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By X. Ballock. Shawnee State University. 2018.

Slide 21 Giant cell arteritis is an important cause of one of the few ophthalmic emergencies cheap aciclovir 400mg with mastercard, sudden painless visual loss discount aciclovir 200mg on-line, because it is treatable buy aciclovir 800mg fast delivery, not necessarily to regain the vision in the affected eye but to preserve vision in the other eye. It is a subacute, granulomatous disease affecting the arteries in several organ systems. Visual loss usually occurs from central retinal artery or ophthalmic artery obstruction. Knowledge of the early non-ophthalmic symptoms as well as the emergent nature of sudden painless visual loss is important for any physician who cares for the elderly. Giant cell arteritis is also called temporal arteritis because the temporal artery is often exquisitely tender when involved and is the most common artery biopsied to confirm the presence of this systemic disease. Neuropathologic signs are panarteritis, intimal 148 hyperplasia, and fragmentation of the internal elastic lamina associated with multinucleated giant cells. Slide 22 Compressive optic neuropathy such as due to meningioma is usually accompanied by insidiously slow, painless visual loss with progressive enlargement of scotomas. Slides 23-24 Inflammatory optic neuropathy is usually associated with optic nerve demyelination and pain exacerbated by eye movements. Subacute visual loss can range from subtle symptomatic loss of central vision (acuity) or asymptomatic loss of peripheral vision to no light perception. These people initially have normal appearing optic discs, hence the statement, “Optic neuritis is a disease when the patient sees nothing and the internist sees nothing. Slide 25 Optic atrophy is a common end sign of many diseases purely ocular as well as systemic. As we have seen, sometimes the pattern of atrophy and visual loss can suggest a diagnosis or localize the lesion. However a diagnosis is best considered by all of the “company” a sign does or doesn’t keep. Slide 26 Glaucoma describes many different diseases characterized by elevated intraocular pressure and optic atrophy associated with saucerization of the optic disc. Acute pain, red eye, and visual change associated with corneal edema producing halos around lights characterizes acute angle closure glaucoma, an ophthalmic emergency. The most common type of glaucoma, chronic open angle glaucoma, is a leading cause of blindness. Elevated intraocular pressure creates an “intraocular compressive optic neuropathy” with initial loss of axons usually predominantly entering the optic disc at its superior and inferior poles resulting in vertical elongation and saucerization of the optic disc cup. The usual pattern of early visual loss is therefore arcuate scotoma reflecting damage to these axon bundles that branch around the fovea. Retinal vascular narrowing is the earliest sign of this disturbance of outer retinal layer or retinal pigment epithelium function. Also known as pigmentary retinopathy, retinal degeneration is accompanied by release of pigment from damaged retinal pigment epithelial cells that can migrate into the retina, appearing as focal pigment aggregates or larger “bone spicules. Slide 28 Obstruction of the central retinal artery, usually due to embolic or inflammatory disease, causes sudden complete loss of vision and infarction of the inner retina. The outer retina receives its oxygen supply from the underlying choroid by passive 149 diffusion and survives. The retinal pallor surrounds residual hyperemia beneath the fovea where only cones and glial Muller cells, components of outer retina, survive. Recanalization of the obstructed vessel often occurs, leaving a fundus with ghost vessels, vascular narrowing, and optic atrophy. Causes of elevated intracranial pressure include structural, neoplastic, inflammatory, hemorrhagic, thrombotic, and infectious disorders. The earliest sign of papilledema is increased hyperemia of the optic disc and obliteration of the optic disc cup. Slide 30 Papilledema develops when increased intracranial pressure causes distension of the subarachnoid space leading to centripetal rotation of the meninges and scleral canal, effectively choking the optic disc. Slide 31 Swelling of the optic disc with hemorrhages, exudates, and vascular distension can be marked as in this obese 12-year-old boy with idiopathic intracranial hypertension. Slide 32 In addition to elevated intracranial pressure, swelling of the optic discs occurs in the presence of inflammatory, ischemic, thrombotic, infiltrative, and hypertensive diseases. There are also normal variants of optic disc structure that create the appearance called pseudo-papilledema. Slide 33 The remaining types of visual field loss as illustrated in figures B-H can now be understood with knowledge of visual system anatomy from optic chiasm to visual cortices. Each example has temporal arcuate field loss due to involvement of nasal retinal axons that cross the midline in the chiasm. Figure B occurs when a single lesion involves all of the superior fibers of the right intracranial optic nerve and its inferior nasal fibers that begin to cross the midline just as they enter the chiasm. Figure C, bitemporal hemianopia, occurs when the nasal crossing fibers in the chiasm are asymmetrically involved. Inflammatory disease such as sarcoidosis can also cause isolated chiasmal syndromes.

