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Listening devices will be provided and should be returned at the conclusion of your session. The Den will also serve as overfow for all three Plenary sessions, which are held in the Bellco Theater, located near the Den. Hours of Operation Wednesday, October 17 Thursday, October 18 Friday, October 19 7:00 a. The Badge Express will feature a more concierge feel this year, as we will be coming to you right there in the lobby. The Badge Express at the Hyatt Regency Denver  Hyatt Regency Denver Lobby Level Tuesday, October 16 3:30 p. Posters & e-Posters the Exchange – Hall D Posters will be displayed in the Exchange. Late-breaking abstracts will be displayed in their own section of the poster area. When browsing the e-Posters, attendees may search by keyword, poster number and/ or author names (frst and/or last names). Secure your device while it charges in the Charging Locker, which will be equipped with various charging connectors designed to ft most small electronic mobile devices. Relaxation Station the Exchange – Hall D Supported by Walgreens Take a break and visit Booth #509 at the Exchange. Sessions selected for overfow presenta tions will be based on frst and greatest need. All open session seating is limited to capacity and is available on a frst-come basis. If you would like to attend one of these sessions and it has reached capacity, please go directly to the designated overfow room listed below: Session Overfow Friday, October 19, 2018 Room Room 12:15 p. U&C: Tips to Improve Access to Specialty Medications Room 405 Room 207 Session Overfow Saturday, October 20, 2018 Room Room 7:30 a. Room 405 Room 207 Employment & Workplace Issues the overfow rooms will include audio and slide presentations—no live speaker. Please present your conference badge to be scanned at the entrance to the session room. Please present your ticket or badge to be scanned at the entrance to each session room. This is critical to help ensure that all presentations are as technologically seamless as possible. Please provide ample time to review and confrm fnal presentations and troubleshoot any embedded videos, links, sound needs or other components. Session leaders who want to learn how to operate the speaker timer should also visit the Speaker Ready Room. Please contact the meeting coordinator for any presentation-related questions for those meetings. Attendees who have a ticket to a Roundtable Luncheon or to the Closing Event that they will no longer be using should return their ticket(s) to the Ticket Exchange Board at the Bellco Theater Ticket Counter at the Colorado Convention Center so that the seat can be used by another attendee. Attendees who are not pre-registered for one of these sessions/events and wish to attend, should check for extra tickets at the Ticket Exchange Board at the Bellco Theatre Ticket Counter at the Colorado Convention Center. Visit Denver Information Desk Convention Center Main Entrance Need a recommendation for dinner, shopping, nightlife or entertainment? Hours of Operation Wednesday, October 17 Thursday, October 18 Friday, October 19 Saturday, October 20 8:00 a. We invite all who are unable to attend the conference in person to view select live-streamed sessions. We also want to stress that good infection prevention and control measures apply to all people. Thank you for your cooperation in helping to safeguard the health of those who attend our conference. Affliate Meetings & Related Study Groups All related affliate meetings and related study groups that requested to be published have been integrated into the programming section by appropriate day and time. Conference Proceedings Publication the conference proceedings were published as a supplement to Pediatric Pulmonology. Once the app is installed, the supplement will automatically download to the user’s newsstand and will be available for both online and offine viewing. A limited number of hard copies may be available to those who did not request it previously or who wish to purchase an additional copy. Please visit the Pediatric Pulmonology counter at Registration in Hall H the Bellco Theater Ticket Counter at the Colorado Convention Center. Attendees must wear their registration badge at all times when at the Colorado Convention Center and the Hyatt Regency. We encourage attendees to remove their badges when not in offcial conference facilities. If you observe anything that appears suspicious or unusual, please contact the Security Command Center directly by dialing 200 from any beige house phone and immediately report any emergencies to the Customer Service Desk at Registration in Lobby F. In the event of an emergency, 911 will be contacted immediately by Building Security. Please immediately report any emergencies to the Customer Service Desk at Registration in Lobby F. Ticketed Sessions & Events Attendees who pre-registered for limited attendance sessions (Special Classes, Short Courses, Roundtables, Adult Program Directors Meeting, Pediatric Program Directors Meeting, Affliate Program Directors Meeting, Clinic Coordinators Meeting, Center Directors Meeting, Closing Event, and Speakers/Fellows Reception) will receive printed tickets with their badge during the check-in process. Please present your printed ticket or your badge for admittance into your selected ticketed session. Media credentials are granted to representatives of news media outlets that provide widely accessible, regularly appearing, original news coverage to professionals and the public. Representatives from qualifed media outlets must represent the editorial staff, not the advertising or marketing staff of their news organization. Publishers of books and magazines, and representatives of sales, advertising