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Currently cheap atenolol 50mg without a prescription arrhythmia from caffeine, the risk of morbidity from stereotactic biopsy is ~1%; thus buy atenolol 100mg otc blood pressure treatment, tis- sue diagnosis is advocated purchase atenolol with mastercard arterial blood gas interpretation. Paulino Staging for Medulloblastoma and Supratentorial Primitive Neuroectodermal Tumor Clinical staging for pediatric brain tumors are not commonly practiced. Radiology 93:1351– 1359 Prognosis Factors and prognoses of pediatric brain tumors are detailed in Table 36. Radiation therapy is used if complete resection cannot be performed, such as in the thalamus. Another option is observation if the site of tumor will not compromise neurologic function with slow growth, and re-resection is an op- tion. If more immediate treatment is needed, such as in large unresectable tu- mors, chemotherapy has been used in younger children to delay radiothera- py. Fibrillary Astrocytoma and Pleomorphic Xanthoastrocytomas Surgery is the mainstay treatment for these diseases, and radiation therapy and chemotherapy are reserved for unresectable sites or progressive disease after gross total and subtotal resection. Treatment of High-Grade Astrocytoma the surgical and radiotherapeutic management for high-grade astrocytomas are similar in adults and children. Chapter 36 Pediatric Brain Tumors 1025 Treatment of Brainstem Glioma Diffuse Brainstem Glioma Radiation therapy is the mainstay treatment modality for diffuse brainstem glioma. Other Types of Brainstem Glioma the management for dorsally exophytic, cervicomedullary, and focal brain- stem glioma is surgery. These tumors are usually pilocytic astrocytomas, and most are controlled without adjuvant radiotherapy. Treatment of Ependymoma Surgery is the mainstay treatment modality, and radiation therapy is consid- ered the standard adjuvant therapy for intracranial ependymomas. Treatment options for ependymoma include surgery and postoperative ra- diation therapy (Table 36. Paulino Clinical evidence for the use of gross total resection with or without radia- tion therapy is listed in Table 36. Pediatr Hematol Oncol 19:295–308 bSource: Hukin J, Epstein F, Lefton D et al (1998) Treatment of intracranial ependymo- ma by surgery alone. Pediatr Neurosurg 29:40–45 cSource: Rogers L, Pueschel J, Spetzler R et al (2005) Is gross total resection suffcient treatment for posterior fossa ependymomas? Med Pediatr On- col 27:8–14 Treatment of Germ Cell Tumors Pure Germinoma Treatment options include neoadjuvant chemotherapy, followed by radiation therapy or radiation alone. Whether the use of neoadjuvant chemotherapy can reduce radiation dose and volume hence minimize late toxicities as compared with radiation alone with higher dose and larger volume remains to be seen. The use of chemo- Chapter 36 Pediatric Brain Tumors 1029 therapy such as cisplatin introduces another potential long-term toxicity – hearing loss – to these patients. Treatment for Craniopharyngioma Treatment modalities for craniopharyngioma include surgery and postop- erative radiation therapy. Reserved primarily for tumors with solitary cystic lesion with a stable or non- problematic solid component Chemotherapy Indications ??Generally has no role in treatment? ???Exception is occasional use of bleomycin as intracavitary treatment 1030 Arnold C. Paulino Target volumes in radiation therapy, as well as radiation dose and fraction- ation based on diagnosis, are detailed in Table 36. A dose gradient of ?5 to +7% of the prescribed dose is recommended for neuraxis irradiation for dose homogeneity. Feathering of the craniospinal and spinal–spinal junction is performed at least every five treatments to mini- mize under- or overdosing of the junction sites. Note the “dip- ping” of isodose lines to spare the right and left cochlea 1034 Arnold C. Mansur Epidemiology and Risk Factors Epidemiology statistics and etiologic factors for retinoblastoma are presented in Table 37. N Engl J Med 321:1689–1695 Chapter 37 Retinoblastoma 1039 Anatomy the basic anatomy of the eye is presented in Figure 37. Of special note for treating retinal tumors with radiation therapy is the proximity of the lens to the anterior-most retina extent (ora serrata). This has implications when con- sidering the use of lens-sparing techniques, which should only be used when disease is significantly posterior to the lens to prevent shielding of tumor. Ora Serrata Retina Vitreous Base Limbus Lens Cornea 3-4mm 2-3mm 16-23 mm Figure 37. Mansur Patterns of Spread Tumors arise from the retina and typically grow either into the vitreous or subretinal space by direct extension. Clinical Presentation the most common presentation is leukocoria (presence of a white pupillary light reflex). This is typically either seen by ophthalmoscopy during a screen- ing physical examination, or noticed by family