睿学教育Wisdome Education

Frank Seghatol-Eslami, MD, FASE

• Assistant Professor of Medicine
• Division of Cardiovascular Disease
• University of Alabama at Birmingham
• Birmingham, Alabama

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Intraoperative photo revealing a well-demarcated antibiotic knee spacer infected 3 mg stromectol for sale, ovoid antibiotics for sinus infection pregnancy buy online stromectol, brownish tumor approximately 3 × 1 antibiotic before dental work buy stromectol 6 mg without prescription. Isolated benign Schwannoma of the supraorbital nerve presenting as an asymptomatic palpable mass. Patient with herpes zoster along the left ophthalmic and maxillary division of the trigeminal nerve. Fluorescein staining reveals typical branching ulceration and swollen epithelial borders. The supraorbital foramen on the affected side is then identified by palpation (Fig. A high-frequency small linear or hockey stick transducer is then placed in a transverse plane over the previously identified supraorbital notch and slowly moved from a cephalad to caudad direction until a discontinuity in the supraorbital ridge is identified (Fig. In most patients, color Doppler can be used to identify the supraorbital artery which exits the supraorbital foramen along with the supraorbital nerve (Fig. Care should be taken to identify any evidence of soft tissue mass or tumor that may be compressing the nerve and to identify any areas of swelling or entrapment (Fig. B: the high-frequency small linear transducer is placed over the supraorbital foramen. The supraorbital foramen (star) can be viewed as a discontinuity in the orbital ridge with the nerve and artery exiting through it. Because of the proximity of the supraorbital artery combined with the vascularity of the regions, post block ecchymosis and hematoma formation can occur even in the best of hands. These bleeding complications can be decreased if manual pressure is applied to the area of the block immediately after injection. Application of cold packs for 20-minute periods after the block also decreases the amount of postprocedure pain and bleeding the patient may experience. Patients suffering from this painful condition have in common the fact that their headache pain will decrease or resolve when the source of external pressure is removed. It is important to note that patients with acute herpes zoster involving the first division of the trigeminal nerve may first experience vesicular eruptions on the tip of the nose (positive Hutchinson sign) which may presage a particularly severe bout of herpes zoster with ocular complications such as acute glaucoma and keratitis (Fig. In: Comprehensive Atlas of Ultrasound-Guided Pain Management Injection Techniques. Entering the orbit via the inferior orbital fissure, the infraorbital nerve passes along the floor of the orbit in the infraorbital groove (Fig. Along with the infraorbital artery, the infraorbital nerve exits the orbit via the infraorbital foramen (Fig. The nerve then divides into a superior alveolar branch which provides sensory innervation to the upper incisor, canine, and associated gingiva and a cutaneous branch that fans out to provide sensory innervation to the lower eyelid, lateral naris, and upper lip (Fig. In rare instances, the infraorbital nerve may bifurcate within the orbit and exit via separate infraorbital foramen (Fig. The infraorbital nerve is a pure sensory nerve arising from fibers from the maxillary nerve. Entering the orbit via the inferior orbital fissure, the infraorbital nerve passes along the floor of the orbit in the infraorbital groove to exit via the infraorbital foramen. Along with the infraorbital artery, the infraorbital nerve exits the orbit via the infraorbital foramen. The nerve then divides into a superior alveolar branch which provides sensory innervation to the upper incisor, canine, and associated gingiva and a cutaneous branch that fans out to provide sensory innervation to the lower eyelid, lateral naris, and upper lip. In some patients, the infraorbital nerve may divide while within the orbit, with two or more branches exiting via separate infraorbital foramen. View of duplication of the infraorbital nerve detected during the dissection 66 performed for the Le Fort I surgery. The nerve is subject to trauma from surgical procedures and facial fractures, as well as compression by tumors or infection anywhere along its path (Figs. Bony excrescence of the infraorbital foramen can also cause compromise of the infraorbital nerve.

Diseases

• PEPCK deficiency, mitochondrial
• Ichthyosis microphthalmos
• Spondylometaphyseal dysplasia, X-linked
• Cleft lip palate oligodontia syndactyly pili torti
• Night blindness, congenital stationary
• Atresia
• Silent sinus syndrome
• Crow Fukase syndrome
• Chromosome 14 trisomy

