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Hayden Barry Bosworth, PhD

• Professor in Population Health Sciences
• Professor in Psychiatry and Behavioral Sciences
• Professor in Medicine
• Associate of the Duke Initiative for Science & Society
• Core Faculty in Innovation & Entrepreneurship
• Affiliate Faculty Member, Duke-Margolis Center for Health Policy
• Senior Fellow in the Center for Study of Aging
• Member of the Duke Cancer Institute

https://medicine.duke.edu/faculty/hayden-barry-bosworth-phd

Stop beta blockers for 2 weeks prior to the sample (as beta blockers prevent renin release) and stop mineralocorticoid receptor antagonists (spironolactone muscle relaxant bruxism 25 mg lioresal free shipping, eplenerone) 6 weeks before sample muscle relaxant esophageal spasm buy lioresal mastercard. Other drugs need not be stopped unless further investigations are required (see below) although stopping other drugs will give a clearer result spasms hand generic 25 mg lioresal fast delivery. If clinical details and list of medications are provided then full interpretation of results will be provided spasms shoulder cheap lioresal 10 mg free shipping. This test should not be performed in patients with severe uncontrolled hypertension muscle relaxant medications buy lioresal 25 mg with mastercard, renal insufficiency back spasms 4 weeks pregnant generic lioresal 25 mg without prescription, cardiac insufficiency, cardiac arrhythmia, or severe hypokalemia. Patient should be in the seated position for at least 30 mins before infusion begins 3. Spironolactone and amiloride can cause de-suppression of renin, leading to aldosterone secretion from the contralateral adrenal gland. Catheter inserted via femoral vein and adrenal veins selectively cannulated under X-ray control. Some centres use bolus of tetracosactrin 250 mcg (Synacthen) 20 minutes prior to sampling in which case interpretation cut-offs are different, see below. Note if using tetracosactrin stimulation then cut-offs are suggested as follows: For catheter placement investigators use at least 3:1 ratio for cortisol concentration in the adrenal vein relative to peripheral sample. Therefore on the basis of incomplete contralateral suppression we would classify this as most likely bilateral disease. Remember that cortisol secretion rates are 1000 times higher than aldosterone secretion rates, so even a single missed dose of dexamethsone can jeapordise the results. The initial biochemical testing for Phaeochromocytomas and Paragangliomas should include measurement of plasma free metanephrines or urinary fractionated metanephrines. Measurements of metanephrines in plasma or urine using liquid chromatography with spectrometric or electrochemical detection methods provides the highest diagnostic sensitivities for detection of phaeochromocytomas and paragangliomas. Urine can be collected in the same bottles with acid preservatives as catecholamines. The 24-hour urine collection should include measurement of urinary creatinine to ensure a complete collection. For measurement of the dopamine metabolite 3-methoxytyramine, sampling should be carried out following an overnight fast. Importantly, metanephrines are being produced in a continous manner within tumours. This process is independent of catecholamine release, which can be episodic or can occur at low rates in certain tumours. They should also be given a disposable jug to urinate into and instructions to collect. Plasma catecholamines have a sensitivity of 76-81% and specificity of 81-88% and their role in the diagnosis of phaeochromocytoma therefore remains limited. Give, at time zero, 300 micrograms (3 x 100mcg tablets) clonidine hydrochloride orally. To exclude the diagnosis of phaeochromocytoma in patients with hypertension and borderline changes in plasma catecholamines or 24 hour urinary catecholamines. Patient should empty bladder before lying down as they might not be allowed to stand for a while. Normal subjects may show an initially elevated plasma adrenaline and noradrenaline but these will fall to within the normal plasma range with Pentolinium. It is particularly useful for extra-adrenal and metastatic or residual phaeochromocytoma. Tumour detection was lower for extra-adrenal paragangliomas (58%) versus adrenal (85%) phaeochromocytomas. All disorders have the potential to be de novo, so the absence of family history does not reduce risks. Sporadic phaeochromocytomas are often diagnosed on the basis of symptoms or following incidental discovery on imaging, whereas hereditary phaeochromocytomas are frequently diagnosed earlier in the course of the disease because of biochemical screening/surveillance or genetic testing. This of course is only the case if the individual is known to have a predisposition. Exeter and some other labs offer a similar panel for similar cost and turn-around-time. Single gene mutation analysis is not typically available any longer (except in the case of a known familial mutation). Ensure that you have discussed with the patient the potential of making a diagnosis, which puts them and their children at risk of multiple tumours other than phaeochromocytoma, to guarantee fully informed consent. Inhibition of alpha-adrenergic receptors by phenoxybenzamine is not overcome by extra catecholamine release intra-operatively. However, this irreversible binding can lead to increased risk of post-operative hypotension. Doxazosin is a competitive, selective fi-1 receptor blocker with a relatively short duration of action. Due to its competitive nature, it can be overcome by extra catecholamine release intra-operatively with a potentially increased risk of hypertensive crisis. However, the shorter half-life makes it less likely to cause post-operative hypotension. There is no conclusive evidence to favour the use of selective fi-1 adrenergic receptor blockers. A retrospective study of Mayo versus Cleveland experience showed that use of phenoxybenzamine is associated with less intra-operative hypertension and more post-operative hypotension. However, there was no difference in post-operative surgical outcomes or length of hospital stay. Other studies have found no differences in intra-operative or post-operative blood pressures. This is due to fi-adrenergic receptor mediated vasoconstriction without the opposition of the fi2 adrenergic receptor mediated vasodilation. Where surgery for whatever reason is urgent, one needs to balance the risk of shorter pre-op treatments with the benefits of earlier surgery. Phentolamine (see below) can be used for very rapid control of blood pressure, but be aware of the risks of sudden acute falls in blood pressure. Warn patients about postural dizziness, nasal