or marketing departments of publications and broadcast outlets, are not considered part of the editorial staff and are not permitted to register as media. Physicians covering the meeting for a media outlet may register as a regular attendee or as the representative of an approved media organization, but not as both. We ask that on-site registrants present valid press credentials or a letter of assignment. All press registration credentials are subject to review by the Foundation’s Media Relations offce. Other Guidelines Photography and Video: Photography, video, and audio recording of any kind for any purpose is prohibited without prior authorization. Interview Requests: No interviews of Foundation representatives or staff may be conducted without express consent by the Foundation’s Media Relations offce. The Foundation’s press staff will be available onsite to facilitate interviews and other requests, but cannot guarantee availability of specifc spokespersons. In addition, representatives wearing media badges may not work in any exhibit sponsored by their publishing companies. Individuals who need to work in an exhibit are required to register as an exhibitor. Media found in violation will lose media credentials for this and subsequent meetings. False certifcation of individuals as media or paid meeting attendees, misuse of badges, assisting unauthorized persons to gain access to any Foundation meeting or co-sponsored symposia event or materials, or any inap propriate or unauthorized conduct will be just cause for. Expelling all parties involved from the meeting without obligation for refund of any fees. In addition, individuals who attend or are part of a Foundation meeting or co-sponsored symposia may not engage in any demonstrations or other behavior that the Foundation deems to be potentially disruptive to the conduct of the meeting. Violation of this rule is grounds for immediate dismissal from the meeting and/or ineligibility for attendance at future Foundation meetings. All information is confdential unless express, written consent is granted by the author(s). If consent is granted by the author to release the content of their presentation, the embargo will lift at the start of the session that includes the presentation.

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Retinal detachment this serious postoperative complication is, fortunately, rare but is more common in myopic (shortsighted) patients after intraoperative complications. Postoperative refractive error Most operations aim to leave the patient emmetropic or slightly myopic, but in rare cases biometric errors can occur or an intraocular lens of incorrect power is used. Despite all efforts to produce accurate biometry, in occasional cases the desired refractive outcome is not achieved. Retinal detachment Posterior capsular rupture and vitreous loss If the very delicate capsular bag is damaged during surgery or the fine ligaments (zonule) suspending the lens are weak (for example, in pseudoexfoliation syndrome), then the vitreous gel may prolapse into the anterior chamber. This complication may mean that an intraocular lens cannot be inserted at the time of surgery. Uveitis Postoperative inflammation is more common in certain types of eyes for example in patients with diabetes or previous ocular inflammatory disease. Cystoid macular oedema Accumulation of fluid at the macula postoperatively can reduce the vision in the first few weeks after successful cataract surgery. Opaque posterior capsule has been cut away with a laser to clear the visual axis Glaucoma Persistently elevated intraocular pressure may need treatment postoperatively. Posterior capsular opacification Scarring of the posterior part of the capsular bag, behind the intraocular lens, occurs in up to 20% of patients. Postoperative care Most patients are treated for several weeks with steroid drops to Postoperative care after cataract surgery reduce inflammation and with antibiotic drops to prevent infection. Patients have traditionally been advised to avoid ● Steroid drops (inflammation) ● Antibiotic drops (infection) activities that may considerably raise the pressure in the eyeball, ● Avoid very strenuous exertion and ocular such as strenuous exercise or heavy lifting, for a few weeks after trauma the operation. However, with modern small incision surgery 50 Cataracts patients can return to normal activities within a few weeks. If sutures have been necessary, these often need to be taken out before glasses can be prescribed because of the changes they induce in the shape and refractive state of the eye. Thickening of the lens capsule the remaining lens capsule may thicken (usually over months or years) and this may need to be cut open. In patients who have had previous cataract surgery, capsular thickening is the most common cause of gradually worsening vision. This avoids the need to open the eye surgically, and it can be performed painlessly (the capsule has no pain fibres) on an outpatient basis, under topical anaesthesia, with the patient sitting at a slit-lamp microscope. This treatment has given rise in part to patients’ commonly held misconception that cataracts can be removed by laser alone. Optical correction after surgery Cataract glasses—thick, heavy, expensive, with magnified image and reduced field of vision—are now rarely Removal of the crystalline lens results in an eye with a large necessary because of intraocular lens implants hypermetropic refractive error. This refractive error is usually corrected with an intraocular lens implant at the time of surgery. If the implant results in clear vision for distance, glasses usually will be required for reading fine print, as the new lens has a fixed focus. If the patient had a cataract