members in a flash photograph. Enucleation is typically avoided in over 90% of group I eyes, but only 50% of group V eyes. The main limitation of the Reese-Ellsworth Classification is that it has less utility for modern approaches that utilize chemoreduction and local therapies. The success of chemoreduction is better predicted with the International Classification of Retinoblastoma (Table 37. Prognosis the Reese-Ellsworth and the International Classification Systems (Tables 37. Ophthalmology 113:2276–2280 patients with intraocular disease is typically greater than 90%. A staging system for retinoblastoma that takes into account all dis- ease extents has been recently proposed (Table 37. Pediatr Blood Cancer 47:801–805 Treatment the goal of treatment is maximizing cure rates while preserving vision and reducing late effects of therapy. To achieve this end, a multidisciplinary ap- proach is required to rationally apply the various modalities available in treating this disease (Table 37. Close collaboration is required between ophthalmology, pediatric oncology, and pediatric radiation oncology. However, with the development of modern focal therapies and effective systemic chemotherapy, the role of radiation therapy in this disease has become more limited. To achieve nega- and no potential for useful tive surgical margins, vision or in the presence of a generous length (15 tumor-related glaucoma. Optimal treatment depends on proper patient selection, which requires a comprehensive, multi- disciplinary approach. In the absence of alone risk factors, patients will be observed Chapter 37 Retinoblastoma 1047 the goals of these studies are to confirm chemotherapy response rates and efficacy described in single-institutional reports, to demonstrate the useful- ness of the International Classification System in the modern era of retino- blastoma therapy, and to establish national collaboration in the therapy of ret- inoblastoma. Retinoblastoma has been historically treated with lateral beams to encom- pass the affected retina(s), and spare the lens anteriorly, if possible. The beam is oriented posteriorly a few degrees to avoid divergence through the contralateral lens. When considering the penumbra of the beam and the proximity of the ora serrata to the posterior aspect of the lens ure 37. In cases where there is disease more extensive such as vitreous seeding, it is necessary to treat a larger volume. The prescription dose is quite conformal at the expense of low doses delivered to a large, uninvolved area.
The right gastroepiploic artery gives branches to the stomach and to the greater omentum buy cheapest atenolol and atenolol arteria tibial anterior. They descend respectively ante- rior and posterior to the junction of the second part of the duodenum with the pancreas purchase atenolol once a day heart attack 5 hour energy. They supply the pancreas generic 50mg atenolol otc arrhythmia heart murmur, and the duodenum up to the level of the major duodenal papilla. Here, they anasto- mose with the inferior pancreaticoduodenal artery (branch of superior mesenteric artery). Note that the part of the duodenum above the major duodenal papilla is a derivative of the foregut. It is, therefore, supplied by branches of the coeliac trunk, which is the artery of the foregut. The rest of the duodenum is derived from the midgut, the artery of which is the superior mesenteric. The part of the duodenum below the major duodenal papilla is, therefore, supplied by the branches of the supe- rior mesenteric artery. It passes to the right behind the hepatic and cystic ducts to reach the gall bladder that it supplies. Hepatic Branches the right and left hepatic branches enter the corresponding lobe of the liver and divide within them in a fairly constant manner. As a result of this fact the liver can be divided into a number of arterial segments (described in Chapter 28). Its initial part runs to the left on the posterior abdominal wall along the upper border of the pancreas (29. Reaching the front of the left kidney the artery passes into the lienorenal ligament to reach the hilum of the spleen where it divides into several branches. Several branches are given off to the pancreas, as the artery runs along this organ. It passes downwards, forwards and to the right through the gastrosplenic ligament to reach the greater curvature of the stomach. It gives branches to the stomach, and to the greater omentum and ends by anastomosing with the right gastroepiploic artery. From the above account of the coeliac trunk and its branches it will be seen that, apart from the liver, pancreas and spleen, the trunk supplies the infradiaphragmatic part of the gut up to the middle of the descending part of the duodenum (up to the major duodenal papilla). Its area of supply extends cranially up to the middle of the descending part of the duodenum, and caudally to the junction of the right two-thirds and left