stuffiness, fatigue and retrograde ejaculation in men. Warn patients about side effects including cold peripheries, fatigue and dizziness fi Calcium channel blockers. Measure 24-hour urine metanephrines at 6 weeks, 6 months and then annually thereafter. Note that phentolamine is supplied as 10mg per ml, so very tiny volumes are required to bring down blood pressure. The protocol below includes lithium, however the use of lithium is not essential and the protocol can be followed with lithium omitted. Information session & signing of consent form in Department of Nuclear Medicine, Charing Cross Hospital. Everything else (below) is for information only, and will be carried out from that clinic. If they need to ring and enquire regarding results/treatment they should be given the switchboard number and bleep4998. The purpose of the telephone clinic is to rapidly determine when thyroxine replacement should be started, thus avoiding unnecessary outpatient appointments or leaving patients with untreated hypothyroidism, which has many undesirable effects, including possible worsening of thyroid eye disease. If you think that a patient might be suitable for radioiodine they should be referred to Dr Zarni Win (Consultant Radiologist, Charing Cross Hospital) by cc-ing him a copy of your clinic letter or sending him an email (zarni. This does not mean that the patient will have radioiodine but they should have an expert consultation to discuss this treatment option. In particular, radiation protection issues are not generalisable and should therefore be discussed with each patient on a case by case basis. Anti-thyroid drugs should be stopped as soon as the decision to use radioiodine is made. If you know roughly when the patient wants radioiodine, further planning can be made. If it is clear that the patient will defer treatment for more than 2 months, then the antithyroid drugs should be continued until closer to the date of radioiodine. As a guide, the antithyroid drugs should be stopped at least 1 week and at most 2 months before radioiodine. If patient has active thyroid eye disease, see also section on thyroid eye disease for information on steroid cover for radioiodine treatment. Meeran), c/o Dept of Endocrinology th 9 Floor, East Wing, Charing Cross Hospital (Fax: 020 33 111862). All computerised results are updated and reviewed on a weekly basis by a designated Doctor and patients telephoned if they become either biochemically hypo or hyperthyroid following treatment. Blood samples will be checked on the day of radioiodineI, and 1 week later for lithium levels. Samples will be collected at 3, 6, 9 and 12 weeks, and the patient attend clinic at about 14 weeks. If the patient feels toxic (tremor, tachycardia etc), and the fT4 > 40 pmol/L, then suggest propranolol. This page to be filled in with each phonecall in the thyroid clinic made and stored in the thyroid file. Advice given: start thyroxine or wait until further samples taken: If fT4 > 30pmol/Land patient feels unwell (tremor, tachycardia etc), then consider propranolol. If there is any doubt, all patients should be referred to Mrs Veronica Ferguson (Consultant Ophthalmologist at Charing Cross Hospital). In all cases, one must always balance the risks of delay against the benefit of being euthyroid pre-operatively. In an emergency, the following combination of drugs can be used to try and achieve this in approximately ten days: 1. Atenolol 100 mg or Nadolol 16 0mg can be administered only once daily and hence might improve compliance 2. This is a higher dose than used normally, but in emergency higher doses more frequently are required in view of the fact that the liver increases the metabolism of these drugs. For night time paraffin based ointment such as Xailin Night or Lacrimal Lube are good. Ensure the patient is lying down before administering pentagastrin, which makes some patients feel very unwell for a few seconds. Combining two studies only two out of 25 patients with medullary thyroid carcinoma had normal responses to pentagastrin. Potentially affected family members should be screened biennially until aged 65 years. If no suspisious a non-neoplastic lesion such as normal associated clinical/radiological 2 thyroid tissue, a colloid nodule or a thyroidits. The histological possibilities 3 then include a hyperplastic nodule, follicular adenoma or follicular carcinoma. The Fourth International Workshop on the Management of Asymptomatic Primary Hyperthyroidism (2014) identified the following features in asymptomatic patients who might benefit from surgery: J Clin Endocrinol Metab (2014) 99(10):3561-3569 Age <50 years. Patient requires hospital admission, and investigation needs to be booked with Dr Jackson well in advance. Plan in advance to avoid severe post-operative hypocalcaemia following bisphosphonate therapy. In that situation, the long term risk is nephrocalcinosis as the urinary calcium-phosphate product will be high. The clinical significance of osteoporosis lies in the morbidity and mortality associated with fracture. Secondary causes of osteoporosis are commonly found amongst men, so this population requires thorough investigation. Consideration should be given to referring men with osteoporosis to specialist centres, particularly younger men or those with severe disease. The spine is not a suitable site for diagnosis in the elderly because of the high prevalence of arthrosis and osteoarthritis, but it is the preferred site for assessing response to treatment. Indeed, the low sensitivity means that the majority of osteoporotic fractures will occur in individuals who do not have osteoporosis as defined by a T-score of fi-2. Other factors that determine intervention thresholds include the presence of clinical risk factors and the cost and benefits of treatment. Treatment can be considered in those in whom fracture probabilities lie above the intervention threshold. Individuals at high risk should start bone protective therapy at the time of starting glucocorticoids. For further information see References Royal College of Physicians (2002) Glucocorticoid induced osteoporosis. Maintenance of mobility, regular weight bearing exercise, smoking cessation, reduction of alcohol intake, and correction of nutritional deficiencies, particularly of calcium, vitamin D and protein. Both the bisphosphonates and denosumab have been associated with osteonecrosis of the jaw (particularly in cancer patients setting) and atypical fractures. Prevention and once/wk osteoporosis 70 mg Rx Prevention of once/week Treatment of glucocorticoid postmenopausal induced osteoporosis (5 osteoporosis (5 mg mg daily) od or, in postmenopausal women not receiving hormone replacement therapy 10 mg daily).