extraction before intraocular lenses were used commonly, optical correction has to be achieved with glasses or a contact lens. Glasses the natural lens has great refractive power and consequently the glasses required to correct the refractive error after cataract extraction are thick and heavy, even when they are made of plastic. This means that the image from an eye that has had a cataract removed, with subsequent glasses correction, cannot be fused with the image from the other eye, unless the lens in the other eye is also removed. Objects are also perceived to be closer than they are, often resulting in accidents—for example, pouring tea into the lap rather than into the cup. The field of vision is restricted, and there is a “blind ring” (scotoma) within this field because of the optical aberrations inherent in such powerful lenses. These optical problems do not occur with contact lenses or an intraocular lens implant. Contact lenses the size of an image with a contact lens is only 10% larger than the image in the normal eye. The brain can fuse this disparity and thus both an operated eye and an unoperated eye may be used simultaneously. However, most patients with cataracts are elderly and problems may arise in using the contact lens because of an inadequate tear film, difficulties with handling, and infection. Peripheral image distortion that may be present with cataract glasses Secondary intraocular lens implantation If the problems posed by using glasses or contact lenses are too great, secondary implantation of an intraocular lens can be considered. However, this procedure has associated risks, particularly in patients who have had intracapsular cataract extraction. The potential advantages and disadvantages of the various options need to be fully considered by the patient and the ophthalmologist before a final decision is made. The glaucomas are the second commonest cause of blindness in the world, and the commonest cause of irreversible blindness. The most effective Block in flow through meshwork way of preventing this damage is to lower the intraocular pressure. Raised episcleral venous pressure Normally the ciliary body secretes aqueous, which flows into the posterior chamber and through the pupil into the anterior chamber. It leaves the eye through the trabecular meshwork, flowing into Schlemm’s canal and into episcleral veins. Symptoms and signs A patient with primary open angle glaucoma (also known as chronic open angle glaucoma) may not notice any symptoms Flattening of iris against until severe visual damage has occurred. This is because the Block in flow between trabecular meshwork iris and lens rise in intraocular pressure and consequent damage occurs so slowly that the patient has time to compensate. In contrast, the Normal aqueous drainage and possible sites of obstruction clinical presentation of acute angle closure glaucoma is well known, as the intraocular pressure rises rapidly and results in a red, painful eye with disturbance of vision. Each normal eye makes about 2 l of aqueous a minute—that is, about 70 litres during the course of a lifetime. Haloes around lights and a cloudy cornea Measuring intraocular pressure by applanation the cornea is kept transparent by the continuous removal of tonometry fluid by the endothelial cells. When the pressure rises quickly (acute closed angle glaucoma) the cornea becomes waterlogged, causing a fall in visual acuity and creating haloes around lights (like looking at a light through frosted glass). Pain If the rise in pressure is slow, pain is not a feature of glaucoma until the pressure is extremely high. Pain is not characteristically a feature of primary open angle Cloudy cornea after sudden rise in intraocular glaucoma. However, this spares central vision initially, and the patient does not notice the defect. Sophisticated visual field testing techniques are required to detect early visual field defects. The terminal stage of glaucomatous field loss is a severely contracted field, because only a few fibres from the more richly innervated macula area survive. Optic disc changes the optic disc marks the exit point of the retinal nerve fibres Normal distribution of nerve fibres in the retina from the eye. Enlargement of the eye In adults no significant enlargement of the eye is possible Glaucomatous cupping of because growth has ceased. In a young child there may be the optic nerve enlargement of the eye (buphthalmos or “ox-eye”). Nerve fibres Disc Cup Disc diameter diameter Enlarged watering eyes Normal Cup/Disc with cloudy ratio (0. The resistance to outflow haemorrhages through the trabecular meshwork gradually increases, for ‘Baring’ of Cup Disc reasons not fully understood, and the pressure in the eye vessels diameter diameter (loss of support) slowly increases, causing damage to the nerve. There may be Increased Cup/Disc other damage mechanisms, particularly ischaemia of the optic ratio (0. Optic disc Glaucomatous disc changes in Symptoms glaucoma Because the visual loss is gradual, patients do not usually present until severe damage has occurred. The disease can be detected by screening high risk groups for the signs of glaucoma. At present most patients with primary open Risk factors for primary open angle angle glaucoma are detected by optometrists at routine glaucoma examinations. Recently, genetic mutations have been identified that account for 3-4% of primary open angle glaucomas. Asymmetry of disc cupping is also important, as the disease often is more advanced in one eye than the other. Longer term changes in disc cupping are best detected by serial photography, and the more recently introduced scanning laser ophthalmoscope may be able to detect structural changes in the nerve at an early stage of the disease.