one-third of the transverse colon. The artery arises from the front of the abdominal aorta a little below the coeliac trunk and runs downwards and forwards. The artery then crosses in front of the horizontal part of the duodenum to enter the root of the mesentery. Passing through the root of the mesentery it runs downwards and to the right to reach the ileocaecal junction. This part lies deep to the pancreas and the splenic vein, and superfcial to the left renal vein that separates it from the front of the aorta. The next part of the artery passes in front of the horizontal part of the duodenum. The artery is accompanied by the superior mesenteric vein, which lies to its right side, and by a plexus of nerves. It divides into anterior and posterior branches that run upwards on corresponding aspects of the head of the pancreas. They supply the pancreas and duodenum and anastomose with the branches of the superior pancreati- coduodenal arteries. They arise from the left side of the superior mesenteric artery and pass through the mesentery to reach the gut. The branches anastomose with each other to form a series of arches from which numerous straight arteries arise to supply the gut (29. The ileocolic artery arises from the right side of the lower part of the superior mesenteric artery. The inferior branch anastomoses with the terminal part of the superior mesenteric artery. The ileocolic artery gives off various branches that supply the terminal part of the ileum, the caecum, the appendix and the lower one-third of the ascending colon (29. The right colic artery arises from the right side of the superior mesenteric artery at about its middle. It passes to the right (on the posterior abdominal wall) to reach the ascending colon. It terminates by dividing into descending and ascending branches that anastomose with the ileocolic and middle colic arteries, respectively. The middle colic artery arises from the right side of the superior mesenteric artery just below the duodenum. Its branches anastomose (on the right side) with those of the right colic artery, and (on the left side) with those of the left colic artery (a branch of the inferior mesenteric artery). Note that the inferior pancreaticoduodenal, right colic and ileocolic branches have a retroperitoneal course (29. Its area of supply extends from the junction of the right two-thirds and left one-third of the transverse colon to the rectum. Beginning over the middle of the aorta (deep to the horizontal part of the duodenum) it gradually crosses to its left side. It then crosses the left common iliac artery below which its continuation is called the superior rectal artery. The branches given off by the inferior mesenteric artery are the left colic, sigmoid and superior rectal arteries. The left colic artery runs upwards and to the left behind the peritoneum of the posterior abdominal wall and divides into ascending and descending branches. Here, it anastomoses with the middle colic branch of the superior mesenteric artery. The various branches of the left colic artery subdivide and form arcades from which straight arteries arise to supply the left one-third of the transverse colon and most of the descending colon. They anastomose with the lower branches of the left colic artery and help to supply the lower part of the descending colon. The superior rectal artery is a continuation of the inferior mesenteric artery into the true pelvis. It divides into two main branches one of which descends on either side of the rectum and supplies it. They anastomose with the middle rectal artery (branch of internal iliac) and with the inferior rectal artery (branch of internal pudendal artery). Normally the arteries supplying an organ end in a set of capillaries from which blood is collected by veins that carry it to the heart (29.
Syndromes
Diaphragmatic injuries are usually left sided (90%) (31) However generic atenolol 50mg free shipping prehypertension and viagra, because fractures of the ?rst through third ribs are 463 purchase 100 mg atenolol fast delivery arteria definicion. Right-sided injuries are less common cheap atenolol online american express blood pressure jumping around, indicative of high-velocity trauma, other intrathoracic 21:20:04 32 Jonathan Patane and Megan Boysen-Osborn Figure 32. However, a frontal chest radiograph misses most sternal injuries should be investigated (27). Fractures of the eighth through eleventh ribs may be associated with upper abdominal visceral Vertebral fractures injury (27). Flail chest occurs when multiple rib fractures the most common vertebral fractures are transverse process, occur to three or more ribs. Like sternoclavicular dislo- patients with vertebral fractures compared with 73% on radio- cations and ?rst through third rib fractures, they are a marker graph (53). The surgical management of these fractures depends on the particular center’s orthopedic preference (35). Lateral