A single muscle relaxant 5859 cheap lioresal master card, early magnetic Sustained motion perception deficit following optic neuritis: resonance imaging study in the diagnosis of multiple sclerosis spasms brain order lioresal without a prescription. Chronic relapsing 22 Optic Neuritis Study Group the clinical profile of optic neuritis muscle relaxant for children purchase generic lioresal canada. J Neurol Neurosurg Psychiatry spatial vision in the optic neuritis treatment trial back spasms 9 months pregnant order lioresal canada. The dyschromatopsia of optic neuritis: a descriptive analysis impact of antibodies to aquaporin-4 in patients with optic neuritis spasms left side discount 10mg lioresal free shipping. Colour and luminance vision in human optic neuritis: clues from a long-term follow up study of recurrent and neuritis muscle relaxant and pain reliever buy lioresal us. Chromatic discrimination 52 Plant G, Acheson J, Clarke C, Graham E, Howard R, Shorvon S. Its significance for the pathogenesis of 61 Akman-Demir G, Tuzun E, Waters P, et al. Experience of the Optic Neuritis Treatment 63 Kitley J, Woodhall M, Waters P, et al. The pathophysiology of multiple sclerosis: the mechanisms underlying the production of symptoms and the 38 Visual function 15 years after optic neuritis: a final follow-up report natural history of the disease. Ganglion cell loss in and function of the afierent visual pathway in multiple sclerosis and relation to visual disability in multiple sclerosis. Correlation of fat tomography segmentation reveals ganglion cell layer pathology after suppression magnetic resonance imaging and electron microscopy. Systemic T-cell activation in acute clinically isolated nerve fiber layer thickness in patients with neuromyelitis optica. Evaluation of inner histopathological correlation in experimental autoimmune optic retinal layers in patients with multiple sclerosis or neuromyelitis neuritis. Sodium channels and multiple sclerosis: roles in disease characteristics in multiple sclerosis: a retrospective study. Retinal nerve fiber layer patients with neuromyelitis optica versus multiple sclerosis. Quantifying axonal loss Distinguishing optic neuritis in neuromyelitis optica spectrum after optic neuritis with optical coherence tomography. Optic nerve difiusion function to retinal nerve fiber layer thickness in multiple sclerosis. Difiusion tensor imaging in retinal nerve fibre layer thinning following optic neuritis: evidence acute optic neuropathies: predictor of clinical outcomes. Disability in optic neuritis transfer imaging and measures of axonal loss and demyelination in correlates with difiusion tensor-derived directional difiusivities. Color vision Magnetisation transfer ratio in optic neuritis is associated with is strongly associated with retinal thinning in multiple sclerosis. Axonal loss and myelin in Magnetization transfer ratio evolution with demyelination and early optic neuritis loss in postacute optic neuritis. Selective magnetization transfer ratio decrease in the of steroid-unresponsive optic neuritis with plasma exchange. Rituximab dosing interactions in acute optic neuritis to investigate neuroplasticity. A randomized, controlled trial of corticosteroids in double-blind, placebo-controlled trial. A randomized, beta-1a therapy initiated during a first demyelinating event in controlled trial of oral high-dose methylprednisolone in acute optic multiple sclerosis. Corticosteroids for treating optic clinically isolated syndrome and long-term outcomes: a 10-year neuritis. Azathioprine: associated optic neuritis: clinical experience and literature review. Does interferon beta azathioprine in neuromyelitis optica spectrum disorders with treatment exacerbate neuromyelitis optica spectrum disorderfi Impact of rituximab on relapse rate and disability immunosuppression for treatment of corticosteroid dependent in neuromyelitis optica. Successful treatment of memory B cells in patients with relapsing neuromyelitis optica over optic neuropathy in association with systemic lupus erythematosus 2 years. Antibody to aquaporin-4 in to pulse cyclophosphamide in neuromyelitis optica: evaluation of the long-term course of neuromyelitis optica. Autologous mesenchymal in neuromyelitis optica: increase in relapses and aquaporin 4 stem cells for the treatment of secondary progressive multiple antibody titers. Endo: adrenal suppression avoid use of systemic corticosteroids and delay pulmonary damage that occurs from (high-dose,long-termtherapyonly),pbonemineraldensity,pgrowth(inchildren), chronicasthma. Action is primarily local after inhala vir, saquinavir, andtelithromycinpmetabolismandqlevels;concurrentusenot tion. With the use of a spacer, a greater percentage may reach Route/Dosage therespiratorytract. Contraindications/Precautions Powderfororalinhalation Contraindicated in: Hypersensitivity (contains propellants); Acute attack of Inhaln(AdultsandChildren 12yr):Patientswhosepreviousasthmatherapy asthma/statusasthmaticus. Assesspulmonaryfunctiontestsperi odicallyduringand forseveralmonthsafteratransferfromsystemictoinhalation Patient/FamilyTeaching fi Advise patient to take medication as directed. InstructpatienttoreadthePatient fi Assess patients changing from systemic corticosteroids to inhalation corticoste Information and Instructions for Use before using and with each Rx refill, in roids for signs of adrenal insufficiency (anorexia, nausea, weakness, fatigue, hy case of new information. Advise patient not to discontinue medication without potension, hypoglycemia) during initial therapy and periods of stress. Inhalershould be primed beforeusingforfirsttimebyreleasing4sprays into air, away from face. When inhaler has not been used for more than 7 days, reprime unit by releasing 1 spray into air away from face. Rinsemouthwithwaterormouth wash after each use to minimize fungal infections, dry mouth and hoarseness. DiscardDiskusinhalerde vice6wks(50-mcgstrength)or2mo(100-mcgand250-mcgstrengths)afterre moval from protective foil overwrap pouch or after all blisters have been used (whichevercomesfirst). It is an overview of the most important endocrine diseases, it helps to learn the correct endocrine diagnostics and offers an effective treatment of endocrine diseases. I wish it would be a principal aid in basic medicine study for students of medicine, but also a concise endocrinology guide for physicians who exert a medical practice. The system is based on a number of glands, which secrete hormones into internal medium to act on target tissues. Hormones first interact with specific high-affinity receptors in the cells, or on the cells of target tissues. Receptor activation then initiates a cascade of linked biochemical reactions within the cells, that produce the specific response. Hormones represent chemical messengers diverse molecular structures (proteins, peptides, steroids) are released from endocrine glands coordinate the activities of many different cells. They play an important role in development and growth of the body, they control the reproduction mechanisms, they help how to adapt on everyday life-stress and how to survive. Hormones can be classified according to chemical composition, solubility properties, the location of receptors, or the nature of the signal used to mediate their