allergies, hypersensitivity with other medications, and children <2 yr (decreased efficacy and increased risk for rash, vomiting, diarrhea, and fever). Serious and fatal hypersensitivity reactions, including anaphylaxis, have been reported in <1% of patients and can occur at anytime; discontinue use immediately and permanently. During therapy, uric acid blood samples must be sent to the laboratory immediately. Use with extreme caution in patients with hemoglobin < 8 mg/dL and thrombocytopenia or bleeding disorders. Intravascular hemolysis resulting in anemia and renal insufficiency has been reported. The 6 g ribavirin vial is diluted in 300 mL preservative-free sterile water to a final concentration of 20 mg/mL. The 6 g ribavirin vial is diluted in 100 mL preservative-free sterile water to a final concentration of 60 mg/mL. Use with caution in preexisiting cardiac disease, pulmonary disease, and sarcoidosis.

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Prenasal thickness to erectile dysfunction in diabetes treatment generic 100mg kamagra visa nasal bone length ratio in normal and trisomy 21 fetuses at 11-14 weeks of gestation erectile dysfunction treatment maryland buy kamagra 100mg low price. Prenasal thickness erectile dysfunction after drug use buy kamagra visa, prefrontal space ratio and other facia profile markers in first-trimester fetuses with aneuploidies erectile dysfunction statistics uk buy kamagra 100 mg, cleft palate, and micrognathia. Retronasal triangle: a sonographic landmark for th screening of cleft palate in the first trimester. Absent mandibular gap in the retronasal triangle view: a clue to the diagnosis of micrognathia in the first trimester. Ultrasound evaluation of the length of the fetal nasal bones throughout gestation. Nuchal translucency and other first-trimester sonographic markers of chromosomal abnormalities. Second trimester ultrasound prenasal thickness combined with nasal bone length: a new method of Down syndrome screening. Frontomaxillary facial angle in chromosomally normal fetuses at 11 + 0 to 13 + 6 weeks. Frontomaxillary facial angle in screening for trisomy 21 at 11 + 0 to 13 + 6 weeks. Frontomaxillary and mandibulomaxillary facial angles at 11 + 0 to 13 + 6 weeks in fetuses with trisomy 18. Frontomaxillary facial angle in fetuses with trisomy 13 at 11 + 0 to 13 + 6 weeks. Frontomaxillary facial angle at 11 + 0 to 13 + 6 weeks: effect of plane of acquisition. Maxilla-nasion-mandible angle: a new method to assess profile anomalies in pregnancy. Brains and faces in holoprosencephaly: pre- and postnatal description of 30 cases. Prenatal diagnosis of severe epignathus in a twin: case report and review of the literature. Prenatal ultrasonographic diagnosis of cataract: in utero manifestations of cryptic disease. Incidence of cleft lip, cleft palate, and cleft lip and palate among races: a review. Three-dimensional sonographic imaging of fetal bilateral cleft lip and palate in the first trimester. Bilateral cleft lip and palate diagnosed sonographically at 11 weeks of pregnancy. Ultrasonographic features of orofacial clefts at first trimester of pregnancy: report of two cases [in French]. Clinical significance of first-trimester screening of the retronasal triangle for identification of primary cleft palate. Early prenatal diagnosis of orofacial clefts: evaluation of the retronasal triangle using a new three-dimensional reslicing technique. Antenatal detection of cleft lip with or without cleft palate: incidence of associated chromosomal and structural anomalies. Fetal cleft lip and palate: sonographic diagnosis, chromosomal abnormalities, associated anomalies and postnatal outcome in 70 fetuses. Bilateral cleft lip and palate without premaxillary protrusion is associated with lethal aneuploidies. Ultrasonographic diagnosis of glossoptosis in fetuses with Pierre Robin sequence in early and mid pregnancy. The "equals sign": a novel marker in the diagnosis of fetal isolated cleft palate. First-trimester diagnosis of micrognathia as a presentation of Pierre Robin syndrome. Agnathia-otocephaly with holoprosencephaly on prenatal three-dimensional ultrasound. First-trimester septated cystic hygroma: prevalence, natural history, and pediatric outcome. Defects and syndromes in chromosomally normal fetuses with increased nuchal translucency thickness at 10-14 weeks of gestation. Genomic microarray in fetuses with increased nuchal translucency and normal karyotype: a systematic review and meta-analysis. Using fetal nuchal translucency to screen for major congenital cardiac defects at 10-14 weeks of gestation: population based cohort study. Increased nuchal translucency at 10-14 weeks of gestation as a marker for major cardiac defects. The performance of an intermediate 16th-week ultrasound scan for the follow-up of euploid fetuses with increased nuchal translucency. Because of the importance and prevalence of cardiac anomalies, normal and abnormal anatomy of the heart and surrounding vasculature are presented in Chapter 11. Normal and abnormal appearance of lungs, diaphragm, and rib cage in the first trimester are discussed in this chapter. Pentalogy of Cantrell, involving a sternal defect, and ectopia cordis are discussed in Chapter 12. As the lung bud grows, it is surrounded by mesoderm, which gives rise to the lung vasculature, connective tissue, and muscle within the bronchial tree. The lengthening lung bud bifurcates on day 28 into the right and left lung buds, which gives rise to the right and left lung, respectively. Growth and bifurcation of the lung buds along with the surrounding mesenchyme continues throughout pregnancy. The terminal bronchioles are seen by the 28th week of gestation (menstrual) and the terminal sacs are formed by the 36th week of gestation. The four embryonic structures-septum transversum, pleuroperitoneal membranes, mesoderm of body wall, and the esophageal mesoderm-coalesce to form the diaphragm. The central tendon of the diaphragm is primarily formed from the septum transversum. The diaphragm is completely formed by the end of the 10th to 11th week of gestation. Note that the diaphragm is formed by the fusion of the septum transversum, the pleuroperitoneal membranes, the mesoderm of body wall and the esophageal mesoderm, with the central tendon being primarily formed from the septum transversum. In the sixth week of embryogenesis, the sternum arises from the somatic mesoderm as paired longitudinal sternal bars. These bars fuse in the midline to form a cartilaginous sternum at around the 10th week. In the normal fetus, the lungs appear slightly more echogenic than the liver and cardiac muscle. At the four-chamber view plane, the right and left lungs are seen and the rib cage assessed. Comprehensive evaluation of the lungs in axial views requires the assessment at the level of the four-chamber view. B: Axial view of the thorax at the level of the four-chamber view in the same fetus. Comprehensive evaluation of the fetal lungs in axial views requires an evaluation at the level of the four-chamber view (A) and the threevessel-trachea view (B). The cardiac axis and position as evaluated in the four-chamber plane (A) is not only important for detecting cardiac abnormalities, but also for suspecting lung anomalies. The ribs can also be assessed from an axial plane of the chest at the level of the four-chamber view. In our opinion, the evaluation of the diaphragm is best achieved in coronal views. In these planes the diaphragm muscle and tendon on the right and left chest can be well visualized. The transvaginal approach improves visualization of all chest structures due to higher resolution.