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John E. Cole Professor of Urology,
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Chief, Division of Pediatric Urology,
University of Virginia Health System
Charlottesville, Virginia

As for the Eastern Mediterranean Region blood pressure medications that start with l buy vasotec 5 mg free shipping, unfortunately blood pressure chart of human body purchase vasotec online now, it has for many years suffered from man made conflicts that widely affected the general population’s health in some countries hypertension 130 90 buy 5 mg vasotec overnight delivery, especially the most vulnerable groups children and mothers prehypertension table cheap vasotec 10 mg without a prescription. Physical and verbal abuse heart attack pain in left arm buy discount vasotec, lack of previous consent and poor communication are seen in the region blood pressure zone cheap vasotec online american express. Rates of maternal mortality are shown to be significantly high in Islamic countries, and some reasons include low average age of marriage, illiteracy, lack of prenatal care, and obstetric complications [8]. In Morocco, the result of a survey found women who reported physical abuse have a frequency of 12. Most of these women were uneducated, socio-economically disadvantaged and had a partner with toxic habits [9]. When Jordanian women were surveyed regarding their birthing experience to understand the situation, the women saw childbirth as a dehumanized experience, feeling that childbirth was processed technologically, experienced a lack of human support as they were not permitted birthing partners and were in an inappropriate childbirth environment [10]. In the African continent social inequalities and intersectionality are also susceptible to the changes of gender perception in childbirth. In some African countries awareness and an increase in a demand for the understatement of patient’s rights has begun though the rediscussion of social and cultural values is still necessary [13]. The women reported that the female paramedics made women deliver lying down, did not always use aseptic procedures and were too busy to give information, making birth a passive experience [14]. Similarly in India, an urban slum was surveyed to assess the quality of maternal healthcare. Women reported lack of essential drugs, being left unsupported and evidence of physical and verbal abuse 1. Afghanistan is one of the few countries constantly labelled at being ill-equipped in providing appropriate ante and perinatal care. Women reported dissatisfaction with childbirth services, particularly the poor attitudes and behavior of health workers, including discrimination, neglect, and verbal and physical abuse. Despite negative experiences with the health services, women appreciated having any access to health services. Health workers reported that low salaries, high stress and poor working conditions contributed to the poor quality of care [16]. Clinical Aspects of the Obstetric Violence Panorama Obstetric violences are not only simple consequences of obstetric procedures but actually develop a pathological state that harms both mother life and fetal development. In 2010 Browser and Hill identified initial verbal abuse, lack of privacy, lack of consent, and denial of care as factors that affected significantly maternal morbidity and mortality because of its links to the development of complications [17]. Besides these, the world has encountered other examples of mistreatment such as unnecessary episiotomy that leads to the loss of sphincter control, abuse of oxytocin levels for partum induction and also the denial to safe abortion by multiple barriers that lead to complications of unsafe abortion procedures such as sepsis and hemorrhage [18, 19, 20]. This is especially important seeing the current upscale in cesarean sections over natural birth procedures in maternal care settings. This survey showed that about one quarter of mothers who had induced their labors felt pressure to do so and that 63% of women who had a primary cesarean identified their doctor as the “decision maker” of the procedure [22]. Obstetric Violence are not only found in large or complex procedures but as well in the pre and post partum care. One example are routine enemas for the clearance of intestinal content previous to delivery. This practice aims to improve sanitary conditions of partum stances but there is still no evidence on its real benefit while it is very uncomfortable for the patient and generally done without consent [25]. The denial of companion and alternative pain alleviation strategies also take out the patient’s rights to choose proper guidance of medical care. Most of the prenatal factors that make a partum longer or the forcing of partum using kristeller maneuvers (which are contraindicated currently) show a high risk potential of complications such as obstetric fistula that affects over 2 million women in Africa and Asia and that has a low resolution rate depending on the deficient comprehensive care systems that systematically allow obstetric violence to occur without legal consequences [26]. From the legal perspective many discussions are yet to be done for many countries in the world. Many healthcare providers attempt to justify obstetric violence by allocating goodwill to the fetus but then in this situation putting at risk the potential life of the mother which under a governmental law would be more evident. Some of this unethical behavior is likely related to the fact that the law has failed to directly rectify the lingering controversy among practitioners as to the appropriateness of overriding the decisions of pregnant patients in all jurisdictions. The Benefits of Humanized Birth Humanized birth is putting the woman giving birth in the center, giving her the control and authority to make all the decisions about what will happen not the doctors or anyone else [28]. Although humanized birth is contrary to obstetric violence, the simple eradication of obstetric violence does not completely evoke the concept of humanized birth. As per now, the medical academy has not reached to a full consensus about obstetric violence, but there are different perspectives in modern literature relevant for the knowledge and advocacy of medical students. The first aspect is that Humanized Birth is not only attributed to specific technical skills and the process of birth, but rather a whole unison of cultural, social and ethnicity aspects. As well, it is not simplified giving humanitarian care to a pregnant individual [29]. The concept rises in the aim of accepting and understanding these other faces of humanity that determine birth in such a way that physical and emotional privacy together with preparation of a comfortable environment in the prenatal and postnatal care aids in the development of a healthy pregnancy and a successful delivery [30]. Most importantly, humanizing birth means giving women the center of will within a clinical setting and it does involve the further analysis of women empowerment within a health system instead of prioritizing technicians needs over those of our patients. The presence of doulas during labor, and the supportive role they provide, advocates for normal births and generally result in better maternal and neonatal outcomes as well as lowering the use of technology. This also leads to a reduction in the caesarean rate, a lower rate of analgesia use for pain relief and use of oxytocin, a decrease in the duration of labor, and an overall increase in maternal satisfaction regarding the birth experience [32]. Here, especially domestic violence by an intimate partner is reported as a problem leading to miscarriage, perinatal death, preterm delivery and low birthweight [34]. Obstetric Violence express the stereotypes that we hold against women as a social view and reinforces the systemic discrimination that puts women into a position that categorizes women as fragile individuals, strictly mothers and incapable to make decisions [35]. During pregnancy, women can be exposed to both psychological violence and physical/sexual violence. Not seldom, the violence will be intensified or even begin when the women gets pregnant. Social determinants as low socioeconomic status, low level of social support, black race/ethnic group, young age, drug and alcohol abuse and mental disorders is disponating to obstetric violence. Regarding abortion, health care personnel must respect the woman’s liberty, dignity, autonomy and ethical authority to decide when and how many children to have. Women can be met with prejudice and discrimination that can dehumanize the treatment, including denying or delaying abortion or medical treatment due to unsafe abortion; questioning the woman about causes to the abortion; performing procedures, predominantly invasive ones, without explanation, consent or anesthesia; threatening, accusing or blaming the woman; as well as forcing confession and denunciation to the police. Together with the clinical and social argumentation, a further debate on a larger social scale must be mentioned as well. Obstetric Violence is not only rooted on a systemic social hierarchy but as well in a marquet control context that is woven by healthcare providers and diverse stakeholders like pharmaceutical industries. Cesarean sections, for instance, represent a more complex procedure that requires a higher investment which translates in many ways a greater gain for healthcare providers