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  • Distinguished Professor and Chair, Department of Pathology, University of California San Francisco, San Francisco, California


This includes the rare forms (congenital and acquired) and the more common forms (traumatic and iatrogenic) of arteriovenous communications women's health clinic portage purchase 10 mg sarafem with visa. To understand the role of history and physical examination in the diagnosis of arteriovenous communications womens health associates cheap 20mg sarafem free shipping. To define appropriate menstruation longer than 7 days order sarafem 20mg online, cost effective diagnostic testing for arteriovenous communicatons breast cancer hair bows sarafem 10mg discount. To understand the role of the vascular diagnostic laboratory for the diagnostic evaluation of arteriovenous communications. To understand the role of magnetic resonance imaging and magnetic resonance angiography for the diagnostic evaluation of arteriovenous communications. To understand the role of contrast angiography for the diagnostic evaluation of arteriovenous communications. To understand the role of diagnostic studies for the selection of the patient and site, and the preparation for the creation of a therapeutic arteriovenous communication. To understand the diagnostic evaluation of the complications and problems with therapeutic arteriovenous communications. To understand the role of conservative management for arteriovenous communications. To understand the role of catheter based intervention in the treatment of arteriovenous communications. To understand the role of open surgery in the treatment of arteriovenous communications. To understand the interactions of the treatments and the expected impact of combinations of treatments of 76 arteriovenous communications. To understand the technical considerations for creation of arteriovenous communications, for therapeutic indications, such as dialysis access, and distal extremity bypass grafts and venous bypass grafts. To understand the complications and problems with therapeutic arteriovenous communications. To know that arterial and venous anatomy involved in the commonly palced grafts and sited for hemodialysis in the upper and lower extremities; know the options for unusual grafts sites when extremities are not available. To know the local and systemic, anatomic effects of creating an arteriovenous fistula for the purpose of hemodialysis. To know the anatomic landmarks for the various routes of access to the circulation for the use of chemotherapy, chronic infusion, obtaining blood samples, and physiologic monitoring. To know the hemodynamic and physiologic effects of creating an arteriovenous fistula; understand the effects of large and small fistulae on the adjacent arteries and veins and on the body as a whole. To know the diagnostic tests used in evaluating an arteriovenous access with high resistance, poor pressure, thrombosis, and infection. To know the complciatiosn of obtaining access to the central curclation and the diagnostic examinations and tests used to diagnose pneumothorax, misplaced line, pseudoaneurysm, venous thrombosis, and hemorrhage. To know the uses and benefits of using autologous or synthetic grafts for the purpose of hemodialysis including the locations, timing of placement, maturation of and longevity of the various access routes and grafts. To know the treatment of complications of arteriovenous fistulas for hemodialysis including infection, steal syndrome, aneurysms, venous hypertension, thrombosis, stenosis, and the failing graft. To know the advanteages, techniques and commensurate applications of each route of access to the circulation for the use of administering chemotherapy, chronic infusions, obtaining blood samples and hemodynamic monitoring. To know the catheter types, their advantages, available for gaining access to the circulation. Duplex ultrasound scanning int he assessment of arteriovenous fistulas created for hemodialysis access: comparison with digital subtraction angiography. Surveillance policy for early detection of failing arteriovenous fistulae for hemodialysis. Correction of steal syndrome secondary to hemodialysis access fistulas: a 79 simplified quantitative technique. Follow-up results after stent plcement in failing arteriovenous shunts: a three-year experience. Insufficient dialysis shunts: improved long-term patency rates with close hemodynamic montioring, repeated percutaneous balloon angioplasty, and stent placement. To understand the basic anatomy of the autonomic nervous system including the course of sympathetic fibers through the spinal cord, the location of the sympathetic ganglia an the course of the post synaptic fibers. To understand the relationship between the sympathetic fibers and the abdominal aorta and iliac vessels. To understand the functions of the sympathetic nervous system and the pathologic conditions resulting from abnormal sympathetic activity. To understand the potential beneficial effects of sympathetic ablation and possible adverse side effects. To be aware of the limitations of the diagnostic tests used to assess sympathetic activity. To understand the historic and current role of sympathectomy for arterial occlusive disease. To understand the probable outcome when sympathectomy is used for ischemic ulcers, gangrene, rest pain, and the differences in clinical response for diabetes and non-diabetes. To be aware of the technique for surgical ablation of the lumbar sympathetic