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The temperature can vary by almost 3°F discount aciclovir 800mg without prescription, depending patient’s temperature can give you clues to on where the thermometer is placed in the mouth purchase aciclovir 200 mg with mastercard. Furthermore order aciclovir 800 mg without a prescription, in the perioperative period, and management there are inaccuracies in all forms of temperature begins with accurate body temperature monitoring. Hypothermia is by far the most reasons and others, body temperature should be common among these thermal disturbances, measured during all general anesthetics lasting and reductions in core temperature of only 2°C more than about 20 minutes and during major are associated with adverse outcomes including conduction anesthesia. Monitoring temperature prolonged post-anesthetic recovery, increased can also provide an early clue to the diagnosis of bleeding and transfusion requirement, ventricular malignant hyperthermia. Conversely, mild colleagues found good clinical correlation hypothermia may be induced therapeutically between core and skin temperature. Their legs were cooled sufficiently with forced air and circulating water Estimates of core temperature obtained from the to maintain arteriovenous shunt vasoconstriction forehead are superior to those from the neck. The upper Forehead temperature is clearly better linked to chest, neck, and head were covered with a the thermal core than the neck is. Usual intraoperative alterations in ambient Air temperature within the canopy was randomly temperature are unlikely to produce clinically set to 18, 20, 22, 24, and 26°C. Aside from estimating core temperature, there Flows and core and skin temperatures were are several other reasons anesthesiologists may recorded at 5-minute intervals for 30 minutes wish to measure skin-surface temperatures: at each ambient temperature. Changes in core-to-skin temperature an important thermal input to the central differences induced by manipulating ambient thermoregulatory system. Skin-temperature gradients are a simple evaluated using thermocouples or (uncorrected) method to quantity peripheral liquid crystals. Skin temperature monitoring can prevent burns during active external Inspection of the raw data indicated that re-warming. Our products have been used in over 35 million • Receive reimbursement at time of signing up surgical procedures across the nation. Benefts Save your hospital money on products they • Hospital is reimbursed for their commitment already use – sign up today! As A Temperature Trend Indicator for the Surgical • Automatic shipments reduce cost of cutting Patient,” October 1992 multiple purchase orders. Commit to purchase our temperature Assembly of the New York State Society indicators at the same average volume as of Anesthesiologists, present by Dr. The number of aProfessor of Anesthesiolorgy, Jefferson indicators used each month and the total Medical College of Thomas Jefferson University, $ value of the agreement determines the Philadelphia. Program is written for 12 or 24 months -- the Temperature Variation on the Accuracy of Core- longer the commitment, the higher the temperature Estimates by Cutaneous Liquid- amount of cash savings. Crystaline™ forehead strips are ideal for use with laryngeal mask airways, and mac, or regional anesthesia when you don’t have to intubate. From pre-op The Reliability of An Electronic Probe Without the F 100 105 85 90 95 through recovery Electronics. Temperature monitoring in the expensive than disposable probes, it also eliminates holding area has traditionally been done orally or hidden costs such as maintenance, repairs, with infrared tympanic thermometers. This can create acquisition, inventory, dispensing and biohazardous inconsistencies between readings taken by other disposal associated with electronic monitoring. Crystaline It Makes Good Sense To Monitor Every has been successfully used in over 60 million Surgical Patient. During recovery, The danger of hypothermia, malignant hyperthermia when surgical complications may be manifested, and other life-threatening conditions can be as there can be long periods of time when patients are great for patients undergoing brief surgeries as for not monitored for temperature. Yet many surgeries, indicator in place throughout surgery and recovery, especially less-invasive procedures, are performed there are no interruptions in monitoring, and you can without temperature monitoring. Because the be sure that comparative readings reflect changes in Crystaline indicator is a non-invasive device, it is the patient, not in the monitor. The correct carrier gas (much less than 20%, which becomes approach for other models differs, so