action within the cell. Endocrine pathology Pathology arising within the gland is called a primary disease. Adrenal gland: (two glands, left and right adrenal gland): Adrenal cortex: aldosterone, cortisol /steroids/, androgens, esterogens /steroids/. Adrenal medulla: epinephrine (adrenaline), norepinephrine (noradrenaline), opamine /catecholamines/. Anterior pituitary (adenohypophysis) hormone secretion is controlled by substances produced in hypothalamus and released into portal blood circulation. Anterior pituitary hormones = trophins are controlled by hypothalamic releasing/ or inhibiting hormones. Hormone release (in the hypothalamus and pituitary) is regulated by numerous stimuli of nervous metabolic, physical hormonal origin, in particular feedback control by hormones produced by the target glands (thyroid, adrenal cortex and gonads). Disorders of the hypothalamus and pituitary may present as endocrine or neurologic dysfunction. The pituitary plays a central role in several major endocrine axes, so that investigation and treatment involves several other glands. The presence of hypothalamic tumours may initiate the early onset of normal mechanisms of pubertal maturation, with excessive skeletal growth but a reduced ultimate height. Dominant clinical signs are obesity in childhood, associated with underdeveloped infantile genitalia as a consequence of gonadotrophin deficiency. The reduction in genital size is not real, as a penile shaft is buried in the suprapubic fat pad and is normal in size. The testes are also normal in size for a prepubertal boy = Pseudo dystrophia adiposogenitalis. Laurence-Moon-Biedl syndrome is a central hypogonadism associated with retinitis pigmentosa, polydactylia and congenital heart defects. Disorder presents as anorexia, severe weight loss, amenorrhea, behavioral changes hyperactivity and preoccupation with food. Treatment: estrogens replacement is indicated, continued preoccupation with food and persistent dieting behaviour. Metoclopramide, domperidone) Dopamine-depleting drugs * Reserpine * alpha Methyldopa * Oestrogens * Oral contraceptive pills Pathological Common * Disconnection hypeprolactinemia. See lecture: Diseases of adrenal cortex Adrenal insufficiency, Addisonsfis disease p. Intravenous isotonic saline fluid and 10% dextrose, or 5% glucose Parenteral hydrocortisone 100 mg i. Diabetes insipidus is characterised by a persistent excretion of excessive quantities of diluted urine and by thirst. D Non functioning tumours Pituitary adenoma Metastatic tumours Craniopharyngioma Pituitary tumours are usually benign adenomas. Primary carcinoma of the pituitary gland is rare, but a metastatic tumour from a primary in the breast, lung, kidney may occur in the hypothalamus and reduce pituitary function. Craniopharyngioma Benign tumour develops in cell rests of Rathkefis pouch Location: within sella turcica and in suprasellar space. Sex hormone replacement treatment, when necessary 20 Thyroid disease Thyroid disease is common in its various types, affecting some 5% of the population, predominantly females. The thyroid secretes thyroxine (T4) triiodothyronine (T3) 85% of T3 deiodination of T4 in peripheral tissues: liver, muscle, kidney. Splenomegaly and lymphadenopathy are seen in a few patients with long-standing disease. In men the goitre may be less apparent, often being small, firm and close to the trachea. When the distance from the lateral orbital margin to the anterior point of the cornea exceeds 18 mm, exophthalmos is present (b). When lid retraction is severe lid closure may be incomplete (b) particularly at night, and can lead to exposure keratitis.

Cuterebriasis typically small wild mammals (rodents spasms mouth buy lioresal australia, rabbits) muscle relaxant natural order 25 mg lioresal free shipping, but occasionally infest cats and others muscle relaxant chlorzoxazone discount 25mg lioresal with amex. Screwworm myiasis obligate parasites that invade the edges of fresh muscle relaxant recreational discount lioresal 10mg without prescription, uncontaminated wounds stomach spasms 6 weeks pregnant proven 10 mg lioresal. Helminth Disease O Cutaneous larval migration C adults live in non-cutaneous sites while larval stages migrate through skin muscle relaxant tincture discount 10mg lioresal amex. C starts on face, feet, ventral abdomen, perineum; with chronicity can become generalized. Flea-bite hypersensitivity (Flea Allergy Dermatitis) C most common hypersensitivity of cats & dogs in flea-endemic regions. C may see spongiotic perivascular dermatitis with eosinophils; +/ eosinophilic microabscesses (flea nibbles). C autoimmune diseases are relatively rare in domestic animals, seen in dogs > horses, cats > others. C endocrine disoders often affect the skin, but the resulting skin lesions are usually not specific for any particular endocrinopathy. C [T3 / T4] affects basal metabolic rate ie protein synthesis and mitotic activity. Some Other Endocrine Skin Disease (for information only) Alopecia X (growth hormone / castration-responsive dermatosis) Equine pars intermedia pituitary adenoma Gonadal Hormone Imbalances eg female hyperestrogenism, sertoli cell tumor-associated skin disease. Zinc deficiency / Zinc-responsive dermatosis C in swine, dogs, ruminants; see marked parakeratotic hyperkeratosis 2. Nutritional panniculitis / steatitis C in cats, mink, foals and pigs; associated with high dietary levels of unsaturated fatty acid and/or vitamin E / selenium deficiency 4. Seborrhea o o C broad classification for many clinical syndromes with scaling, crusting, +/ greasiness (1 vs 2). Diagnosis C distinct gross morphology and location often relate to identification and prognosis. Classification C tumors derived from multipotential stem cells in skin which differentiate toward a variety of skin components Ectodermal: tumors of the epidermis and adnexa. C most papillomaviruses are highly species-specific (with exception of bovine papillomaviruses, see sarcoids). C can induce either squamous papilloma or fibropapilloma (ie both epithelial & fibroblastic proliferation). C histologically: papillary proliferation of epidermis, with viral cytopathic effects and intranuclear inclusions. Gross C dark brown-black, macules, papules, nodules o tumors; usually single in the dog, multiple in horse. Mesenchymal Neoplasms O Cutaneous soft-tissue sarcomas (spindle cell tumor/sarcoma) C grouping of some spindle cell tumor types that are common in dogs; esp schwannomas (= peripheral nerve sheath tumors), hemangiopericytomas, etc. Your doctor, however, may have Some symptoms of an allergic prescribed Epilim for another It does not contain all of the reaction include skin rash, itching, reason. It does not shortness of breath or swelling of take the place of talking to your Ask your doctor if you have any the face, lips or tongue, which may doctor or pharmacist. Your doctor has weighed There is no evidence that Epilim is For bipolar disorder, you must the risks of your taking Epilim addictive. For epilepsy, you must not use Please read this leaflet very Epilim if you are pregnant, unless carefully before you start to take your doctor has determined that your Epilim, even if you have no alternative treatment works taken Epilim before. Before you take it If you are a woman able to