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By: William A. Weiss, MD, PhD

  • Professor, Neurology UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA

https://profiles.ucsf.edu/william.weiss

In addition to buy imuran 50mg visa spasms pregnancy after tubal ligation this order imuran 50 mg fast delivery spasms due to redundant colon, the jaw is the occasional 8 site for secondary deposits order 50 mg imuran mastercard spasms near anus, the common sources Michael Anthony Epstein (b buy imuran 50 mg line muscle relaxant and nsaid. This is an interesting benign tumour, which is derived from the epithelial cells of the enamel Lateral extension organ. Its histological appearance resembles these Swelling of the face, which often has an in amma cells arranged in clumps within a brous stroma. Any age may be affected, but the majority Upward extension present in the second and third decades with Orbital invasion with proptosis, diplopia and equal sex distribution. Anaesthesia of the cheek may result from invasion of the maxillary branch of the trigeminal nerve. Surface tumours Inferior extension Carcinoma, mixed salivary tumour or rarely Bulging and ulceration into the palate. Metastases melanoma of the palate, gum, cheek or oor of the to the upper jugular lymph nodes occur at a rela mouth may invade the underlying bone. Special investigations Antral tumours • Skull X rays usually reveal decalci cation and erosion of the maxilla. There may be Probably the commonest tumour of the upper opaci cation of the normally translucent jaw is the squamous carcinoma arising from maxillary antrum. The antral carcinoma occurs in middle-aged and elderly subjects with equal sex distribution. Treatment Clinical features • Benign tumours are treated by local excision; in the case of the lower jaw, this may require Symptoms and signs are late in manifesting them bone graft to the resected portion of the selves; indeed, the tumour must burst through the mandible. Presentation then depends on the direc maxillary antrum are treated initially by tion of growth of the tumour and can be deduced radiotherapy, followed by hemi by the application of some knowledge of the mandibulectomy or maxillectomy. The salivary glands comprise three paired glands – the parotid, submandibular and sublingual – together with tiny accessory salivary glands scat In ammation tered over the walls of the buccal cavity. The parotid gland secretes a serous saliva, in contrast Aetiology to the mucus product of the sublingual glands. The • Mumps, usually affects the parotid, rarely the parotid and submandibular glands drain into the 1 submandibular gland. Their • Mikulicz ’ s syndrome: involving all the salivary ori ces are easily visible in your own mouth and and the lacrimal glands. The sublingual gland’s mucus secretion drains by a series of very short ducts into the oor of the mouth. Mumps the two principal surgical conditions of the sali vary glands are in ammation, with or without cal A viral infection (incubation period 17–21 days), culus, and neoplasm. The nature of the glandular which is common in children and affects the cells determines the saliva’s composition, explain parotid glands; it is usually bilateral. Rarely the ing the different incidence of these conditions in submandibular or sublingual glands may be each of the salivary glands. Mumps may present to the surgeon in the fol lowing ways: • Acute parotitis: usual in childhood but may occasionally occur as a painful parotid swelling 1Niels Stensen (1638–1686), Professor of Anatomy, University of Copenhagen, Denmark. Pain and swelling in the testicle occur 7–10 days after the onset of the parotitis and Lecture Notes: General Surgery, 12th edition. This complication may also A swelling in the parotid region may be one of the occur in any severe debilitating illness and in following: uraemia. Adequate hydration with elimination of the above aetiological factors • Ameloblastoma (adamantinoma) and other has rendered this complication rare nowadays. In tumours of the mandible the established case, the patient must be kept fully hydrated and the ow of saliva encouraged by sucking sweets or chewing gum. The following should always be performed, in addi tion to examination of the gland itself: • Inspection of the parotid duct: redness, oedema Chronic recurrent of the duct or exudation of pus indicate parotitis parotid sialadenitis • Testing the integrity of the facial nerve: it is invariably intact in benign swelling, but may be Repeated episodes of pain and swelling in one or paralysed in malignant disease both parotids is not uncommon and is caused by • Inspection and palpation of the fauces: a parotid a combination of obstruction and infection of the tumour may plunge into the pharynx gland. There may be an associated dilatation of the duct system and alveoli of the gland, termed • Palpation of the regional lymph nodes: they may be involved with secondary deposits from a sialectasia (which resembles bronchiectasis in the parotid carcinoma lung), associated with a stricture of the duct or a stone. Massage of the gland several times a day, and the use of sialogogues (such as ‘ acid drops ’) encourage drainage. Acute bacterial parotitis Occasionally, in severe and refractory cases, exci sion of the gland with preservation of the facial Ascending infection of the parotid gland via its nerve is required. The