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Visual agnosia: disorders of object recognition and what they tell us about normal vision symptoms yeast infection women epivir-hbv 100mg otc. Cross References Simultanagnosia; Visual agnosia Visual Extinction Visual extinction is the failure to medications and mothers milk 2014 epivir-hbv 150 mg with mastercard respond to symptoms 20 weeks pregnant purchase epivir-hbv 100 mg line a novel or meaningful visual stimulus on one side when a homologous stimulus is given simultaneously to medicine 512 buy epivir-hbv 100mg free shipping the contralateral side. Cross References Extinction; Neglect Visual Field Defects Visual fields may be mapped clinically by confrontation testing. The most sensitive method is to use a small (5 mm) red pin, moreso than a waggling finger. Peripheral fields are tested by moving the target in from the periphery, and the patient asked to indicate when the colour red becomes detectable, not when they 364 Visual Form Agnosia V first see the pinhead. The central field may be mapped using the same target presented statically to points within the central field. The exact pattern of visual field loss may have localizing value due to the retinotopic arrangement of fibres in the visual pathways: any unilateral area of restricted loss implies a prechiasmatic lesion (choroid, retina, optic nerve), although lesions of the anterior calcarine cortex can produce a contralateral monocular temporal crescent. Bilateral homonymous scotomata are postchiasmal in origin; bilateral heteronymous scotomata may be seen with chiasmal lesions. Topographically, typical visual field defects are as follows: • Retina: monocular visual loss, altitudinal field defects; central or centrocaecal scotoma, ring scotoma; • Optic nerve: central or centrocaecal scotoma; junctional scotoma of Traquair; • Optic chiasm: bitemporal hemianopia; junctional scotoma; • Optic tract: homonymous hemianopia, usually incongruous; • Lateral genciulate nucleus: homonymous hemianopia, usually incongruous; • Optic radiations: homonymous hemianopia, usually congruous; quadrantanopia; • Visual cortex: homonymous hemianopia, usually congruous; quadrantanopia; cortical blindness. Cross References Altitudinal field defect; Hemianopia; Junctional scotoma, Junctional scotoma of Traquair; Macula sparing, Macula splitting; Quadrantanopia; Scotoma; Tilted disc Visual Form Agnosia this name has been given to an unusual and a highly selective visual perceptual deficit, characterized by loss of the ability to identify shape and form, although colour and surface detail can still be appreciated, but with striking preservation of visuomotor control. This syndrome is thought to refiect selective damage to the ventral (‘what’) stream of visual processing in the lateral occipital area, whilst the dorsal (‘where’) stream remains intact, yet the workings of the latter are not available to consciousness. It may be heard in: • Essential tremor; • Cerebellar disorders; • Spasmodic dysphonia/laryngeal dystonia; • Parkinson’s disease; • Motor neurone disease. The pathophysiology is uncertain but may relate to rhythmic contractions of the cricothyroid and rectus abdominis muscles. Cross References Dysphonia; Tremor Von Graefe’s Sign Von Graefe’s sign, or Graefe’s sign, is the retarded descent of the upper eyelid during movement of the eye from the primary position to downgaze; the lid ‘follows’ the eye. This may be termed ‘lid lag’, although some authorities reserve this term for a static situation in which the lid is higher than the globe on downgaze. Cross Reference Myopathy ‘Waiter’s Tip’ Posture Lesions of the upper trunk of the brachial plexus (Erb–Duchenne type) produce weakness and sensory loss in the C5 and C6 distribution, typically with the arm hanging at the side, internally rotated at the shoulder with the elbow extended and the forearm pronated: the ‘waiter’s tip’ posture, also sometimes known as the ‘porter’s tip’ or ‘policeman’s tip’. Cross References Myotonia; Paramyotonia Wartenberg’s Sign (1) In ulnar neuropathy, Wartenberg’s sign refers to the slightly greater abduction of the fifth digit on the affected side, due to paralysis of the adducting palmar interosseous muscle and unopposed action of the radial-innervated extensor muscles (digiti minimi, digitorum communis). With the patient standing, the examiner holds the shoulders and gently shakes backwards and forwards, the two sides out of phase. Normally, the passive arm swing induced by this movement will be out of phase with the trunk movements, but in rigidity the limbs and trunk tend to move en bloc. Passive swinging of the wrist or elbow joint may also be performed to assess rigidity. Cross References Parkinsonism; Rigidity; ‘Rolex’ sign; Spasticity Wasting Wasting refers to a thinning of the musculature, also known as atrophy or, if of neurogenic origin, amyotrophy. Wasting may be a consequence of disorders of: • muscle (myopathies, dystrophies); • peripheral nerve (more so in axonal than demyelinating peripheral neuropathies); • anterior horn cells. Wasting may also be seen in general medical disorders associated with a profound catabolic state. However, this is not a linear scale; grade 