have a If you have any concerns about taking this medicine, ask your baby, you must not take Epilim, doctor or pharmacist. Medicines used in if you are planning to have a baby for the treatment of epilepsy, or are pregnant. Epilim can be harmful to unborn carbapenem antibiotics such as If you have not told your doctor Invanz and Merrem. If you take valproate Taking other medicines these medicines and others may be during pregnancy you have a higher Tell your doctor or pharmacist if affected by Epilim, or may affect risk than other women of having a you are taking any other how well it works. Epilim may depend on your age, your putting yourself at risk of a should have little effect on the condition and whether or not you seizure, or fit. If you become pregnant while you Epilim helps control your condition Swallow the tablets whole with a but does not cure it. Therefore you are taking this medicine, tell your full glass of water or other liquid must take it every day. Always remember to take your Your doctor will check your Do not take them with "fizzy" prescribed dose otherwise you may progress and may want to take some water, soda or soft drinks. If you have trouble remembering Do not use this medicine to treat Epilim Syrup and Liquid when to take your medicine, ask any other complaints unless your your pharmacist for hints. If you take too much lower the dosage, without Shake the bottle well and (overdose) checking with your doctor. Children should not ride a bike, Take Epilim at about the same climb trees or do anything else time each day. It Epilim may cause drowsiness, will also help you remember when While you are taking dizziness or sleepiness in some to take the tablets. The effects of alcohol could be Tell all the doctors, dentists and made worse while taking Epilim. Your doctor may any new medicine, tell your suggest you avoid alcohol while you doctor that you are taking Epilim. Epilim should have little effect on Tell your Doctor immediately or Keep your tablets in the blister the oral contraceptive pill, however, go to the Accident and Emergency pack until it is time to take them. Epilim Liquid Sugar Free Sorbitol, saccharin sodium, citric acid, hyetellose, sodium methyl hydroxybenzoate, sodium propyl hydroxybenzoate, ponceau 4R, cherry flavour, purified water. Associate Professor in Oral Medicine and Pathology, Dental School, University of Athens. Insofar as this book Color atlas of oral diseases / George Laskaris; foreword mentions any dosage or application, readers may rest by Gerald Shklar. The English text now offers a brief but ground, and wealth of experience in the disci authoritative discussion of each condition. Brackett Professor of Oral Pathology guage journals, and it is fitting that his extensive and Head of the Department of Oral Medicine experience with oral diseases is now made avail and Oral Pathology, able to the English-speaking world. Sixty-four illustrations of lesions and clinical entities affecting the oral cavity, not published in the first edition, are now included. Fortunately, the oral plates and a description of the clinical features, cavity is accessible to visual examination, and I differential diagnosis, helpful laboratory tests, and have attempted to record oral lesions in color a brief statement on treatment. During my career as a stomatologist, I have Selective bibliography and index are included. My gratitude is extended to the late Professor Finally, I wish to thank my colleagues at the of Dermatology, John Capetanakis, and the cur Department of Oral Medicine and Pathology of rent Professor of Dermatology and Head of the the Dental School, University of Athens, with Department of Dermatology, University of whom I have worked closely for more than 25 Athens, "A. Eleana Stufi for their assistance in the prepa I am also indebted to Associate Professor of ration of the first edition of the Atlas. My deepest gratitude is due to Professor Cris Last, but by no means least, I can never fully pian Scully, Department of Oral Medicine and repay all that I owe my wife and three children for Surgery, University of Bristol, England, and Pro their constant patience, support, and encourage fessor Gerald Shklar, Department of Oral ment. Normal Anatomic Variants Linea Alba Leukoedema Linea alba is a normal linear elevation of the Leukoedema is a normal anatomic variant of the buccal mucosa extending from the corner of the oral mucosa due to increased thickness of the mouth to the third molars at the occlusal line. As a rule, it occurs bilaterally and with normal or slightly whitish color and normal involves most of the buccal mucosa and rarely the consistency on palpation (Fig. The oral opalescent or grayish-white color with slight mucosa is slightly compressed and adjusts to the wrinkling, which disappears if the mucosa is dis shape of the occlusal line of the teeth. However, areas of dark discoloration may often be a normal finding in black or dark skinned persons. In healthy persons there may be clini cally asymptomatic black or brown areas of vary ing size and distribution in the oral cavity, usually on the gingiva, buccal mucosa, palate, and less often on the tongue, floor of the mouth, and lips (Fig. They occur Congenital lip pits represent a rare developmental most often in the mucosal surface of the upper lip, malformation that may occur alone or in combina commissures, and the buccal mucosa adjacent to tion with commissural pits, cleft lip, or cleft the molar teeth in a symmetrical bilateral pattern. Clinically, they present as bilateral or They are a frequent finding in about 80% of unilateral depressions at the vermilion border of persons of both sexes. There is no satisfactory explana tion for the occurrence of oral hair although a developmental anomaly is the most likely possibil ity. The presence of oral hair and hair follicles may offer an explana tion for the rare occurrence of keratoacanthoma intraorally. Rarely, the condition may occur as a exhibit a defect at the midline of the palate that result of fusion between the tongue and the floor may vary in severity (Fig. The malfor sents a minor expression of cleft palate and may mation may cause speech difficulties. Surgical clipping of the frenum cor Cleft palate may occur alone or in combination rects the problem. It may coexist with shape may be spindlelike, lobular, nodular, or the oro-facial digital syndrome. Because of its slow growth, the Double Lip lesion causes no symptoms, and it is usually an Double lip is a malformation characterized by a incidental finding during physical examination. It may be congenital, but it may be anticipated if a total or partial denture is can also occur as a result of trauma. Developmental Anomalies Facial Hemiatrophy Masseteric Hypertrophy Facial hemiatrophy, or Parry-Romberg syndrome, Masseteric hypertrophy may be either congenital is a developmental disorder of unknown cause or functional as a result of an increased muscle characterized by unilateral atrophy of the facial function, bruxism, or habitual overuse of the mas tissues. The differential diagnosis includes true lipodystro phy, atrophy secondary to facial paralysis, facial hemihypertrophy, unilateral masseteric hypertro phy, and scleroderma. Gingival Fibromatosis the differential diagnosis includes