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By: John Theodore Geneczko, MD

  • Assistant Professor of Medicine

https://medicine.duke.edu/faculty/john-theodore-geneczko-md

Cross References Allochiria; Allokinesia skin care 2012 cheap cleocin generic, Allokinesis; Neglect Allochiria Allochiria is the mislocation of sensory stimuli to skin care treatments best order cleocin the corresponding half of the body or space skin care 2013 buy cleocin 150mg without prescription, a term coined by Obersteiner in 1882 skin care magazines purchase cleocin 150 mg online. There is overlap with alloaesthesia, originally used by Stewart (1894) to describe stimuli displaced to a different point on the same extremity. Cross References Alloaesthesia; Allokinesia, Allokinesis; Neglect; Right–left disorientation Allodynia Allodynia is the elicitation of pain by light mechanical stimuli (such as touch or light pressure) which do not normally provoke pain (cf. Examples of allodynia include the trigger points of trigeminal neuralgia, the affected skin in areas of causalgia, and some peripheral neuropathies; it may also be provoked, paradoxically, by prolonged morphine use. Various pathogenetic mechanisms are considered possible, including sensi tization (lower threshold, hyperexcitability) of peripheral cutaneous nociceptive fibres (in which neurotrophins may play a role); ephaptic transmission (‘cross talk’) between large and small (nociceptive) afferent fibres; and abnormal central processing. The treatment of neuropathic pain is typically with agents such as carba mazepine, amitriptyline, gabapentin, and pregabalin. Interruption of sympa thetic outflow, for example with regional guanethidine blocks, may sometimes help, but relapse may occur. Cross References Hyperalgesia; Hyperpathia -21 A Allographia Allographia this term has been used to describe a peripheral agraphia syndrome character ized by problems spelling both words and non-words, with case change errors such that upper and lower case letters are mixed when writing, with upper and lower case versions of the same letter sometimes superimposed on one another. These defects have been interpreted as a disturbance in selection of allographic forms in response to graphemic information outputted from the graphemic response buffer. A model of writing performance: evidence from a dys graphic patient with an “allographic” writing disorder. Cross Reference Agraphia Allokinesia, Allokinesis Allokinesis has been used to denote a motor response in the wrong limb. Others have used the term to denote a form of motor neglect, akin to alloaesthesia and allochiria in the sensory domain, relat ing to incorrect responses in the limb ipsilateral to a frontal lesion, also labelled disinhibition hyperkinesia. Altitudinal field defects 22 Amblyopia A are characteristic of (but not exclusive to) disease in the distribution of the cen tral retinal artery. Central vision may be preserved (macula sparing) because the blood supply of the macula often comes from the cilioretinal arteries. Cross References Hemianopia; Macula sparing, Macula splitting; Quadrantanopia; Visual field defects Amaurosis Amaurosis is visual loss, with the implication that this is not due to refractive error or intrinsic ocular disease. The term is most often used in the context of amaurosis fugax, a transient monocular blindness, which is most often due to embolism from a stenotic ipsilateral internal carotid artery (ocular transient ischaemic attack). Giant cell arteritis, systemic lupus erythematosus, and the antiphospholipid antibody syndrome are also recognized causes. Gaze-evoked amaurosis has been associated with a variety of mass lesions and is thought to result from decreased blood flow to the retina from compression of the central retinal artery with eye movement. Amblyopia Amblyopia refers to poor visual acuity, most usually in the context of a ‘lazy eye’, in which the poor acuity results from the failure of the eye to establish nor mal cortical representation of visual input during the critical period of visual maturation (between the ages of 6 months and 3 years). Amblyopic eyes may demonstrate a relative afferent pupillary defect and sometimes latent nystagmus. Amblyopia may not become apparent until adulthood, when the patient sud denly becomes aware of unilateral poor vision. The finding of a latent strabismus (heterophoria) may be a clue to the fact that such visual loss is long-standing. The word amblyopia has also been used in other contexts: bilateral simulta neous development of central or centrocaecal scotomas in chronic alcoholics has often been referred to as tobacco–alcohol amblyopia, although nutritional optic neuropathy is perhaps a better term. This is a component of long-term (as opposed to working) memory which is distinct from memory for facts (semantic memory), 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. Episodic memory generally accords with the lay perception of memory, although many complaints of ‘poor memory’ represent faulty atten tional mechanisms rather than true amnesia. A precise clinical definition for amnesia has not been