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Orthopaedics Arthroscopic Arthroscopic sub-acromial decompression is a surgical shoulder procedure that involves decompressing the sub-acromial decompression space by removing bone spurs and soft tissue for subacromial arthroscopically. If not treated the finger(s) may bend so far into the palm that they cannot be straightened. However none cure the condition which can recur after any intervention so that further interventions are required. Splinting and radiotherapy have not been shown be effective treatments of established Dupuytren’s contractures. No-one knows which interventions are best for restoring and maintaining hand function throughout the rest of the patient’s life, and which are the cheapest and most cost-effective in the long term. Ongoing and planned National Institute for Health Research studies aim to answer these conditions. Ganglion excision Ganglia are cystic swellings containing jelly-like fluid which form around the wrists or in the hand. Ganglia which form just below the nail (mucous cysts) can deform the nail bed and discharge fluid, but occasionally become infected and can result in aseptic arthritis of the distal finger joint. Trigger finger Trigger digit occurs when the tendons which bend the release in adults thumb/finger into the palm intermittently jam in a tight tunnel (flexor sheath) through which they run. Vascular Vein Intervention Varicose veins There are various interventional procedures for treating interventions varicose veins. Asymptomatic: not causing any symptoms (problems), for example not causing pain Atrophic tympanic membrane: Thinned, collapsing or retracting ear drum that can affect hearing or lead to erosion of hearing bones Benign skin lesions: lumps or bumps on the skin that are not suspicious for skin cancer Biopsy: small sample of tissue, for example the lining of the womb, is taken out for examination under a microscope Breast hyperplasia: enlargement of the breasts Breast reduction: surgery to reduce the size of the breast by removing fat, breast tissue and skin Calcific tendinopathy: a condition where small particles or crystals collect in the tendons that connect muscle to bone. Ganglion excision: surgery to remove a ganglion and the stalk from the tendon it is attached to. Globus: Persistent feeling of something in the throat when there is nothing there Glue Ear: Build up of fluid in the middle part of the ear, behind the ear drum. Sciatica: tingling and pain in the buttocks and travelling down the leg due to irritation of the sciatic nerve Sclerotherapy: injection of a substance into the varicose vein to shrink it Shoulder girdle dysfunction: pain and restricted movement of the shoulder Spinal injection: using a needle to insert medication, for example steroid, into the back around the nerves near the spine Splinting: a support is used to keep a body part from moving to allow it to heal Stenosis: tightening of an opening in the body, for example the anus Subacromial pain or impingement: the bones and tendons in the shoulder rub against each other when the arm is raised, causing pain. Subcutaneous lesion: a lump or bump that lies underneath the skin Trigger finger: tightening of the tendons in a finger that prevent the finger from being completely straightened. Systematic Review: Literature review of multiple existing research studies to answer defined research question Tendon bowstringing: tendon comes away from its attachments and causes difficulty in bending the finger Therapeutic mammoplasty: breast surgery to remove cancer and reshape the breast Thrombophlebitis: inflammation that causes a blood clot in a vein causing redness and pain Transtympanic instillation of medication: Injection of medication through the ear drum. Trigger finger release: surgery to cut the tendon sheath (the coat around the tendon) to release the tendon. The Evidence-Based Interventions Programme refers to two schemes: Individual Funding Requests for Category 1 interventions and Prior Approval for Category 2 interventions. Arguments on the basis of exceptionality are requests where a patient is deemed to have exceptional clinical circumstances, i. In these cases the request is then considered via the Individual Funding Request process. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise, without the prior written permission of the publishers. We are grateful to Alan Lacey from the Department of Medical Illustration at Moorfields Eye Hospital for his superb artistry and the diagrams. We would also like to thank Peggy Khaw for her tremendous work on the many drafts of the book from its inception, and Jennifer Murray for her help with the 4th edition. In the past Jane Smith, Mary Evans, Mary Banks, Deborah Reece, Alex Stibbe, and currently Eleanor Lines and Sally Carter have also been very supportive, steering us through the pitfalls of publishing. We also thank Steve Tuft for his expert advice on the refractive surgery section and Marie Tsaloumas for the photographs of age-related macular degeneration. Jackie Martin (supported by the Royal London Society for the Blind), Barbara Norton, and Jennifer