leukoplakia, lichen planus, leukoedema, pachyonychia con Gingival fibromatosis is transmitted as an auto genita, congenital dyskeratosis, hereditary benign somal dominant trait. The upper gingiva are more severely affected Hereditary Benign Intraepithelial and may prevent the eruption of the teeth. Dyskeratosis the differential diagnosis should include gingival hyperplasia due to phenytoin, nifedipine, and cy Hereditary benign intraepithelial dyskeratosis is a closporine, and gingival fibromatosis, which may genetic disorder inherited as an autosomal domi occur as part of other genetic syndromes. The ocular lesion pre sents as a gelatinous plaque covering the pupil partially or totally and may cause temporary 3. Hereditary benign intraepithelial dyskeratosis, white lesions on the buccal mucosa. It is characterized by symmetrical thickening a recessive autosomal and X-linked trait. The differential diagnosis should include leuko Atrophy of the oral mucosa is the result of re peated episodes. Finally, leukoplakia and squa plakia, lichen planus, white sponge nevus, dys keratosis congenita, hereditary benign intra mous cell carcinoma may occur (Fig. In some cases xerostomia may mucosa, lateral border of the tongue, retromolar occur as a result of salivary gland hypoplasia. No reliably successful treatment exists, but aromatic retinoids may occasionally be as early as possible. Papillon-Lefevre Syndrome agranulocytosis, Chediak-Higashi syndrome, leukemia, and diabetes mellitus. The severe periodontitis and oral hygiene instruction are to be recom results in premature loss of all the deciduous teeth mended. The periodontitis again develops with the eruption of the permanent teeth and results in their loss by the age of 14. The differential diagnosis should include juvenile periodontitis, histiocytosis X, acatalasia, hypophosphatasia, hypohidrotic ectodermal dys phasia, focal palmoplantar and oral mucosa hyperkeratosis syndrome, other disorders that are associated with palmoplantar hyperkeratosis, congenital neutropenia, cyclic neutropenia, 3. The benign variety is subdivided into: (1) ge netic type that is manifested during childhood Dyskeratosis Follicularis or early adolescence and rarely affects the oral cavity; (2) acanthosis nigricans that occurs as Dyskeratosis follicularis, or Darier-White disease, part of other syndromes, such as Prader-Willi, is an uncommon disorder inherited as an auto Crouzon, and Bloom syndromes, insulin-resistant somal dominant trait. The scalp, forehead, chest and back, 25 to 60 years of age and involves the skin only. They are brownish-red in color and are involves the oral mucosa in about 10 to 15% of the covered by a yellowish to tan scaly crust. The oral mucosa is affected in 20 the filiform papillae, resulting in a shaggy appear to 40% of the cases, but the severity of oral lesions ance of the tongue (Fig. Clinically, it is characterized molysis bullosa letalis, and generalized atrophic by a reccurent group of small flaccid vesicles aris benign epidermolysis bullosa. The skin lesions are usually consist of generalized bullae formation, which localized, with a tendency to spread peripherally, heal without scarring. The although the center heals with pigmentation or oral mucosa shows bullae, severe ulcerations, and exhibits granular vegetations.

The finding of a latent strabismus (heterophoria) may be a clue to the fact that such visual loss is long-standing spasms throughout body buy cheap lioresal 25 mg line. This is a component of long-term (as opposed to working) memory which is distinct from memory for facts (semantic memory) spasms left upper quadrant purchase lioresal toronto, in that episodic memory is unique to the individual whereas semantic memory encompasses knowledge held in common by members of a cultural or linguistic group infantile spasms 2 month old buy discount lioresal on-line. Amnesia may be retrograde (for events already experienced) or anterograde (for newly experienced events) muscle spasms zoloft generic 10mg lioresal amex. In a pure amnesic syndrome spasms lower back order 25 mg lioresal overnight delivery, intelligence and attention are normal and skill acquisition (procedural memory) is preserved muscle relaxant carisoprodol purchase lioresal online. Plasma exchange or intravenous immunoglobulin therapy may be helpful in non-paraneoplastic limbic encephalitis associated with autoantibodies directed against voltage-gated potassium channels. Functional or psychogenic amnesia may involve failure to recall basic auto biographical details such as name and address. Subtypes have been described: receptive or sensory amusia is loss of the ability to appreciate music; and expressive or motor amusia is loss of ability to sing, whistle. Amusia may occur in the context of more widespread cognitive dysfunc tion, such as aphasia and agnosia. Congenital amusia: a group study of adults affiicted with a music-specific disorder. Receptive amusia: evidence for cross-hemispheric neural networks underlying music processing strategies. Hence, although the term implies neurogenic (as opposed to myogenic) muscle wasting, its use is non-specific with respect to neuroanatomical substrate. These negative sensory phenomena may occur as one component of total sensory loss (anaesthesia) or in isolation. Consequences of analgesia include -27 A Anal Refiex the development of neuropathic ulcers, burns, Charcot joints, even painless mutilation, or amputation. Congenital syndromes of insensitivity to pain were once regarded as a central pain asymbolia. Cross References Anaesthesia; Frontal lobe syndromes Anal Refiex Contraction of the external sphincter ani muscle in response to a scratch stim ulus in the perianal region, testing the integrity of the S4/S5 roots, forms the anal or wink refiex. This refiex may be absent in some normal elderly indi viduals, and absence does not necessarily correlate with urinary incontinence. External anal responses to coughing and sniffing are part of a highly consistent and easily elicited polysynaptic refiex, whose characteristics resemble those of the conventional scratch-induced anal refiex. It -29 A Anisocoria is thought to represent a focal dystonia and may be helped temporarily by local injections of botulinum toxin. This may be detected as abrupt cut-offs in spontaneous speech with circumlocutions and/or parapha sic substitutions. Patients may be able to point to named objects despite being unable to name them, suggesting a problem in word retrieval but with preserved compre hension. La belle indifference describes a similar lack of concern for acknowledged disabilities which are psychogenic. Some authorities would question whether this unaware ness is a true agnosia or rather a defect of higher-level cognitive integration. The neuropsychological mechanisms of anosognosia are unclear: the hypothesis that it might be accounted for by personal neglect (asomatognosia), which is also more frequently observed after right hemisphere lesions, would seem to have been disproved experimentally by studies using selective hemisphere anaesthesia in which the two may be dissociated, a dissociation which may also be observed clinically. The syndrome most usually results from bilateral posterior cerebral artery territory lesions causing occipital or occipitoparietal