their enriched – saturated, actually – with vapor) individual operating manuals must be consulted. The splitting Simultaneous inhaled agent administration ratio of these two flows depends on the ratio of • If removing the central vaporizer from a group of resistances to the flow, which is controlled by three on an Ohmeda machine, move the the concentration control dial, and the automatic remaining two so that they are adjacent. On models which were manufactured prior to 1995, removing the center vaporizer of three How to Fill Vaporizers defeats the interlock and allows the outer two vaporizers to be turned on simultaneously. For either funnel or keyed filler types, fill the vaporizer only to the top etched line within the Reliance on breath by breath gas analysis sight glass. Do not hold the bottle up on a keyed rather than preventive maintenance filler until it stops bubbling (this will overfill the • Problem: Failure of temperature compensation chamber, particularly if the concentration control device may result in a rapid onset, high output dial is “on”, or if leaks are present). Important safety features include: Typically, 1 mL of liquid volatile agent yields about 200 mL vapor. This is why tipping is so • Keyed fillers hazardous – it discharges liquid agent into the • Low filling port control mechanisms or distal to the outlet. And • Secured vaporizers (less ability to move them minute amounts of liquid agent discharged about minimizes tipping) distal to the vaporizer outlet result in a large • Interlocks bolus of saturated vapor delivered to the patient • Concentration dial increases output in all when instantaneously. Vapofil is designed with 2 inner tubes, Stainless one to let the air escape and the other to let the agent flow into the vaporizer. Vaporizer Order # Ultane /Sevoflurane® 8907-S Forane®/Isoflurane 8907-F If you prefer a corrugated tube with a stainless block. Much less of a problem, since breathing circuit and scavenger tubing sizes have been standard- The biggest problem with ventilators is the ized.

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The two new project co-ordinators assumed many of the administrative roles that Dias had previously fulfilled order aciclovir 800mg otc. During the expansion phase generic aciclovir 200mg with mastercard, the commitment statement was amended to include a request that parents consent to receive a follow-up call seven months after their infant’s birth purchase aciclovir 800 mg otc. The call was intended to assess parents’ recollection of the information received in the hospital and to solicit program feedback. The timing of the follow-up call coincided with the midpoint in the peak incidence of shaken baby syndrome and was designed to test the hypothesis that parental retention of the program material could endure for a minimum of seven months (Dias et al. With the addition of the Finger Lakes Region, 33 hospitals in 17 counties would be participating in the Upstate New York Shaken Baby Syndrome Parent Education Program. The following quantitative program performance goals were set at the outset of the expansion: 1) to establish a regional program including all 17 counties in Western New York and the Finger Lakes Region, 2) to educate at least 70% of new parents about shaken baby syndrome prior to discharge from the hospital, and 3) to reduce and maintain the incidence rate of shaken baby syndrome in each region to 50% of the historical baseline figures (Dias & Barthauer, 2001). All other aspects of the program, including staff 24 25 infrastructure, program materials, and incidence-tracking strategies, were introduced in the same manner as in Western New York. They also act as a valuable resource for staff regarding program innovations, trouble-shooting, and the provision of feedback. Additionally, they supervise and communicate directly with the two project co-ordinators, who are responsible for the bulk of the administrative tasks associated with routine program operations. The project co- ordinators orchestrate the purchase, receipt, and delivery of all program materials to the hospitals and conduct obstetrical and perinatology nurse training sessions. Additionally, they communicate regularly with the nurse managers and assist them in tackling local logistical problems. They also monitor the monthly collection of signed commitment statements and maintain the program database. As active participants in the vigilant tracking of new shaken baby syndrome cases, project co-ordinators regularly contact hospitals, the media, and other child abuse professionals to identify new cases. They also conduct the seven-month follow-up phone calls, assist with the preparation of program data for statistical analysis, and