61. Pectus Info Pages: Our Experience Thanks to an old US children's health book I'd had for years, we knew that Gina'scondition was commonly called funnel chest , and even that severe cases http://www.users.bigpond.com/conover/PE/pe3.htm

Our Experience bronchiolitis , infant bronchitis. As can happen in tiny babies, the congestion made breathing harder, and in trying to get enough air through the blocked passages, the spaces between the ribs were retracted. She didn't seem very ill, she wasn't feverish , irritable or unable to feed. When I noticed the retraction I took her to the Children's Hospital. She and I stayed in hospital overnight for observation but she had no treatment. I don't recall noticing that her breastbone was depressed at this time, but not long afterward it became obvious. croup . Her first attack of croup happened when we were camping in the bush, and we ended up taking her to hospital where she spent the night in an oxygen tent. Later attacks weren't so bad and were resolved by using a vaporiser. shortness of breath, heart pounding painfully against her breastbone, dizziness, faintness, tingling in lips, fingers and toes and even midriff . She'd break out in a sweat and get red in the face but her lips and nails would go very pale. mild increase in beat is going to feel uncomfortable and be noticed. This began to happen to Gina much of the time she ate.

62. Flat Chest Kitten (FCK) Defect the veterinary literature. In cats, the two most common are pectusexcavatum ( funnel chest ) and flat chest (FCK). There are over http://www.catvet.homestead.com/FCK.html

Burmese Kitten Project Home Home Flat Chest Kitten (FCK) Defect Cross sectional diagram of a normal chest: The chest cavity is oval in shape, with the spinal column at the top and the sternum at the bottom. The black squares represent the costochondral junctions, the point where the cartilage portion of the rib attached to the sternum joins the boney portion of the rib attached to the spine. Cross sectional diagram of a pectus excavatum chest: In pectus excavatum, the chest cavity is narrower top to bottom as the sterum is displaced upward. In severe cases, the lack of space compresses the heart and lungs. Common signs in moderate to severely affected cats include exercise intolerance, trouble breathing, cough, weight loss or failure to gain weight. Cross sectional diagram of FCK: In FCK, the ribcage is angled sharply at the costochondral junction, causing the ventral part of the chest to be flattened. FCK varies from very mild to very severe and life-threatening. The condition is not apparent at birth, but becomes obvious within the first few weeks of life. Mildly affected kittens may appear perfectly normal as adults. Moderate to severely affected kittens will have difficulty breathing and poor weight gain. The worst affected kittens will die. FCK has been reported in many breeds of cats. Some FCK kittens also have a spinal curvature or may have pectus excavatum. A 1997 study in the U.K. reported that 3 to 4% of all Burmese born there are affected with FCK. The same study tried to evaluate potential causes and concluded that the defect is inherited, but must also be influenced by some other factors, possibly environmental or nutritional. For example, Burmese kittens in the study had much higher blood and skeletal muscle taurine levels than normally expected for cats. It is unknown what association these high taurine levels may have with FCK. No association between FCK and any particular diet or any particular dietary supplements has been found.

63. Funnel Chest funnel chest. A Medical Encyclopedia Maryland General Hospital. A resourcewith information on over 4000 medical topics including funnel chest. http://www.marylandchemotherapy.com/medical-terms/07236.htm

Funnel chest A Medical Encyclopedia Article provided by Maryland General Hospital A resource with information on over 4000 medical topics including: Funnel chest Previous Next

64. ϳÅͶ» Funnel Chest,pectus Excavatum next up previous contents Next ? Up ? Previous. ? funnel chest,pectus excavatum. , , , http://akimichi.homeunix.net/~emile/aki/medical/respiratory/node87.html

Next: Up: Previous: ϳÅͶ» funnel chest,pectus excavatum ¶»¹ü¤ÈÁ°¶»Êɤ¬´ÙËפ·¤¿¶»³ÔÊÑ·Á¤ò¤¤¤¦¡£Marfan¾É¸õ·²¤Î°ìÉÂÊѤȤ·¤Æ¸½¤ì¤ë¤³¤È¤¬¤¢¤ë¡£ ¶»¹üËÝž½Ñ sternal turnover ¶»¹üµó¾å½Ñ sternal elevation Akimichi Tatsukawa