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The 11 Biostimulation and Biorestructuring of the Skin 133 hydrolysis of this amino acid frees the site containing useful in all kinds of skins while aesthetic improvement zinc and permits the action of the enzyme antibiotics for sinus infection safe during pregnancy order stromectol 3 mg overnight delivery. Therefore antibiotics and period order stromectol master card, if fbroblastic As in most parts of the biological systems infection signs buy generic stromectol canada, the dis- biostimulation is to be used in a young patient, we solution of the matrix is governed by activators and have to be sure that the stimulated receptors are only inhibitors of the M M P. The proteins derived from the damage of the extra- the receptors of the tyrosine–kinase that are acti- cellular matrix stimulate the synthesis of its vated by the growth factors (fbroblast growth factor), components. This reaches the endoplasmic lysed reticule where W hile: joining up with a specifc reticule, induces the entry of 1. The adenosine (Purina base) rules the infammation and Fos genes and the subsequent start of the protein and the reparation of the tissues. The extracellular nucleotides have been involved as biological process useful to compensate the loss of part infammatory mediators in many pathological of a tissue as a result of damage. Phlogogen stimulus select the under populations of in this case we have diverse stimuli to induce the con- fbroblasts with an important role in the formation struction of new tissue and not the original tissue. The stimulation of biostimulation tell us of the use of: different receptors could bring biological improvement 1. Laser energy activation of the fbroblast through the use of homolo- It is important before commencing any of these gous growth factors and inducing the normal reconstruc- treatments, to consider the real biological effects of tion of the altered dermal components. The technique by each (as doctors freeing ourselves from the simple eco- Garcia [3] is histologically verifed by its results and is, nomic business and choosing science and conscience). The term biorestruc- these off-label-activated platelets remains the respon- turing is used to indicate an alteration of the normal sibility of the physician. They can be produced by numerous cells older skin to obtain an aesthetic improvement. The join- tions being activated through a functional improve- ing of the tyrosine–kinase receptors to the cellular ment of the epidermal and dermal cells that brings a membrane induces the hydrolysis of poliphosphoinos- normalization to the condition of the skin. This fore- itole of the membrane with the liberation of the 1–3 sees a regular epidermal renewal and the optimization diphosphoinositole. The chemical–physical optimi- activate the proteinkinase C with the stimulus of the zation of the matrix requires the neoformation of the genes at an early induction Jun and Fos and the subse- structural components and the fuidity of its colloidal quent start of the protein synthesis. The platelets, furthermore, also transport requires the maintenance of a physiological ph (7. The merit of Garcia (600–900), the longer the wavelength the deeper and of the studies at Barcelona University is in the penetration of the skin. But where is the site for action of the photobiostim- Histological studies have shown that the introduction ulation? The treatment is carried out photo systems of the vegetable cell by splitting the on the face, neck, décolleté, and hands in three ses- water and uses the hydro genes to activate the synthe- sions (the frst, then after 3 months and after 6 months). Also at an animal level we have the platelets, therefore the plasma, before administra- some biological structures activated by the light. Transfer of the electrons from the cytochrome c to ever to give a positive effect on the cells at a morpho- the oxygen as per action of the cytochromoxidasis logical and molecular level. The treatment is today Essential in the chain of transport of the electrons is placed at an international level amongst the nonablative the protonic fux of the hydrogen ions. The because the mechanism of oxygen reduction foresees a application times for the photo modulation, per ses- necessary amount of time for the inversion of the spin sion, range from 15 to 20 min. In fact, oxygen sessions can vary from 1 to 2 for a total of 8–10 at two electrons with spin parallel in the last orbit and treatments. The lipoperoxidation of the biological membranes eration of the dermis and epidermis, which would results in a loss of function with cellular death. The bring the skin into a youthful state requires the use of loss of double ties of the phospholipids determines a autologous patient’s substances [3], such as: rigidity of the membranes with loss of fuidity and an 1. Support autologous biological tissue the caspasi with induction of the cellular apoptosis the heterologous skin regeneration always involves and death. The regeneration heterologous replaces the successive aggregation and liberation of activated generic term of biostimulation to indicate biological caspasi 9. This activates the cascade of the caspasi activity useful in functional improvement of skin. In fact, the electronic fux moving along the vators of skin biology), but not all, lead to an improve- mitochondrial crests is accompanied by a protein fux ment of the physiological skin, they often show a in the intermembranal space. After the cessation of positive response on the aesthetic result, but with skin the electrons to the oxygen the protons pass into the biological damage.

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In this situation antibiotic resistant uti treatment stromectol 6 mg purchase amex, dosage assessment of the drug concentration will be useful in identifying • When a change in pharmacokinetics is expected (e antibiotic resistance global statistics purchase stromectol overnight. In addition to pae- pharmacokinetics (children virus 58 buy cheap stromectol 6 mg on-line, the elderly, patients with certain diatric age, pregnancy, and old age, such conditions include dis- comorbidities such as impaired kidney and liver function, or eases afecting the liver, the kidney and the gastrointestinal tract. If patients taking interacting comedications) applicable, knowledge of a pre-established individual therapeutic • To inform physicians about the optimal magnitude of dose concentration is of particular value in the management of these adjustments for drugs showing non-linear pharmacokinetics, patients. However, it should be noted that, in some of these condi- most notably phenytoin tions, drug binding to serum proteins and pharmacodynamic sen- • When intoxication is suspected, particularly in patients on sitivity to the drug may also be altered, and this should be taken polypharmacy (to facilitate identifcation of the medication into account when interpreting concentration data. For example, responsible for the signs of toxicity) or in patients unable to if an emergent condition resulted in an increased unbound frac- report subjective adverse effects tion of the drug, therapeutic and toxic efects will be expected to • When using drugs with a narrow therapeutic index and large occur at comparatively lower total drug concentrations. When rapid changes in pharmacokinetics during infancy and early child- seizure control is unsatisfactory or toxic signs develop in patients hood. Pharmacokinetic variability can be particularly large in paediatric • When a drug formulation has been changed (e. Adequate quality control measures valuable guide as an aid to optimum patient management. Tese determinations should be re- 20–50%), and they are also susceptible to pharmacokinetic inter- quested only when there is a sound indication, and dosage adjust- actions with medications used to treat comorbid conditions. Note not only the non-linear relationship but also the wide variability across patients. For drugs with a long half-life, such as pheno- suggestion has been made that in the presence of altered binding barbital, the daily fuctuation in plasma concentration is negligible to plasma proteins it would be preferable to monitor directly the and the exact time of sampling is not important. In practice, however, this is not al- pounds, it is preferable to collect the sample in the morning before ways necessary because ofen the increase in unbound fraction may the frst daily dose, when the concentration is usually at its trough. In during the dosing interval, such as carbamazepine, it is at times addition, unbound plasma drug concentrations are much smaller useful to obtain a second sample at the time of the expected peak than total concentrations and not always easy to measure. Results concentration, in order to estimate the degree of fuctuation as a may vary depending on the assay technique, and there is a greater potential cause of intermittent adverse efects. Terefore, salivary concentrations have been proposed for increased, the total concentration in serum may underestimate the monitoring purposes, particularly in children who fnd venepunc- amount of drug that is pharmacologically active, and this should tures distressing. However, the use of salivary samples is not with- be taken into account when interpreting the serum concentration out problems because leakage of exudate (e. An increased unbound fraction of these drugs is observed in Moreover, measuring drug concentrations is subject to error, par- conditions associated with hypoalbuminaemia (e. Furthermore, it should be stressed by drug interactions: valproic acid, for example, increases the un- that the relationship between unbound drug concentration in plas- bound fraction of phenytoin by displacing phenytoin from protein ma and drug concentration in saliva is not the same for all drugs binding sites. In the case of phenobarbital, the concentration in saliva is Pharmacokinetic Optimization of Therapy 131 dependent upon salivary pH and cannot be used as a measure of Ensuring optimal analytical quality is important, because ana- free concentration in plasma unless calculations are made to ac- lytical errors can result in inappropriate clinical decisions and seri- count for diferences in pH. Terefore, participation in both internal concentrations is meaningless because the drug concentration and external quality control schemes is necessary to ensure reliable in saliva bears no consistent relationship with the concentration results, and is an absolute requirement for any laboratory engaged in plasma. Measuring drug concentrations in sequential segments of hair, for example, First generation antiepileptic drugs can be applied to monitor fuctuations in adherence over prolonged period of time, and may also be valuable to detect drug exposure in Benzodiazepines forensic medicine. The main benzodiazepines used for chronic treatment in epilepsy are clonazepam and clobazam (see Chapter 30). Most laboratories currently cokinetic variability, and both are extensively (>80%) bound to use immunoassays or chromatographic techniques. Chromatographic techniques include gas and liquid chromatog- The serum concentrations of both clonazepam and clobazam are raphy. In the case of clobazam, however, coadministration of metabolites, in a single run. Elimination of the lat- and that interference from other drugs and metabolites is excluded. Technically, it can be possible for the physician to be tration not only across individuals, but also within individuals be- informed of the drug concentration before completion of the clinic cause of gradual development of pharmacodynamic tolerance to the visit, or whenever rapid determinations are necessary. Because of these limitations, The use of chromatographic techniques generally requires spe- reference ranges should be interpreted very fexibly. In recent years, liquid chromatogra- range cited for serum clonazepam concentrations is 0. Likewise, ultrafast analysis of several newer user-dependent sodium channels [34].