4 often becomes subdivided into 4fi,4,and4+(oreven5fi) according to the increasing degree of resistance which the examiner must apply to overcome activity. It is also important to assess what effort the patient is making to comply with the testing; ‘apparent weakness’ or ‘pseudoparesis’ may be shorthand for lack of patient effort. Testing records only 370 Wernicke’s Aphasia W the best-forced maximal contraction and should not develop into an unseemly trial of strength between patient and examiner. Accepting all these difficulties, it should be acknowledged that the grading of weakness, like all clinical observations, is subject to some degree of observer bias. However, there is no evidence that pure lesions of the pyramidal tracts produce this picture: pyramidotomy in the monkey results in a deficit in fine finger movements, but without weakness. Moreover, a similar pattern of weakness may be observed in lower motor neurone disorders such as Guillain–Barre syndrome. Coexistent wasting suggests that muscle weakness is of lower motor neurone origin, especially if acute, although wasting may occur in long-standing upper motor neurone lesions. Weakness with minimal or no muscle wasting may be non-organic, but may be seen in conditions such as multifocal motor neuropathy with conduction block. Cross Reference Rinne’s test Wernicke’s Aphasia Wernicke’s aphasia is the classical ‘receptive aphasia’, in distinction to the ‘expressive aphasia’ of Broca, although this classification is problematic since there are concurrent ‘expressive’ problems in Wernicke’s aphasia. Other terms sometimes used for Wernicke-type aphasia are sensory aphasia or posterior aphasia. Considering each of the features suggested for the clinical classification of aphasias (see Aphasia), Wernicke’s aphasia is characterized by: • Fluency: fiuent speech with phonemic and semantic paraphasias and paragrammatism (inappropriate use of syntax); ‘empty speech’ with few verbs and nouns; prosody usually preserved; at worst, fiowing speech (logorrhoea) 371 W Wheelchair Sign devoid of semantic meaning (jargon aphasia, semantic aphasia); automatic speech is often better preserved than spontaneous. Broca’s aphasia); • Reading: usually impaired, with numerous paralexic errors and impaired reading comprehension (cf. There may be associated anxiety, with or without agitation and paranoia, and concurrent auditory agnosia. Because of a loss of self-monitoring of output, patients are often not aware of the impairment, and behavioural disturbance sometimes misdiagnosed as ‘acute confusional state’ and even referral or admission to psychiatric hospital may occur, particularly if there is no or minimal accompanying hemiparesis. The differential diagnosis of Wernicke’s aphasia includes delirium and schizophasia. Wernicke placed it in the posterior two-thirds of the superior temporal gyrus and planum temporale (Brodmann area 22), but more recent neuroradiological studies (structural and functional imaging) suggest that this area may be more associated with the generation of paraphasia, whereas more ventral areas of temporal lobe and angular gyrus (Brodmann areas 37, 39, and 40) may be associated with disturbance of comprehension. A correlation exists between the size of the lesion and the extent of the aphasia. A similar clinical picture may occur with infarcts of the head of the left caudate nucleus and left thalamic nuclei. Cross References Agnosia; Agraphia; Alexia; Anomia; Aphasia; Broca’s aphasia; Jargon aphasia; Logorrhoea; Paraphasia; Pure word deafness; Schizophasia; Transcortical aphasias Wheelchair Sign the so-called wheelchair sign describes patients with parkinsonism who start to use a wheelchair for mobility early in the course of their disease, usually because of repeated falls. Early falls are a typical feature of progressive supranuclear palsy (Steele–Richardson–Olszewski syndrome), but not idiopathic Parkinson’s disease or other parkinsonian syndromes. Cross References Parkinsonism; ‘Rocket sign’ 372 Woltman’s Sign W Wing-Beating Tremor Wing-beating tremor is absent at rest but develops when the arms are extended, hence this is a postural tremor. Cross Reference Tremor Winging of the Scapula Winging of the scapula, or scapula alata, is a failure to hold the medial border of the scapula against the rib cage when pushing forward with the hands. It is most easily observed by asking the patient to push or press against a wall or the examiner’s hand whilst observing the scapula which lifts away from the posterior chest wall. Winging of the scapula may be a consequence of weakness of the serratus anterior muscle, usually due to a neuropathy of the long thoracic nerve of Bell, but sometimes as a consequence of brachial plexus injury or cervical root (C7) injury. Weakness of trapezius, particularly the middle trapezius muscle, may also cause winging of the upper part of the scapula, more prominent on abduction of the arm, when the superior angle of the scapula moves farther from the midline. Witzelsucht Witzelsucht, or the joking malady, refers to excessive and inappropriate facetiousness or jocularity, a term coined in the 1890s for one of the personality changes observed following frontal (especially