65. Cardiothoracic Surgery - Dept. Of Surgery - University Of Utah Health Sciences C Pectus deformities are one of the most common congenital chest wall deformities andare more popularly known as funnel chest or sunken chest (pectus excavatum http://uuhsc.utah.edu/cardiothoracic/chest.html

Cardiothoracic Surgery Home Dept. of Surgery A-Z Index The Heart ... Continuing Education (sponsored by Surgery) Contact Us Search Cardiothoracic Surgery Department of Surgery 30 North 1900 East Room 3C127 SLC, UT 84132-2301 phone: 801-581-5311 fax: 801-585-3936 E-mail the Division Additional Chest Procedures Mediastinal resections This is a surgical procedure done to resect or remove tumors in the mediastinum. The mediastinum is the area between the right and left pleural cavities(where the lungs are) and contains the heart, great vessels, lower esophagus and trachea, multiple lymph nodes and thymus gland. Types of tumors that may occur here include lymphomas (Hodgkin's and Non-hodgkin's), germ cell, mesenchymal and neural tumors. Referral to the Thoracic Oncology Program may be warranted in some cases. Thymectomy This is a surgical procedure done to remove part or all of the thymus gland. It is frequently performed in conjunction with medical therapy for myasthenia gravis or a thymoma. The thymus gland is located in the upper chest under the breastbone. It is composed of small lobes and is shaped somewhat like a butterfly wing over the windpipe. Hormones produced by the thymus gland are thought to affect the immune system and neuromuscular transmission although its exact role in Myasthenia Gravis is not completely understood. A thymectomy may be performed in one of two ways, the transsternal approach or the transcervical approach. Your surgeon will discuss with you which approach would be best.

66. Pectus Excavatum: FAQ On Surgery, Exercises & MVP Phono and echocardiographic studies of the genesis of mitral valve prolapse inpatients with funnel chest. In 44 patients with funnel chest, 20 (45%) had http://www.ctds.info/pectus_excavatum_faq.html

Con nective Tissue Disorder Home Search Site Map ... Links Pectus Excavatum Frequently Asked Questions What can you tell me about surgery for pectus excavatum? I have PE and I get weird pains and palpitations in my chest and heart Are there exercises to correct pectus excavatum? Should everyone with PE have an echocardiogram? Read my Continued at Pectus Excavatum FAQ - Part II The book I own with the most information on pectus excavatum, enlarged foreheads and other signs of rickets is Let's Have Healthy Children by Adelle Davis. Miss Davis was a nutritionist who wrote at length in this book on the signs of rickets in children and how these signs of rickets were often ignored by doctors. Question : What can you tell me about surgery for pectus excavatum Answer One point to note is that if I had to do my pectus excavatum surgery over again, I would only go to a surgeon who specialized in pectus excavatum repair. I had my operation when I was 17 and didn't know how to evaluate and compare surgeons, so I just went to a a thoracic surgeon referred to me by my family doctor. The surgeon I went to did not specialize in pectus excavatum, and I realize now he probably had not done very many of these types of surgeries and was not aware of the latest techniques.

67. Progress Notes Update - Pectus Excavatum Pectus excavatum, more commonly called funnel chest, is a congenital problem inwhich the anterior chest wall is displaced backward, as if it were Acaved in http://www.muschealth.com/Pnotesupdate/pectus.htm

Update on Minimally Invasive Surgical Repair of Pectus Excavatum Pectus excavatum, more commonly called funnel chest, is a congenital problem in which the anterior chest wall is displaced backward, as if it were A caved in. Chronic chest pain and reactive airway disease are frequently seen in conjunction with this abnormality. Occasionally, patients will experience respiratory, circulatory or digestive problems. In addition, the disfiguring physical appearance of this abnormality can have an enormous impact on a child s emotional and social development. Surgical correction is generally indicated. The standard open surgery for repair of pectus excavatum is an extensive operation that produces good results. Depending on the patient s age, the repair can take up to six hours to perform and occasionally requires blood transfusion. The postoperative stay averages about one week, and management of postoperative pain can be complex. For approximately two years, Drs. Andre Hebra and Edward Tagge , pediatric surgeons at MUSC Children s Hospital, have used a new minimally invasive technique to manage the repair. Originated by Donald Nuss, M.D., of Norfolk, Va., the surgery involves only two small incisions on either side of the chest wall. Overall results have been excellent. The technique results in shorter hospital stays and faster recovery times.