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After cleavage by plasma membrane integrity are lost infection behind ear stromectol 3 mg order line, resulting in spilling of caspase-8 bacterial vagainal infection order discount stromectol, it moves to the mitochondria where it causes release cytosolic and organellar contents into the surrounding envi- of cytochrome c possibly by altering the conformation of Bax virus ti snow cheap stromectol 12 mg overnight delivery. Thus, under- Thus, cell death in the absence of an infammatory response standing the molecular mechanisms responsible for regulating may be the best way to distinguish apoptosis from necrosis. At the extremes, apoptosis proapoptotic member of the Bcl-2 family and is sequestered in and necrosis clearly involve different molecular mechanisms. Phosphorylated Bad is sequestered Cell death induced by free radicals, however, may have char- in the cytosol by the 14-3-3 protein. Each leads to activation of cysteine pro- ligation has been shown to initiate apoptosis. Ligands are typically trimeric and bind to cell surface recep- Apoptosis, suppressors: the induction of apoptosis or pro- tors causing aggregation (trimerization) of cell surface recep- gression through the process of apoptosis is inhibited by a tors. Receptor oligomerization orients their cytosolic-death group of proteins called inhibitors of apoptosis. Bcl-2 family appear to regulate the membrane permeability to ions and possibly to cytochrome c as well. Although these pro- Death domains are protein molecular structures involved teins can themselves form channels in membranes, the actual in protein to protein interactions. They were frst recognized Molecules, Cells, and Tissues of the Immune Response 137 in proteins encoded by genes involved in programmed cell death or apoptosis. A death receptor is molecular confguration of the cell sur- face, which when engaged initiates apoptosis. Ligation of Fas by FasL or anti-Fas antibody can induce apoptotic cell death in cells expressing Fas. Fas is expressed on selected cells, including T cells, and renders them susceptible to apoptotic death mediated by cells expressing Fas ligand. Spleen FasL/Fas toxicity: Cytotoxic sequence that commences with crosslinking of target cell Fas by FasL on the effec- tor cell. FasL crosslinks Fas triggering signals, Peyer’s which leads to a target cell apoptotic response. Fas-mediated killing of T lymphocytes is critical for the maintenance of self-tolerance. Binding Fas ligand to Fas initiates the signaling pathway that leads to apoptotic cell death of the cell expressing Fas. The Fas pathway is an apoptotic pathway leading to death of Fas expressing cells, which is induced by ligation of the death receptor Fas by FasL. Necrosis is cell or tissue death caused by chemical or physi- cal injury as opposed to apoptosis, which is biologically pro- figure 2. Extensive cellular debris that must be removed by phagocytes is left by necrosis but not by apopto- sis. Danger signal mediators that initiate infammation may lymph nodes, spleen, tonsils, Peyer’s patches, and mucosal- be released from necrotic cells. Exposure Ikaros is a requisite transcription factor for all lineages of of immature dendritic cells to danger signals leads to their lymphoid cells to develop. The thoracic duct is a canal that leads from the cisterna Peripheral lymphoid organs (Figure 2. T Thoracic duct drainage is the deliberate removal of lym- lymphocytes percolate through the lymph nodes. They enter phocytes through drainage of lymph from the thoracic duct from the blood at the postcapillary venules of the deep cor- with a catheter. They then enter the medullary sinuses and pass out of the node through the efferent lymphatics. It is surrounded by a capsule and con- Postcapillary tains lymphocytes, macrophages, and dendritic cells in a venule loose reticulum environment. Lymph enters this organ from Afferent lymphatics afferent lymphatics at the periphery, percolates through the node until it reaches the efferent lymphatics, exits at the hilus, and circulates to central lymph nodes and fnally to the thoracic duct. The superfcial cortex contains B lymphocytes in Paracortical area follicles, and the deep cortex is comprised of T lymphocytes. Differentiation of the specifc cells continues in these areas Medulla and is driven by antigen and thymic hormones.