themselves, insurance and/or pharmaceutic companies [36]. Obstetric Violence and Human Rights As described earlier, obstetric violence is a way of gender based violence. Every woman is equally free to exercise her human rights and freedoms which include: the right to respect for life; the right to respect for physical, psychological and moral integrity; the right to freedom and personal safety; the right to not be subjected to torture; the right to have her dignity respected and her family protected; the right to equality of protection from the law and by the law; the right to freedom of association; the right to profess her own religion and beliefs within the framework of the law [39]. Abuse, neglect or disrespect during childbirth can amount to a violation of a woman’s fundamental human rights, as described in internationally adopted human rights standards and principles [38]. Relevance to Medical Students As early as the first day of medical school, students must be encouraged not only to build up their medical knowledge but also their identities and personalities as future practitioners. This means that they have the right and the duty to acquire, learn, practice, and get the proper education about the right ways to communicate with patients of all types and orientations, including pregnant women and all the medical and ethical consequences of doing or witnessing any kind of abusive treatment towards patients. Therefore, there must be general awareness among medical students about the importance of properly gaining the trust of their future patients, statistically, ethically, and based on the fact that they should aim and be totally equipped to be able to transform the process of child delivery into a natural, spontaneous and unrestrained process in order for it to take its right place in every mother as the moment she were able to grant life to a new human being [40]. Furthermore, it is even suggested that medical students should by the end of their medical education years be able to witness, follow up, and even have helped in an entire process of normal child delivery. The integration of awareness also stimulates more medical students to follow this academic pathway in a more ethical way [41]. On the other hand, it is fairly common that in public hospitals, pregnant women are abused basically due to the fact that they are probably from a vulnerable background and lack the proper education or awareness of their own sexual and reproductive health rights. Nevertheless, society does not even try to make any better, and such acts of obstetric violence are usually overlooked by social security as well. Also, health care personnel and practitioners are generally not interested in playing key roles in the promotion of women’s rights, since the lack of impelling laws and constitutions as well as policies that forbid obstetric violence altogether combine to make it worse [42]. Implement scientific and evidence-based information in the curricula of medical schools and also on all postgraduate courses in obstetrics and gynecology in order to understand the danger of such practice, to prevent, treat, punish and eradicate violence towards women. Training of the teachers in this procedure is essential, so that they can correctly teach the students. The entire modern obstetric and neonatological literature is essentially based on ‘observations’ of medicalized birth” [43]. Their aim was to educate doctors to be able to deliver quality healthcare and to apply and respect the principles of human rights [44]. Organic Law on the Right of Women to a Life free of Violence, 2007, Caracas, Venezuela. Retrieved: Ley Orgánica sobre el derecho de las mujeres a una vida libre de violencia. Integral Law for the Sanction, Prevention, and Eradication of Violence against Women, article 6(e). Obstetric violence: a new framework for identifying challenges to maternal healthcare in Argentina. Applying a framework for assessing the quality of maternal health services in urban India. Antenatal and obstetric care in Afghanistan – a qualitative study among health care receivers and health care providers. Third Appellate Chamber on Civil, Commercial, Mining, Peace and Tax Law of the Province of Mendoza (Argentina). Maternity support survey: a report on the cross national survey of doulas, childbirth educators and labor and delivery nurses in the United States and Canada. The prevention and elimination of disrespect and abuse during facility-based childbirth, 2014. Muñoz J, Restrepo Moreno C, Gil L, González Vélez A, Obstetric Violence and Abortion. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. Technical Institute of Nursing, Faculty of Nursing, Mansoura University Egypt, also affiliated to Faculty of Nursing, Mansoura University Egypt. It is thought to result from having a sense of control, having expectations met, feeling empowered, confident and supported. Tools: a structured interview questionnaire included 3 parts; demographic data, childbirth expectations fulfillments and childbirth satisfaction data, semi structured interview with nurses and physician, observation check list to assess maternal & neonatal outcomes. Results: the intervention group had a statistically higher degree of positive childbirth experiences and improved labor outcomes than that of the control group (p<0,001). Conclusion: women who receive care with birth plan during her birth are more satisfied than those who not. Introduction Birth plans were initially implemented in the 1980 in Europe and America in response to the increasing [35] medicalisation of childbirth. A birth plan is a written communication tool prepared by a pregnant woman, which involves her preferences for the management of her labor and delivery. Birth plans have different formats to help women gain a better experiences of child birth. So, the birth plan was originally intended as a tool to educate and empower women, encourage shared decision making, facilitate communication about expectations, and develop trust between women and their [32] caregivers. The common elements of the birth plan include requests to ambulate during labor, drink fluids as [6] desired, to receive the baby to the abdomen after birth, and to have support persons in attendance. They also often contain a list of things that the woman wishes to avoid, such as continuous fetal monitoring, episiotomies, pain medications, and epidurals. Adequate investment in preparation for birth is key to having an un medicated birth. These six care practices are (1) labor begins on its own, (2) freedom of movement throughout labor, (3) continuous labor support, (4) no routine interventions, (5) spontaneous pushing in upright or gravity-neutral positions, and (6) no separation of mother and baby with unlimited opportunities for breastfeeding. Patients may feel unsupported because nurses and doctors may focus more on technology rather than [20]. It has been reported that some physicians and nurses seem to believe that women who enter the healthcare system carrying birth plans are at greater risk of a cesarean birth had an overall [24]. Common obstetric interventions can greatly improve maternal and neonatal outcomes Beneficial outcomes of 24 Journal of Education and Practice Supporting women’s preferences during labor has been shown to increase satisfaction with birth the creation [23,24] of a birth plan helped to ameliorate a disabling fear of childbirth. Women stated that it was helpful to think about and write down their preferences, and know that their needs would be attended to . Medicalisation of childbirth in developing countries has not always translated into satisfactory childbirth experiences among [25] women. In addition, while midwives have taken a lead role in promoting birth plans in other countries. It was interesting to know how nurses can take the lead role in implementing the birth plans for primiparae. Introducing birth plan in the regime of care during antenatal care is novel in Egypt. It translated & introduced to pregnant women in intervention group to choose and write her birth plan in antenatal clinic, it consisted of women preferences such as (clothes, birth attendances, mode of delivery, method for starting labor, support person and pain relief measures), care during 1st stage such as (routine care, fetal monitoring, food, hydration, bathing and movement), care during 2nd stage such as (type of pushing, position of delivery and perineal condition) care after delivery such as(suction, other baby care, first one carrying and dressing the baby, first feeding and hospital discharge). It reviewed by supervisors and implemented by researcher on the intervention group, it consisted of complete history taking, Physical examination, supportive care measures for each stage of labor were applied for women, the partograph was used for every participant to record data about: fetal condition, labor progress and maternal condition. It consisted of 3 parts: Part 1 'Socio demographic data' as: age, level of education, phone number, gestational age, occupation and monthly income. Part 2 'Childbirth expectations fulfillment sheet' it is 25 Journal of Education and Practice It consisted of 40 questions from 1 to 34 the responses will be comprises of Five point ranged from (1) very dissatisfied,(2) dissatisfied, (3) neither satisfied nor dissatisfied,(4) satisfied, (5) very satisfied. Questions 35 & 36 were open ended for the woman to contribute her over all satisfaction /dissatisfaction with her child birth experiences.