orbitofrontal) lobe injury. Cross References Emotionalism, Emotional lability; Frontal lobe syndromes; Moria Woltman’s Sign Woltman’s sign denotes slow-relaxing, or ‘hung-up’, tendon refiexes. These are most commonly seen in the context of untreated hypothyroidism, but have also been recorded in other situations, including treatment with fi-blockers, diabetes mellitus, and complete heart block. The phenomenon is sometimes labelled ‘pseudomyotonia’ because of its superficial resemblance to the slow muscle relaxation of myotonia, but electrophysiological testing does not show myotonic discharges. Chorea may result in apparently ‘hung-up’ refiexes, perhaps due to a choreiform jerk after muscle relaxation. The mechanisms underlying Woltman’s sign are uncertain: changes in basal metabolic rate and in muscle fibre types (selective loss of fast twitch fibres) have been suggested. Normalisation of slow-relaxing tendon refiexes (Woltman’s sign) after cardiac pacing for complete heart block. Cross References Chorea; Myotonia; Pseudomyotonia Wrestler’s Sign this name has been given to the excessive effort in irrelevant muscle groups accompanied by prominent non-verbal signs of effort such as grunting in patients with apparent (‘functional’) weakness. It may coexist with intermittent voluntary effort, collapsing weakness, cocontraction of agonist and antagonist muscles, and inconsistency in clinical examination. Cross Reference Collapsing weakness Wrist Drop Wrist drop describes a hand hanging in fiexion due to weakness of wrist extension.

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Psychological effects of the disorder may cause severely impaired judgement leading to treatment plans for substance abuse buy discount epivir-hbv 150 mg online dangerous decisions and accidents medicine 95a epivir-hbv 150mg for sale. Depressed women may experience an overconcern for Startle the baby treatment yellow fever trusted 150mg epivir-hbv, guilt medicine 2 times a day 150mg epivir-hbv with amex, or feelings of inadequacy. Symptoms can include prominent, generalized anxiety symptoms, Panic attacks, or obsessions or compulsions. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. Specify if: With Generalized Anxiety: if excessive anxiety or worry about a number of events or activities predominates in the clinical presentation With Panic Attacks: if Panic Attacks predominate in the clinical presentation With Obsessive-Compulsive Symptoms: if obsessions or compulsions predominate in the clinical presentation Coding note: Include the name of the general medical condition on Axis I. Questions Symptoms can range from generalized anxiety symptoms (worry, restlessness, etc) to panic attacks (discrete periods of intense fear or discomfort) to obsessions or compulsions. There must be evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. The diagnosis of an anxiety disorder due to a general medical condition cannot be made if the symptoms can be accounted for by another mental disorder. The disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. This link must be made with some relative certainty, in order for the diagnosis to be accurate. Q: Is there any evidence of recent or prolonged substance use (including medications with psychoactive effects)fi The use of many illicit substances such as amphetamines, marijuana, cocaine, ecstasy, alcohol, and prescription medications may lead to symptoms of anxiety. Questions the diagnosis of substance-induced anxiety disorder may be more appropriate. There must be a prominent general medical condition for the diagnosis of anxiety disorder due to a general medical condition. In primary anxiety disorders, there is typically no specific and direct causative physiological mechanism associated with the onset of the anxiety symptoms. A variety of general medical conditions may cause anxiety symptoms, including endocrine conditions (thyroid disease, pheochromocytoma, etc), cardiovascular conditions (congestive heart failure, arrhythmia, etc), respiratory conditions (pneumonia, hyperventilation, etc), metabolic conditions (porphyria), and neurological conditions (neoplasms, encephalitis, etc). Q: Does the plaintiff have a history of any medical conditions that may cause anxiety or panic attacksfi The plaintiff with Specific Phobia experiences a marked and persistent fear of a clearly discernible object or situation. Plaintiffs claiming a specific phobia often have an early history of childhood fears, including school phobia. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging. The phobic situation(s) is avoided or else is endured with intense anxiety or distress. The anxiety, Panic Attacks, or phobic avoidance associated with the specific object or situation are not better accounted for by another mental disorder, such as Obsessive-Compulsive Disorder. Familial conditions are more common in bioFamilial logical relatives, and may have pre-existed the cause of action. In the case of Pattern Specific Phobia, fears of blood and injury have a particularly strong familial pattern. The plaintiff suffers from an immediate anxiety response in the form of a situationally bound or situationally predisposed panic attack. The plaintiff may try to avoid the situation or if not possible, he/she may endure it with intense anxiety or distress as described above. In many cases, the anxiety and avoidance behaviors would have pre-existed the cause of action. Questions If the witness indicates the possibility of other life stressors or other conditions, see (continued) the section on life stressors for further questions. It often produces personality changes, confusion, dizziness, tremor, anxiety, tachycardia, and sweating during acute attacks. A panic disorder is characterized by discrete periods of panic or intense anxiety. Between attacks, the plaintiff is anxious, worried, and fears having another attack. Panic symptoms include dizziness, shortness of breath, heart palpitations, smothering or choking sensations, feelings of unreality, tingling in hands or feet, hot and cold flashes, sweating, faintness, trembling or shaking, and the fear of dying or going crazy. The plaintiff typically avoids crowds, being outside alone, General standing in line, crossing a bridge, or riding in a vehicle. Agoraphobia is the fear and avoidance of places and situations in which the plaintiff would be unable to escape or get help if s/he had embarrassing symptoms. Symptoms of a limited agoraphobic attack may include dizziness or falling, depersonalization or derealization, loss of bladder or bowel control, vomiting, and cardiac distress. The avoidant plaintiff is characterized by social inhibition or discomfort, fear of negative evaluation, and timidity, along with a great desire for companionship and guarantees of uncritical acceptance. These plaintiffs rarely seek help because of a tendency to be moralistic, grandiose, and extrapunitive. The plaintiff with social phobia or social anxiety disorder, fears situations in which s/he may be scrutinized by others or in which s/he may do something humiliating or embarrassing. The plaintiff avoids or endures with intense anxiety situations such as public speaking, eating or writing in front of others, using public toilets, or answering questions in social situations. Questions the schizoid plaintiff is introverted, withdrawn, and prefers to be alone. S/he (continued) tends to be indifferent to social relationships and has few close friends outside the family. Panic attacks also occur in disorders other than panic disorder such as, mood disorders, in certain intoxication and withdrawal syndromes–in fact, any mental disorder. In addition, panic attacks may be observed in certain nonpsychiatric medical conditions. In some persons, the fear of having a panic attack becomes associated with certain situations, most commonly, using public transportation, driving across a bridge, being in a crowd, waiting in line, or leaving familiar settings alone. There are many alternate causes for panic attacks and the numerous symptoms related to this disorder. Both (1) and (2): (1) recurrent unexpected Panic Attacks (See linked section) (2) at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: (a) persistent concern about having additional attacks (b) worry about the implications of the attack or its consequences. The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia or social anxiety disorder. A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes: (1) palpitations, pounding heart, or accelerated heart rate (2) sweating (3) trembling or shaking (4) sensations of shortness of breath or smothering (5) feeling of choking (6) chest pain or discomfort (7) nausea or abdominal distress (8) feeling dizzy, unsteady, lightheaded, or faint (9) derealization (feelings of unreality) or depersonalization (being detached from oneself) (10) fear of losing control or going crazy (11) fear of dying (12) paresthesias (numbness or tingling sensations) (13) chills or hot flushes Note: Attacks involving four or more symptoms are panic attacks; attacks involving fewer than four symptoms are limited symptom attacks (see Agoraphobia Without History of Panic Disorder). First-degree biological relatives of Familial individuals with Panic Disorder are up to 8 times more likely to develop Panic Pattern Disorder (reference 7, p. Questions Panic disorder is characterized by the presence of recurrent, unexpected panic attacks followed by concern about having other panic attacks. Panic attacks are characterized by discrete periods of intense fear or discomfort with varying degrees of symptomology which develop abruptly. If the witness indicates that the fear between attacks is not associated with having another attack, the plaintiff may be experiencing generalized anxiety disorder and not panic disorder. Q: Does the plaintiff have concern about having another attack, worry about the implications of the attack or a change in behavior related to the attackfi Along with recurrent unexpected panic attacks, at least one of the attacks in one month must be accompanied by concern about another attack, worry about the implications of the attack and/or a change in behavior related to the attack. It is very difficult for any clinician to determine the cause of panic attacks, with any degree of certainty, without the completion of a thorough medical examination, blood-work including a thyroid study and a cardiovascular examination. Later in the illness certain situations may become so associated with panic attacks that the likelihood of having an attack increases, but the plaintiff can not be certain when an attack will occur or if it will occur at all. If the witness indicates that the attacks occur immediately before or on exposure to a situation that almost always causes anxiety, the plaintiff may have a specific phobia. The witness must indicate the occurrence of at least four panic symptoms during one attack. Q: Does the plaintiff have a history of intense anxiety and panic before the injury in questionfi Symptoms include muscle tension, restlessness, fatigue, difficulty concentrating, sleep disturbance, and irritability.