demarcated, perhaps reflecting the heterogeneity of the syndrome. Amnesia may be retrograde (for events already experienced) or anterograde (for newly experienced events). Retrograde amnesia may show a temporal gradi ent, with distant events being better recalled than more recent ones, relating to the duration of anterograde amnesia. In a pure amnesic syndrome, intelligence and attention are normal and skill acquisition (procedural memory) is preserved. Retrograde mem ory may be assessed with a structured Autobiographical Memory Interview and with the Famous Faces Test. Poor spontaneous recall, for example, of a word list, despite an adequate learning curve, may be due to a defect in either stor age or retrieval. This may be further probed with cues: if this improves recall, then a disorder of retrieval is responsible; if cueing leads to no improvement or false-positive responses to foils (as in the Hopkins Verbal Learning Test) are equal or greater than true positives, then a learning defect (true amnesia) is the cause. The neuroanatomical substrate of episodic memory is a distributed system in the medial temporal lobe and diencephalon surrounding the third ventricle (the circuit of Papez) comprising the entorhinal area of the parahippocam pal gyrus, perforant and alvear pathways, hippocampus, fimbria and fornix, mammillary bodies, mammillothalamic tract, anterior thalamic nuclei, inter nal capsule, cingulate gyrus, and cingulum. Basal forebrain structures (septal nucleus, diagonal band nucleus of Broca, nucleus basalis of Meynert) are also involved. Korsakoff ’s syndrome), which causes difficulty retrieving previously acquired memories (extensive retrograde amnesia) with diminished insight and a tendency to confabulation, has been suggested, but overlap may occur. A frontal amnesia has also been suggested, although impaired attentional mechanisms may contribute. Functional imaging studies suggest that medial temporal lobe activation is required for encoding with additional prefrontal activation with ‘deep’ processing; medial temporal and prefrontal activations are also seen with retrieval. Acute/transient: Closed head injury; Drugs; Transient global amnesia; Transient epileptic amnesia; Transient semantic amnesia (very rare). Few of the chronic persistent causes of amnesia are amenable to specific treatment. 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. Reversal of the usual temporal gradient of memory loss may be observed (but this may also be the case in the syndrome of focal retrograde amnesia). Cross References Confabulation; Dementia; Dissociation Amphigory Fisher used this term to describe nonsense speech. Cross Reference Aphasia Amusia Amusia is a loss of the ability to appreciate music despite normal intelligence, memory, and language function. 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. Clearly a premorbid apprecia tion of music is a sine qua non for the diagnosis (particularly of the former), and most reported cases of amusia have occurred in trained musicians. Others have estimated that amusia affects up to 4% of the population (presumably expressive; = ‘tone deafness’). Amusia may occur in the context of more widespread cognitive dysfunc tion, such as aphasia and agnosia. It has been found in association with pure word deafness, presumably as part of a global auditory agnosia. Isolated amusia has been reported in the context of focal cerebral atrophy affecting the non dominant temporal lobe. However, functional studies have failed to show strong hemispheric specificity for music perception, but suggest a cross-hemispheric distributed neural substrate. An impairment of pitch processing with preserved awareness of musical rhythm changes has been described in amusics. Congenital amusia: a group study of adults afflicted with a music-specific disorder. Receptive amusia: evidence for cross-hemispheric neural networks underlying music processing strategies. Cross References Agnosia; Auditory agnosia; Pure word deafness 26 Analgesia A Amyotrophy Amyotrophy is a term used to describe thinning or wasting (atrophy) of muscu lature with attendant weakness. Hence, although the term implies neurogenic (as opposed to myogenic) muscle wasting, its use is non-specific with respect to neuroanatomical substrate. Cross References Atrophy; Fasciculation; Neuropathy; Plexopathy; Radiculopathy; Wasting Anaesthesia Anaesthesia (anesthesia) is a complete loss of sensation; hypoaesthesia (hypaes thesia, hypesthesia) is a diminution of sensation. Anaesthesia may involve all sensory modalities (global anaesthesia, as in general surgical anaesthesia) or be selec tive. Anaesthesia is most often encountered after resection or lysis of a peripheral nerve segment, whereas paraesthesia or dysaesthesia (positive sensory phenom ena) reflects damage to a nerve which is still in contact with the cell body. Anaesthesia dolorosa, or painful anaesthesia, is a persistent unpleas ant pain. This deafferentation pain may respond to various medications, including tricyclic antidepres sants, carbamazepine, gabapentin, pregabalin, and selective serotonin-reuptake inhibitors.