Rignold guided us through the services for the visually handicapped. We are grateful to many people and organisations for use of their photographs in Chapter 14. The map on page 83 showing areas affected by onchoceriasis is adapted from a slide from the Image Bureau. The menu screen will appear and you can then navigate by clicking on the headings. Tips To minimise the bookmarks pane so that you can zoom the page to full screen width, simply click on the “Bookmarks” tab on the left of your screen. The bookmarks can be accessed again at any time by simply clicking this tab again. To search the text simply click on “Search Text”, then type into the window provided. You can stop the search at any time by clicking “Stop Search”, and can then navigate directly to a search result by double-clicking on the specific result in the Search pane. You can now scroll through pages uses the scroll-wheel on your mouse, or by using the cursor keys on your keyboard. Most ocular ● Rate of onset conditions can be diagnosed with a good history and simple ● Presence and type of field loss examination techniques. Conversely, the failure to take a history ● Associated symptoms—for example, flashing lights or floaters and perform a simple examination can lead to conditions being ● Effect on lifestyle missed that pose a threat to sight, or even to life. A sudden deterioration in vision tends to be vascular in origin, whereas a gradual onset suggests a cause such as cataract. The loss of visual field may be characteristic, such as the central field loss of macular degeneration. Symptoms such as flashing lights may indicate traction on the retina and impending retinal detachment. Difficulties with work, reading, watching television, and managing in the house should be Vision identified. It is particularly important to assess the effect of the Working visual disability on the patient’s lifestyle, especially as conditions Reading Watching television such as cataracts can, with modern techniques, be operated on at an early stage. Drug history Family history the patient should also be asked exactly what is worrying Chloroquine Glaucoma them, as visual symptoms often cause great anxiety. Questions about particular symptoms Ophthalmic history Some specific questions are important in certain circumstances. Examples of specific questions A history of ocular trauma or any high velocity injury— particularly a hammer and chisel injury—should suggest an intraocular foreign body. Other questions, for example about the type of discharge in a patient with a red eye, may enable you to make the diagnosis. Medical history Ocular history Diabetes— Shortsighted— vitreous haemorrhage retinal detachment Previous ocular history Special questions Easily forgotten, but essential. The patient’s red eye may be Hammer and chisel injury— associated with complications of contact lens wear—for foreign body example, allergy or a corneal abrasion or ulcer. A history of Discharge— infection severe shortsightedness (myopia) considerably increases the risk of retinal detachment. A history of longsightedness Answers to specific questions in the ophthalmic history will give (hypermetropia) and typically the use of reading glasses before clues to the diagnosis and help to exclude other problems the age of 40 increases the risk of angle closure glaucoma. Patients often forget to mention eye drops and eye operations if they are asked just about “drugs and operations. A history of a lazy eye (amblyopia) in a patient with a problem with their effective “only” eye is extremely Medical history important, as disturbance of vision in the good eye would Many systemic disorders affect the eye, and the medical history result in definite functional impairment may give clues to the cause of the problem; for instance, diabetes mellitus in a patient with a vitreous haemorrhage or sarcoidosis in a patient with uveitis. Family history A good example of the importance of the family history is in A family history of glaucoma is a risk factor for the primary open angle glaucoma. This may be asymptomatic until development of glaucoma severe visual damage has occurred. The risk of the disease may be as high as 1 in 10 in first degree relatives, and the disease may be arrested if treated at an early stage. Steroid drugs in many different forms (drops, ointments, tablets, and inhalers) may all lead to steroid induced glaucoma. Examination of the visual system Vision An assessment of visual acuity measures the function of the eye and gives some idea of the patient’s disability. It may also have considerable medicolegal implications; for example, in the case of ocular damage at work or after an assault. In the United Kingdom, visual acuity is checked with a standard Snellen chart at 6 m. If the room is not large enough, a mirror can be used with a reversed Snellen chart at 3 m. The numbers next to the letters indicate the distance at which a person with no refractive error can read that line (hence the 6/60 line should normally be read at 60 m). If the chart cannot be read at 1 m, patients may be asked to count fingers, and, if they cannot do that, to detect hand movements.