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Overview the complications of ulcerative colitis can be divided into those that affect the colon and those that are extracolonic. Toxic Megacolon Overview the most feared complication of ulcerative colitis is the development of toxic megacolon. It occurs as a result of extension of the inflammation beyond the submucosa into the muscularis, causing loss of contractility and ultimately resulting in a dilated colon. Dilation of the colon is associated with a worsening of the clinical condition and development of fever and prostration. Diagnosis this diagnosis is based on radiographic evidence of colonic distention in addition to at least three of the four following conditions: fever higher than 38. At least one sign of toxicity must also be present (dehydration, electrolyte disturbance, hypotension, or mental changes). There may be rebound tenderness, abdominal distention, and hypoactive or absent bowel sounds. However, perforation can also present in severe ulcerative colitis even in the absence of toxic megacolon. Steroid therapy has been suggested to be a risk factor for colonic perforation, but this is controversial. Radiography X-rays of the abdomen reveal colonic dilation, usually maximal in the transverse colon, which tends to exceed 6 cm in diameter. Serial plain abdominal x-rays of the abdomen taken at 12–24-hour intervals are useful in following the clinical course. Medical Therapy the goal of medical therapy is to reduce the likelihood of perforation and to return the colon to normal motor activity. A nasogastric tube is placed in the stomach for suction and decompression of the upper gastrointestinal tract. The use of the rolling technique, during which the patient lies on the abdomen for 10–15 minutes every 2 hours while awake, allows for passage of gas and easier decompression of the dilated colon. Broad-spectrum antibiotic coverage is instituted in anticipation of peritonitis resulting from perforation. Intravenous steroids are usually administered in doses equivalent to more than 40 mg of prednisone per day. Surgical Therapy Colectomy occurs in about 25% of patients and is required in almost 50% of patients with pancolitis. Surgical intervention is undertaken if the patient does not begin to show signs of improvement during the first 24–48 hours of medical therapy, as the risk of perforation increases markedly. Colectomy with creation of an ileostomy is the standard procedure, although single-stage proctocolectomy is done occasionally. If surgical therapy is performed before there is colonic perforation, the mortality is approximately 2%. In cases in which there has been bowel perforation, however, the mortality risk increases to 44%. However, some degree of narrowing may be seen in approximately 12% of surgical specimens. Histologically, strictures present with hypertrophy and thickening of the muscularis mucosa without evidence of fibrosis. Strictures tend to occur late in the course of disease, usually 10–20 years after onset of disease. Most strictures occur in the sigmoid and rectum, with an approximate length of 2–3 cm. Strictures have been associated with malignancy, and biopsy of the strictures is warranted. In fact, in patients with long-standing history of ulcerative colitis, a stricture should be considered potentially malignant. Primary Sclerosing Cholangitis Primary sclerosing cholangitis is a chronic cholestatic liver disease characterized by fibrosing inflammation of extra and intrahepatic bile ducts. Patients may have symptoms of fatigue, pruritis, abdominal pain, fever, or jaundice. This usually appears in men after 10–15 years of very mild, even subclinical, pancolitis, and may necessitate liver transplantation in some patients. Treatm entEvidence Sum m ary  Urine culture isN O T indicated in m ostasym ptom aticpatients,asthere isno benefit and potentialharm. H ow ever,iffirstcystitisepisode,susceptibility likely 19 betterthan itappearsin the antibiogram,w here patientsw ith m ore com plicated & hem olytic)are rare w ith shortterm therapy (≤14 days). There w asno difference in clinicalcure;how ever,1 study dem onstrated 41 com pared to placebo in a m eta-analysis(N =4,n=275),butdata islim ited. Studiesare lim ited by the num berofpatientsincluded w ith renalfunction 42 43 23 (N N H =14). H ow ever, Table 4:OralRegim ens– RecurrentCystitisTherapy resistance concernshave arisen in som e countries. Post-coital  Considerin patientsw hen cystitisroutinely presentsw ithin Prophylaxis 24-48 hoursofintercourse. N orfloxacin **   200m g po x1  Reinfection:Differentorganism (generally)presentsafter2 w eeksoftherapy. Itis Beers2015 recom m endsavoiding long-term use ofnitrofurantoin in those ≥65 yearsdue to adverse effects 11 Low Quality Evidence, Strong Recom m endation B st. Considersw abbing the  Age:<2 yearsold & >65 yearsold  Recentinvasive procedurese. M ay add antibioticsif  Antibiotic use in the past6 m onths  Traum a associated  risk. Delayed rashescaused by penicillin,ifafterfirstfew doses/days& no  Beta-lactam s:group ofantibioticsw ith a distinctive beta-lactam ring;includespenicillins,cephalosporins,and carbapenem s. Allergym ayoccurto itchiness/hives,are nottypically indicative ofa true IgE-m ediated eitherthe beta-lactam ring (in w hich case apatientisallergicto allbeta-lactam s)orto the unique side chain (in w hich case the allergyisonlyto specificagents). Afterencountering a specificantigen,IgE antibodiescan triggeran im m une response. When possible,referpatientsw ith uncertain penicillin allergy for  "True"IgE-m ediated allergy:potentiallylife-threatening reaction;also know n asa type-1 im m ediate hypersensitivityreaction. Skin testing isespecially helpfulw hen the allergy history  Graded challenge:som e variation in approaches,butoften a sm alldose ofa potentialallergen. When the risk oftrue penicillin allergy islow,a graded challenge th  Desensitization:sim ilarto the graded challenge,butata slow erpace. A sam ple protocolforan oral using a cephalosporin w ith a dissim ilarside-chain isappropriate. Table 1:Factorsthatdecrease the likelihood ofa true allergy 10,000 In a given group of10,000 patients: 5 Skin testisnegative:thisprovidesa 