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On physical examination antibiotics for uti azithromycin cheap stromectol 6 mg, the finding of point tenderness over the tibial tubercle is pathognomonic for Osgood–Schlatter disease treatment for gardnerella uti order stromectol australia. Enlargement of the tibial tubercle is invariably present with consistently reproducible pain with direct palpation antibiotics for dogs with salivary gland infection generic stromectol 12 mg mastercard, resisted knee extension, and jumping which causes the quadriceps muscle to contract and place traction via the quadriceps tendon, expansions, and patellar tendon on the tibial tuberosity (Figs. Moderate rubor may be present around the tibial tuberosity, but there will be no obvious joint effusion as is seen with bursitis of the knee. The range of motion of the knee is within normal limits as is the neurovascular examination. It is important to rule out other diseases that may cause permanent damage to the knee if left untreated (Fig. Lateral view demonstrating prominence of the tibial tuberosity in Osgood–Schlatter disease. Pain with palpation over the tibial tuberosity is suggestive of Osgood–Schlatter disease. Based on the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, sedimentation rate, and antinuclear antibody testing. Plain radiograph showing prominent tibial tubercle and ossicle consistent with Osgood–Schlatter disease. Surgical treatment of unresolved Osgood-Schlatter disease: ossicle resection with tibial tubercleplasty. Lateral film, obtained with a low-kilovoltage/soft-tissue technique, reveals fragmentation of the tibial tuberosity (black arrows) in association with soft-tissue swelling (white arrow)—characteristic findings in Osgood– Schlatter disease. A: Sagittal proton density-weighted image demonstrates thickening and increased signal intensity in the patellar tendon at the tibial tuberosity (arrow). B: Axial T2-weighted image demonstrates tendon thickening with central increased signal intensity (arrow) and marrow edema (arrowheads). T1-weighted (A) and T2*-weighted (B) sagittal magnetic resonance images of Osgood–Schlatter disease demonstrate focus of decreased signal within normal sharp V-shaped area formed by the patellar ligament and anterior tibia (arrow). A: Lateral radiograph shows soft-tissue swelling and small calcifications at the site of ossification center of tibial tuberosity (arrows). Longitudinal (B) and transverse (C) ultrasound images show a fracture and delamination of the cartilaginous portion of ossification center of tibial tuberosity, characteristic of Osgood–Schlatter disease. Arrows point to the margins of the patellar ligament; double solid arrow indicates the thickness of cartilage between the ossification center and patellar ligament insertion; double dashed arrow indicates delamination thickness within the ossification center; double black arrow indicates fibrosis within deep infrapatellar bursa; asterisk, effusion within deep infrapatellar bursa; dot, ossification center; E, epiphysis; M, metaphysis. A high-frequency linear ultrasound transducer is placed over the center for patella in the transverse plane (Fig. A survey scan is taken which demonstrates the characteristic appearance for fibers for quadriceps tendon passing over and inserting into the hyperechoic anterior margin for dome-shaped patella (Fig. The ultrasound transducer is then moved inferiorly to identify the inferior border for patella and the fibers of the patellar tendon lying inferior to the patella (Fig. After the proximal patellar tendon is identified, the tendon is evaluated for tendinosis, tears, rupture, abnormal mass, crystal tendinopathy, and tendinitis (Figs. The ultrasound transducer is then moved inferiorly to identify and assess the patellar tendons insertion on the tibial tuberosity (Figs. The tibial tuberosity is then assessed for irregularity that is pathognomonic for Osgood–Schlatter disease (Fig. Color Doppler may help identify acute inflammation of the healing tibial tuberosity (Figs. Correct transverse position for ultrasound transducer for ultrasound evaluation of the patellar tendon and its insertion on the tibial tuberosity. Ultrasound image for knee joint demonstrating the medial border for proximal femur (arrow). Transverse ultrasound image demonstrating the inferior pole patella and the patellar tendon. A: Normal tendon with regular and smooth fiber structure, no hypoechoic areas or vascular flow.

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Recording ses- ious morphologies and polarities are ofen observed in individual sions may last from 3 days to 4 weeks but most long-term intracra- patients antibiotic xigris generic 3 mg stromectol with amex. The presence of multiple phase reversals along an elec- nial monitoring sessions average 2 weeks antibiotic resistance questionnaire 6 mg stromectol buy with visa. Distinction between propagated spikes and focal spikes is difcult General comments when spikes appear difusely antibiotic joint spacer 12 mg stromectol purchase otc. Reports vary on the concordance of Considering that intracranial studies have been around since the the predominant spike focus with the ictal onset focus and the oc- 1960s, it is remarkable that so little has been written on their proper currence of multiple divergent spike populations in patients despite interpretation. Few systematic studies of morphology, frequency, a single epileptogenic zone, as proven by seizure freedom follow- extent, spread and termination of intracranial epileptic activity in ing surgical resection, has led to the minimization of their use for diferent cerebral locations have been published. Correlation of signal character- highly correlated with the presence of epilepsy, their physiological istics with surgical outcome is biased by variable selection criteria. The Over the last quarter of century, a set of rules for the interpretation spatial distribution of interictal spikes, their representation with of intracranial recordings has partly been achieved for medial tem- respect to regions of structural/functional abnormalities, clinical poral lobe epilepsies, whereas interpretation of extrahippocampal manifestations of seizures, patient state at seizure onset and the epilepsies remains rudimentary [1,35]. Ev- idence is sometimes conficting, and results vary between humans Background and animal models of epilepsy [64]. Some of spike analysis may provide additional localizing information, possi- the commonly encountered normal behavioural patterns include: bly improving surgical outcomes, although data on this relationship occipital alpha, central mu rhythm, frontal beta, lambda waves remain controversial [65,66,67,68,69]. Because of the loss of frequency fltering from scalp and skull, and because the recordings are made from a small Medial temporal lobe epilepsy volume of tissue, the waveforms appear sharper and higher fre- Interictally, intracranial recordings reveal medial temporal spikes quencies are detected, mistaken at times for epileptiform activity in >95% of patients. Some cardinal features, such as rosis is a bilateral disorder, up to 80% of patients will have bilateral state dependency, variability with activation procedures, that is eye independent interictal discharges [19,21]. Even in patients who will opening/closure, hand opening/closure, regularity, lack of propa- subsequently be found to have unilateral onset of seizures, at least gation and lack of clinical activity, can help identify these patterns 50% will show bilateral spike distribution [19,24]. Extrahippocampal epilepsies Filter settings A variety of intracranial interictal epileptic discharges may be Sensitivity of the depth electrode recordings must be lower than found, some focal, while others are widespread. Tey have been those on the surface so as to avoid missing key electrographic characterized by their continuity and rhythmicity, with spikes ap- fndings. Tey cite studies reporting Apart from bitemporal depth or strip electrode studies, asymmetry that the persistence of epileptiform discharges seen afer resection is can rarely be assessed in tailored intracranial studies. Others cite studies denying rical activity is defned, it has the same implications as extracranial an association with the ictal onset zone [75,76]. How- ed to the recording electrode, particularly if clinical manifestations ever, continuous spiking is more common in developmental lesions precede the frst electrographic changes [3]. Second, there is no such as cortical dysplasia or when associated with glialneuronal consensus on what constitutes an appropriate defnition of seizure tumours or gliosis [77]. Identifcation of the tude and spatial distribution; and (vi) presence of ictal behaviour. First, one must assume that the intracranial decremental pattern with loss or fattening of background activity. Tese patterns ofen overlap and diferent logical fndings have yielded conficting results, with some [81] onset patterns can be seen in the same patient. This preictal stage consists of poral onset location, ranging from variations in one to two adjacent periodic sharp waves or spikes occurring in a rhythmic fashion with depth electrode contacts to a widespread regional pattern involving a frequency of <2 Hz, lasting from 5 s to over 100 s, confned to the mesial and lateral temporal regions, as well as the length of the hip- hippocampus, and transitioning into an ictal pattern characterized pocampus. The frst pattern consists of a mild hippocampal atrophy are associated with initial ictal discharges high-voltage 10–16 Hz paroxysmal rhythm that is superimposed in both the hippocampal and medial temporal cortex or only the over the characteristic preictal slow 1–2 Hz periodic spike activity medial paleocortex or lateral neocortex, while marked hippocampal described above [78]. The second pattern begins as a low-voltage, atrophy and high-graded hippocampal sclerosis are associated with high-frequency discharge without the preictal spiking [78] and initial ictal discharges restricted to the hippocampus [85]. Tere is Propagation Most hippocampal-onset seizures (60%) propagate prominent irregular slow-wave activity in regions outside of the initially to ipsilateral temporal neocortical areas, with variable temporal lobe during temporal lobe seizures, most dramatic in the subsequent involvement of contralateral temporal and frontal lobe bilateral frontal and in the ipsilateral parietal association cortex. As adjacent entorhinal and temporal neocortex are Tese slow waves are not necessarily indicative of ictal propagation recruited, a synchronous and regular 5–9 Hz ictal rhythm evolves but may refect ‘surround inhibition’ [90]. About 25–30% of hippocampal-onset seizures will Termination Tere are three typical patterns of termination: (i) sud- spread frst to the contralateral hippocampus and the remaining den cessation of difuse of focal seizure activity; (ii) gradual decrease 10% of seizures involve the contralateral hippocampus and ipsi- in frequency and increase in amplitude, usually focally; and (iii) lateral temporal neocortex simultaneously [87]. Long propagation decreased frequency of a burst-suppression-like pattern, usually dif- time from one hippocampus to the other (>8–50 s) correlates with fusely. Low frequency flter was set at 1 Hz, high frequency flter was turned of and notch flter was of.