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Although these studies do not assess the overall efficacy of radiotherapy when compared with no radiotherapy treatment quadricep strain buy epivir-hbv 100mg overnight delivery, they do highlight that the vast proportion (60-80%) of patients receive palliative benefit with radiation and that a dose response is evident medications quetiapine fumarate 100 mg epivir-hbv with amex. The Swedish Council on Technology Assessment in Health Care (44) states that palliative radiotherapy is both clinically effective and economically justified and is therefore “the treatment method of choice in patients who have pain localised to treatment 31st october discount epivir-hbv 100mg online a skeletal region with a verified metastatic tumour” treatment cervical cancer discount epivir-hbv 100mg with amex. This may over-estimate the situation although no quality of life comparisons have ever been performed to prove that radiotherapy is inferior to other modalities in palliating pain. A study of patients with bone metastases from breast cancer (45) reports that 80% of bone metastases are painful. No comparable studies could be identified for patients with bone metastases from lung cancer and it was thought reasonable for the decision tree analysis that the 80% figure be used for the incidence of pain in patients with small or non-small cell lung cancer as most studies quoted here are based on clinical findings of bone metastases rather than investigation-based diagnosis. The only available data on the proportions of patients with these attributes were in studies of patients treated with best supportive care. However, there are wide variations in the use of radiotherapy between studies, reflecting different study durations and the potential subjectivity of the indication for delivery of radiotherapy. No firm criteria were established in any study to justify the use of radiotherapy. They found that radiotherapy was used in 9 49% of cases in the trial chemotherapy arms, versus 23 79% in the best supportive care arms of the trials. Most of these studies reported on the overall use of radiotherapy, without differentiating between patients with local primary symptoms requiring radiotherapy and those requiring radiotherapy for distant symptomatic disease. They reported that 40% of patients treated with mitomycin, ifosfamide and cisplatin required radiotherapy for local symptoms. In addition, sensitivity analysis using the data from these other studies was performed. For earlier stage disease where best supportive care was used because of poor performance status, information provided in the study by Muers et al. In this population-based study, once a decision was made on initial treatment, all non small cell lung cancer patients were followed up. One hundred and three patients in this study received best supportive care due to poor performance status, refusal of treatment and co-morbidity. Some of these patients had early stage disease but the overall proportion of early stage disease patients in this supportive care group was not reported. Twelve percent of the patients who received best supportive care ultimately required radiotherapy for progressive local or distant symptomatic disease. This study is based on actual practice rather than on evidence and therefore may either overor under-estimate the actual need for radiotherapy based on evidence. However, we could not identify any other study that reports on a lung cancer population with a proportion of early stage disease where best supportive care was used and then the patient developed local or distant relapse. N2 node positivity and radiotherapy the role of radiotherapy in patients who undergo surgical resection and have N2 disease on pathology assessment is highly controversial. There was no difference in survival and no statistical difference in local control when pooling the results (local recurrence = 195/1056 (18. Sub-group analysis revealed that radiotherapy was detrimental to survival for N0 disease, with no difference in survival for N1 and N2 disease. No raw local control data was presented in the paper to assess whether there was a difference in local control according to nodal status. In terms of guideline recommendations, there was conflict as to whether radiotherapy is recommended for N2 patients. The Scottish Intercollegiate Guidelines Network (2) states that there is evidence from randomised controlled trials for an increase in local control from giving