97-99% certainty thatthe patientisnotallergic. Tim ing:ifreaction occurred afterdaysto w eeksoftaking antibiotic,itisunlikely to be IgE-m ediated. M anagem entofPenicillin Allergy Aftera reaction to penicillin,can a beta-lactam be prescribed in the future? The answ errequiresaccurate differentiation betw een three typesofbeta-lactam adverse reactions. Penicillin Adverse Event SeriousPenicillin Adverse Event True IgE-M ediated Penicillin Allergy. Stevens-Johnson syndrom e,interstitial Atm inim um,presentsasan itchy rash orhives. M ore severe sym ptom sinclude itchy,occursin ≤10% ofpatientstaking penicillin,usually nephritis,hem olyticanem ia,serum sickness*. These reactionscan be life-threatening and 12 9-11 after2-5 daysoftherapy,and m ay lastseveralw eeks. These reactionsusually occur>72hrsafterbeta usually occur<1hraftertaking a beta-lactam dose. Ifthe skin testresultis IgE-m ediated,and so a cephalosporin ordifferent an alternative agent. Stevens-Johnson syndrom e,interstitialnephritis,hem olyticanem ia,serum sickness)are contraindicationsto anybeta-lactam ; reactionslisted. G enerally,these occur  Ifallergy islikely IgE-m ediated,skin test(ifpossible)using a cephalosporin w ith a differentside chain than the cephalosporin thatpreviously reacted. Ifno after7-10 daysoftherapyand relate to 12-15 reaction,give a graded challenge;ifreaction,orifskin testing notavailable,use an alternative agent(ordesensitization). Sym ptom s 2017 include urticarialvasculitis,renal -Skin testsin Saskatchew an are available via referral(currently <6 m onth w aiting list). Evidence suggeststhatcarbapenem shave a ~1% cross-reactivity w ith penicillins,and are appropriate in 16 desensitization are contraindicated. Com m on A dverse Events O verallN N H = 8-12 Yeastinfection N N H = 23  In a m eta-analysis(10 trials,2450 patients)com paring antibioticsto placebo foracute rhinosinusitis,com m on adverse events(such asnausea,vom iting, 2,5 diarrhea,orabdom inalpain)occurred in 27% ofpatientson antibioticsversus15% on placebo (N N H = 8-12). The antibioticsused in thism eta-analysis 3,4,5 included penicillins,m acrolides,and tetracyclines. A llergic Reactions N N H from 20 (rash,hives)to 10,000 (anaphylaxis) 7,8 Allergic reactionscan occurw ith any antibiotic;penicillin in particularisw ellstudied. About5-10% ofpatientsw illself-reporta penicillin allergy; how everthe 9 vastm ajority ofthese reactionsare delayed reactions,occurring daysto w eeksafterinitiating therapy,and do nottypically indicate a true allergy. Serious A dverse Events N N H from 300 to 30,000 Rare butseriousadverse eventsare associated w ith allantibiotics. Large,long-term random ized controlled trialsare uncom m on,and so itisdifficultto puta precise estim ate on how prevalentthese eventsare. Although thisisthoughtto be unlikely,there isa sm allbutrealrisk & a backup birth controlm ethod isalw aysrecom m ended. Every course ofantibiotic islikely to resultin som e em erging resistance w hich could affectthe next choice ofantibiotic regim en forthatindividual,especially ifw ithin 3 m onthsofthe previousantibiotic. Forexam ple,strainsofStreptococcuspneum oniae resistantto levofloxacin w ere docum ented in the sam e year 21 22 levofloxacin w asintroduced to the m arket. Rare,butw orrisom e,reportsofbacteria resistantto every available antim icrobialcan be found in the literature. Q uotes from the team :H arm sspeak louderw hen there islittle orno benefitto offsetthem! In concentration-dependentkilling,an antim icrobialism ore effective ata higherdose. Classificationsare notabsolute -forexam ple,agentsm ay be bacteriostaticin m ostsituationsbutbactericidalathigh concentrations,orbacteriostaticagainstsom e organism sand bactericidalagainstothers. Anaerobiccoverage can be im portantin situationssuch asaspiration pneum onia,intra-abdom inalinfections,and diabeticfootulcers. Antim icrobialsw ith good activity include m etronidazole,clindam ycin,am ox-clav,and m oxifloxacin. Asa result,they cannotbe view ed undera gram stain and are naturally resistantto allbeta-lactam s. Antim icrobialsw ith good activity include m acrolides,fluoroquinolones,and tetracyclines. Com m on beta-lactam ase producersinclude H aem ophilus influenzae,Neisseria gonorrhoeae,M oraxella catarrhalis,Escherichia coli,Proteus,Klebsiella,and Bacteroidesfragilis. H ow ever,today Staph aureusisreliably resistantto penicillin,am oxicillin,and am picillin through beta-lactam ase production. In response,beta-lactam ase-resistantantibioticsw ere invented,like m ethicillin,cloxacillin,and oxacillin. Am oxicillin  Considerw atchfulw aiting in acute otitism edia forsuitable children (see page 78). M ax: 1000-4000m g/day $40 risk 2-4/1000 vsbaseline riskof1-2/1000  Excellentbioavailability. M ax: 3000m g/day Cephalosporins:Bindsto penicillin binding proteinson bacterialcellw alls,inhibiting cellw allbiosynthesis. G onorrhea resistance to cefixim e ~ 2% in Canada (com bine cefixim e w ith am acrolide due to resistance + to add chlam ydiacoverage). Riskofallergy cross-sensitivitybetw een cephalosporinsand penicillinsislow -see AntibioticOverview page. Enterobacter; Peds: 8m g/kg po q24h $29 20m g/m Lsusp straw berry Neisseria;Proteus;E. Stearate:250m g po q6h $20 Erythrom cyin Estolate 50m g/m Lsusp ❄  H asbeen used to increase G Im otilitye. Non-estolate:  Estolate form ulation:contraindicated in pregnancy ( hepatotoxicity),butbestin kidsasm ostacid stable. Situp aftertaking foratleast30 m inutes,and take w ith a fullglassofw ater,to reduce riskofpillslodging in the esophagusand causing ulceration. Pg 13 OralAntibiotics(continued) Treatw ith adequate dose & appropriate duration © w w w. M ayhave lessabsorption via jejunostom ytube since fluroquinolonesare likelyabsorbed in the duodenum. Note:ifPseudom onassuspected in seriousinfection,m ayuse com bination therapyem pirically. Neisseria;H aem ophilus; Peds: 20-30m g/kg/day po divided q12h $29 P1P2,3 L 250,500,750m g tab   M oraxella;Pasteurella;m anyatypicals. Sulfam ethoxazole & trim ethoprim inhibitsuccessive stepsin folicacid pathw ay,& thusare synergisticin com bination. Coverage:Staphylococci; Peds: 10-30m g/kg/day po divided q6h $34 150,300m g cap Streptococci;m anyoralanaerobes.