salivary glands 155 Special investigations 3 Mikulicz’s syndrome • X rays invariably con rm the presence of the stone. Mikulicz’s syndrome is characterized by enlarge • A Sialogram, in which contrast material is ment of the salivary and lacrimal glands, and is injected into the duct, may be necessary if no associated with dry eyes, leading to conjunctivok stone is visible. It may occur ostium of the duct, which mimics the in the following conditions: symptoms of a stone, or sialectasis. If one or more stones are impacted in connective tissue disorders such as the gland substance, excision of the whole gland rheumatoid arthritis and systemic lupus is required. Salivary tumours Calculi Stone formation is common in the submandibular Classi cation gland and its duct, rare in the parotid and unknown in the sublingual. The different composition of the Benign saliva from each gland probably explains this dif ference. Stasis of the more viscid secretion of the • Pleomorphic adenoma (mixed salivary submandibular gland in its long duct, changes in tumour). Clinical features Pleomorphic adenoma There is painful swelling of the affected gland, Ninety per cent occur in the parotid, although aggravated by food (classically by sucking a lemon) occasionally they are found in the submandibular, and there may be an unpleasant taste in the mouth sublingual or accessory salivary glands. On examination, per cent present before the age of 50 years, the obstructed gland is enlarged and tender. Gentle pressure on the gland may produce a purulent exudate from the ori ce of the duct. Macroscopic appearance 3 Jan Mikulicz Radecki (1850 – 1905), Professor of Surgery succes the tumour is lobulated and lies within a false sively at Cracow, Konigsberg and Breslau, Poland. The majority show prognosis is excellent but inadequate surgery is glandular acini within a blue-staining stroma, followed by a recurrence in a high percentage of which gives the appearance of a cartilage but cases. The appearance of epi thelial cells and ‘cartilage’ gave rise to the older concept of a ‘ mixed tumour ’.

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When compared imuran 50mg free shipping muscle relaxant otc, longer needles (25 mm) result in fewer local reactions following vaccination compared with shorter needles (16 mm) discount 50mg imuran mastercard muscle relaxant 771. For example generic imuran 50 mg with amex muscle relaxant kava, the simultaneous administration of cholera vaccine and yellow fever vaccine is associated with interference order 50 mg imuran visa muscle relaxants kidney failure. Should premature babies receive immunization on the basis of postconception age or chronologic age In most cases, premature babies should be immunized in accordance with postnatal chronologic age. American Academy of Pediatrics Committee on Infectious Diseases, Pediatrics 112:193–198, 2003. However, in most cases, these children should not receive the influenza vaccine and should instead be prescribed chemoprophylaxis as necessary. These vaccines contain lipo-oligosaccharide and other cell wall components that result in a high incidence of adverse effects. The acellular vaccines are associated with a much lower incidence of side effects and thus are preferred for all doses in the United States. Because of the slow, steady resurgence of pertussis in the past two decades and the availability of an acellular pertussis Vaccines combined with diphtheria and tetanus toxoid (Tdap), the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention has recommended that all adolescents >11 should receive a booster dose. A concern has been the possible shift of pneumococcal serotypes causing invasive disease to those not covered by the vaccine, particularly serotype 19a. Serogroup B isolates account for about one third of cases of meningococcal disease, but serogroup B polysaccharide is absent from these vaccines. A study in infants with the a new tetravalent vaccine using a nontoxic mutant of diphtheria toxoid as the carrier protein has demonstrated good immunogenicity and may become part of the vaccination schedule for infants in the future. All 11 to 12-year-olds should be vaccinated with the conjugate vaccine routinely. In addition, unvaccinated college freshmen living in dormitories should be offered either the plain polysaccharide vaccine or the conjugate vaccine. In addition, the current vaccines may be useful as an adjunct to chemoprophylaxis for the control of outbreaks caused by a vaccine serogroup. The varicella vaccine is highly effective (95% for the prevention of any disease, 100% for the prevention of moderate to severe disease) when used within 36 hours of exposure in an environment involving close contact. The reason for the high efficacy is that naturally acquired varicella-zoster virus usually takes 5 to 7 days to propagate in the respiratory tract before primary viremia and dissemination occur, whereas vaccine virus may elicit humeral and cellular immunity in significantly less time. However, breakthrough disease was reported with increasing frequency in vaccinated children because a single dose of the vaccine was found to be only 85% effective. In 2007, the recommendations by the Advisory Committee on Immunization Practices were for the first dose of a varicella containing vaccine at 12 to 15 months of age and a second dose at 4 to 6 years. Asch-Goodkin