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If such a reaction occurs skin care games buy cleocin in india, further injection should be discontinued and appropriate medical therapy initiated immediately skin care during winter buy 150 mg cleocin otc. There have been rare cases of administration of botulinum toxin to skin care basics buy 150 mg cleocin with amex patients with known or unrecognized neuromuscular junction disorders where the patients have shown extreme sensitivity to acne juvenil order discount cleocin the systemic effects of typical clinical doses. In some of these cases, dysphagia has lasted several months and required placement of a gastric feeding tube. New onset or recurrent seizures have been reported, typically in patients who are predisposed to experiencing these events. The reports in children were reports predominantly from cerebral 9 palsy patients treated for spasticity. One case of corneal perforation in an aphakic eye requiring corneal grafting has occurred because of this effect. Careful testing of corneal sensation in eyes previously operated upon, avoidance of injection into the lower lid area to avoid ectropion, and vigorous treatment of any epithelial defect should be employed. Because of the anticholinergic activity of botulinum toxin, caution should be exercised when treating patients at risk for angle closure glaucoma, including patients with anatomically narrow angles. Acute angle closure glaucoma has been reported very rarely following periorbital injections of botulinum toxin. It is recommended that appropriate instruments to decompress the orbit be accessible. Inducing paralysis in one or more extraocular muscles may produce spatial disorientation, double vision, or past-pointing. Skin As is expected for any injection procedure, localized pain, inflammation, paresthesia, hypoaesthesia, tenderness, swelling/edema, erythema, localized infection, bleeding and/or bruising have been associated with the injection. Needle-related pain and/or anxiety have resulted in vasovagal responses, including transient symptomatic hypotension and syncope. Primary hyperhidrosis of the axillae Medical history and physical examination, along with specific additional investigations as required, should be performed to exclude potential causes of secondary hyperhidrosis. This will avoid symptomatic treatment of hyperhidrosis without the diagnosis and/or treatment of underlying disease. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential risks, including abortion or fetal malformations, which have been observed in rabbits. Pediatrics (2-18 years of age): There have been very rare spontaneous reports of death sometimes associated with aspiration pneumonia in children with severe cerebral palsy after treatment with botulinum toxin. Post-marketing reports of possible distant spread of toxin have been very rarely reported in pediatric patients with co-morbidities, predominantly with cerebral palsy, who received > 8 U/kg. Extreme caution should be exercised when treating pediatric patients who have significant neurologic debility, dysphagia, or have a recent history of aspiration pneumonia or lung disease. In general, dose selection for an elderly patient should be cautious, usually starting at the lowest recommended dose for the specific indication. However, weakness of adjacent muscles associated with local diffusion and/or injection technique has been reported. Muscle weakness remote to the site of injection and other serious adverse effects. As is expected for any injection procedure, localized pain, inflammation, paresthesia, hypoesthesia, tenderness, swelling/oedema, erythema, localized infection, bleeding and/or bruising have been associated with the injection. Clinical Trial Adverse Drug Reactions Because clinical trials are conducted under very specific conditions the adverse reaction rates observed in the clinical trials may not reflect the rates observed in practice and should not be compared to the rates in the clinical trials of another drug. Adverse drug reaction information from clinical trials is useful for identifying drug-related adverse events and for approximating rates. The frequency is defined as follows: Very Common (≥ 1/10); Common (≥1/100, <1/10). Nervous system disorders Common: Headache, paresthesia Vascular disorders Common: Hot flush Gastrointestinal disorders Common: Nausea Skin and subcutaneous tissue disorders Common: Hyperhidrosis, skin odor abnormal, pruritus, subcutaneous nodule, alopecia Musculoskeletal and connective tissue disorders Common: Pain in extremity General disorders and administration site conditions Very common: Injection site pain Common: Pain, injection site edema, injection site hemorrhage, injection site 14 hypersensitivity, injection site irritation, asthenia Note: increase in non-axillary sweating was reported in 4. Neurogenic Detrusor Overactivity associated with a neurologic condition the table below presents the most frequently reported adverse reactions in double-blind, placebo-controlled studies within 12 weeks of injection for detrusor overactivity associated with a neurologic condition. Among patients who were not catheterizing at baseline prior to treatment, catheterization was initiated in 38. Overactive Bladder the table below presents the most frequently reported adverse reactions in double-blind, placebo-controlled, pivotal Phase 3 studies within 12 weeks of injection for overactive bladder. Events considered to be procedure-related by the investigator reported at any time following initial injection were dysuria (6%) and haematuria (2%). The frequency is defined as follows: Uncommon (≥1/1,000, <1/100); Rare (≥1/10,000, <1/1,000); Very Rare (<1/10,000). Blepharospasm Nervous system disorders Uncommon Dizziness, facial palsy Eye disorders Uncommon Keratitis, ectropion, diplopia, entropion, vision blurred. Very rare Ulcerative keratitis, corneal epithelium defect, corneal perforation Skin and subcutaneous tissue disorder Uncommon Rash General disorders and administration site conditions Uncommon Fatigue Strabismus Eye disorders Uncommon Ocular retrobulbar hemorrhages, eye penetration, Holmes-Adie pupil Rare Vitreous hemorrhage Cervical dystonia Eye disorders Uncommon Diplopia, eyelid ptosis General disorders and administration site conditions Uncommon Pyrexia Focal Spasticity Nervous system disorders Uncommon: Hypoesthesia, headache, paresthesia Vascular disorders Uncommon: Orthostatic hypotension Gastrointestinal disorders Uncommon: Nausea Skin and subcutaneous tissue disorders Uncommon: Dermatitis, pruritis, rash Musculoskeletal and connective tissue disorders Uncommon: Arthralgia, bursitis 18 General disorders and administration site conditions Uncommon: Asthenia, pain, injection site hypersensitivity, malaise Chronic Migraine Gastrointestinal disorders Uncommon: Dysphagia Skin and subcutaneous tissue disorders Uncommon: Pain of skin Musculoskeletal and connective tissue disorders Uncommon: Pain in jaw Abnormal Hematologic and Clinical Chemistry Findings No specific trends in abnormal hematologic or clinical chemistry findings have been reported. Adverse events after treatment with botulinum toxin include rare spontaneous reports of death, sometimes associated with dysphagia, respiratory compromise, pneumonia, and/or other significant debility. Some of these patients had risk factors including pre-existing cardiovascular disease. The reports in children were predominantly from cerebral palsy patients treated for spasticity. Drug-Drug Interactions Table 1: Established or Potential Drug-Drug Interactions Proper name of drug Ref Effect Clinical comment the effect of botulinum toxin may be aminoglycoside antibiotics or T Theoretically, potentiated by aminoglycoside antibiotics or spectinomycin, or other medicinal the effect of spectinomycin, or other drugs that interfere products that interfere with botulinum with neuromuscular transmission. The effect of administering different botulinum Different botulinum neurotoxin T Unknown neurotoxin serotypes at the same time or within serotypes several months of each other is unknown. Excessive weakness may be exacerbated by administration of another botulinum toxin prior to the resolution of the effects of a previously administered botulinum toxin. Drug-Laboratory Interactions Interactions with laboratory tests have not been established. The exact dosage and number of injection sites should be tailored to the patient’s needs based on the size, number and location of muscles involved, the severity of disease, presence of local muscle weakness, response to previous treatment, and the patient’s medical condition. This dose can be gradually increased in subsequent treatments to the maximum recommended dose, if needed. In treating adult patients, when combining indications, the maximum cumulative dose in a 3 month interval should generally not exceed 6 Units/kg, or 360 Units, whichever is lower. In treating pediatric patients, the maximum cumulative dose in a 3 month interval should generally not exceed 6 Units/kg body weight, or 200 Units, whichever is lower. In general, the initial effect of the injections is seen within three days and reaches a peak at one to two weeks post-treatment. Treatment effects last approximately three months, following which the procedure can be repeated indefinitely. At repeat treatment sessions, the dose may be increased up to two-fold if the response from the initial treatment is considered insufficient. Avoiding injection near the levator palpebrae superioris may reduce the complication of ptosis. Avoiding medial lower lid injections, and thereby reducing diffusion into the inferior oblique, may reduce the complication of diplopia. The paralysis lasts for 2-6 weeks and gradually resolves over a similar time period. About one-half of patients will require subsequent doses because of inadequate paralytic response of the muscle to the initial dose, or because of mechanical factors such as large 22 deviations or restrictions, or because of the lack of binocular motor fusion to stabilize the alignment. For vertical muscles, and for horizontal strabismus of less than 20 prism diopters: 1. It is recommended that patients be reexamined 7-14 days after each injection to assess the effect of that dose. Patients experiencing adequate paralysis of the target muscle that require subsequent injections should receive a dose comparable to the initial dose. Subsequent doses for patients experiencing incomplete paralysis of the target muscle may be increased up to two-fold compared to the previously administered dose. Subsequent injections should not be administered until the effects of the previous dose have dissipated as evidenced by substantial function in the injected and adjacent muscles. However, in clinical practice, a range of 200 U to 360 U have been used effectively. A 25, 27 or 30 gauge needle may be used for superficial muscles, and a 22 gauge needle may be used for deeper musculature. For cervical dystonia, localization of the involved muscles with electromyographic guidance may be useful. The optimal number of injection sites is dependent upon the size of the muscle to be chemically denervated.