68. Alphabetical Topic Index (AZ) Jump To A B C D E F G H I J K L M Endothelial Dystrophy Fuchs' Endothelial Dystrophy Fucosidosis Fucosidosis FungemiaFungemia Fungus (Yeast) of Nails Nails, Malformed funnel chest funnel chest http://www.uscuh.com/apps/Intermap/topiclist/SectionF.html

Alphabetical Topic Index (A-Z): Jump To: A B C D ... Fu F Fa Fabry Disease Fabry Disease Facial Asymmetry Facial Asymmetry Facial Hemiatrophy Facial Hemiatrophy Facial Nerve Injuries Facial Nerve Injuries Facial Neuralgia Facial Neuralgia Facial Pain Facial Pain Facial Paralysis Facial Paralysis Facies Facies Factor V Deficiency Factor V Deficiency Factor VII Deficiency Factor VII Deficiency Factor X Deficiency Factor X Deficiency Factor XI Deficiency Factor XI Deficiency Factor XII Deficiency Factor XII Deficiency Factor XIII Deficiency Factor XIII Deficiency Failure to Thrive Failure to Thrive Fallopian Tube Tumors Fallopian Tube Neoplasms False Aneurysm of Artery Aneurysm, False Familial Mediterranean Fever Familial Mediterranean Fever Fanconi Anemia Fanconi Anemia Fanconi Syndrome Fanconi Syndrome Farmer's Lung Farmer's Lung Fasciculation Fasciculation Fasciola (Liver Fluke) Infection Fascioloidiasis Fascioliasis Fascioliasis Fat Necrosis Fat Necrosis Fatigue Fatigue Fatigue Syndrome, Chronic Fatigue Syndrome, Chronic Fatty Liver, Alcoholic Fatty Liver, Alcoholic Favism Favism Back To Top ^ Fe Fecal Incontinence Fecal Incontinence Feces, Impacted

69. MEDLINEplus Medical Encyclopedia: Topics Beginning With F Fungus ball see Pulmonary aspergilloma (mycetoma). funnel chest seePectus excavatum; funnel chest repair see Pectus excavatum repair; http://www.nlm.nih.gov/medlineplus/ency/encyclopedia_F.htm

Skip navigation Other encyclopedia topics: A-Ag Ah-Ap Aq-Az B-Bk ... Z Medical Encyclopedia Topics beginning with "F" FA see Fanconi's anemia Face pain Face powder Facelift Facial edema see Facial swelling Facial injury see Facial trauma facial nerve palsy see Cranial mononeuropathy VII Facial nerve palsy due to birth trauma Facial palsy see Bell's palsy Facial paralysis Facial swelling Facial tics ... Facial trauma Facioscapulohumeral see Facioscapulohumeral muscular dystrophy (Landouzy-Dejerine) Facioscapulohumeral muscular dystrophy (Landouzy-Dejerine) Factitious hyperthyroidism Factitious thyrotoxicosis see Factitious hyperthyroidism Factor I see Fibrinogen Factor II assay Factor II deficiency Factor IX assay Factor IX hemophilia see Hemophilia B Factor V assay Factor V deficiency Factor VII assay ... Factor XII assay Fad diets see Intentional weight loss Failure to thrive Fainting Fair skin cancer risks Falciparum malaria see Malaria Fallen arches see Pes planus Familial chylomicronemia see Familial lipoprotein lipase deficiency Familial combined hyperlipidemia Familial dysautonomia see Riley-Day syndrome Familial dysbetalipoproteinemia Familial hypercholesterolemia Familial hypertriglyceridemia Familial juvenile nephrophthisis see Medullary cystic disease Familial lipoprotein lipase deficiency Familial Lipoprotein Lipase Deficiency see Chylomicronemia syndrome Familial Mediterranean fever Familial non-hemolytic - non-obstructive jaundice see Gilbert’s syndrome Familial paroxysmal polyserositis see Familial Mediterranean fever Familial primary pulmonary hypertension see

70. Abstract Maciej Mraz, Grzegorz Kacprzak. Pre and postoperation physiotherapy in cases offunnel chest. funnel chest is the deformity of the anterior wall of the chest. http://www.awf.wroc.pl/fizjoterapia/english/t03nr2/art05.htm