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The dose went up by a factor of 4 from 100 mAs to 400 mAs, so the standard deviation goes down by a factor of 2. Key: D References: Bushberg, Seibert, Leidholdt, Boone, Essential Physics of Medical Imaging. Although the ability to distinguish small low contrast objects is affected by image noise, the spatial resolution of the system is not directly affected by the mAs. Which of the following digital detectors directly converts x-ray signals into an electrical charge? When photostimulable storage phosphers absorb x rays, some of the energy is trapped and stored, and is read out later using laser light. When x rays are absorbed the energy is converted directly into charge, producing electron hole pairs in proportion to incident x ray energy. Which of the following occurs when the x-ray field is collimated to the smallest possible size to cover the specific anatomic region? Geometric magnification is increased Key: B References: nd Bushberg, Seibert, Leidholdt, Boone, Essential Physics of Medical Imaging. Geometric unsharpness depends on geometric factors such as focal spot size and magnification. Collimation to a smaller field of view reduces scatter, which improves image contrast. Incorrect Higher grid ratios will reduce scatter, but reducing the field of view by collimating to the smallest possible size already reduces scatter, so making that change would not make a higher grid ratio needed. Magnification is determined by distances from x ray source to image receptor and x ray source to object. The chemical shift phenomenon arises as a result of the slightly shielded magnetic environment experienced by protons in fat, causing a lower frequency (about 3 parts per million) compared to protons in water. Because of this frequency shift, the major chemical shift artifact occurs in the frequency encode gradient direction (answer A). Note; the “slice encode” gradient is a gradient that is applied for volumetric ordering of the proton locations in a 3D acquisition. Higher tube voltage decreases image noise, with all other factors the same, since more x rays are used to form the image (more x rays are produced and a greater percentage are transmitted through the patient). Increasing slice thickness actually decreases image noise, since more photons are used to form the image. The lower tube current results in fewer x ray photons, thereby increasing image noise. Ultrasound Radiology In-Training Test Questions for Diagnostic Radiology Residents May, 2018 Sponsored by: Commission on Publications and Lifelong Learning Committee on Residency Training in Diagnostic Radiology © 2018 by American College of Radiology. You are shown color and spectral Doppler evaluation of the right hepatic artery of a 34-year-old woman, 72 hours status post liver transplant (Figure 6). The upstroke in this waveform is also abnormal, both delayed and lower than expected compatible with a “tardus parvus” waveform, which is also suspicious for proximal narrowing. Pseudoaneurysm is a rare complication of liver transplant that typically occurs at the arterial anastomosis. On greyscale imaging a pseudo aneurysm appears as a cystic structure with turbulent flow shown on color and spectral Doppler imaging. You are shown longitudinal gray scale image of the testis in an asymptomatic 57 year old man (Figure 2). Tubular ectasia of the rete testis typically occurs as a result of inflammatory of traumatic obstruction of the epididymis. Sonographic findings of cystic or tubular structures along the mediastinum testis with no internal flow on color Doppler imaging is characteristic of this diagnosis. Intratesticular varicoceles appear as dilated, tubular structures coursing through the testis. Most lesions are solid and hypoechoic compared to the normal testicular parenchyma. Sonographic features of intra-testicular abscess include enlarged testis with a focal fluid-filled or hypoechoic mass. Gas may be identified within an abscess as bright echogenic foci with posterior acoustic shadowing. Benign tumors and tumorlike lesions of the gallbladder and extrahepatic bile ducts: radiologic-pathologic correlation. Gas within the gallbladder in patient s with emphysematous cholecystitis appear as liniear, echogenic foci with posterior "dirty" shadowing. In porcelain gallbladder, the gallbladder wall is calcified and appears diffusely echogenic with posterior acoustic shadowing. Impacted gallstones are located in the neck of the gallbladder and are echogenic, shadowing and non-mobile. The grey scale image shows focal thickening of the gallbladder wall with echogenic foci that show posterior comet tail artifact. The color Doppler image shows twinkle artifact associated with the echogenic foci. Stein-Leventhal syndrome, also called poly cystic ovary syndrome is associated with an abnormal appearance of the ovaries on ultrasound including ovaries with increased volume and numerous, small, typically peripherally oriented cysts. Theca lutein cysts are not seen in association with elevated serum progesterone levels. Theca Lutein cysts are not an expected finding in the setting of a normal singleton pregnancy. You are shown a transverse image of the uterus from a 24-year-old woman with a positive urine pregnancy test (Figure 3). Failed intrauterine pregnancy is diagnosed with no embryo is seen on transvaginal ultrasound with a mean sac diameter of greater than or equal to 25mm. This image shows an enlarged uterus with an intrauterine mass that is echogenic with cystic spaces of varying size. In a normal intrauterine gestation, the gestational sac, yolk sac and fetus should be visible by 8 weeks. Fetal head circumference during the second trimester of pregnancy on an obstetrical ultrasound should be measured at the level of the: A. Practice guidelines for performance of the routine mid-trimester fetal ultrasound scan. Fetal head circumference is the length of the outer cranium perimeter, obtained in the transaxial plane at the level of the paired thalami and septi pellucidi. You are shown Doppler images of the main, left, and right hepatic arteries (Figure 1, Figure 2 and Figure 3) in a patient who underwent a liver transplant two months ago. Tardus parvus waveforms and low resistance flow as shown on these images indicate an arterial stenosis proximal to the site of imaging. The main, left and right hepatic arteries all show tardus parvus waveforms and low resistive index, imaging features suspicious for an upstream hepatic arterial stenosis. The main, left and right hepatic arteries all show tardus-parvus waveforms and low resistive index, imaging features suspicious for an upstream hepatic arterial stenosis. Well-defined unilocular or multilocular cystic mass with low level internal echoes B. The characteristic appearance of an endometriomais a well-defined unilocular