infarctions but has occasionally been described with anterior visual pathway lesions associated with frontal lobe lesions. Selective serotonin-reuptake inhibitors may sometimes be helpful in the treatment of apathy. Cross References Abulia; Akinetic mutism; Dementia; Frontal lobe syndromes Aphasia Aphasia, or dysphasia, is an acquired loss or impairment of language func tion. Non-linguistic components of language (emotion, infiection, cadence), collectively known as prosody, may require contributions from both hemispheres. Transcortical: Broca Wernicke Conduction motor/sensory Fluency vv N N v/N Comprehension N vv N N v Repetition N/N Naming Nfi N = normal; v=impaired Aphasias most commonly follow a cerebrovascular event: the specific type of aphasia may change with time following the event, and discrepancies may be observed between classically defined clinicoanatomical syndromes and the find ings of everyday practice. Dystonia of the abductor muscles of the larynx can result in aphonic segments of speech (spasmodic aphonia or abductor laryngeal dystonia); this may be diagnosed by -37 A Applause Sign hearing the voice fade away to nothing when asking the patient to keep talk ing; patients may comment that they cannot hold any prolonged conversation. Cross References Anarthria; Dysphonia; Mutism Applause Sign To elicit the applause sign, also known as the clapping test or three clap test, the patient is asked to clap the hands three times. This may be associated with the presence of a grasp refiex and alien limb phenomena (limb-kinetic type of apraxia). These difficulties, into which the patient has insight and often bitterly complains of, are commonly encountered in the memory clinic. These patients generally achieve normal scores on formal psychometric tests (and indeed may complain that these assessments do not test the function they are having difficulty with). The aprosodias: functional-anatomic organization of the affective com ponents of language in the right hemisphere. Sudden tendon stretch, as produced by a sharp blow from a tendon hammer, activates muscle spindle Ia afferents which pass to the ventral horn of the spinal cord, there activating fi-motor neurones, the efferent limb of the refiex, so completing the monosynaptic arc. It fails to react to light (refiex iridoplegia), but does constrict to accommodation (when the eyes converge). Cross References Aphasia, Apraxia Asomatognosia Asomatognosia is a lack of regard for a part, or parts, of the body, most typically failure to acknowledge the existence of a hemiplegic left arm. Cross References Agnosia; Dysmorphopsia; Graphaesthesia; Two-point discrimination Asterixis Asterixis is a sudden, brief, arrhythmic lapse of sustained posture due to involun tary interruption in muscle contraction. Unilateral asterixis has been described in the context of stroke, contralateral to lesions of the midbrain (involving corticospinal fibres, medial lemniscus), tha lamus (ventroposterolateral nucleus), primary motor cortex, and parietal lobe; and ipsilateral to lesions of the pons or medulla. Dyssynergy of speech may also occur, a phenomenon sometimes termed scan ning speech or scanning dysarthria. This is typically seen in cerebellar syndromes, most often those affecting the cerebellar hemispheres, and may coexist with other signs of cerebellar disease such as ataxia, dysmetria, and dysdiadochokinesia. Ataxia is used most frequently to refer to a cerebellar problem, but sensory ataxia, optic ataxia, and frontal ataxia are also described, so it is probably best to qualify ataxia rather than to use the word in isolation. An International Cooperative Ataxia Rating Scale has been developed to assess the efficacy of treatments for cerebellar ataxia. These fibres run in the corticopontocerebellar tract, synapsing in the pons before passing through the middle cerebellar peduncle to the contralateral cerebellar hemisphere. Athetosis often coexists with the more fiowing, dance-like movements of chorea, in which case the movement dis order may be described as choreoathetosis. Cross References Chorea, Choreoathetosis; Pseudoathetosis; Pseudochoreoathetosis Athymhormia Athym(h)ormia, also known as the robot syndrome, is a name given to a form of abulia or akinetic mutism in which there is loss of self-autoactivation. It is associated with bilat eral deep lesions of the frontal white matter or of the basal ganglia, especially the globus pallidus. It may also be applied to other tissues, such as subcutaneous tissue (as in hemifacial atrophy). In the presence of severe attentional disorder (as in delirium) it is dif ficult to make any meaningful assessment of other cognitive domains. Auras are exclusively subjective, and may be entirely sensory, such as the fortifica tion spectra (teichopsia) of migraine, or more complex, labelled psychosensory or experiential, as in certain seizures. Cross References Hallucination; Heautoscopy Autotopagnosia Autotopagnosia, or somatotopagnosia, is a rare disorder of body schema charac terized by inability to identify parts of the body, either to verbal command or by imitation; this is sometimes localized but at worst involves all parts of the body. The plantar response is most commonly performed by stroking the sole of the foot, although many other variants are described. It may assist in differentiating hemifacial spasm from other craniofacial movement disorders. The recumbent patient is asked to sit up with the arms folded on the front of the chest. This pattern of facial sensory impairment may also be known as onion peel or onion skin. These movements most usually involve one-half of the body (hemiballismus), although they may sometimes involve a single extremity (monoballismus) or both halves of the body (paraballismus). Poorer prognosis is associated with older age (over 40 years) and if no recovery is seen within 4 weeks of onset. Combined corticosteroid and antiviral treatment for Bell palsy: a systematic review and meta-analysis. This is a synkinesis of central origin involving superior rectus and inferior oblique muscles. On the motions of the eye, in illustration of the use of the muscles and nerves of the orbit. The test is usually negative in a skew deviation causing vertical divergence of the eyes. This test may also be used as part of the assessment of vertical diplopia to see whether hypertropia changes with head tilt to left or right; increased hypertropia on left head tilt suggests a weak intortor of the left eye (superior rectus); increased hypertropia on right head tilt suggests a weak intortor of the right eye (superior oblique). Various causes are recorded including syphilis, glaucoma, drusen, and chronically raised intracranial pressure. Conditions mimicking bitemporal hemianopia include congenitally tilted discs, nasal sector retinitis pigmentosa, and papilloedema with greatly enlarged blind spots. Usually bilateral in origin, it may be sufficiently severe to result in functional blind ness. Blepharospasm is usually idiopathic but may be associated with lesions (usu ally infarction) of the rostral brainstem, diencephalon, and striatum; it has been occasionally reported with thalamic lesions. Minor enlargement of the blind spot is difficult to identify clinically, formal perimetry is needed in this situation.