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See also gout (arthritis degenerative), polyarthritis rheumatica, coxitis, periarthritis, scapulohumeral, etc. Arthritis of the hip (Cavodermal reaction, deposition and degeneration phase) (Main remedy: Colocynthis-Homaccord) Graphites-Homaccord at 10 a. Traumeel S with Medulla ossis suis-Injeel and Cartilago suis-Injeel, Hepar suis-Injeel and Placenta suis-Injeel periarticularly, otherwise Graphites-Homaccord, Colocynthis Homaccord and Antimonium crudum-Injeel forte, on Mondays i. Discus compositum ampoules (remedy for disorders of the vertebral column, bones and tendons) for long-term therapy once weekly i. Cartilago suis-Injeel, Glandula parathyreoidea suis-Injeel and Funiculus umbilicalis suis-Injeel as mixed injection on Thursdays i. Testis compositum (revitalization in men) or Ovarium compositum (for women), in addition possibly Placenta compositum (peripheral circulation) as intermediate injection. Hepar compositum (ascites with cirrhosis of the liver), possibly alternating with Solidago compositum S, at intervals (stimulation of the liver and kidney functions). Engystol N (detoxicating agent), Traumeel S (regeneration of the sulphide enzymes) at intervals i. Asthma, bronchial (Sympathicodermal, mucodermal or organodermal impregnation phase) (Main remedy: Tartephedreel) Tartephedreel at 8 a. Carbo vegetabilis-Injeel as ampoules to be taken orally (1 ampoule to be dissolved in a glass of water and taken in draughts in the course of a day). Duodenoheel, Spascupreel, Bryaconeel and Cardiacum-Heel for simultaneous epigastric affections (administered together). Rhododendroneel S with Colocynthis-Homaccord and possibly Ignatia-Homaccord (inability to breathe deeply) or Nervoheel often bring rapid alleviation and then act as a sleeping draught. Injection therapy Ignatia-Injeel (forte) S, Carbo vegetabilis-Injeel and Sulfur-Injeel S (in place of these, possibly Engystol N) and possibly Bryonia-Injeel (forte) S i. Tuberculinum-Injeel (forte), Medorrhinum-Injeel (forte) or possibly Psorinoheel, also Psorinum-Injeel (forte) as intermediate Nosode preparations. Mercurius praecipitatus ruber-Injeel (forte S) for nightly awakening by attacks of breathlessness. Yerba santa-Injeel, Wyethia helenoides-Injeel and Zingiber-Injeel are recommended. Additional hepatic therapy (Hepeel, Hepar suis-Injeel, Chelidonium-Homaccord, Injeel Chol), further, Arnica-Injeel S, Traumeel S, Naja tripudians-Injeel, etc. Coenzyme compositum (enzyme functions), possibly also Ubichinon compositum or collective pack of catalysts of the citric acid cycle, at intervals also Mucosa compositum (remedy for affections of the mucous membranes) and Hepar compositum (stimulation of the detoxicating functions of the liver), otherwise, also Corpus pineale suis-Injeel, Pulmo suis-Injeel, Vesica urinaria suis-Injeel, Colon suis Injeel (drainage preparations), later also Ren suis-Injeel and Hepar suis-Injeel alternating or mixed i. Mucosa nasalis suis-Injeel (in the case of simultaneous affection of the nasal mucous membranes with swelling and dyspnoea). Progressive auto-sanguis therapy with the preparations mentioned once to twice weekly. Asthma, cardiac (Haemodermal impregnation or degeneration phase) (Main remedy: Aurumheel N) Aurumheel N drops at 8 a. Injection therapy Ignatia-Injeel S, Arnica-Injeel S, Carbo vegetabilis-Injeel and Arsenicum album-Injeel (forte) S alternating with Naja tripudians-Injeel (forte), Phosphorus-Injeel S, Digitalis Injeel forte S, possibly Convallaria-Injeel forte and Strophanthus-Injeel; in place of these, also Strophanthus compositum. Cor compositum (after compensation has been achieved, for continuous treatment once to twice weekly i. See also asthma (bronchial), myocardial infarction, emphysema, fatigue, Addison’s disease, dyspnoea, etc. Athlete’s heart (Haemodermal deposition