or multilocular cystic lesion with low level internal echoes. A complex cyst with reticular type pattern is commonly seen with a hemorrhagic cyst. Mature cystic teratomas, commonly referred to as ovarian dermoid cysts, tend to have a highly echogenic component with posterior acoustic attenuation or shadowing. You are shown two images of the left lower extremity in a patient with left lower extremity pain. Pseudoaneurysm can appear as a cystic structure in the popliteal fossa on B mode imaging but would show internal vascular flow on color Doppler imaging. A Baker’s cyst is fluid within a distended bursa between the median head of the gastrocnemius and semimembranosus tendon. The most sensitive finding of deep vein thrombus in the popliteal vein is non compressibility of the popliteal vein. Popliteal artery aneurysm would appear as focal cystic dilation of the popliteal artery of B-mode imaging and would show internal vascular flow on color Doppler imaging. Normal tissue responses with radiation doses used for radiotherapy of benign disease 10 3. The risk of a radiation-induced malignancy following low to intermediate dose radiotherapy 18 4. Head and neck 29 Head and neck paraganglioma 29 Juvenile nasopharyngeal angiofibroma 33 Salivary gland pleomorphic adenoma 36 Sialorrhea 39 5. Eye 42 Thyroid eye disease 42 Orbital pseudotumour/idiopathic orbital inflammation 48 Pterygium 52 Age-related macular degeneration 55 Choroidal haemangioma 59 6. Central nervous system 60 Meningiomas 60 Cerebral arteriovenous malformations 70 Trigeminal neuralgia 75 Vestibular schwannoma (acoustic neuroma) 81 7. Orthopaedic/musculoskeletal 85 Dupuytren’s disease of the hand 85 Plantar fibromatosis (Ledderhose disease) 90 Plantar fasciitis 92 Peyronie’s disease 94 Heterotopic ossification of the hip 96 Pigmented villonodular synovitis 102 Vertebral haemangioma 104 Aneurysmal bone cyst 106 8. Skin/soft tissues 108 Keloid scarring 108 Lentigo maligna 111 Hidradenitis suppurativa 114 Psoriasis 115 Chronic eczema 116 the use of radiotherapy for the prevention of gynaecomastia caused by hormonal 117 therapy for prostate cancer Summary and recommendations 121 Appendix 1. It is also hoped that this review will help to raise awareness of the wider potential uses of radiotherapy – beyond treating patients with cancer – among referring professions. The review therefore recommends that radiotherapy departments should reassess their protocols for the treatment of benign diseases, including, where appropriate, the use of modern techniques. I would like to express my grateful thanks to members of the working party (Appendix 1) – Dr Paul Hatfield, Professor Stephanie McKeown, Dr Robin Prestwich and Dr Richard Shaffer – for their extensive input and excellent contributions to this review. Professor Roger Taylor Vice-President, Clinical Oncology the Royal College of Radiologists It is likely that this is largely due to the clinicians to consult when referred a patient with a increased availability of alternative medical therapies, benign condition. However, a that, in general, the numbers treated are much number of benign tumours were considered to be smaller and they vary considerably from one beyond the scope of this review (see below). The document includes discussion of general Interpretation of the literature is problematic. Therefore, may influence the judgement of referring clinicians much of the literature is ‘historic’. Follow-up tends to since most of these patients are referred from other be relatively short term in comparison with the life clinical specialties, for example, ophthalmologists, expectancy of patients with benign conditions and it is dermatologists and orthopaedic surgeons. Information on treating consultants since the numbers required to estimate the risk are was also requested. This demonstrated a With this proviso, some attempt has been made to core of activity in many centres, particularly for some identify the risk from available evidence and benign tumours, but also for heterotopic ossification, international risk estimates to inform discussion with keloid, thyroid eye disease and Dupuytren’s patients. The large activity for trigeminal neuralgia the context of the risks of alternative therapies. For example, one centre treated 64 patients with keloid Conditions not considered for review per annum, whereas others treated none. There is extensive German patterns of care study literature and a European protocol available. Mailed questionnaire surveys were undertaken there is a contribution from unsealed source therapy, in 1994, 1995 and 1996 requesting departmental which is beyond the scope of this review. Intra-arterial brachytherapy – this has currently fallen treated annually: 456 (2%) for inflammatory diseases out of use with the development of stents and other (221 hidradenitis, 78 local infection, 23 parotitis, 134 not advances in treatment. However, there were significant German Working Group study and the Clinical departmental and geographic variations in its use. Acute/chronic painful degenerative disease – for the use of modern example, insertion tendinitis and chronic or acute painful osteoarthritic diseases of various joints radiotherapy techniques (such as hip or knee). Functional diseases – for example, Grave’s developments in immobilisation and image guidance orbitopathy, arteriovenous malformations, age can allow reduced margins during treatment. Other related macular degeneration or persisting techniques, such as intensity-modulated radiation lymphatic fistula. Other indications – for example, prophylaxis of simultaneously increase the volume of tissue receiving heterotopic ossification, prophylaxis of neointimal lower doses). Dermatological diseases – for example, pruritis due to itching dermatoses and eczemas, inaccessible psoriatic foci. Consensus guidelines for radiation therapy of benign diseases: a multicentre approach in Germany. In this section and Section 3, the against the potential benefit of controlling the aim is to identify the underlying mechanisms and to malignant disease. Radiation dose ranges pertinent to experimental and clinical radiotherapy Description Dose (Gray [Gy]) Comment Very low <2 Used clinically as part of a multiple fraction dosing regimen, very rarely used as a single dose; often used in tissue culture experiments Low 2–10 Used for a few indications. In cell/animal experiments this is the most frequently used dose range Intermediate 10–40 Used for most non-malignant indications in a variable number of fractions sizes. Early and late normal tissue reactions *Occur in normal tissues in the radiation field. Exposure of critical structures in the Normal tissue effects are dependent on the radiosensitivity of the radiation field tissue(s) included in the radiation field; at doses <45 Gy this is unlikely to be an acute effect.