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In the initial stabilization virus under a microscope buy stromectol 12 mg amex, control of the airway - directed to opening–protecting antibiotic for dogs generic stromectol 3 mg buy on line, and maintaining the airway (to prevent hypoxia and the deleterious effects of hypercarbia) adequate oxygenation bacteria que causa la gastritis discount stromectol, and ventilation are the first priorities. Blood Pressure in Head Injury Hypotension is common and blood loss should never be attributed to the head injury alone. Rapid and aggressive treatment is needed to prevent secondary damage from hypoxic-ischemic injury. Hypertension as part of the Cushing’s triad- hypertension, bradycardia and hypoventilation; is more common. Nonglucose containing fluids should be used in the initial resuscitation and normal saline is the best choice. The importance of this cannot be overemphasized as is clear from a 1981 study in Lancet7where it showed that the outcome differences between hypotensive and normotensive patients was vastly different. If there was no hypotension or hypoxemia- 39% had poor outcome, if hypoxemic- 59 %, If hypotensive at presentation–75 % and if both hypotensive and hypoxemic were present then 100% had a poor outcome. If the child needs to have a study for any abdominal injury, it is usually wise to include a head scan even if there is no absolute indication. This may prevent a second visit to the scanner and if the child is to undergo surgery on any other part of the body, anaesthesia will prevent repeated neurological examinations for several hours. It gives no additional information besides a possible fracture and is best avoided. A negative ultrasound cranium in an infant may give a false sense of security as it will miss details. The threshold for ordering a scan is so low that it is not worth elaborating on the indications. A quick cross table lateral X-ray can help visualize at least the top 3 vertebrae and a complete series can be taken later. Basic equipment needed for cervical and back immobilization: • Hard board with side handles to be carried by 2 or more people • Broad straps with Velcro for binding at 5 places-forehead, chin, shoulder level, hips, thighs and legs. Run your fingers down each cervical spinous process and ask if there is any pain or tenderness. If the answer is no then ask the child to gently move the neck up and down and sideways on his/ her own volition. Other Associated Injuries During the process of placing the child on the spine board while log rolling, a person whose hands are free should quickly examine the back, thighs and legs for bruising, lacerations, crepitus and obvious fractures. Injures can be easily missed and out of sight is out of mind once the child is intubated and sedated. If there is gross contamination along a fluid pathway, such as with a comminuted fracture of the paranasal sinus resulting from acute trauma, antibiotic prophylaxis does have a role. Severe hypocapnia by causing severe constriction of cerebral vessels can cause unwarranted ischemia and further exarcerbate secondary neuronal damage. Unrecognized seizure: Prophylactic phenytoin may be considered, especially if an intraventricular catheter is placed. For this reason, hypothermia is being investigated as a possible modality of treatment with encouraging results. Constrictive cervical collars or large bore internal jugular lines obstructing venous flow should be avoided. Recumbent posture is to be avoided and the head should be elevated at 30 not more. Environmental stimulation: All unnecessary touch, rough handling, moving, noise should be controlled or kept to a minimum. Propofol is a hypnotic with no analgesic properties and hence an opioid must be used in combination. This being usually unavailable in most settings, reliance on clinical signs and rapid action with other methods is needed. It promotes flow of the extracellular edema fluid into the intravascular compartment to be excreted by the kidneys. It reduces blood viscosity12 and hence improves cerebral blood flow and prevents stasis. This in turn results in constriction of cerebral blood vessels and reduces blood flow. If that becomes necessary, persistent hyperosmolar states can be induced using other means. Serum Osmolarity rather than Sodium levels should be monitored for effect, with a target osmolarity of 340-370.