chest radiographs have help identify the course of a bullet or knife (21). Arch computed tomography versus chest x-ray in patients with Intern Med 2009;269:2078–86. Radiol supine chest radiograph and bedside ultrasound for the Clin North Am 2006;44:213–24. Radiology pulmonary embolism: a multicenter study of 1,025 emergency 1994;192:803–8. Ketai L, Brandt M-M, Schermer C: Nonaortic mediastinal the spine necessary during evaluation after blunt trauma? J Thorac Imaging 2000;15: Accuracy of screening torso computed tomography in thoracic/ 120–7. Dolich 3 or infection, and revealing traumatic injuries not seen with Indications earlier generation scanners. The rapid diagnosis of and it may help prevent unnecessary admissions from underlying pathology in the “acute abdomen” is critical to emergency departments. Physical examination and laboratory ?ndings are itate determination of which patients require surgical inter- often nonspeci?c, so e?cient diagnostic tools are essential. Scanning without intravenous contrast cities of 95% to 100% for the diagnosis of bowel and mesen- generates the fastest, but most limited, images. The sensitivities for diagnosing contrasted studies need to be later repeated with contrast, solid organ injuries are even higher. In the latter circumstance, renal excretion of the tion of water and diminution of bowel wall edema, allowing contrast material may opacify the collecting system and resolution of mechanical small bowel obstruction. In almost all to generate reconstructions in di?erent planes on multidetec- other cases, contrast is indicated. Findings suggestive of closed-loop intestinal obstruc- setting of blunt abdominal trauma has diminished over recent tion include a C-shaped, U-shaped, or “co?ee bean” appear- years as the added bene?t is relatively small and the risk of ance to the bowel, as well as a “whirlpool sign” of mesentery aspiration is higher in this patient population. This informa- rectal contrast may be administered for cases of suspected tion is vital, as closed-loop bowel obstructions generally man- colonic or rectal perforation from penetrating abdominal, date emergent surgical intervention. To obtain the highest quality sition of images has reduced motion artifact because the images and to answer the clinical question e?ciently, con- entire abdomen can be scanned on a single breath-hold. In more severe cases of appendicitis, the presence of pancreatic protocol is often useful in visualizing all por- a right lower quadrant phlegmon, ?uid, extraluminal air tions of the organ. A discussion with the radiologist about visualize the appendix in challenging cases. Pancreatitis may present the most sensitive ?ndings in acute cholecystitis are gall- with a wide spectrum of severity, from mild, self-limited bladder wall thickening greater than 3 mm and increased cases to life-threatening necrosis with septic shock. Patients typically present with rounding liver from in?ammation, subserosal edema, and fever, left upper quadrant pain, and leukocytosis. Cases of cecal volvulus require urgent surgical eva- A normal liver receives 75% of its blood ?ow from the portal luation because it is a closed-loop obstruction; delay in treat- vein and 25% from the hepatic artery. The most common primary liver quite helpful in grading cases of acute diverticulitis. In cases of cause clinical confusion if the provider is not aware of possible aortic dissection, the onset of the dissection is often associated anatomical variations. If the appendix is quite long, it can with severe chest or back pain, described as tearing that moves track up along the right paracolic gutter and reach as high as distally as the dissection propagates. In this circumstance, in?ammation iso- aneurysms are asymptomatic and are often found incidentally lated to the distal end of the appendix, or “tip appendicitis,” during workup of another ailment. The pain is the cancer risks because cancer induction rates are approximated result of stretching retroperitoneal tissues and is associated from historical data from occupational and wartime exposures. Solid organ injury after blunt abdominal trauma can be graded according to standard radiologic scales, and stable patients with lower grade injuries may frequently be managed nonoperatively. Focal small bowel thickening, free ?uid without solid organ injury, and mesen- teric bleeding may signal intestinal injury and typically prompt further diagnostic studies or early surgical interven- tion. Free intraperitoneal air is a relatively rare occurrence in the early period after blunt trauma to the abdomen, and its absence should not falsely reassure the clinician. Imaging pitfalls and limitations the administration of contrast in a patient with undiagnosed renal insu?ciency may precipitate renal failure. The limiting factor may ultimately be the technical speci?cation of the scanner table because patients over a certain weight