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The Surviving Sepsis Campaign is a joint collaboration of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine committed to acne 9 year old cleocin 150mg fast delivery reducing mortality from severe sepsis and septic shock worldwide acne hacks purchase cleocin 150mg visa. Definition according to acne body wash cleocin 150 mg amex the third edition of "Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012” appear in the February 2013 issues of Critical Care Medicine and Intensive Care Medicine acne tretinoin cream 005 generic cleocin 150 mg without a prescription. Type of indicator : Rate-based process indicator Numerator : Number of severe sepsis patients managed according to modified surviving sepsis bundle within (≤) 60 minutes of diagnosis Denominator : Total number of severe sepsis patients Formula : Numerator x 100% Denominator Standard : ≥ 70% Data Collection : 1. During designated duty period (during on-call and designated specialist during office hours). All brought in dead cases to the Emergency Department or deaths pronounced at the Emergency Department. Type of indicator : Rate-based outcome indicator Numerator : Number of acceptable completeness (fair or good) in the registration of deaths from the wards for non-police cases at the Forensic Department/ Forensic Unit Denominator : Total number of registration of deaths from the wards for non-police cases at the Forensic Department/ Forensic Unit Formula : Numerator x 100% Denominator Standard : ≥ 75% Data Collection : 1. Who: Data will be collected by assigned Officers/ senior Assistant Medical Officers or Forensic Scientific Officers of the department/ unit. Who should verify: All performance data must be verified by Assigned Medical Officers/ Forensic Specialists/ Head of Department/ Head of Unit/ Hospital Director/ 5. To ensure that the process of management of the deceased is handled effectively, efficiently and with due respect for the dead by the forensic medicine department and forensic unit. To expedite the release of bodies to the rightful claimant for burial or cremation in accordance with the respective religious beliefs. Definition of Terms : Body released: Claim of body (non-police case) by the appropriate claimant – next of kin/ authorized representative or handing over the document to the next of kin with the statement that body are ready to be claimed in term of Forensic Department Procedure. Next-of-kin: spouse(s), daughter(s)/ son(s), parent(s), sibling(s), grandparent(s), first degree relative(s). Authorised representative: representative of next-of-kin and relatives, representative of Embassy/ High Commission, religious authorities, employer. Unidentified body (no identification/ decomposed body / mutilated body/ skeletonised remains). Claimants whom request for body storage and not immediately claimed Type of indicator : Rate-based process indicator Numerator : Number of bodies (non-police cases) released to the appropriate claimant within (≤) 3 hours from the time of receipt of body at Forensic Medicine Department/ Forensic Unit Denominator : Total number of bodies (non-police cases) released to the appropriate claimant at Forensic Medicine Department/ Forensic Unit Formula : Numerator x 100% Denominator Standard : ≥ 75% Data Collection : 1. Who: Data will be collected by assigned Officers/ Senior Assistant Medical Officers or Forensic Scientific Officers of the department/ unit. Who should verify: All performance data must be verified by Assigned Medical Officers/ Forensic Specialists/ Head of Department/ Head of Unit/ Hospital Director. Indicator 3 : Departmental Discipline : Forensic Medicine Name of indicator : Percentage of bodies released to the right claimant by the Forensic Medicine Department/ Forensic Unit. Dimension of Quality : Effectiveness Rationale : To respect the rights of the appropriate claimants which are the next-of-kin or authorised representative Definition of Terms : Right claimant: Person who is next-of-kin or authorized representative. Next-of-kin: spouse(s), daughter(s)/ son(s), parent(s), sibling(s), grandparent(s), first-degree relative(s). Receiving and registration of bodies from the wards or brought in dead to the forensic medicine department or emergency department. Indicator 4 : Individual Discipline : Forensic Medicine Name of indicator : Turnaround time of ≤ 48 hours for performing forensic autopsies of police/ medico-legal cases from the issuance of ‘Polis 61’ order by the Forensic Specialist Dimension of Quality : Effectiveness Rationale : To ensure that forensic/ medico-legal autopsies are performed efficiently and effectively in accordance with the Malaysian law. Definition of Terms : Forensic/ medico-legal autopsy: Autopsy of police/ medico-legal cases with the issuance of Polis 61 order. Police/ medico-legal case: A death case under police investigation and the purview of the law. Autopsies of forensic / medico-legal cases such as homicides and other cases performed by the forensic specialists. Autopsies of forensic cases involved in mass disasters and infectious disease outbreaks and anthropological/ human skeletal examinations. Who: Data will be collected by Forensic Medical Officer/ Forensic Assistant Medical Officer/ Forensic Scientific Officer/ Forensic Record Officers of the department/ unit. Who should verify: All performance data must be verified by Head of Department/ Head of Unit/ Senior Forensic Specialists/ Hospital Director/ National Head of Forensic Medicine Services. Remarks : To comply with the standard operating procedure/ work procedure for handling autopsies/ post-mortem examinations of the Forensic Medicine Department. Indicator 5 : Individual Discipline : Forensic Medicine Name of indicator : Turnaround time of ≤ 12 weeks for preparing forensic autopsy reports of police cases from the performance of autopsy