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In most situations antibiotic resistance scholarly articles discount stromectol 3 mg without prescription, how- This approach is justifed by the desire to minimize the probability ever antibiotic 3rd generation buy stromectol 12 mg low price, this aggressive approach is neither necessary nor desirable antibiotics for uti in renal failure generic stromectol 3 mg with mastercard, of exposing individuals to long-term treatment with dosages higher and treatment should be initiated with a small dose and increased than necessary. Gradual dose escalation has In recent years, evidence has accumulated that most individuals several advantages. In a slowly afer initiation of treatment [46], and immediate use of a large single-centre study that explored the efectiveness of the frst full maintenance dosage may cause major tolerability problems. In a recent randomized trial that com- topiramate, tiagabine, zonisamide and perampanel. Primidone pared carbamazepine and levetiracetam in adults with newly di- may cause a particularly marked transient intolerance reaction in agnosed focal epilepsy, about 90% of seizure-free individuals were individuals not previously exposed to barbiturates, and it should controlled at doses of 400 mg/day for carbamazepine and 1000 mg/ be started at a dose (62. An indication of possible initial target maintenance dosages • Despite common belief, allergic and idiosyncratic reactions are is provided in Table 9. In practice, the target dosage should be ofen dependent on starting dose and rate of dose escalation [47]. Many genetic (syn: idiopathic) general- ated at too-high doses are especially frequent with carbamaze- ized epilepsies respond well to treatment, and it may be justifed in pine, phenytoin and lamotrigine. Because valproic acid increases these individuals to aim at initial maintenance dosages and plasma the plasma levels of lamotrigine, the risk of lamotrigine-induced drug levels in the low range. For example, the dosage of valproic allergic reactions is greatly increased in individuals comedicat- acid required to control primary generalized tonic–clonic seizures ed with valproic acid, and in these individuals it is essential that has been found to be about 30% lower than that required to control lamotrigine dosage is escalated at a very slow rate. A high seizure frequency before starting ther- • Some individuals can be optimally controlled at doses below the apy, symptomatic epilepsy, focal seizures, multiple seizure types, initial target maintenance dosage. When seizure frequency is suf- associated neurological handicaps and an unfavourable response to fciently high to permit a meaningful assessment of therapeutic previous antiepileptic drug therapy all infuence the prognosis neg- response over a short period, slow dose escalation may allow atively [51,52], and individuals with these features are expected to identifcation of the lowest dose regimen at which individuals require comparatively higher doses and plasma drug levels. Conversely, some individuals are unusually sensitive to factors afecting choice of the initial maintenance dosage include adverse efects, and slow dose escalation will prevent them from the presence of physiological or pathological conditions leading being exposed to dosages higher than those tolerated. Elderly individuals, in par- tration rates are seldom established in regulatory clinical trials and ticular, generally require dosages in the low range, because they therefore they are mostly identifed through postmarketing experi- exhibit an increased sensitivity to the efects of antiepileptic drugs ence. Usual initial target Usual maintenance maintenance Frequency of Drug dosage (mg/day) dosage (mg/day) administration Suggested titration rate Carbamazepine 400–600a 400–1600 2–3 times/day (twice Start with 100 or 200 mg/day and increase to target daily with controlled- dosage over 1–4 weeks release formulations) Clobazam 10–20 10–40 Once or twice daily Start with 10 mg/day. If indicated, increase to 20 mg/ day after 1–2 weeks Eslicarbazepine 800 800–1200 Once daily Start with 400 mg/day and increase to target dosage acetate after 1 or 2 weeks Ethosuximide 500–750 500–1500 2–3 times/day Start with 250 mg/day and increase to target dosage over 1–3 weeks Felbamate 1800–2400 1800–3600 3 or 4 times/day Start with 600–1200 mg/day and increase to target dosage over 10–21 days Gabapentin 900–1800 900–3600 2 or 3 times/day Start with 300–900 mg/day and increase to target dosage over 5–10 days Lacosamide 200–300 200–400 Twice daily Start with 100 mg/day and increase to target dosage by increments of 100 mg/day every week Lamotrigine 50–150 50–200 Twice daily (once Monotherapy: start with 25 mg/day for 2 weeks, then (monotherapy); (monotherapy or daily possible with increase to 50 mg/day for 2 weeks. Further increases 50–100 (patients on patients on valproic monotherapy by 50 mg/day every 2 weeks valproic acid); acid); 200–500 and valproic acid Valproic acid comedication: start with 25 mg on 200–300 (patients (patients on comedication) alternate days for 2 weeks, then 25 mg/day for 2 weeks. Further increases by 50–100 mg/day every 2 weeks Levetiracetam 1000–2000 1000–3000 Twice daily Start with 500 or 1000 mg/day and increase, if indicated, after 2 weeks Oxcarbazepine 600–900 600–3000 2 or 3 times/day Start with 300 mg/day and increase to target dosage over 1–3 weeks Perampanel 4–8 4–12 Once daily Start with 2 mg and increase to target dosage at 2-week intervals (weekly intervals may be used for patients taking comedications that shorten the half-life of perampanel) Phenobarbital 50–100 50–200 Once daily Start with 30–50 mg at bedtime and increase, if indicated, after 10–15 days Phenytoin 200–300 200–400 Once or twice/day Start with 100 mg/day and increase to target dosage over 3–7 days Pregabalin 150–300 150–600 2 or 3 times/day Start with 75 mg/day for 3 days, then increase to 150 mg/day. If indicated, increase to 300 mg/day after 2 weeks Primidone 500–750 500–1500 2 or 3 times/day Start with 62. In patients on enzyme-inducing comedication a faster titration may be used Retigabine 600 600–1200 3 times/day Start with 50–150 mg/day and increase to target dosage at about weekly intervals Rufnamide 1200 1200–3200 Twice daily Start with 400 mg/day and increase by 400 mg/day increments every 2–4 days (Continued) 116 Chapter 9 Table 9. This information refects the author’s assessment of available evidence and may differ from information reported in data sheets in individual countries. Some patients will require dosages, titration rates and dosing regimens different from those given in this table. The individual’s attitude and circumstances should also be con- with valproic acid, which prolongs the half-life of lamotrigine (see sidered. Some neurologists have agabine, more than two daily administrations may be required to also in the past favoured the use of relatively high initial mainte- minimize excessive fuctuations in plasma concentration. This is nance dosages out of a fear that a delay in achieving complete sei- especially important for individuals in whom half-lives are at the zure control might increase the probability of the epilepsy becom- shorter end of the spectrum, such as children and enzyme-induced ing intractable. With these drugs, intermittent adverse efects are for most of the epilepsy syndromes, there is no evidence that this not uncommon at the time of peak drug concentration, whereas is the case. More than twice-daily dosing may similarly be Frequency of administration required for gabapentin, which also has a short half-life and, ad- For most antiepileptic drugs, attainment of an adequate response is ditionally, is absorbed from the intestine by a saturable transport dependent on the persistence of efcacious drug concentrations at mechanism (see Chapter 36). Because the concentration at the site high dosages, utilizing multiple daily administrations of gabapen- of action is in equilibrium with the concentration in plasma, a dos- tin provides a strategy to improve the oral absorption of the drug.