chain as well as the technique for chemical ablation. To understand the potential complications from lumbar and thoracoabdominal sympathectomies and how to reduce the risk of complication. Hemodynamic response to vasodilation and exercise in " critical" arterial stenosis. Effects of lumbar sympathectomy on skin capillary blood flow in arterial occlusive disease. Prediction of the success of a sympathectomy: A prospective study using discriminating function and multiple regression analysis. Limited success of lumbar sympathectomy in the prevention of ischemic limb loss in diabetic patients. Endoscopic thoracoscopic sympathetic in the treatment of upper limb hyperhidrosis. Understand the relationships of extra- and intrahepatic pathological abnormalities resulting in portal hypertension and a tendency to variceal bleeding secondary to the elevations in portal pressure. Understand the physiology of increased splanchnic blood flow observed in the later stages of intrahepatic and extrahepatic disease. The importance of splanchnic vasodilation and its contribution to portal hypertension should be appreciated. Understand the hemodynamics associated with the portal hypertension syndrome to include decreases in mean arterial pressure and peripheral resistance, while increases in cardiac index and output are observed. As a result of an associated peripheral vasodilation, describe the neurohumoral pathways which are activated leading to sodium retention, expansion of plasma volume, and increased arterial pressure and cardiac output. Describe intrahepatic and extrahepatic (pre- and posthepatic) causes of obstruction to the portal circulation. Understand the causes of portal hypertension which are extrahepatic, intrahepatic, sinusoidal and hepatic venous in etiology. Categorize portal vein thrombosis, schistosomiasis, cirrhosis, and Budd-Chiari syndrome in this classification. Understand the clinical evaluation of the portal hypertensive patient and describe the stigmata of liver disease detailed during a history and physical examination. Understand angiographic imaging of the portal vein by selective splanchnic angiography. Alternative techniques including computed tomography and magnetic resonance imaging may also contribute and should be understood in the evaluation of these patients. Describe the role for hemodynamic measurements including wedge hepatic venous pressure as well as duplex imaging of the portal vein. Understand the role of fluid management, pharmacological treatment with splanchnic vasoconstrictors (vasopressin), vasodilators (nitroglycerin) and other pharmacologic agents. Understand the role of the Sengstaken-Blakemore and Linton tubes in the control of acute variceal bleeding. Describe the value of endoscopic sclerotherapy in the management of acute variceal bleeding. Understand the efficacy and timing as well as the technique used for endoscopic injection. Describe endoscopic variceal band ligation and percutaneous transhepatic embolization in the control of variceal bleeding.


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Plasma cell granuloma (benign) Treatment of a true benign plasma cell granuloma is surgical resection pregnancy options cheap sarafem 10mg fast delivery. About one third of these will transform into the malignant version if left untreated women's health clinic midland tx sarafem 20mg on-line. Radiation therapy is indicated for those which recur or for more extensive lesions pregnancy exercise videos buy sarafem paypal. Radiation therapy has been used in the past for both an attempt at improving fertility (see anovulation) and for the termination of intrauterine or tubal pregnancy (see abortion) pregnancy vs period quality sarafem 20 mg. Generally radiation is a treatment of last resort and is reserved for inaccessible locations such as the nail beds. Typical radiation treatment utilizes superficial x-ray, electron beam, or complex photon beam therapy in four or fewer fractions. Pterygium the use of radiation to treat a pterygium is supported in the clinical references reviewed. Pyogenic granuloma Despite one case report in the literature of successful treatment of a pyogenic granuloma of the middle ear with radiation, treatment of a pyogenic granuloma is surgical. Rheumatoid arthritis Attempts at treating rheumatoid arthritis with radiation have included single joint external beam radiation, intra-articular infusions of radioactive isotopes, and total lymphoid irradiation for immunosuppression. Rosai-Dorfman Disease Rosai-Dorfman Disease is a rare disorder characterized by a benign histiocyte proliferation. In lesions involving the airway not responding to more conservative measures, radiation therapy has been used with success. When utilized, radiation planning using complex or three-dimensional technique and delivered in up to twenty-two sessions is typical. Policy: cases will require medical review and documentation that non-radiation alternatives have been exhausted. Sarcoidosis If primary medical management fails to control those lesions in need of treatment, the use of radiation therapy is appropriate. Sinusitis Sinusitis caused by infection does not have literature support for treatment by radiation therapy. Splenomegaly Splenomegaly treated by radiation therapy is most commonly caused by leukemic or myeloproliferative diseases, and to a lesser extent by metastases from solid tumors. The policy for the use of radiation therapy in these malignant conditions is not covered in this Guideline for the treatment of non-malignant