or impregnation phase) (Main remedy: Aurumheel N) Aurumheel N drops at 8 a. Cor compositum (action on the cardiac circulation), possibly also Placenta compositum (circulatory disorders), otherwise Coenzyme compositum, Strophanthus compositum and possibly Diphtherinum-Injeel; Cor suis-Injeel i. Atrial fibrillation (Haemodermal impregnation phase) (Main remedy: Aurumheel N) Chelidonium-Homaccord at 8 a. Injection therapy Strophanthus compositum (disturbances of the cardiac circulation) i. Chelidonium-Homaccord with Arsenicum album-Injeel S (conditions of anxiety) and Aconitum-Homaccord i. Natrium-Homaccord and Apis-Injeel forte S as intermediate injection, Kalium carbonicum-Injeel (forte) for arrhythmia, Rauwolfia compositum (for hypertonic heart), otherwise Coenzyme compositum and Ubichinon compositum (improvement of disturbed enzyme functions), possibly also Cor compositum (cardiac tonic for chronic affections) and Hepar compositum (improvement of disturbed hepatic enzyme functions). See also arrhythmia (cardiac), cardiac insufficiency, angina pectoris, tachycardia, thyrotoxicosis, etc. Bacterial growth, disturbed (Entodermal deposition or impregnation phase) (Main remedY: Nux vomica-Homaccord; bacterial substitution) Veratrum-Homaccord 8-10 drops in the morning Nux vomica-Homaccord 8-10 drops midday Hepeel 1 tablet in the afternoon Diarrheel S 1 tablet in the evening possibly all four preparations taken together morning and evening. Injection therapy Anacardium-Homaccord, Nux vomica-Homaccord, Veratrum-Homaccord, Hepeel and possibly Galium-Heel with Hepar suis-Injeel, Colon suis-Injeel, Jejunum suis-Injeel, Rectum suis-Injeel, Pancreas suis-Injeel, alternating or mixed i. Bacterium coli-Injeel, Bacterium proteus-Injeel, Bacterium lactis aerogenes-Injeel, Salmonella typhi-Injeel and Salmonella paratyphi B-Injeel, possibly also as forte preparations at intervals. Balanitis (Germinodermal reaction phase) (Main remedy: Traumeel S) Traumeel S at 8 a. Traumeel S ointment rubbed in twice daily or a cotton gauze coated thickly with ointment laid around the glans penis. Bartholinitis (Ectodermal or germinodermal reaction phase) Mercurius-Heel S at 8 a. Bechterew’s disease (Osteodermal deposition phase) China-Homaccord S 8-10 drops at 8 a. Rhododendroneel S for pains dependent on the weather, at intervals as massive initial-dose therapy. Injection therapy Neuralgo-Rheum-Injeel, China-Homaccord S, Dulcamara-Homaccord, Colocynthis Homaccord, Traumeel S, Tonico-Injeel and Phosphor-Injeel (forte) (typical when the spine is bent forward, long-term remedy), alternating or mixed i. Blepharitis (Ectodermal reaction phase) (Main remedy: Oculoheel) Oculoheel at 8 a. Kalmia-Injeel (forte) S for ciliary injection Mercurius-Heel S for suppurations Lymphomyosot for scrofulosis Psorinoheel (chronic cases) Traumeel S tablets (anti-inflammatory, antisuppurative action) Traumeel S ointment to be applied extremely thinly and rubbed in. Injection therapy Ferrum jodatum-Injeel and Graphites-Homaccord, possibly also Traumeel S alternating, i. Mercurius bijodatus-Injeel (forte S), for blepharitis ciliaris with chronic granulation. Variolinum-Injeel (forte) and Vaccininum-Injeel (forte) as intermediate remedy in chronic cases. Mucosa compositum (remedy for disorders of the mucous membranes, particularly for chronic affections). Traumeel S, Hormeel S, Psorinoheel and possibly Galium-Heel as intermediate injection. Anthracinum-Injeel (forte), in serious cases also Variolinum-Injeel (forte) for Nosode therapy, collective pack of the catalysts of the citric acid cycle, possibly also Coenzyme compositum or Ubichinon compositum (regulation of the enzyme functions), at intervals also Cutis compositum (remedy for disorders of the dermal functions) and Placenta compositum (regulation of the peripheral circulation), otherwise also Funiculus umbilicalis