J: Varicella vaccines: time for a second dose, Contemp Pediatr 24:9S–10S, 2007. Of the vaccines included in the routine schedule, which ones contain live viruses Oral polio vaccine is a live attenuated virus vaccine, but it is no longer recommended for routine use. Other live virus vaccines include cold-adapted, live-attenuated influenza, rotavirus, and yellow fever virus vaccines. Without a booster after age 5 years, protection against pertussis infection is about 80% during the first 3 years after immunization, dropping to 50% at 4 to 7 years and to near zero at 11 years. Live vaccines: measles-mumps-rubella, varicella, cold-adapted, live-attenuated influenza, rotavirus, yellow fever virus, oral polio. What are the recommendations regarding the administration of live-virus vaccines to patients receiving corticosteroid therapy By the end of 2001, all vaccines in the routine schedule for children and adolescents were free or virtually free of thimerosal with the exception of the some inactivated influenza vaccines. However, they may be present for a day or less and should not be relied on for the diagnosis. By contrast, measles keratitis in developed countries is usually self-limited and benign. There are two principal reasons for the progression to blindness among patients with measles in underdeveloped countries: n Vitamin A deficiency: Vitamin A is needed for corneal stromal repair, and a deficiency allows epithelial damage to persist or worsen. On rare occasions, the virus has been associated with fulminant hepatitis, encephalitis, and a syndrome of massive lymphadenopathy called Rosai-Dorfman disease. Within 24 hours of defervescence, a discrete erythematous macular or maculopapular rash appears on the face, neck, and/or trunk. Erythematous papules (Nakayama spots) may be noted on the soft palate and the uvula in two thirds of patients. Other common findings on examination include mild cervical lymph node enlargement, edematous eyelids, and a bulging anterior fontanelle in infants. Presumptive empirical therapy can be begun pending diagnostic studies (biopsy or serology). Studies have shown that oral acyclovir therapy (20 mg/kg, up to 800 mg) four times daily for 5 days, initiated within 24 hours after the onset of rash, decreases the maximal number of lesions by 15% to 30%, shortens the duration of the development of new lesions, and shortens the duration of fever by 1 day. The American Academy of Pediatrics Committee on Infectious Diseases opted not to recommend acyclovir for routine use in uncomplicated varicella for otherwise healthy children younger than 13 years because of “marginal therapeutic effect, the cost of the drug, feasibility of drug delivery in the first 24 hours of illness, and the currently unknown and unforeseen possible dangers of treating as many as 4 million children each year. Thrombocytopenia, arthritis, hepatitis, and glomerulonephritis occur less commonly. Before the introduction of the varicella vaccine in 1995, about 4 million cases of chickenpox occurred in the United States each year, resulting in roughly 10,000 hospitalizations and 100 deaths.

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Noradrenaline (norepinephrine) 2 A t moderate doses (5 g/kg/min) order imuran 50 mg fast delivery infantile spasms 4 year old, 1 effects predominate with positive inotropic activity Noradrenaline has predominantly effects order imuran 50 mg with amex spasms face, but (increasing myocardial contractility and rate) buy imuran 50mg line muscle relaxant yoga. It is used to order 50 mg imuran mastercard spasms after urinating increase sys 3 A t higher doses (over 5 g/kg/min), effects temic vascular resistance through its vasocon predominate with vasoconstriction. Adrenaline (epinephrine) Dopexamine Adrenaline has strong and actions, and may be Dopexamine has predominantly 2 actions, used to increase peripheral resistance while also increasing myocardial contractility; it also acts on increasing cardiac output. The powerful vasocon peripheral dopamine receptors, increasing renal strictor actions of both adrenaline and noradrena perfusion. Dobutamine has predominantly 1 actions, increasing myocardial contractility and rate, thus 7 Tumours Learning objectives To know the pathology and clinical features of tumours, as well as the ways in which a tumour might present, the histological features which in uence prognosis, and the principles of tumour staging. Clinical features and Pathology diagnosis When considering the tumours affecting any A malignant tumour may manifest itself in any or organ, this simple classi cation should be used: all of four ways. These are remote It is surprising how often failure to remember effects caused by hormone or other tumour this basic scheme leads one to omit such an ele cell products, which are most common in mentary fact that common tumours of brain and carcinoma of the lung, particularly small cell bone are secondary deposits. Published 2011 by the only common exceptions to this scheme Blackwell Publishing Ltd. Special investigations Diagnosis is always made by history, clinical examination and, where necessary, special • the primary tumour: chest X ray, computed investigations. History this simple scheme applied to any of the prin cipal malignant tumours will enable the student • the primary tumour may present with cough, to present a very full clinical