by the Forensic Specialist Dimension of Quality : Effectiveness Rationale : To ensure that autopsy reports are prepared in a timely manner for legal purposes and the administration of justice. Definition of Terms : Forensic autopsy: Autopsy of police / medico-legal cases with the issuance of Polis 61 order. Forensic autopsy reports of police/ medico-legal cases with ascertained cause of death. Who: Data will be collected by Forensic Medical Officer/ Forensic Scientific Officer/ Forensic Assistant Medical Officer/ Forensic Record Officers of the department/ unit. Who should verify: All performance data must be verified by Senior Forensic Specialists/ Head of Department/ Head of Unit/ Hospital Director/ National Head of Forensic Medicine Services. Remarks : To comply with the standard operating procedure/ work procedure of the Forensic Medicine Department. Indicator 6 : Individual Discipline : Forensic Medicine Name of indicator : Percentage of compliance of forensic autopsy reports on homicide cases prepared by the Forensic Specialist Dimension of Quality : Effectiveness Rationale : To ensure that the quality of the forensic autopsy reports is in accordance with the acceptable standards of the profession and the requirements of the law. Definition of Terms : Forensic autopsy: Autopsy of police/ medico-legal cases with the issuance of Polis 61 order. Forensic autopsy report: Report drawn up detailing the autopsy findings and the cause of death. Police/ Medico legal case: A death case under police investigation and the purview of the law. Homicide cases: Death of a person caused by another person/ third party which include murder cases. Forensic autopsy reports of non-homicidal cases, skeletonised human remains/ human bones, autopsy cases with undetermined/ unascertained causes of death, autopsy cases with pending laboratory investigation results and autopsy cases of mass disasters and infectious disease outbreaks. Type of indicator : Rate-based outcome indicator Numerator : Number of compliance forensic autopsy reports of homicide cases prepared by Forensic Specialist Denominator : Total number of forensic autopsy reports of homicide cases prepared by Forensic Specialist Formula : Numerator x 100% Denominator Standard : ≥ 80% Data Collection : 1. Who: Data will be collected by Forensic Medical Officers/ Forensic Scientific Officers/ Forensic Assistant Medical Officers of the department/ unit. Who should verify: All performance data must be verified by Senior Forensic Specialists/ Head of Department/ Head of Unit/ Hospital Director/ National Head of Forensic Medicine Specialists. Definition of Terms : Repeat study: Cases that require reinjection of the same radiopharmaceutical when and where the first injected radiopharmaceutical has not achieved its intended purposes as a result of any technical or non-technical causes. Who: Data will be collected by Officer/ Nuclear Medicine Technologists/ Paramedic/ Nurses in-charge (indicator co-ordinator) of the department/ unit. Remarks : Indicator 2 : Departmental Discipline : Nuclear Medicine Name of indicator : Percentage of patients with waiting time of  90 minutes to see the doctor at Nuclear Medicine Clinic Dimension of Quality : Customer centeredness Rationale : 1. Definition of Terms : Waiting time: Time of registration/ appointment time (whichever is later) to the time patient is first seen by the doctor. All patients attending the nuclear medicine clinic (these include all patients attending clinic for diagnostic, therapy or follow up). Type of indicator : Rate-based process indicator Numerator : Number of patients with waiting time of ≤ 90 minutes to see the doctor at Nuclear Medicine Clinic Denominator : Total number of patients seen at the Nuclear Medicine Clinic Formula : Numerator x 100% Denominator Standard :  90% Data Collection : 1. Remarks : Indicator 3 : Departmental Discipline : Nuclear Medicine Name of indicator : Percentage of patients with benign thyroid disease received radioiodine therapy within () 1 month Dimension of Quality : Timely Rationale : 1. Definition of Terms : Within () 1 month: Time taken from date of request to the date of administration of therapy. Centres with facility not able to provide liquid radioiodine administration Type of indicator : Rate-based process indicator Numerator : Number of patients with benign thyroid disease received radioiodine therapy within () 1 month Denominator : Total number of patients with benign thyroid disease received radioiodine therapy Formula : Numerator x 100% Denominator Standard :  80% Data Collection : 1. Type of indicator : Rate-based process indicator Numerator : Number of diagnostic nuclear medicine reports available within () 7 working days after completion of studies Denominator : Total number of diagnostic nuclear medicine studies performed Formula : Numerator x 100% Denominator Standard :  80% Data Collection : 1. Who: Data will be collected by Officer/ Nuclear Medicine Technologist/ Paramedic/ Nurse in-charge (indicator co-ordinator) of the department/ unit. Remarks : Indicator 5 : Individual Discipline : Nuclear Medicine Name of indicator : Turnaround time of  2 working days for urgent diagnostic nuclear medicine reports after completion of studies Dimension of Quality : Timely Rationale : Early completions of reports are important for patient’s management plan and treatment. Definition of Terms : Turnaround time: Time taken after completion of studies to the availability of reports. The urgent appointment is only given after discussion between the referral team and the nuclear medicine physician/ doctor based on clinical nature and urgency of the disease management. Remarks : Indicator 6 : Individual Discipline : Nuclear Medicine Name of indicator : Percentage of patients counselled against pregnancy within (≤) 4 months post-radioiodine therapy Dimension of Quality : Safety Rationale : 1.