may interfere with movement of the table during the scan. There is concern for ionizing radiation exposure in patients, especially the pediatric population, leading to increased risk for development of certain malignancies later Figure 33. Multiple air-?lled diverticula are noted ?uid is present between bowel loops (white arrows), as well as active throughout the sigmoid colon (arrows). Note prominent gallbladder wall with 474 active extravasation of contrast (arrow). Note free intraperitoneal blood surrounding both the however, signi?cant peripancreatic edema is present (arrows). The body of the pancreas is transected in the midline from compression against the spine (black arrows). Peripancreatic ?uid is noted along the tail of the pancreas as well (white arrows). Infrarenal abdominal aortic aneurysm with contained abdominal trauma (white arrow). Note extensive anterior displacement of the left kidney, as the left thorax (black arrows). Food and Drug Administration: Radiation-Emitting computed tomography of acute abdomen. Gurudevan and Reza Arsanjani 3 Prompt diagnosis and institution of anticoagulant therapy is Indications crucial to a favorable clinical outcome. Aortic dissection is an uncommon disease, with a peak incidence of 3 to 5 cases per 1 million people per year.
The constant compromise and coping disease or impairment of body or mind that is not with developing disability is an ever-increasing yet curable by any branch of medicine order 50 mg atenolol mastercard arteria circumflexa scapulae. We are activity purchase atenolol 50mg with amex blood pressure zantac, loss of previously held freedoms and the aware that many people who see themselves as changing/shrinking world around me means disabled resist being thought of as ill order atenolol with paypal blood pressure jokes, even chroni- dealing with an unknown situation, on a regular cally ill. The effort that has to go into finding tion is that it is defined by medicine as an abnormal information is an exhausting process and occurs at condition, and even if it cannot be cured medicine a time of low energy. Whether the patient resists receiving a sympathetic and supportive response the classification of disability as an illness, medi- could play a strong part in the process of healing. This leads to the challenging when practitioners recognize that the way they issue of where patient narratives fit in the clinical respond to the panic, stress and trauma associated decision-making process. On the one hand we with life-challenging diagnoses have such a challenge practitioners to listen well to the narra- tremendous impact on survival. On the other hand, perhaps we should Some people who are diagnosed with a chronic ill- replace the terms clinical (pertaining to biomedical ness or disability do not get better, are not cured pathology) and decision making (commonly imply- and never return to ‘normal’. People working ing a dominant role for, and expertise of, the prac- across the whole spectrum of the health profes- titioner) with lifestyle negotiation, where partners sions both know and avoid acknowledging and with different areas of expertise and potential con- dealing with this reality. The dominant narrative, tributions negotiate on ways of supporting the cli- or belief, is that once diagnosed you will be treated, ent’s optimal lifestyle. All energies, all treat- are recognizing and honouring the fact that, ments and all interventions are geared to the goal although stranded in illness as far as their medical that it is possible to get better. This is the promise status is concerned, people who live with a chronic Beyond the restitution narrative: lived bodies and expert patients 351 condition try to create a way of life that makes them behave towards illness. There are dis- chronic conditions try to create a new ‘normal’ for cursive layers where the rhetoric about health and themselves? There are social layers that tell us how to behave with illness and around illness. Because they are taken for granted, seen as normal, they are mostly A stroke patient is pleased at first that she has invisible. As the impossible to negotiate ways around and through medical efforts subside, however, she begins to them. The attitudes around her It is my body, reflect her lost value to the community, her my life helplessness and the paucity of options available. Expertise is supposed to rest with the professional entirely and not at all with the patient. The sheer A person living with an incurable illness is firmly weight of history that professionals have had with located as abnormal, ill and disabled. As this per- other patients works against an individually- son turned patient begins to negotiate the spatial referenced perception being made. The system is layers of discourse, attitudes and assumptions unwieldy and inflexible. There is an appalling lack concerning being ill and disabled, she encounters of imagination