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Global hypoxic-ischaemic encephalopathy hypertension 15090 cheap vasotec on line, resulting from amoebiasis arteria umbilical percentil 90 vasotec 10 mg on-line, trypanosomiasis and cysticerosis (Fig prehypertension warsaw 2014 cheap 5 mg vasotec with mastercard. Cerebrovascular diseases are all those diseases in which one Global Hypoxic-Ischaemic Encephalopathy or more of the blood vessels of the brain are involved in the pathologic processes pulse pressure between aorta and capillaries buy 10mg vasotec visa. Various pathologic processes commonly the brain receives 20% of cardiac output for maintaining its implicated in cerebrovascular diseases are: thrombosis arteria3d elven city pack discount 10mg vasotec with mastercard, vital aerobic metabolism pulse pressure variation values order discount vasotec online. However, 880 fall of systemic arterial systolic pressure below this critical cortex; the loss of pyramidal cell layer is more severe than value results in rapid fall in cerebral perfusion pressure and that of granular cell layer producing laminar necrosis. Such types of medical Longer duration: Use of modern ventilators has led emergencies occur at the time of cardiac arrest followed by to maintenance of cardiorespiratory function in the relatively delayed resuscitation, severe episode of hypo presence of total brain necrosis unassociated with vital tension, carbon monoxide intoxication and status epilepticus. Hypoxic encephalopathy may be followed by a post ischaemic confusional state and complete recovery or a state Cerebral Infarction of coma and even a persistent vegetative life and brain death. Depending upon the proneness of different cells of the Cerebral infarction is a localised area of tissue necrosis caused brain to the effects of ischaemia-hypoxia, three types of lesion by local vascular occlusion—arterial or venous. Selective neuronal damage: Neurons are most vulnerable compression on the cerebral arteries from outside and from to damaging effect of ischaemia-hypoxia and irreversible hypoxic encephalopathy. In particular, oligodendroglial cells are most associated with cerebral infarction depend upon the region susceptible, followed by astrocytes while microglial cells and infarcted. In general, the focal neurologic deficit termed vascular endothelium survive the longest. Occlusion of the cerebral arteries by ii) Presence of acidic excitatory neurotransmitters called either thrombi or emboli is the most common cause of excitotoxins. Thrombotic occlusion of the cerebral iii) Excessive metabolic requirement of these neurons. Laminar necrosis: Global ischaemia of cerebral cortex occlusion is commonly derived from the heart, most often results in uneven damage because of different cerebral from mural thrombosis complicating myocardial infarction, vasculature which is termed laminar or pseudolaminar from atrial fibrillation and endocarditis. In this, superficial areas of cortical layers escape of an infarct are determined by the extent of anastomotic damage while deeper layers are necrosed. Watershed infarcts: Circulatory flow in the brain by Circle of Willis provides a complete collateral flow for anterior, middle and posterior cerebral arteries has internal carotid and vertebral arteries. In ischaemia-hypoxia, perfusion of Middle and anterior cerebral arteries have partial overlapping zones, being farthest from the blood supply, anastomosis of their distal branches. Particularly vulnerable is the border zone of the arteries and have no anastomosis. Hence, occlusion of these cerebral cortex between the anterior and middle cerebral branches will invariably lead to an infarct. The pathologic appear infrequent phenomenon due to good communications of the ance of the brain in hypoxic encephalopathy varies cerebral venous drainage. However in cancer, due to depending upon the duration and severity of hypoxic increased predisposition to thrombosis, superior sagittal episode and the length of survival. Compression of the cerebral arte Survival 12-24 hours: No macroscopic change is ries from outside such as occurs during herniation may cause discernible but microscopic examination reveals early cerebral infarction. Mechanism of watershed (border zone) neuronal damage in the form of eosinophilic cytoplasm cerebral infarction in hypoxic encephalopathy has already and pyknotic nuclei, so called red neurons. The In any case, the extent of damage produced by any of the area supplied by distal branches of the cerebral arteries above causes depends upon: suffers from the most severe ischaemic damage and may i) rate of reduction of blood flow; develop border zone or watershed infarcts in the junctional ii) type of blood vessel involved; and zones between the territories supplied by major arteries. Microscopically, the nerve cells die and disappear and are replaced by reactive fibrillary gliosis. Grossly, cerebral infarcts variations in the distribution of neuronal damage to the may be anaemic or haemorrhagic. The affected area is soft and swollen and there is blurring of junction between grey and white matter. The histologic firm glial reaction and thickened leptomeninges, forming changes are reactive astrocytosis, a few reactive macrophages and neovascularisation in the wall of the cystic lesion. It is usually the result of fragmentation of occlusive arterial emboli or venous thrombosis. Initially, there is eosinophilic neuronal necrosis and Spontaneous intracerebral haemorrhage occurs mostly in lipid vacuolisation produced by breakdown of myelin. Most hypertensives over middle Simultaneously, the infarcted area is infiltrated by age have microaneurysms in very small cerebral arteries in neutrophils. After the first 2-3 days, there is progressive invasion microaneurysms is believed to be the cause of intracerebral by macrophages and there is astrocytic and vascular haemorrhage. In the following weeks to months, the macrophages the common sites of hypertensive intracerebral haemor clear away the necrotic debris by phagocytosis followed rhage are the region of the basal ganglia (particularly the by reactive astrocytosis, often with little fine fibrosis putamen and the internal capsule), pons and the cerebellar (Fig. Ultimately, after 3-4 months an old cystic infarct is the lesion, hemispheric, brainstem or cerebellar signs will formed which shows a cyst traversed by small blood be present. About 40% of patients die during the first 3-4 vessels and has peripheral fibrillary gliosis. Small cavi days of haemorrhage, mostly from haemorrhage into the tary infarcts are called lacunar infarcts and are commonly ventricles. The survivors tend to have haematoma that found as a complication of systemic hypertension. There are two main types of copically, the haemorrhage consists of dark mass of spontaneous intracranial haemorrhage: clotted blood replacing brain parenchyma. Intracerebral haemorrhage, which is usually of hyper of the lesion are sharply-defined and have a narrow rim tensive origin. Subarachnoid haemorrhage, which is commonly aneu rhages in the Virchow-Robin space in the border zone are rysmal in origin. Ipsilateral ventricles are distorted and In addition to hypertension and rupture of an aneurysm, compressed and may contain blood in their lumina. After a few weeks to months, intracerebral and subarachnoid haemorrhage, haemorrhagic the haematoma undergoes resolution with formation of a diathesis and haemorrhage into tumours. Its margins are yellow-brown and have are the result of rupture in the posterior circulation, vascular haemosiderin-laden macrophages and a reactive zone of malformations and rupture of mycotic aneurysms that occurs fibrillary astrocytosis. In all types of aneurysms, the rupture of thin-walled dilatation occurs in Subarachnoid Haemorrhage association with sudden rise in intravascular pressure but Haemorrhage into the subarachnoid space is most comm chronic hypertension does not appear to be a risk factor in only caused by rupture of an aneurysm, and rarely, rupture their development or rupture. On rupture, they produce severe generalised A general discussion of aneurysms is given on page 405. Initial mortality intracranial arteries—berry, mycotic and fusiform, berry from first rupture is about 20-25%. They account for 95% of aneurysms which are liable rysm frequently spreads haemorrhage throughout the to rupture. Berry aneurysms are rare in childhood but subarachnoid