disorders. Typically radiation is delivered in ten or fewer sessions, planned using complex or three-dimensional technique. While once common, this procedure has been less frequently performed with the availability of drug eluting stents. Support for this has not continued into newer references other than Pigmented Villonodular Synovitis. There is ample world literature that describes the successful use of radiation to treat insertion tendonitis, a practice that is more common in Europe than the Americas. The mainstay of treatment is conservative using a pharmacologic or physical therapy approach. Typical treatment is with photon beam therapy using, at most, complex treatment planning, and delivered in up to five sessions. Policy: Radiation therapy is medically necessary for those cases not responding to conservative measures and case will require medical review. There are several types of thymoma ranging from the benign medullary thymoma to true invasive thymic carcinomas. There is general agreement that thymomas respond to radiation therapy, but controversy exists on the value of using radiation in low and intermediate stages and grades, especially if encapsulated and fully resected. Radiation therapy is appropriate if unresectable or incompletely resected, particularly if causing a paraneoplastic syndrome. Thyroiditis Presently there is no indication for the use of radiation therapy for the treatment of thyroiditis. Tolosa-hunt syndrome (episodic orbital pain) this is caused by nonspecific inflammation of the cavernous sinus or superior orbital fissure. The successful use of low dose radiation has been reported and may be used as a last resort. Tonsillitis In the modern era of antibiotics, the use of radiation to treat inflamed or infected tonsils is obsolete. Total body irradiation For the preparation of patients for bone marrow or stem cell transplant for malignant disorders, see the Guideline for the primary disease. For non-malignant, pre-malignant and quasi-benign marrow disorders such as aplastic anemia or myelodysplastic disorders, total body irradiation prior to transplant may be appropriate if chemotherapeutic preparation is not possible. The use of total body irradiation for immunosuppression as treatment of totally non-malignant disorders, such as auto-immune diseases is not medically appropriate. Total lymphoid irradiation Total lymphoid irradiation has been used for the purpose of immunosuppression in the treatment of immune-mediated disorders. Further research is needed to establish its role, but it remains an option in situations of chronic rejection in which conventional antirejection treatment is no longer viable. Policy: Requests require medical review and confirmation that alternatives have been exhausted. Trigeminal neuralgia (tic douloureux) Radiation therapy is considered appropriate for cases not responding to conservative management if a surgical approach is not possible for technical or medical reasons. Tuberculosis lymphadenitis Prior to the availability of antibiotics for tuberculosis, lymphadenitis caused by this disease responded to therapeutic radiation. Vernal catarrh this disorder is characterized by inflammation of the conjunctiva associated with infiltration by eosinophils, lymphocytes, plasma cells and histiocytes. The resultant hyperplasia of the conjunctival epithelium may respond to ionizing radiation, but alternative therapy is readily available and the use of radiation is no longer supported in any literature. Warts Older literature describes an 80% response rate in treating warts with a relatively low dose of radiation and it is described in at least one modern text (Gunderson). With the availability of alternative therapy, the use of radiation should be reserved for those cases requiring treatment for which alternative, simpler therapy has been unsuccessful. Committee to Review the Use of Ionizing Radiation for the Treatment of Benign Diseases. Preventing Breast Cancer: the Story of a Major, Proven, Preventable Cause of this Disease. Consensus guidelines for radiation therapy of benign diseases: a multicenter approach in Germany. Radiotherapy for non-malignant disorders: state of the art and update of the evidencebased practice guidelines. Has had or who will undergo curative treatment of the primary tumor (based on T and N stage) and 2. Presents with 1 to 3 metastases in the lung or liver in the synchronous setting and 3. A clinical presentation of one 1 to 3 adrenal gland, lung, liver or bone metastases in the metachronous setting when all the following criteria are met: a. Histology is non-small cell lung, colon, breast, sarcoma, renal cell, or melanoma b. Oligometastatic disease found at the time of the diagnosis of the primary tumor C. Progression of a limited number of metastatic sites while other metastatic disease sites remain controlled. Discussion Oligometastases is described as an intermediate state in the spread of cancer between early-stage localized disease and widespread metastases. Specifically, it is a malignancy that has progressed to a limited number of hematogenous metastatic sites, defined in most studies as 1 to 3 sites. Chemotherapy remains the standard of care for patients with metastatic cancer, however this is rarely curative. The concept of oligometastasis has important implications for cancer treatment because it is believed that patients with limited numbers of metastasis previously thought by some clinicians to be incurable may be cured with local treatments such as radiotherapy.