Sympathomimetic Syndrome Thebloodpressure andpulse rate areelevated muscle relaxant powder purchase lioresal on line amex, though with severe hypertension refex bradycardia may occur spasms pain rib cage cheap lioresal on line. The coma spasms 1983 youtube cheapest generic lioresal uk, apnea muscle relaxants quizlet generic lioresal 25mg mastercard, severe hypotension muscle relaxant norflex buy generic lioresal 10mg on-line, fuid and electrolyte or temperature is often elevated muscle relaxant in pregnancy generic 10 mg lioresal overnight delivery, pupils are dilated, and the acid-base disturbance, or extreme body temperature skin is sweaty, though mucous membranes are dry. Repeat-dose charcoal-Repeated doses of activated charcoal, 20-30 g orally or via gastric tube every 3-4 hours, C. Nicotinic receptor stimulation may produce initial each dose, or resulting large stool volumes may lead to hypertension and tachycardia as well as fasciculations and dehydration or hypernatremia. Examples: Carbamates, nicotine, organophosphates (including nerve agents), physostigmine. Patients may vated anion and osmol gaps suggests poisoning by methanol have myoclonic jerking or choreoathetoid movements. Drug or Toxin Treatment Acetaminophen Specific antidote (N-acetylcysteine) based A. Osmol Gap on serum level the osmol gap (Table 38-5) is increased inthe presence of Carbon monoxide High carboxyhemoglobin level indicates large quantities of low-molecular-weight substances, most need for 100% oxygen, consideration of commonly ethanol. Other common poisons associated hyperbaric oxygen with increased osmol gap are acetone, ethanol, ethylene Carbamazepine High level may indicate need for glycol, isopropyl alcohol, methanol, and propylene glycol. Anion Gap causeofcoma (eg, trauma, other drugs, other alcohols); serum ethanol may also Metabolic acidosis associated with an elevated anion gap is be useful in monitoring ethanol therapy usually due to an accumulation oflactic acid or other acids for methanol or ethylene glycol (see Chapter 21). Massive acetaminophen overdose can cause early-onset anion gap metabolic acidosis. Lithium Serum levels can guide decision to institute hemodialysis Methanol, ethylene Acidosis, high levels indicate need for glycol hemodialysis, therapy with ethanol or Table 38-5. Patients with enhanced P450 2E1 activity, such as those drocannabinol [marijuana]). L]) can cause early onset of to remove the drug or poison; or when advice is needed acute coma, seizures, hypotension, and metabolic acidosis regarding the indications, dose, and side effects of unrelated to hepatic injury. When to Admit level versus the time since ingestion on the acetaminophen o the patient has symptoms and signs ofintoxication that nomogram shown in Figure 38-1. If vomiting interferes with oral N-acetylcysteine Acetaminophen (paracetamol in the United Kingdom, administration, consider giving the antidote intravenously. However, metabolized mainly by glucuronidation and sulfation, with other regimens have demonstrated equivalent success with a small fraction metabolized via the P450 mixed-function 20-48 hours of treatment. E 50 el el 300 Q Q 40 ((el el E E 200 30:: Q Q 20 C C 100 10 0 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Time (hours). Nomogram for prediction of acetaminophen hepatotoxicity following acute overdosage. Patients with serum levels above the line after acute overdose should receive antidotal treatment. Guidelines for the management of paracetamol poisoning in Australia and New Zealand-explanation and elaboration. A consensus statement from clinical toxicologists consultingtothe Australasian poisons information centres. The Medical Journal of Australia does not accept responsibility for any errors in translation. Treatment Treatment with N-acetylcysteine is most effective ifitis started within 8-10 hours after ingestion. Severe systemic metabolic acidosis may occur both as a Flood with water for 15 minutes. For hydrofuoric acid burns, soak the affected area in Severe deep destructive tissue damage may occur after benzalkonium chloride solution or apply 2. Skin Contact bed; consult with a hand surgeon or poison control center Wash with running water until the skin no longer feels (1-800-222-1222). Disk (or "button") batteries are also a depends on the route of administration and individual source. Ingestion contain stimulant or sympathomimetic drugs such as Dilute immediately with a glass of water. Clinical Findings afer ingestion of liquid caustic substances, in order to remove residual material. Rapidly lower the body temperature (dabigatran, rivaroxaban, apixiban, and edoxaban) do not (see hyperthermia, p. Add phenobarbital 15 mg/kg intravenously dence of anticoagulation (elevated prothrombin time). Treat hyperthermia as described prosthetic heart valve), give much smaller doses of vitamin above (see p. Treat hyonatremia as outlined in K (1 mg orally) and fresh-frozen plasma (or both) to titrate Chapter 21. Accidental death via intravaginal absorption of vation (over weeks) and repeated administration of large methamphetamine. L] or valproic acid levels greater than 800 mg/L Anticonvulsants (carbamazepine, phenytoin, valproic acid, [5544 mcmol! Beneft ofhemodialysis incarbamazepine cardial depression and cardiac arrest owing to the solvent intoxications with neurological complications. Chronic phenytoin intoxication can occur following 22582484] only slightly increased doses because of zero-order kinetics Pons S et al. Acute overdose of enteric-coated valproic acid and olanzapine: unusual presentation and delayed toxicity. L), although severe poisoning is usually agents, and sometimes as antiemetics and potentiators of associated with concentrations greater than 30-40 mg/L analgesic and hypnotic drugs. Hypoglycemia may occur as a result of hepatic the newer agents, quetiapine is more likely to cause coma metabolic dysfunction. Treatment For recent ingestions, give activated charcoal orally or by gastric tube (see p. Naloxone was reported to have reversed valproic acid overdose in one anecdotal case. Consider hemodialysis for zine poisoning may respond to intravenous sodium massive intoxication with valproic acid or carbamazepine bicarbonate as used for tricyclic antidepressants. Arsenic exposure and toxicology: a historical usually treated with intravenous magnesium or overdrive perspective. Chronic arsenic poisoning following ayurvedic mg/kg intravenously, or benztropine mesylate, 0. Treatment with oral doses of these 24696169] agents should be continued for 24-48 hours. Acute dyskinesia, myoclonus, and akathisa in an adolescent male abusing quetiapine via nasal insufation: a vision. Emergency and Supportive Measures often include pancytopenia, painful peripheral sensory Administer activated charcoal (see p.

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References

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