Maciej Mraz, Grzegorz Kacprzak Pre- and postoperation physiotherapy in cases of funnel chest Funnel chest is the deformity of the anterior wall of the chest. The indications for operation on funnel chest are dysfunctions of heart and lungs, and aesthetical reasons. Pre- and postoperative physiotherapy while away the time of the patient's hospitalization and have the good effects on coexisting faulty postures corrections. Key words funnel chest, pre- and postoperation physiotherapy, operations. Back

71. Pulmonary | Examination Chest shape • Barrel chest (emphysema). • Pigeon chest aka pectus carinatum(rickets). • funnel chest aka pecus excavatum (congenital defect). http://www.clinicalexam.com/pda/p_exam.htm

Pulmonary: Examination Environment general appearance Nails hands ... legs Environment Table: inhalers, cigarettes. Ventilator, O2 mask, nasal tube. Sputum cup. Pneumatic boots (PE risk). General appearance Ask pt. to sit over edge of bed, if well enough. Colors: Skin Colors Reference Dyspnea, wheeze, difficulties. Breathing rate [normal: 14 breaths/min]. Using accessory muscles of respiration. Edema. Cough type. More detail later in Cough, Sputum exam below. Thyroxicosis (goiter impinging on trachea). Nails Nicotine stains. C L UBBING ( L ung dz: hypoxia, lung cancer, bronchiectasis, CF). don't cause clubbing. Leuconychia (hypoalbuminism 2° to cirrhosis). Muehrke's lines (hypoalbuminism 2° to cirrhosis). See Nails Reference Hands Peripheral cyanosis. CO2 flapping tremor (CO2 retention): • Pt.does a policeman "stop" position with both hands. HPO (lung CA). Erythema (CO2). Tremor (asthma inhaler). Veins (CO2). Muscle wasting of hands: inspect, then ask pt. to adduct/abduct against Dr's resistance (brachial plexus palsy 2° to lung CA). Pallor of palmar creases (anemia 2° to blood loss).

72. Funnel Chest funnel chest. A Medical Encyclopedia Article provided by North Arundel Hospital.A resource with information on over 4000 medical topics including funnel chest. http://www.marylandplasticsurgery.org/medical-terms/07236.htm

Funnel chest A Medical Encyclopedia Article provided by North Arundel Hospital A resource with information on over 4000 medical topics including: Funnel chest Previous Next

73. Abstract Reference funnel chest/co Complications funnel chest/su Surgery Human PneumonectomyPulmonary Emphysema/co Complications Pulmonary Emphysema/su Surgery. http://everest.radiology.uiowa.edu/nlm/app/brnchstn/refer/fukumoto.html

Abstract Reference Unique Identifier Authors Fukumoto K. Matsuzaki Y. Yoshioka M. Edagawa M. Shibata K. Koga Y. Title [Congenital bronchomalacia of left main bronchus combined with lobar emphysema, pectus excavatum and right aortic archa case report]. [Japanese] Source Nippon Kyobu Geka Gakkai Zasshi - Journal of the Japanese Association for Thoracic Surgery. 39(6):943-7, 1991 Jun. Abstract One-year-old girl was admitted because of recurrent pneumonia and pectus excavatum. Chest X-ray showed hyperlucency at the upper lung field and infiltrated shadow at the lower field of the left lung. Bronchoscopy and bronchograms revealed marked collapse in a long segment of the left main bronchus during expiration. CT scan showed an emphysematous change and a giant bulla of left lung. Angiogram showed right aortic arch. Sternoturnover was performed at 5 years of age for pectus excavatum. After 10 months, left pneumonectomy was performed for bronchomalacia and lobar emphysema. Pathologic findings of the bronchus revealed that the rings were flattened, while the cartilage was microscopically normal. MeSH Heading Aorta, Thoracic/ab [Abnormalities]

74. LLUCH - Pediatric Surgery - Pectus Excavatum Pectus excavatum is the most common congenital chest wall deformity, also knownas funnel chest or sunken chest. It involves a depression of the anterior http://www.llu.edu/lluch/pedsurg/pectus.htm