picture of the disease haemoptysis, dyspnoea and pneumonia with little mental effort. If a marker was raised before treat syndrome); 1 ment, it should fall when the disease is controlled, hypertrophic pulmonary osteoarthropathy but will rise again if recurrence occurs. Treatment • Secondary deposits may produce cervical lymph node enlargement, hepatomegaly or the treatment of malignant disease should be obvious bony deposits. Eaton (1905–1958), Professor of Neurology at the be taken to ease the symptoms of the patient. The bile duct may be stented particularly sensitive to particular agents, such endoscopically via the duodenal papilla for the as teratoma of the testis to platinum relief of jaundice and pruritus in patients with compounds. Surgery may also be used for pain including surgery and/or radiotherapy and/or relief by interrupting nerve pathways. The palliative excision of a primary given to localized secondary deposits in bone, lesion may be indicated, although secondary irremovable breast tumours and inoperable deposits may be present. It is 3 anatomical situation; particularly indicated for localized irremovable 4 general condition of the patient. Applicable in carcinoma of the extent of spread (staging) the breast and prostate. A wide range of drugs the extent of the tumour (its staging) on clinical have anticancer action, but this action is not examination, at operation and on studying the speci c; all the drugs damage normal dividing excised surgical specimen, is of great prognostic cells, especially those of the bone marrow, the importance. They may be palpable distant secondaries or gross xation of classi ed into the following: the primary tumour are serious. Finally, histological study may reveal methotrexate, gemcitabine); involvement of the nodes which had not been c plant alkaloids. Some tumours have additional classi ca A balance must be made between the tions which are more familiar to the clinician. These are administered for pain relief (non-steroidal analgesics, opiates), hypnotics, Microscopic appearance tranquillizers and anti-emetics. As a general principle, the prognosis of a tumour 6 Nerve blocks, with phenol or alcohol for relief is related to its degree of histological differentia of pain. A small tumour with no apparent spread at the time of operation may still Prognosis have a poor prognosis if it is highly anaplastic, the prognosis of any tumour depends on four whereas an extensive tumour is not incompatible main features: with long survival of the patient after operation if the microscopic examination reveals a high degree 1 extent of spread; of differentiation. For example, a tumour at the lower restricted to older women (over 50 years) and end of the oesophagus may be easily removable cervical cancer screening for women over 25 whereas an exactly similar tumour situated years. In cervical cancer, for example, a distinct behind the arch of the aorta may be technically progression exists from dysplasia through carci inoperable; a brain tumour located in the frontal noma in situ to invasive cancer. Hence, screening the popula in the brain stem will be a desperate surgical tion every 3–5 years by cervical smear cytology is proposition. General condition of the patient Screening for high-risk individuals A patient apparently curable from the point of view of the local condition may be inoperable A number of cancer syndromes exist in which because of poor general health. It is commonly performed for identi cation may be possible through either tumours, but may be used in other contexts such genetic mapping of the cancer or early recognition as abdominal aortic aneurysm and hypertension. Familial clustering • Treatment at an early stage could improve the Many of the familial cancers are now being associ prognosis, and is of more bene t than ated with mutations of speci c genes. Mutations of either gene confer an 80% risk of it should be both sensitive and speci c). Causes 2 Super cial partial thickness: burn extends down through the epidermis to involve the • Thermal burn: the commonest cause of a burn, germinal layer, but the dermal appendages due either to direct contact with a hot object such as sweat glands and hair follicles remain or ames or to hot vapour such as steam largely preserved. This • Electrical burn: severity depends on strength of separates after about 10 days, leaving healthy, current and duration of contact. Healing is much slower and is as in the local erythema that may follow associated with signi cant scarring. There may be initial blistering, but this is soon replaced by a coagulum or slough; more Classi cation often, this is present from the onset in an intense deep burn. Unlike the more super cial burns, this Burns may be classi ed into partial thickness and slough separates only slowly over 3–4 weeks, full thickness, depending on whether or not the leaving an underlying surface of granulation germinal epithelial layer of the skin is intact or tissue. The underlying germinal layer is intact, and Clinical features Pain Lecture Notes: General Surgery, 12th edition. Published 2011 by this is due to the stimulation of numerous nerve Blackwell Publishing Ltd. It is more severe in 42 Burns Zone of keratinization Germinal zone Dermis (a) Partial thickness burn (b) Healed partial thickness burn (c) Full-thickness burn Scar tissue (d) Healed full-thickness burn Figure 8.