radiotherapy following surgery to patients with N2 disease. The Royal College of Radiologists (4) suggest ”postoperative radiotherapy for residual disease may reduce locoregional relapse. In the decision tree, we have included the recommendation for postoperative radiotherapy for N2 on the basis of improved local control. There was no difference in survival between the groups and no difference in the distant metastatic rate. Note that these two studies include N2 patients whereas the branch point includes N01 only. The proportion of small cell lung cancer patients in whom radiotherapy was recommended at least once was 79%, and the proportion for non small cell lung cancer is 75%. Sensitivity Analysis There are several data elements where there was uncertainty because of different proportions reported in the literature. This includes the proportion of patients with small cell lung cancer with good performance status and local symptoms (0. To assess the impact of these uncertainties on the overall estimate of the need for radiotherapy in all lung cancers, and for small and non small cell lung cancer respectively, a one-way sensitivity analysis was performed for each of the variables. The impact of these variables on the overall results is illustrated by tornado diagrams (see graphs below). The graphs below show that the proportion of lung cancer patients that should receive radiotherapy based on evidence and incidence of attributes for radiotherapy was 73-76%, the proportion of small cell lung cancer to receive radiotherapy was 76-79%, and the proportion for non small cell lung cancer was 72-75%. A comparison of the results by histology and stage between the two studies is shown below. Comparison between 2 studies of the proportions of lung cancer patients recommended to receive radiotherapy. The differences between the studies in terms of methodology and data are summarised below: v In this study, Australian data on the incidence of the different decision node attributes was used wherever possible. Our study identifies that this proportion is at least 10% higher when you factor in local and distant recurrences. Instead they reported on the actual use of radiotherapy for symptoms of metastatic disease. As a consequence the incidence data used was often from patterns of care studies where the use of radiotherapy was reported. We have attempted to avoid doing this wherever possible as it is based on actual practice rather than on evidence, and it is likely that this under-represents the indications for radiotherapy. In contrast, our study relied on branches indicating the incidence of bone and brain metastases rather than reporting on the use of radiotherapy. In some instances it was necessary to use radiotherapy utilisation data as no other information was available. They recommend radiotherapy only if the patient responds to chemotherapy, which removes the 4% who do not respond. Our recommendations are based on guidelines where early radiotherapy is suggested and hence waiting for a response to chemotherapy is not recommended. This recommendation is based on randomised trial evidence of early radiotherapy improving survival over delayed radiotherapy (48) (49). This will underpredict the use of radiotherapy as there are instances where short palliative radiotherapy is recommended to palliate symptoms in patients with poor performance status. The current study avoids the incorporation of patient choice into the decision tree. The reason is that the acceptance or refusal of radiotherapy by patients will depend upon factors such as the availability of and access to radiotherapy services, and the selection biases and the type of information given to the patient by their doctor, and thus may not reflect best evidence. Following a review of the differences between the current study and the study by Tyldesley et al (34), we concluded that the differences in the radiotherapy utilisation rates for lung cancer between the two studies can be explained by the above factors and further modification of our tree was unnecessary. Clinical practice guidelines for the treatment of unresectable non-small-cell lung cancer. Reported management of lung cancer in Victoria in 1993: comparison with best practice. Randomized trial comparing weekly versus 3-week chemotherapy in small-cell lung cancer: a cancer research campaign trial. Patients with Stage I Non-small cell lung carcinoma at postoperative risk for local recurrence, distant metastasis and death: implications related to the design of clinical trials. The role of post-operative radiotherapy in non-small cell lung cancer: a multicentre randomised trial in patients with pathologically staged T1-2, N1-2, M0 disease. Postoperative radiation therapy in lung cancer: a controlled trial after resection of curative design. Incidence of local recurrence and second primary tumors in resected stage I lung cancer. The epidemiology of bony metastases: a comparison of metastatic disease rates over the past 20 years. Palliation of symptoms in non-small cell lung cancer: a study by the Yorkshire Regional Cancer Organisation thoracic group. Adjuvent external radiation of the mediastinum in radically resected non-small cell lung cancer.