space with rise in intracranial pressure and increase in frequency in young adults and middle life. An intracerebral are, therefore, not congenital anomalies but develop over the haematoma may develop if the blood tracks into the brain years from developmental defect of the media of the arterial parenchyma. The region of the brain supplied by the wall at the bifurcation of arteries forming thin-walled saccu affected artery frequently shows infarction, partly lar bulges. Important In more than 85% cases of subarachnoid haemorrhage, causes of head injuries are: motor vehicle accidents, the cause is massive and sudden bleeding from a berry accidental falls and violence. The four most may result in three consequences which may occur in common sites are as under (Fig. At the origin of the posterior communicating artery from subdural haematoma; and the stem of the internal carotid artery. Epidural haematoma is accumulation of blood between the dura and the skull following fracture of the skull, most commonly from rupture of middle meningeal artery. The haematoma expands rapidly since accumulating blood is arterial in origin and causes compression of the dura and flattening of underlying gyri (Fig. The patient develops progressive loss of consciousness if haematoma is not drained early. Subdural Haematoma Subdural haematoma is accumulation of blood between the dura and subarachnoid and develops most often from rupture of veins which cross the surface convexities of the cerebral hemispheres. Acute subdural haematoma develops following trauma and consists of clotted blood, often in the frontoparietal region. The serial numbers indicate the frequency of is of venous origin, symptoms appear slowly and may involvement. Chronic subdural haematoma is composed torn and cause multiple intracerebral haemorrhages. Head injury may be accompanied by brain is a membrane composed of granulation tissue. Some degree of axonal damage may also occur but demyelination is the predominant feature. The No significant morphologic change is noticed but more exact cause for demyelination is not known but currently severe concussion may cause diffuse axonal injury viral infection and autoimmunity are implicated in its (discussed below). These common cause of persistent coma or vegetative state conditions have known etiologies such as: genetically following head injury. The underlying cause is sudden determined defects in the myelin metabolism (leucodys angular acceleration or deceleration resulting in widespread trophies), slow virus diseases of oligodendrocytes (pro axonal shearing in the deep white matter of both the gressive multifocal leucoencephalopathy), and exposure to hemispheres. All these entities are Grossly, the changes are minimal to small multiple currently not classified as demyelinating diseases. Contusions and lacerations injured and are associated with considerable inflammatory are the result of direct damage to the brain parenchyma, exudate are included under the term ‘demyelinating particularly cerebral hemispheres, as occurs in the soft diseases’. Multiple or disseminated sclerosis subarachnoid haemorrhage invariably accompanies cerebral 2. Multiple (Disseminated) Sclerosis Microscopically, brain parenchyma at the affected site is haemorrhagic, necrotic and fragmented. The disease presents as recurrent attacks of focal neurologic disorder with predilection for involvement 884 of the spinal cord, optic nerve and brain. The first attack these groups along with the list of diseases included in each usually begins with a single sign or symptom, most group are briefly outlined below without going into the commonly optic neuritis, followed by recovery. As the details of individual diseases for which the interested reader disease becomes more progressive, remissions become may consult pertinent text on neuropathology and neurology. The etiology of multiple sclerosis remains unknown but a role for genetic susceptibility, Degenerative Diseases infectious agent and immunologic mechanism has been Degenerative diseases are disorders of unknown etiology proposed. The identification of these is the presence of many scattered discrete areas of diseases depends upon exclusion of diseases with known demyelination termed plaques. A consider defined, usually bilaterally symmetric areas in the white able proportion of degenerative disorders are genetic in matter. In venules and at the plaque margin where demyelination virtually all cases, the lesions have characteristic bilaterally is occurring. Another striking characteristic of the and presence of reactive astrocytosis with numerous lipid degenerative disorders is that particular anatomic or laden macrophages (microglia) in the plaque. The axons physiologic system of neurons may be selectively affected, in the plaque are generally intact. In old inactive plaques, there is no perivascular inflam Classification of degenerative diseases into individual matory cell infiltrate and nearly total absence of syndromes is based on clinical aspects and anatomic oligodendrocytes. Two of the Gliosis is well-developed but astrocytes are less important examples—Alzheimer’s disease and parkin prominent. Alzheimer’s disease is the most Perivenous Encephalomyelitis common cause of dementia in the elderly. The condition Perivenous encephalomyelitis includes two uncommon occurs after 5th decade of life and its incidence progressively diseases: acute disseminated encephalomyelitis and acute increases with advancing age. Both are monophasic but a few factors are implicated in its etiology which include diseases characterised by perivenous mononuclear positive family history and deposition of Aβ amyloid derived inflammatory cell infiltration. Microscopically, the main features are as under: Acute disseminated encephalomyelitis occurs usually i) Senile neuritic plaque is the most conspicuous lesion and following viral infection (measles, mumps, rubella, consists of focal area which has a central core containing chickenpox), whooping cough or vaccination. Signs of meningeal irritation and fever neurofilaments and neurotubules within the cytoplasm may be present. Acute necrotising haemorrhagic leucoencephalitis is a iii) Amyloid angiopathy is deposition of the same amyloid rare disease occurring more often after a respiratory infection. Neuronal storage diseases—characterised by storage of Parkinson’s disease; other causes of parkinsonism are a metabolic product in the neurons due to specific enzyme trauma, toxic agents, and drugs (dopamine antagonists). Leucodystrophies—are diseases of white matter charac neuromelanin pigment from neurons and accumulation terised by diffuse demyelination and gliosis. Some of the by deficiency of one of the enzymes required for formation residual neurons in these areas contain intracytoplasmic, and maintenance of myelin. That is why these conditions eosinophilic, elongated inclusions called Lewy bodies. Common types of leucodystrophies are: sudanophilic leucodystrophy, Metabolic Diseases adrenoleucodystrophy, metachromatic leucodystrophy and globoid cell leucodystrophy (Krabbe’s disease). Wilson’s Hereditary metabolic disorders predominantly manifest in disease (hepatolenticular degeneration), glycogen-storage infancy or childhood and include genetically-determined diseases, phenylketonuria and galactosaemia. Acquired or secondary metabolic diseases are the these include the following: disturbances of cerebral function due to disease in some other 1. Anoxic-ischaemic encephalopathy organ system such as the heart and circulation, lungs and 2. Hypoglycaemic encephalopathy respiratory function, kidneys, liver, endocrine glands and 3. Acute hepatic encephalopathy (Reye’s syndrome) be caused by toxic injuries induced by metals, gases, 5. Uraemic encephalopathy storage, degenerative changes, and sometimes parenchymal 8. The predominant types of hereditary and acquired All these conditions have already been discussed in the metabolic disorders are as under: relevant chapters. In the United States and Europe, however, nutritionally-induced disease is chiefly found in association with chronic alcoholism or due to defect in absorption, transport or metabolism of dietary nutrients. Some of the common neurologic diseases included in the category of deficiency diseases are as under: 1. Wernicke’s encephalopathy and Korsakoff’s psychosis (vitamin B1 or thiamine deficiency).

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