provide program updates for a monthly newsletter distributed to all participating centres regarding ongoing concerns, progress reports, and project status. Finally, the project co-ordinators are public speakers and community advocates for the prevention of shaken baby syndrome, as requested by local public service groups, researchers, and other regions interested in replicating the program (Dias & Barthauer, 2001). The nurse managers are responsible for: 1) educating the maternity nurses about shaken baby syndrome and about how to implement the program; 2) receiving and delivering all program materials; 3) collecting and delivering all signed commitment statements from the maternity nurses to the project co-ordinators each month; and 4) providing the project co-ordinators with monthly delivery statistics to be used in future incidence rate calculations. Any logistical difficulties that arise are solved through direct communication with the project co-ordinators. Maternity ward nurses are trained to educate parents, distribute program materials, and collect signed commitment statements from a maximal number of parents, especially fathers. They return signed commitment statements to the nurse managers for delivery to the project co- ordinators each month. These nurses are the “front-line” program workers, directly interacting with the target population and delivering the primary prevention information. Within several months, nearly all hospitals were fully participating and returning commitment statements to the program office. The project co-ordinators were invaluable in ensuring consistent, open communication with nurse managers, diligently tracking returned commitment statements, and providing prompt assistance for hospital staff in tackling logistical hurdles. The smooth expansion can likely be attributed to two main factors: 1) the creation of the two nearly 26 27 full-time project co-ordinator positions, and 2) the demographic similarities shared by the two participating regions. The Finger Lakes Region program was just as well received as that in Western New York, and the program performance goals were consistently met. The seven-month follow-up questions provided valuable insight into parental retention of program information, and the feedback from parents was overwhelmingly positive. A survey of nurse managers in 2001 revealed that nearly every hospital was routinely providing brochures, posters and commitment statements to parents (Dias et al. Most impressively, the project co-ordinators’ persistent efforts in improving the percentages of returned commitment statements produced an increase in return rates from 46% in Western New York before 2001 to 77% from the combined Upstate New York program (Dias & Barthauer, 2001). In all, Western New York has experienced a 47% drop in the incidence of shaken baby syndrome since the inception of the Shaken Baby Syndrome Parent Education Program (Dias et al. Of the 21 infants that did incur shaking injuries during the study period, less than half of the parents participated in the program and signed a commitment statement. Preliminary data from the Finger Lakes Region in 2003 revealed 27 28 that the number of reported cases of shaken baby syndrome had dropped by 41% (Dias et al. These results likely represent a minimum drop in incidence, due to the increased vigilance with which cases have been tracked during the program (Dias et al. Other child abuse statistics suggest that the dramatic and temporal reduction in shaken baby syndrome cases in Western New York can be directly attributed to the Shaken Baby Syndrome Parent Education Program. The incidence rates of other forms of child maltreatment referred to the Children’s Hospital of Buffalo remained stable throughout the duration of the program, and no congruent decline was observed in the number of cases of shaken baby syndrome reported in neighbouring regions of New York State. Finally, a documented sharp decline in the incidence of shaken baby syndrome is not known to have occurred in any other region in the world, as investigated by the Special Interest Group on Child Abuse (Dias et al. The results support the overall program hypothesis that a primary prevention program providing timely education about shaken baby syndrome to new parents can be effective in preventing inflicted infant head injury. The returned commitment statements revealed that 93% of parents were previously aware of the dangers of shaking an infant, yet 95% still felt that shaken baby syndrome educational materials should be provided to all parents (Dias & Barthauer, 2001; Dias et al. Over 90% of parents found the information helpful, regardless of their level of prior knowledge about shaken baby syndrome (Dias et al.