among health scientists and a sticky web of professional, social and cultural professionals that sometimes makes it hard for attitudes and practices that have been constructed them to see outside the label box. Everything Medicine examines and treats bodies and minds that now happens in the life of the patient is (Fosket 2000; Foucault 1982; Illich 1977; Porter coloured by that dualism and those values. The status of these bodies and minds values are deeply seated and reflect Western is determined by a series of tests which subject society’s fears about decay and death (Garland- the body–mind to minute and objective surveil- Thomson 1997). Classification by way of Gender theorists suggest that we act out what it diagnosis follows. Ideally, diagnosis leads to treat- is to be male or female according to pre-written cul- ment options and some idea of prognosis. This tural scripts that tell us what to do, how to be, and whole performance is theoretically independent that allow other people to read us and be able to tell of the subjective world of the patient. The patient who we are (Butler 1993, Connell 2002, Kimmel is expected to render herself a passive recipient of 2000). There are well-trodden paths that tell professional care, acting only when asked to carry patients and doctors and the rest of the community out medical instructions. Have you caused or contribu- alienates her medical carers when she refuses ted to this black hole? Is your motivation the some medications on the basis that they will existence of life or the support of living? Medicine often proceeds on I have to go on living with forever the principle that all instances of disease are essen- then maybe tially the same. The lived body encompasses the idea what I know about it is as valid and valuable that the body–mind under the medical gaze is not as what you know about it free of values, is not interchangeable with any other perhaps my expertise body–mind, and cannot be properly read without in my life narrative the original inhabitant and her life world. What- is greater than yours ever is going on in the body is influenced and affected by the subjectivity of the person who lives the lived body produces an expert patient. The in it, and has to be incorporated into a particular expert patient accumulates an impressive research life. It follows that any health care will be more or history as she works through the issues of her ill- less successful depending on whether it takes the ness and begins to know what works for her and subjectivity of a lived body into account. Along this journey to expertise body is the sum of all the physical and mental signs there are many stages and many levels of self- and symptoms normally regarded as the proper empowerment and self-awareness. For those com- focus for health care, plus the experiences of living ing to terms with their new living reality, under- those signs and symptoms in the day-to-day world. By trum of bodily and mental experience and the sub- comparison, the expert patient brings her lived jective values that guide the life lived with/in that body into every medical encounter and insists on body. The lived body brings all its experiences into its recognition in that environment. This insistence the surgery and refuses to be treated without these often meets resistance from professionals: being part of the decision-making equation. Living with an atypical form of Parkinson’s disease, After her stroke she was told by her doctors that a woman who lives alone needs medical there was little point in hoping for improvement reassurance when her breathing is threatened. She was left to her own encounters different staff all the time at Accident devices. She wanted to die because there was no and Emergency, all of whom insist on reading her hope. She never thought that her doctors might body by the usual methods and not listening to be wrong. The knowledge of the body possessed by the staff is supposed to be all that is required. She has Here is the difference between feeling like a body refused certain medications because they have and feeling like a lived body. She is sidelined is interested in is the drama of the fight to keep as a difficult patient. She With/in the medical narrative, authority on the wants the help of medicine insofar as it is able to lived body of the chronically ill person is posi- help at all, and she wants to benefit from future tioned with the practitioner, not with the patient. But for the time being, she is trying This authority enables the practitioner to tell the to live out a life that feels as normal and satisfying ‘truth’ about the patient’s body. She is trying to bridge the narrative gap exercised through the use of a highly technical between the old life that she could live before ill- and specialized language that is valued over the ness or disability disrupted narrative flow and a subjective discourse of patients.