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Simple liver cysts (or biliary cysts) Definition: simple liver cysts are non-parasitic symptoms 2016 flu generic epivir-hbv 100 mg overnight delivery, benign entities medications before surgery discount epivir-hbv 100mg line, relatively common in clinical practice (1-3% of the ultrasounds performed) medicine hat jobs epivir-hbv 150 mg visa. Very rarely medicine 0552 proven 150mg epivir-hbv, large cysts with intracystic hemorrhage can generate symptoms, such as discomfort or pain in the right hypochondrium. However, once diagnosed, liver cysts may cause symptoms, particularly in patients with cenestopathic neurosis, who, knowing the diagnosis of liver cyst, will hold it responsible for some dyspeptic symptoms or functional pain in the right hypochondrium or flank (irritable colon-like). In this case, the patient must be assured of the benign character of the liver cyst, of the lack of danger and complications, which will usually lead to symptoms relief. Liver palpation generally reveals a normal liver, but hepatomegaly may be found in some cases. The ultrasound appearance of simple liver cysts is relatively typical, as anechoic structures with a very thin wall (Figs. The outline of the cyst may be clear-cut or irregular (generating a ”geographical” aspect of the outline) (Fig. In general, the cyst is completely anechoic and displays ”posterior enhancement”(Figs. This posterior enhancement is typical of all liquid structures and is due to the acceleration of ultrasound speed when passing from a solid environment (the liver) to the liquid environment of the cyst. When inner septa are present, particularly if the cyst has a thick wall, differential diagnosis with a hydatid cyst should be made. We must advise the ultrasound beginners to avoid a possible trap: the first anechoic (cystic) lesion seen by ultrasound is generally the gallbladder. After detecting and examining the gallbladder in a non-cholecystectomized patient, if another anechoic image is detected, this will be considered a cyst. Otherwise, a gallbladder seen in a transverse section will generate an image similar to the one of a liver cyst. However, in current practice, the most difficult differential diagnosis of simple liver cysts is with hydatid cysts. In these cases, searching for anti-Echinococcus granulosus antibodies will allow the differentiation. The Cassoni intradermal reaction is completely outdated and is no longer used in the medical practice. In rare situations, liver cysts can be complicated by intracystic hemorrhage, possibly posttraumatic or spontaneous (the cyst may change from anechoic to hypoechoic). Another possible complication that is exceptionally rare is the cyst’s superinfection, which clinically manifests trough fever, chills and pain in the right hypochondrium. On ultrasound, the anechoic image inside the cyst will show debris and can become hypoechoic or inhomogeneous. Since simple liver cysts are asymptomatic and with no risks for complications, they are ”leave me alone lesions”. They should be periodically monitored by ultrasound for possible growth (first biannually, then annually or even more rarely). The patient will be assured that the lesion is benign and that there is no risk of complications. The tip of the needle appears as a hyperechoic point inside the lesion, back and forth movements will facilitate its recognition. The fluid extracted is usually clear or more rarely slightly brownish (in case of old hemorrhage). If the liquid is bilious, biloma or communication with the bile ducts should be suspected (in order to elucidate the bilious content, bile pigments can be evidenced in the fluid – revealing communication with the bile ducts). After the needle has penetrated the cyst, its content is aspirated under ultrasound guidance with a 100 ml syringe until the disappearance of the anechoic content. For differential diagnosis with hydatid cyst, scolexes should be searched for in the fluid by microscopic examination. To prevent it, cyst sclerosis with absolute alcohol can be performed, but only if no communication with the bile ducts is present, otherwise, bile duct sclerosis will occur. Communication with the bile is checked for by searching for bile pigments in the extracted fluid a clear, transparent fluid suggests absence of communication with the bile ducts. The injected alcohol will be left in the cyst for approximately 10 36 minutes, after which it will be completely aspirated out of the cystic lesion (the amount of the extracted