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The patient’s serum is then passed over the allergen-support complex infection in finger discount stromectol, which permits specifc 104 250 IgE antibodies in the serum to bind with the allergen bacteria reproduce asexually cheap stromectol 6 mg buy on line. After 200 103 washing to remove nonreactive protein antibiotics and sun stromectol 3 mg order, radiolabeled antihu- 150 man IgE antibody is then placed in contact with the insoluble 102 support where it reacts with the bound IgE antibody. Both the 100 1 allergen and the anti-IgE antibody must be present in excess 10 50 for the test to be accurate. The amount of radioactivity on the R3 0 0 10 beads is proportional to the quantity of serum antibody that 100 101 102 103 104 100 101 102 103 104 is allergen specifc. A standard quantity of radiolabeled IgE Immunoradiometry is a radioimmunoassay method in which is added to the serum sample to be assayed. The patient’s IgE competes with the radiolabeled IgE on a “sandwich” technique using radiolabeled antibody, or antibody attached to the beads. Add IgE Add anti-IgE (test sample) (labeled) * * Ag covalently bound to * * * cellulose disc Anticytokine Addition of * Labeled anti-IgE antibody * cytokine etc. A few days following antigen adminis- tration, antibodies appear in the circulation and eliminate Strain refers to genetically identical animals such as mice the antigen at a much more rapid rate than occurs in nonim- or rats used in medical research. Splenic and liver macrophages express Fc receptors that bind antigen–antibody complexes as well A transgenic animal is an animal into whose genome a for- as complement receptors which bind those immune com- eign gene has been introduced. This is followed gene into a mouse can be by either microinjection into a pro- by removal of immune complexes through the phagocytic nucleus of an egg that has been fertilized recently or through action of mononuclear phagocytes. The egg that has received the foreign gene is also describes an assay to evaluate the antibody response transferred to the oviduct of a pseudopregnant female. If the by monitoring the rate at which a radiolabeled antigen is gene becomes integrated into a chromosome, it is passed on eliminated in an animal with specifc (homologous) anti- to the progeny through the germ line and will be expressed bodies in the circulation. Natural transcriptional promoters and enhanc- ers, or exogenous regulatory elements engineered into it may Immune clearance: See immune elimination. Following incubation of the lymphoid cells and tumor cells in vivo, the mixture is injected into the Foreign gene: See transgenic mice. T lymphocytes that are specifcally immune to the A knock-in transgene is a transgene with a specifc muta- tumor cells will inhibit tumor growth and provide informa- tion that is fanked by sequences that are homologous to the tion related to tumor immunity. The forward genetics approach is a method of mutating a gene in an experimental animal to prove that gene’s role in a A dominant negative transgene is a transgene whose prod- particular disease and determining whether or not that muta- uct is a protein that is not functional and disrupts the endo- tion produces the disease of interest. Isolate into Termination fertilized pronucleus Promoter sequences Cloned gene Transgenics refers to the transfer of needed genes into an eggs Enhancer fragment organism for the purpose of providing a missing protein Gene which these genes encode. Eggs are reimplanted into pseudopregnant female A germ-free animal is one such as a laboratory mouse, raised under sterile conditions, where it is free from exposure Study of hybrid gene expression occurs to microorganisms and is not exposed to larger organisms. Most diffcult is the ability to maintain a virus-free environ- Transgenic is a term that describes an organism that has ment for these animals. Much has been learned about the role of cytokines, develop following injection of several hundred gene copies cell surface receptors, signaling molecules, and transcription into pronuclei are transgenic mice. They are in a designated cell or tissue following induction by a specifc highly signifcant in immunologic research. A transgenic mouse is a mouse developed from an embryo Knockout gene is a descriptor for the generation of a mutant into which foreign genes were transferred. Transgenic mice organism in which the function of a particular gene has been have provided much valuable information related to immu- completely eliminated (a null allele). A sequence been introduced and stably incorporated into germ-line cells insertion targeting approach may be used. Homologous recombination techniques can be used breakpoints and are inherited as simple Mendelian traits. Studies with transgenic mice have yielded much data about Knockout mice deprived of functional genes that encode cytokines, cell surface molecules, and intracellular signaling cytokines, cell surface receptors, signaling molecules, and molecules. Transgenic organisms are animals or plants into which for- eign genes that encode specifc proteins have been inserted. Genetic knockout is a technique to introduce precise However, controlling the site of gene insertion has not been genetic lesions into the mouse genome to cause “gene disrup- accomplished yet.

Knut, 60 years: Double-blind comparison of lamotrigine patients given adjunctive antiepileptic treatment for refractory seizures: a me- and carbamazepine in newly diagnosed epilepsy. An average association constant for ligand atoms and molecules moving their electrons from one side binding to heterogeneous antibodies is the reciprocal of to another (Figure 8. In Viva, examiner may ask… List the hormones of adrenal cortex and the layer from where they are secreted, Specific enzymes involved in synthesis of adrenocortical steroids and the diseases produced by their deficiencies, Functions of cortisol especially permissive actions of cortisol, effects of cortisol on inflammation, allergy, immunity and blood cells, Why steroid therapy should not be stopped abruptly? Fluid replacement is administered routinely as clinically indicated to replace fluid losses in part or completely.

Derek, 48 years: Cornca in Marfan disease: Marfan syndrome: should wc now treat surgical patients with losartan? Transverse ultrasound image using power color Doppler to identify the occipital artery. At this stage of the disease, the pain and limited range of motion can be completely relieved by the administration of intra-articular local anesthetic. There are ref- Resistance against infectious disease agents was the principal erences to this recognition in early literature.

Tempeck, 30 years: Tdt is IgM+ IgD– an enzyme present in immature B and T lymphocytes, but not + demonstrable in mature lymphocytes. B: 732 Reconstructed three-dimensional computed tomography angiogram confirming the findings of the ultrasound examination. Valproic acid may exert synergistic efects with ethosuximide in patients refractory to either drug given alone, and may have variable and inconsistent efects on ethosuximide levels. Perhaps because of the unavailability of suffcient immunological information to understand Coley’s experiments at the time, their signifcance was not appreciated until years later.