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Primary Ocular Abnormalities It may be difficult to womens health articles buy 20 mg sarafem visa distinguish anophthalmia (congenital absence of the eye) from severe microphthalmia (hypoplastic eye) or orbital hypoplasia breast cancer genetics 10 mg sarafem for sale. Ocular structures (lens and globe) are absent in primary anophthalmia but present in microphthalmia womens health 50 years old purchase discount sarafem line. Anophthalmia may be sporadic or may occur with chromosomal syndromes and complex craniofacial anomalies pregnancy 9 weeks 3 days purchase 10mg sarafem with visa. Typical colobomas result from failure of embryonic choroidal fissure closure and are usually bilateral. On imaging, a small cyst is found behind the globe at the head of the optic nerve (see. Optic nerve hypoplasia, defined as a subnormal number of axons, is a common and isolated anomaly. Typical clinical findings include leukocoria (white pupil), microphthalmia, and cataract. Glaucoma is abnormally elevated intraocular pressure due to disordered aqueous humor flow. Primary congenital glaucoma is usually bilateral and may occur with other disorders. Coats disease is a primary retinal vascular anomaly (telangiectasia with retinal and subretinal lipoproteinaceous exudates) with peak occurrence at the end of the first decade. Retinal detachment with leukocoria makes it difficult to differentiate from retinoblastoma. Retrolental fibroplasia, or retinopathy of prematurity, is usually bilateral and asymmetric. There may be retinal detachment or leukocoria, in which case the abnormality can mimic retinoblastoma. Ocular and Orbital Abnormalities Associated with Central Nervous System Malformations Orbital abnormalities are commonly associated with neural tube disorders (see Chapter 8). Cephaloceles, which commonly involve the orbit or optic pathways, can be classified as sphenoidal or frontoethmoidal. Dermal sinuses and dermoid-epidermoids 300 Pediatric Radiology: the Requisites Distal obstruction produces a nasolacrimal duct mucocele that extends beneath the inferior turbinate into the nasal cavity. Imaging demonstrates a medial canthus cystic mass in continuity with an enlarged nasolacrimal duct (and canal) and an intranasal submucosal cystic mass. The latter differentiates the mucocele from other medial canthal cystic masses. Ectopic lacrimal gland tissue may appear as solid or cystic lesions of the orbit and may produce proptosis. Dermoid-epidermoid, the most common congenital lesion of the orbit, arises as a developmental sequestration of ectoderm along the sutures. Fibrous dysplasia produces a characteristic "ground-glass" or sclerotic appearance of the orbit, facial bones, or skull base. Septooptic dysplasia (de Morsier syndrome) involves partial or complete absence of the septum pellucidum and optic hypoplasia. Orbital abnormalities are also part of the craniofacial malformations and craniosynostosis associated with disorders such as Crouzon disease and Apert, Carpenter, and Pfeiffer syndromes. Treacher Collins syndrome is another example of a craniofacial syndrome with orbital/ocular abnormalities. Migrational disorders are often associated with ocular, orbital, or optic pathway abnormalities (callosal hypogenesis, lissencephaly syndromes). Callosal hypogenesis is seen in a wide array of anomalies, including cephaloceles, dermal sinus, septo-optic dysplasia, cleft lip and palate, Apert syndrome, hypertelorism, coloboma, and Aicardi syndrome. Midface and orbital dysmorphia, as well as ocular anomalies, are frequently seen in the lissencephaly syndromes. Malformative Lesions Malformative tumors, nonneoplastic and neoplastic, are aberrations of development. It may be difficult to differentiate a coloboma from a retrobulbar duplication cyst. Hydrops and arachnoid cyst of the optic nerve sheath are exceedingly rare in the absence of suprasellar tumors or cysts. Congenital nasolacrimal duct cyst or mucocele probably results from incomplete canalization of the duct on one or both sides. Proximal obstruction results in a lacrimal sac mucocele and manifests as