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Syndromes

  • Spinal cord injury or compression
  • Breathing support
  • Dislocation of the kneecap (patella)
  • Ectopic pregnancy
  • Wear long-sleeved shirts and long pants with the cuffs tucked into shoes or socks
  • Cancer
  • Delayed or absent puberty
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  • Pale skin

Tractional of such lesions but the lungs acne 6 dpo proven 150 mg cleocin, liver acne zones and meaning order cleocin 150 mg mastercard, spleen skin care chanel cheap cleocin 150 mg fast delivery, skin and eyes detachments of the retina are common and in such cases together with the parotid glands are also affected acne off discount cleocin 150 mg with visa. The Ascaris lumbricoides may also produce ocular infam serum albumin–globulin ratio is disturbed and the serum mation as a result of larval migration. The tuberculin test is Periphlebitis Retinae usually negative but the Kveim reaction, which is a test for skin sensitivity to sarcoid material, may be useful. X-rays this is a relatively common disease which manifests itself of the chest may show bilateral lymph node involvement clinically by infammation of the veins and progressive in the hilar region of the lungs and this may lead eventu ally to pulmonary fbrosis. Occasionally the bones of the hand are affected so that the phalanges show cystic areas. A widespread retinopathy may develop consisting of ‘candle-wax’ like deposits of exudates along the vessels and small, whitish areas which have been shown to be granulo mata. The optic nerve head may be oedematous and also affected by nodular granulomata leading to atrophy. There may be patches of chorioretinitis and periphlebitis in asso ciation with posterior uveitis. Of patients with ocular sar coid, 25% show evidence of posterior segment involvement during their illness. When the retina is involved there is often an associated affection of the central nervous system. This leads to a the foveola, so that central vision returns to normal leaving proliferation of new vessels on the retinal surface or as a paracentral scotoma. It oc curs typically in apparently healthy young adults, usually males (Eales disease) (Fig. Practically all the Foster-Fuchs spot, lacquer cracks, lattice degeneration and visible rays, ultraviolet and many infrared rays pass unim diffuse chorioretinal atrophy are seen in various degrees peded to the retina and these are absorbed by the pigmentary and combinations in these cases (Fig. The lesion is, in fact, a burn of the Age-Related Macular Degeneration retina, generally seen in the paramacular area. The pale spot is seen at the fovea with a brownish-red ring atrophic form is more common than the exudative, with round it. Macular degeneration is often occurs, some defect usually remains and the scotoma more common in people over 65 years of age, Whites and may persist permanently. Light-induced maculopathy due to the strong focused light of the operating microscope has been recorded in Pathogenesis patients who have undergone cataract surgery with posterior the atrophic form possibly results in thinning of macular chamber lens implantation. The macula presents an oval tissues, amorphous deposits and pigmentation in the area of mild yellow–white discoloration on the second macula. Exudative macular degeneration occurs when new postoperative day, which gradually becomes mottled and vessels form a choroidal neovascular membrane. Hereditary factors, age, nutrition, (avastin), ranibizumab (lucentis), pegaptanib sodium (mac smoking, hypertension and exposure to sunlight are all risk ugen) and afibercept (eylea). Common complaints are distorted vision, seeing straight lines such as the side of a Macular Holes doorway appear wavy, bent or fuzzy. There may be shad owed areas in the central visual feld causing diffculty in Macular holes can occur due to ocular injuries, with age reading. Macular degeneration does not cause complete and as a sequel to intraocular infammation. If the vitreous de Ophthalmoscopically, the dry type is characterized by generates as with ageing or trauma, it separates from the drusen and loss of pigment in the retina and pigment epi retina, occasionally leading to traction on the macula, caus thelium (Fig. Drusen are small, yellowish depos ing frst an elevation and later a loss of the retinal layers, its on Bruch’s membrane derived from metabolic products partial in lamellar holes and a loss of the entire sensory of the visual receptors and retinal pigment epithelium de retina in full-thickness holes. They gradually affect central posited as mucopolysaccharides and lipids on Bruch’s vision, while lamellar holes cause distorted and blurred membrane. Full-thickness macular holes lead to a complete loss the neurosensory retina or pigment epithelium beneath of central vision. The edge of a macular hole can be identi which abnormal blood vessels, fuid and haemorrhage are fed using slit-lamp biomicroscopy and a 178 D or 160 D present (Fig. Lamellar holes commonly show yellowish deposits at the base of the hole and do not have a surrounding retinal Management detachment (Fig. Some macular holes seal spontaneously and require no lation is effective in sealing leaking or bleeding subretinal treatment. In many cases, vitreous surgery is required to vessels in some eyes with exudative macular degeneration. Early diagnosis is