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Acceptable in the following indications: h) Considering inflammatory mass / lymphoma / metastasis order aciclovir 400mg, vague Radiology order 200 mg aciclovir overnight delivery, multiple masses cheap aciclovir 200mg with amex, associated significant lymphadenopathy i) Considering non-surgical therapy (e. Stage I Preferred – nephron-sparing surgery if technically feasible Optional – radical nephrectomy* Others 51 9. Ablative therapies (cryotherapy, radiofrequency ablation, microwave thermotherapy, high frequency focussed ultrasound, etc. A mere sampling of the renal hilar lymph nodes is insufficient for pathologic staging. For right sided tumor, paracaval and interaortocaval lymph nodes and for left sided tumor para-aortic and interaortocaval lymph nodes should be removed from the crus of the diaphragm to the common iliac artery. Socio-economic and facility issues – Advanced – • staging tools • surgical facility • follow up facility • socio-economic support may not be available everywhere. A substantial improvement in progression-free survival and overall survival has been 54 achieved in large randomized controlled trials, when compared to Interferon-α. Sarcomatoid variant is associated with poor prognosis, and a modest response with doxorubicin & gemcitabine is observed. Renal cell carcinoma with retroperitoneal lymph nodes: role of lymph node dissection. Lack of retroperitoneal lymphadenopathy predicts survival of patients with metastatic renal cell carcinoma. Lymph Node Dissection at the Time of Radical Nephrectomy for High-Risk Clear Cell Renal Cell Carcinoma: Indications and Recommendations for Surgical Templates. Risk group assessment and clinical outcome algorithm to predict the natural history of patients with surgically resected renal cell carcinoma. Invasive bladder cancer: Bladder cancer that histologically invades the muscularis propria. This may be partially attributed due to better detection and improved health care. Detailed evaluation of all patients with gross hematuria and elderly patients (>40 years) with microscopic hematuria and associated risk factors like smoking 15. Prompt referral of men with advanced bladder cancer to higher centers for further evaluation V. Diagnosis –The diagnosis mainly depends on the cystoscopic examination of the bladder, biopsy, and urine cytology. The management algorithm is based on the diagnosis of invasion of muscularis propria or not. Biopsy of the apical prostatic urethra when there is a bladder neck tumour or when abnormalities of prostatic urethra are visible. Pelvic examination (Bimanual examination) under anaesthesia: Helpful in assessment of local staging in muscle invasive bladder cancer and advanced cases. Bone scan –Indicated in patients with raised alkaline phosphatase and with bone pain. Stage T1 tumours originate from the urothelium but penetrate the basement membrane which separates the urothelium from the deeper layers. T1 tumours invade into the lamina propria, but are not so deep that they reach the detrusor muscle. Carcinoma in situ (Tis) is a high-grade (anaplastic) carcinoma confined to the urothelium, but with a flat non-papillary configuration. Unlike a papillary tumour, Tis appears as reddened and velvety mucosa and is slightly elevated but sometimes not visible. Three types of Tis are distinguishable;  Primary Tis (no previous or concurrent papillary tumours);  Secondary Tis (with a history of papillary tumours);  Concurrent Tis (in the presence of papillary tumours). Predicting recurrence and progression of tumours [15,16]: TaT1 tumours The pattern of recurrence and progression depends on the following clinical and pathological factors: 1. Larger tumours should be resected in fractions, which include the exophytic part, the underlying bladder wall and the edges of resection area. An immediate single post-operative instillation with a chemotherapeutic agent (drug optional – Mitomycin C preferred). Maintenance therapy for at least 1 year (monthly once) is necessary [22,23] although the optimal maintenance scheme has not yet been determined. The major issue in the management of intermediate risk tumours is to prevent recurrence and progression, of which recurrence is clinically the most frequent. Adjuvant intravesical chemotherapy (drug optional), schedule: optional although the duration of treatment should not exceed 1 year. Maintenance therapy for at least 1 year (monthly once) is necessary although the optimal maintenance schedule has not yet been determined. Early radical cystectomy at the time of diagnosis provides excellent disease-free survival, but over-treatment occurs in up to 50% of patients. Muscle invasive bladder cancer: Neo-adjuvant chemotherapy: Neo-adjuvant cisplatin-containing combination chemotherapy improves overall survival by 5-7% at 5 years. Radical Surgery and Urinary Diversion Cystectomy is the preferred curative treatment for localized muscle invasive bladder cancer.