fluid amount should be measured as well as ultrasound control absence of anechoic area should be performed). As a general rule, percutaneous therapy of simple liver cysts is required in only in exceptional cases, in persistently symptomatic cases. Clinical symptoms can be absent or mild: discomfort in the right hypochondrium, sub-fever. Usually there are no echoes inside the anechoic image, except in the case of hemobilia. The fluid aspirated has a bilious appearance (greenish) and contains bile pigments. Most frequently, the therapeutic aspiration of the bile from the cavity is sufficient. Sometimes, there is a recurrence of the fluid collection, which requires reaspiration or ultrasound guided percutaneous drainage, or even surgery to resolve the cause of biloma (bile”leakage”). In order to see the frequency of association of the two disorders, we carried out a retrospective study in the Department of Ultrasound of the Timisoara County Hospital, over a period of 11 years. Based on a total number of 63453 ultrasounds, we identified 130 patients with polycystic disease (0. In conclusion, the association of polycystic liver with polycystic kidneys occurs in approximately 1/3 of the cases with polycystic disease, while in 1/10 of the cases, only liver polycystic disease occurs. The clinical symptoms in polycystic liver are most frequently discrete or absent so that the disease is usually detected on a routine ultrasound. Some patients experience pain in the right hypochondrium, varying from mild discomfort to quasi-permanent pain. Occurrence of complications such as intracystic hemorrhage can exacerbate the symptoms. The ultrasound appearance of polycystic liver is relatively typical, translating into multiple round or oval anechoic images (Figs. There are cases of polycystic liver with a smaller number of cysts (5-20), which can even be counted the oligocystic form. In other cases, there are an impressive number of cysts, which almost completely replace the normal liver structure. In current practice, the oligocystic form of polycystic liver is the most common, usually completely asymptomatic. On ultrasound, the cysts will have a completely anechoic appearance, but sometimes internal septa can be found. The ultrasound aspect of polycystic liver is relatively typical, differential diagnosis being made rather in theory with giant septated hydatid cysts or liver abscess, Caroli disease, or rare cases of multiple necrotic liver metastases. It should be known that the evolution of polycystic liver is completely benign, unlike of polycystic kidneys. In time, no signs of liver failure occur, and complications are exceptional (intracystic hemorrhage). The patient should be assured of the lack of risk of his condition, ultrasound monitoring can be recommended annually or when new symptoms occur. Biological liver function tests are usually not needed, rarely discrete cholestasis is present (increased alkaline phosphatase, gamma-glutamyl transpeptidase and, even rarely, increased bilirubin) in the case of large multiple cysts that compress the bile ducts. In the case of symptoms generated by the increase of pressure in some cysts or by intracystic hemorrhage, cyst decompression can be performed using a fine needle under ultrasound guidance (0. Hydatid liver cyst Definition: it is a parasitic cyst generated by the Echinococcus granulosus. There are endemic areas for this disease such as the Mediterranean Region, Argentina, and the Balkan region. Endemic areas generally correspond to the regions where herbivorous (particularly sheep) are raised. So, Romania is situated within an endemic area for this pathology, which is why this disease is frequently found at a routine ultrasound and in the day to day medical practice. The most frequent location of hydatid cyst is in the liver (in approximately 60% of cases), followed by the lungs (approximately 20%), while the rest of the locations are rare. The way of infection is by involuntarily swallowing parasite eggs (dirty hands, incompletely washed vegetables), after which they penetrate the intestinal wall and, through the portal blood flow, the parasite reach the liver where cysticerci develop in most cases. Due to possible complications that are often severe (anaphylactic shock) and require difficult surgical approaches, with frequent postoperative recurrences, the hydatid cyst is often a disabling disease. Very frequently, it is completely asymptomatic, being incidentally detected on ultrasound.

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