critical for the management of exu dative macular degeneration, and patients can detect early Pigmentary Retinal Dystrophy (Retinitis changes in the second eye by monitoring their central vision Pigmentosa) at home with an Amsler grid. Transpupil this is a slow, degenerative disease of the retina, almost lary thermotherapy and photodynamic therapy using lasers invariably occurring in both eyes, beginning in childhood and submacular and macular translocation surgery have and often resulting in blindness in middle or advanced age. Associated ocular anomalies include a higher incidence of glaucoma and rarely keratoconus. Initially the equatorial region is affected and the posterior pole and the periphery are nor mal, but as the disease progresses the entire retina may be come involved. In the zone affected, the retina is studded with small, jet-black spots resembling bone corpuscles with a spidery outline. The retinal veins, never the arteries, often have a sheath of pigment for part of their course. The pigment spots that lie near the retinal vessels are seen to be anterior to them, so that posteriorly. The macular region is not affected until a late they hide the course of the vessels. This symptom may be present several years before cases, and they are often very scanty in the early stages. The visual felds show concentric con progresses and the ganglion cells become degenerate, optic traction, especially marked if the illumination is reduced. The disc exhibits early cases a partial or complete annular or ring scotoma the characteristics of primary optic atrophy, but is not quite is found corresponding to the degenerated zone of retina typical of this condition for, although pale, it has a wax-like (Fig. As the disease progresses the feld becomes yellowish appearance and is often termed as ‘consecutive gradually smaller until at last it is reduced to a restricted optic atrophy’. Even though the central vi cortical cataract is formed, leading ultimately to complete sion may be retained for a long time, such patients with opacifcation of the cortex. Chapter | 20 Diseases of the Retina 329 prognostic importance in assessing the future of a young in the elastic tissue of the skin (pseudoxanthoma elasti child in an affected family. Vascular and degenerative tosa, a sequel to an infammatory retinitis, on the other choroidal lesions elsewhere in the fundus, particularly a hand, often ophthalmoscopically indistinguishable from the choroidal neovascular membrane at the macula, are com primary condition, the response is only slightly subnormal mon developments. Congenital syphilis syndrome and sickle cell disease may be associated with may produce a similar picture, although the distribution of angioid streaks. The condition is abiotrophic in nature and is genetically Benign Peripheral Retinal Degenerations determined. In the majority of families it appears as a reces sive trait and consanguinity of the parents is not infrequent. There are a number of retinal degenerations which do not Occasionally it shows a dominant heredity when the dis threaten the retina or lead to retinal breaks. Such lesions ease may be transmitted through several generations; this is are called snowfakes, because of their dotted white the mildest form of the disease. No Paving stone degeneration caused by focal chorioretinal advice can therefore be given as to the likelihood of trans atrophy is present in a high percentage of normal eyes; mission in any particular case unless the individual pedi reticular pigmentary degeneration, which looks rather gree has been investigated. Treatment is eminently unsatisfactory since, despite Degenerations Associated with Retinal many claims, nothing appears to have a decided infuence Breaks upon the course of the disease. Retinitis pigmentosa sine pigmento is a variant of the Lattice Retinal Degeneration disease with the same symptoms, but without visible pig Lattice retinal degeneration is recognizable by white arbo mentation of the retina. It is probably only the early stage rizing lines arranged in a lattice pattern occurring in the of the more common dystrophy. It is progressive and upper peripheral fundus near the equator with the long axes leads to optic atrophy, thus differing from congenital parallel to the ora serrata. Retinal thinning is a constant stationary night blindness, which is a rare hereditary dis feature and abnormal pigmentation is often present. The ease without ophthalmoscopic signs, remaining stationary degeneration is slowly progressive and retinal tears are throughout life. Retinitis punctata albescens is an allied condition in which, with the same history and symptoms, the retina White without Pressure shows hundreds of small white dots distributed fairly uni Pale, discrete areas of the retinal periphery without the ap formly over the whole fundus. A stationary form exists; but plication of any external pressure are thought to be the re other cases are progressive and almost certainly represent sult of vitreous traction which could result in the formation atypical varieties of the pigmentary dystrophy. Focal Pigment Proliferation or Clumping this occurs in the equatorial region or near the ora serrata. In the Angioid Streaks equatorial region focal pigment proliferation may be found Dark brown or pigmented streaks which anastomose with with a retinal tear.

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