Pectus excavatum Pectus excavatum is the most common congenital chest wall deformity, also known as "funnel chest" or "sunken chest." It involves a depression of the anterior chest wall and the sternum. It is often present at birth and is usually noted within the first year of life. Pectus excavatum tends to run in the family and occurs more frequently in boys than girls. The cause is still unknown. There is an association of pectus excavatum with other musculoskeletal abnormalities such as Marfan's syndrome or scoliosis. The extent of deformity and symptoms from pectus excavatum range from mild to severe. A pectus is usually well tolerated in infancy or childhood. An operation to correct the deformity may be indicated if there are severe symptoms related to lung or heart functionparticularly if diagnostic tests document these limitations. Cosmetic and psycho-social considerations may also lead to a decision to operate on a child with pectus. The decision to perform a corrective procedure for pectum excavatum must be made carefully, allowing time for consideration of the risks and benefits by both parents and children. The operation The operative management of pectum excavatum has evolved over time. Since the 1940s, pectus excavatum has been treated by removal of the cartilage connecting some of the ribs to the sternum along with cutting through part of the sternum to allow it to be pulled forward. Over the last decade a less invasive approach to pectus excavatum has been developed.

75. Radiology Quiz This is most commonly caused by a previous mastectomy. (5b) Pectus excavatum(funnel chest). The ribs have a characteristic heart shaped contour. http://www.studentbmj.com/back_issues/0401/education/103.html

Please click the Current Issue button above to return to the contents page Anaesthesia explained Picture Quiz Intuition and the ill infant What do I do now? Radiology Quiz Career focus ABC of diseases of liver, pancreas, and biliary system: Portal hypertension-1: varices Write a response to this article Radiology Quiz Case history This 38 year old woman presented at her local accident and emergency department complaining of severe pain on the right side of her chest. The pain started earlier in the day after she had a dizzy spell and fell, hitting a piece of furniture on the way down. The pain was worse on inspiration and on movement. On examination the lower, anterior ribs on the right were tender to palpation, she was in obvious distress, and the nurse reported that her respiratory rate was18, with a SpO2 of 95% on room air. An x ray examination was taken of her chest and the result is shown here. Questions (1) What acute radiological abnormality do you see on this film? Pay attention to the enlarged image. (2) What else would you be particularly careful to look for on a chest radiograph in this case? The patient complained of continuing severe pain despite receiving an initial dose of cyclimorph (morphine and cyclizine). The accident and emergency consultant decided to give additional analgesia via a series of intercostal nerve blocks.

76. AlphaSights - Summer 2000, Volume 10, Number 2 Pectus excavatum, often called a sunken or funnel chest, is a deformity occurringin about 1 in 600 children in which the sternum is significantly recessed http://www.baystatehealth.com/1025/3840/4221/4224/AlphaSights/985207558.html

AlphaSights Subscription Information A New Minimally Invasive Procedure Available at Baystate Author: Karen P. Kolb Published: WED MAR 21 15:43:29 2001 A new procedure has been added to the repertoire of minimally invasive surgical services available at the Baystate Medical Center Children’s Hospital Surgery Center for the treatment of pectus excavatum. Pectus excavatum, often called a sunken or funnel chest, is a deformity occurring in about 1 in 600 children in which the sternum is significantly recessed into the chest. While often recognized at infancy, pectus excavatum usually becomes more apparent in early adolescence, seems to affect girls and boys equally, and is without a known cause. Children with severe deformity may experience cardiopulmonary symptoms. Previously, a four- to five-hour open surgical chest procedure was required to correct the deformity. Now, a new minimally invasive technique, called the Nuss Procedure, is being performed by Stanley H. Konefal, Jr., M.D., and Kevin P. Moriarty, M.D., pediatric surgeons on staff at Baystate Medical Center, which reduces OR time to about 60 minutes. The Nuss Procedure Drs. Konefal and Moriarty were the first physicians to perform the Nuss Procedure in Massachusetts. They learned this specialized technique from Dr. Donald Nuss, a pediatric surgeon at Children’s Hospital of the King’s Daughters in Norfolk, VA. He developed the surgery using a Lorenz Pectus Bar for ten years before patenting his data. According to Dr. Moriarty, Dr. Nuss has been performing the surgery for over ten years, and has very good follow up. The new procedure offers significant advances to the previous techniques.