a medial orbital canthal mass (dacryocystocele). Nasal Cavity, Paranasal Sinuses, and Face Normal Development the mesenchymal primordia of the face form about the stomodeum (primitive mouth) and include the frontonasal prominence, maxillary prominences, and the mandibular prominences. These structures, respectively, give rise to the forehead, nose and nasal septum; turbinates, upper lip, premaxilla, maxilla, hard palate, soft palate, uvula; mandible, lower lip, chin, and lower cheek. The nasal cavities develop and ultimately communicate with the nasopharynx and oral cavity after rupture of the oronasal membrane at the level of the choanae. Left orbitofrontal fibrous dysplasia (arrows) with mixed sclerotic and lytic features and orbital deformity on axial (A) and (B) and coronal epithelium develops in the roof of each nasal cavity and connects with the olfactory bulbs of the prosencephalon. The paranasal sinuses form as diverticula of the walls of the nasal cavities and later become pneumatized. The small size of the face relative to the head at birth results from the more rapid development of the brain. The maxillary sinuses and ethmoid air cells are present at birth but may not be visible until 3 to 6 months of age (adult size by 10 to 12 years). The frontal sinuses, anterior and middle ethmoidal air cells, and maxillary sinuses drain into the middle meatus via the ostiomeatal complex. The posterior ethmoidal air cells and sphenoidal sinuses drain into the sphenoethmoidal recess and superior nasal meatus. During early infancy, there may be physiologic underaeration of the paranasal sinuses owing to redundant normal mucosa. Paranasal sinus disease is characterized by decreased aeration, mucosal thickening, soft tissue masses. Congenital Nasal Stenosis and Atresia Nasal airway obstruction may be the cause of respiratory distress in the newborn and infant. An obstructive abnormality is further indicated by inability to pass nasal catheters. The differential diagnosis usually includes nasal cavity and choanal stenosis or atresia, basal cephalocele, and bilateral nasolacrimal duct cysts. They may manifest as bilateral nasal obstruction and respiratory distress in the newborn and are to be distinguished from nasochoanal stenosis/atresia and nasolacrimal duct cysts (discussed earlier). The fonticulus frontalis and prenasal space are transient nasofrontal structures that involute in early gestation. Persistence of these primitive structures may be associated with a dural diverticulum and protrusion of intracranial contents as a nasofrontal cephalocele or a nasoethmoidal cephalocele. With partial or complete obliteration of the intracranial connection, the cephalocele becomes a sequestered neuroepithelial heterotopia (nasal glioma;. As the dural diverticulum regresses, incorporation of surface ectoderm may form a dermal sinus. Other associated findings include nasal Choanal stenosis and atresia, respectively, are narrowing of the posterior nasal cavity and obstruction by an atresia plate (bony, membranous, or both). Stenosis of the entire nasal airway is usually bony and may be associated with prematurity or maxillary hypoplasia. This may be associated with single midline maxillary incisor (mega-incisor) and midline intracranial anomalies. Segmental stenosis may also result from maxillary hypoplasia, turbinate hyperplasia, or nasal septal deviation. A, Bilateral choanal atresia (lower arrows) with retained secretions plus right nasal septal deviation (upper arrow). B, Right unilateral choanal atresia (arrow) with retained secretions; compare with the normal left choanal aperture. An intracranial communication may result in recurrent meningitis, abscess, or empyema. Other rare congenital nasal masses are nasoalveolar (incisive canal) cysts, dentigerous cysts, mucous cysts, vascular anomalies, branchial cysts, hamartomas, teratoid tumors (embryoma, epignathus), and Tornwaldt cyst. Facial Anomalies Cleft Lip and Palate Clefts involving the lip, alveolus, or palate are common anomalies and may be partial, complete, unilateral, or bilateral.

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