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However buy 50mg imuran mastercard muscle relaxant flexeril 10 mg, often the numbers showed linear dose–response curves even up to cheap imuran 50 mg muscle relaxant spray 60 involved are large buy discount imuran 50mg on-line spasms spinal cord injury, making estimates somewhat Gy; the only exception was thyroid cancer order imuran 50mg with mastercard muscle relaxant causing jaundice, which more reliable. They also confirmed bomb form a very large group, which has been that the risk varied according to the tissue of origin of continuously monitored within the lifespan study the second cancer. This persisted beyond 40 years of follow Tissue-specifc cancer risks following up and was modified by age at treatment. However, since some childhood cancers have an underlying germline mutation, this may also contribute to the observed increase in the previous section has discussed the variety of susceptibility to second malignancies. However, there is still considerable the number of malignant melanomas was unaffected. Overall the authors considered the excess risk of There are many limitations inherent in these malignant skin cancers to be very small. However, there was only one exposed to multiple fluoroscopies, have not shown any death in this group and it has been advised that with significant increase in skin cancer risk. A nested case treatment, although the trends were only marginally 31 control study of secondary sarcomas (105 cases, 422 significant. The secondary sarcomas therefore it was advised that it should be treated with occurred at a median of 11. Five 100 centimetres (cm) skin area treated to a mean excess cases have been documented after a mean dose of 3 Gy have indicated a lifetime risk of local 33 total-body dose of 0. In skin fields not exposed to sunlight, the risk In a key study published in 1965, the cause of death would be smaller by about one order of magnitude. There were 40 leukaemia deaths, which was they presented at a younger age, compared to 70% greater than expected. The incidence of radiation-induced commonly reported tumour type although the risk is astrocytoma was slightly lower than in a control small. The overall incidence was not 15 years’ follow-up, and 56,788 patient-years of data. For adults >40 years, there is no evidence However, in these situations it has been suggested that of an increase in risk. Most studies show that for women, exposure to breast Although the mean follow-up was 12. Nevertheless, following exposure to higher therapeutic doses Further analysis of this cohort suggested that the (such as those for thyroid eye disease, pituitary mechanism underlying the risk may relate to genomic instability at an early stage of tumour development. The risk factor for breast cancer needs to be assessed for women exposed in specific circumstances Thyroid cancer where the breast is directly affected; the effective dose concept which applies to a general population the thyroid of young children is the most 10 is unhelpful in this situation. Several estimates of the radiosensitive organ with regard to radiation risk versus benefit of mammography screening are carcinogenesis; a risk that falls rapidly with increasing available, however, these are very dependent on the age. It has been also been found to show a small but measureable estimated that after a mean lung dose of 1 Gy the increase. Sadetzki S, Chetrit A, Freedman L, Stovall M, unique human population: lessons learned from Modan B, Novikov I. Long-term follow-up for the atomic bomb survivors of Hiroshima and brain tumor development after childhood Nagasaki. Disaster Med Public Health Prep 2011; exposure to ionizing radiation for tinea capitis. Sadetzki S, Chetrit A, Lubina A, Stovall M, of leukaemia, lymphoma and multiple myeloma Novikov I. Solid cancer incidence in atomic bomb A reanalysis of curvature in the dose response for survivors exposed in utero or as young children. Second malignant neoplasms following Int J Radiat Oncol Biol Phys 2013; 85(2): 451–459. Berrington de Gonzalez A, Gilbert E, Curtis R considering radiation effects in the cell and et al. Second solid cancers after radiation therapy: possible implications for cancer therapy: a a systematic review of the epidemiologic studies collection of papers presented at the of the radiation dose–response relationship. Radiother Oncol breast tumors after radiotherapy for a first cancer 2005; 76(3): 270–277. An international collaboration among Second primary neoplasms in patients with cancer registries. Incidence of malignant factors associated with secondary sarcomas in skin tumours in 14,140 patients after grenz-ray childhood cancer survivors: a report from the treatment for benign skin disorders. Mortality from cancer and A report of a Task Group of Committee 1 of the other causes after radiotherapy for ankylosing International Commission of Radiological spondylitis. Tumours and other diseases following childhood X-ray treatment for ringworm of the scalp (Tinea capitis). Malignant of intracranial meningiomas in Nagasaki atomic transformation of a vestibular schwannoma after bomb survivors. Minim Invasive Neurosurg 2005; 48(6): the influence of pretreatment characteristics 334–339. Int J Radiat Oncol Biol Phys 2009; after exposure to external radiation: a pooled 75(5): 1408–1414. Dose and time-response for breast cancer risk J Natl Cancer Inst 2006; 98(21): 1528–1537. Breast cancer risk after radiation treatment at infancy: potential consequences of 51. Rowe J, Grainger A, Walton L, Silcocks P, Radatz radiation-induced genomic instability.

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