77. Neurofibromatosis Resources - Associated Conditions Information Site UK Pectus deformities are the most common congenital chest walldeformities and are more popularly known as 'funnel chest' or 'sunken chest http://neurosurgery.mgh.harvard.edu/NFR/associated.htm

Associated Conditions Additional conditions which may accompany Neurofibromatosis Deafblind Link James Gallagher An exceptional site, created and maintained by a man who is deafblind himself. A wealth of original information and links to resources for people who are blind, deaf, or both. Epilepsy FAQ Maintained by Andrew Patrick Frequently asked questions about a broad range of topics related to epilepsy. Pectus Excavatum and Pectus Carinatum Information Site U.K. "Pectus deformities are the most common congenital chest wall deformities and are more popularly known as 'funnel chest' or 'sunken chest' (pectus excavatum) and 'pigeon chest' (pectus carinatum). This site has been designed primarily to provide those with a pectus deformity with information; to understand what a pectus deformity is, how and why it may affect you and how and where to get further advice. " Pectus Excavatum Information Site Reid and Gwillim Excellent resource for both information and support, including a chat room. lifeclinic.com

78. Funnel Chest Repair funnel chest repair. A Medical Medical System. A resource with informationon over 4000 medical topics including funnel chest repair. http://www.mcadd.net/medical-terms/06047.htm

Funnel chest repair A Medical Encyclopedia Article provided by North Arundel Hospital A resource with information on over 4000 medical topics including: Funnel chest repair Previous Next

79. Pectus Excavatum Other names funnel chest or sunken chest. Indications Repair of pectusexcavatum may be recommended for improved appearance (cosmetic http://www.pediatricsurgeons.com/pectus.html

Other names: funnel chest or sunken chest. Indications: Repair of pectus excavatum may be recommended for: improved appearance (cosmetic repair), improved breathing (respiratory function), or to stop compression of the heart. Description of the operation: The repair of pectus excavatum has changed over the past several years. We now use the minimally invasive Nuss procedure. The old procedure required a large incision on the front of the chest and removal of 6-8 sets of cartilage. The much less invasive Nuss procedure is described here: While the child is deep asleep and pain-free (using general anesthesia), 2 small incisions are made over the sides of the chest and a curved titanium bar is passed behind the breastbone (sternum). The deformed sternum is elevated when the curved bar is turned over. The placement of the bar may be aided by the use of a small scope placed into the chest to monitor the bars progress. Once the bar is in place it is sutured under the muscle so it will not move. Rarely a chest tube may be placed to reexpand the lung if the lining of the lung is entered. Expectations after surgery: The child will have some pain after the procedure but this will be controlled with either an epidural catheter or a PCA (patient controlled analgesia) pump. The child is usually in the hospital 3 to 4 days after the surgery. The metal bar is removed 2-3 years later through a small skin incision. This removal is usually done as an outpatient. After the repair the child will be on restricted activity for a time period and will gradually return to full activity.

80. Untitled protrudes forward. funnel chest in which the breast bone is prominentlycaved inward. A very marked curvature of the spine. Presence http://www.strems.org/aortic.html

Aortic Dissection What constitutes an aortic dissection? An aortic dissection is a tear in the inner layer of the aortic wall. This allows blood to enter and separate the inner and outer layers of the vessel. Dissection can weaken the outer wall, resulting in rupture or formation of an aneurysm, occlusion of aortic branch vessels, and disruption of the aortic valve. What are the symptoms of an aortic dissection? The primary symptom of an aortic dissection is severe pain usually in the chest (front, back or both), but occasionally in the abdomen when the tear begins in that part of the aorta. However, dissections can also cause a variety of other symptoms: pain, pallor, pulselessness, parathesia and paralysis (the 5 P's). If a branch of the aorta is blocked, weakness in one or both legs or arms may be evident. For a person with the Marfan syndrome or another aortic disease, there are no consistent, standard symptoms of an aortic dissection. However, any type of pain in the chest, back or abdomen that is along the midline of the body - in front, back or both - that is either especially severe or sharp and has a burning or tearing quality, or is relatively severe and totally different that has ever been felt before, has the possibility of being an aortic dissection and should be evaluated promptly. Why is emergency diagnosis and treatment of aortic dissection an important issue?

A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S  T  U  V  W  X  Y  Z

Page 4     61-80 of 97    Back | 1  | 2  | 3  | 4  | 5  | Next 20