Taklar, 35 years: On the inhibition of voltage activated calcium currents in rat cortical neurones by the neuroprotective agent 619C89. Some surgeons prefer to approach vacuum steam autoclave necessary to sterilize the the space through an incision inferior to the inframam- cannulae, usual emergency medications, and support. In most cases, cations may occur, including rhabdomyolysis, leading to acute tubular however, this is unnecessary and more efective is the rapid control necrosis, hyperkalaemia and hyponatraemia [104]. A smoke evacua- employed for ablative laser resurfacing: pulsed carbon tor is used to suction airborne particles.

Vibald, 65 years: Mass colonic peristalsis is a stronger peristaltic contrac- tion that forcefully pushes the contents from colon into the rectum. Pedometers have recently become partake in 60 min of moderate-to-vigorous physical popular for motivating people to do more walking. Chlorpromazine, a D2 receptor antagonist and halo- hours after meal in persons who have undergone gastrec­ peridol are also effective antiemetics. This the gene activated by aldosterone is sgk gene (serum and is called aldosterone escape phenomenon as kidney glucocorticoid regulated kinase gene).

Anog, 45 years: The diameter of large intestine is bigger than small tions: intestine, which favours slow passage of chyme − Protects intestinal mucosa through it and also absorption of maximum quantity − Help in stool formation of water during its passage. Target volume and 12 Gy volume malformations remains the standard treatment modality, a series by were the most signifcant predictors of adverse radiation efects, Regis et al. Farr, quantitative measure of primary interaction between bovine serum albumin 1950 A. Source of androgen is usually congenital virilizing adre- Though other chromosomal abnormalities are not com- nal hyperplasia of fetus or virilizing ovarian tumor of mon, they do occur.

Goose, 24 years: A curvilinear low-frequency ultrasound transducer is then placed in the transverse plane just above the previously identified point of nerve entrapment and an ultrasound survey scan is taken (Fig. In some cases, pre-cutting is performed because the snare is kept tightly closed and electrocau- submucosal injection makes the lesion too flat try current is applied by depressing the pedal. Diagnostic Immunohistochemistry 29 Immunohistochemistry is a method to detect antigens in the antibody portion of this complex, which is raised in rab- tissues that employs an enzyme-linked antibody specifc for bits, will be bound to the free antigen-binding site of the antigen. The antimicrobial regimen should always be reassessed after 48–72 hours on the basis of microbiological and clinical data with the aim of using a narrow-spectrum antibiotic to prevent the development of resistance, to reduce toxicity, and to reduce costs.

Ben, 23 years: It has also been shown that the six normal activation cytoplasmic markers reveal the stage of development and events related to membrane Ig turnover and expression do not function of lymphocytes in the B cell lineage. In individuals whose seizures can- The purpose of this chapter is to review the general principles of not be controlled completely, it makes sense to aim at suppressing medical management. Postcontrast T1-weighted axial image shows a contrast-enhancing extramedullary mass in the right side of the spinal canal (short arrow) at T6-T7 with displacement of the cord (long arrow) to the left. When proteins are used, however, covalent link- sessing the common antigen constitutes a positive test.

Pyran, 58 years: Color Doppler can be used to help identify the epigastric artery and vein as they turns upward accompanying the anterior cutaneous nerve as it passes anteriorly (Fig. Bleeding is unusual when epinephrine is used for vaso- Blunt cannula constriction, but can occur and should be controlled by frm external pressure over the breast for at least 10 min. Gamma Knife surgery for large cerebral arteri- epilepsy: a prospective multicenter study. When awake, the patient admitted to have taken ‘many’ pills to attempt suicide (R.

Gnar, 46 years: The sternoclavicular joint: can imaging differentiate infection from degenerative change? Patients are on indigo carmine, and 1 ml of epinephrine) is kept nil by mouth after surgery and nursed in injected into the submucosa. Occurring more commonly in women, bunionette is most commonly the result of wearing shoes with a too-tight toe box, with the wearing of high-heeled shoes exacerbating the problem. A high-frequency linear ultrasound transducer is placed in the transverse axis centered over the bicipital groove and an ultrasound survey scan is taken (Fig.

Musan, 47 years: Am J Hum Genet hypertelorism and psychom otor retardation: a dom inantly inher­ 1997;61:765-8. In a small proportion of patients with aniridia, however, the iris stump did not adhere lo the angle, but there was a thin layer of amorphous tissue covering the angle. The transformed cell increases in size and amount of T and B lymphocytes cytoplasm. Intravenous mannitol is rarely utilized in material-specifc memory in a multimodality approach with pre- epilepsy surgery unless there is an associated tumour with mass ef- operative memory evaluations may be helpful in minimizing post- fect.

Jorn, 26 years: DtschGesundheitswesen In general, topical applications of a variety of “medi- 19:170–174 cations,” popular in European and South American 20. The frst child was a 7-year-old girl with intractable levels of serum ketones [59]. Another ministration of potent inhalation agents and continue anaesthesia consideration is that brain shif, such as might be produced by ex- with a combination of nitrous oxide and narcotic analgesics in cessive hyperventilation during controlled ventilation, theoretically advance of cortical mapping. Antibodies must be identifed which confer Immunological contraception is a method to prevent an passive immunity to this agent.

Fedor, 39 years: These cases of unexplained infertility may be caused by autoimmune responses to organ-specifc anti- gens of the reproductive tract of both males and females and isoimmune reactions of females against semen components. Radiosurgery is also being investigated as treatment for refrac- Hypothalamic hamartoma-associated tory epilepsy following initial temporal lobe resection. A closer look at the radial sesamoid reveals an irregular cortical break (arrow) in its midsubstance splitting the ossicle into two parts (2a and 2b). Clobazam (a 1,5-benzodiazepine) was evaluated was not shown to be superior to placebo [102].

References

• Parekh DJ, Reis IM, Castle EP, et al: Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomized, phase 3, non-inferiority trial, Lancet 391(10139): 2525n2536, 2018.
• Fulgham PF, Essimos DG, Pearle MS, et al: Clinical effectiveness protocols for imaging in the management of ureteral calculous disease: AUA technology assessment, J Urol 189:1203n1213, 2013.
• Akiyama H, Kogure T, Itai Y: The esophageal axis and its relationship to the resectability of carcinoma of the esophagus. Ann Surg 176:30, 1972.
• Biere SS, van Berge Henegouwen MI, Maas KW, et al. Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial. Lancet 2012;379(9829):1887-1892.