suis-Injeel, Cutis suis Injeel and Placenta suis-Injeel i. Bronchiectasis (Organodermal reaction phase) (Main remedy: Bronchalis-Heel) Galium-Heel at 7 a. Lamioflur (for putrid sputum) Tartephedreel (intermediate remedy) for irritating coughs Abropernol, active constitutionally Lymphomyosot (regulation of the Iymphatic circulation) Traumeel S or Mercurius-Heel S (intermediate remedy for abundant suppuration) Injection therapy Traumeel S, alternating with Kreosotum-Injeel, Phosphor-Homaccord Arsenum jodatum-Injeel (forte), Kalium carbonicum-Injeel and Ipecacuanha-Injeel i. Mucosa compositum (acts on the mucosa) and Echinacea compositum S (antitoxic stimulation of the defensive system) as intermediate injections, in addition Bacillinum Injeel (forte) or Tuberculinum-Injeel (forte) as well as Grippe-Nosode-Injeel and Klebsiella pneumonia-Injeel (for Adiposis) as nosode therapy Lymphomyosot (action on the connective tissue) as intermediate injection Stannum-Injeel (forte) for large amounts of sputum, Guajacum-Injeel (forte) for evil smelling, purulent expectoration Coenzyme compositum and possibly Ubichinon compositum (stimulation of disturbed enzyme functions), otherwise also the collective pack of catalysts of the citric acid cycle, as well as Tonsilla compositum (constitutional therapy) and Pulmo suis-Injeel and Bronchus suis-Injeel once weekly i. Bronchitis (Organodermal reaction phase) Gripp-Heel (or Bryaconeel) and Tartephedreel alternating every 1-2 hours. Aconitum-Homaccord for feverish influenzal bronchitis Droperteel for congestive bronchitis (in the elderly) Bronchalis-Heel for smoker’s bronchitis, 1 tablet 3 times daily for irritating coughs Drosera-Homaccord (forms of coughs similar to pertussis) possibly allowing several preparations simultaneously to be taken 2-4-6 times daily. Asthma-Nosode-Injeel and Pertussis-Nosode-Injeel (forte) for chronic (asthmatic) bronchitis. Guajacum-Injeel (forte) for evil-smelling, purulent expectoration, bronchiectasis. Mucosa compositum and Tonsilla compositum ampoules for constitutional therapy in emphysema, asthma, pneumonoconiosis, etc. Brucellosis (undulate fever) (Haemodermal reaction phase) (Main remedy: Traumeel S) Hormeel S in the morning, 8-10 drops Gynäcoheel at midday, 8-10 drops Traumeel S in the afternoon, 1 tablet Arnica-Heel in substitution (8-10 drops) Hepeel in the evening, 1 tablet; possibly the above preparations taken together 2-4-6 times daily. Injection therapy Traumeel S or Echinacea compositum (forte) S (possibly alternating), with the patient’s own blood; at intervals Hormeel S, Brucella abortus Bang-Injeel (forte), Hepeel and possibly Galium-Heel (chronic cases), possibly also Ovarium compositum and Thyreoidea compositum (hormone functions) i. Bruxism (grinding or clenching of the teeth) (Neurodermal impregnation phase) Nervoheel at 8 a. Hyoscyamus-Injeel (forte), China-Injeel (forte) S and Ignatia-Injeel (forte) S as secondary or alternating injection.

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Prevent the supine hypotensive syndrome (pressure on the If you find that the left side of the incision always bleeds vena cava) by tilting her about 5º to the left. Find some way of preventing her slipping If the foetal head is impacted in the pelvis and needs to be off the table. A moderate head down (Trendelenburg) disimpacted from below, ask yourself if a symphysiotomy position, after the spinal anaesthetic is fixed at the correct (21. Ask an assistant, with sterile gloves, to put his hand It will make delivering the foetal head easier if there is a into the vagina, and to disimpact the foetal head. Unfortunately, it is difficult to predict that the head needs Make a cut through the skin and subcutaneous tissue down disimpaction, until after you have opened the uterus. Take care if there has been a previous Caesarean peritoneum over the uterus, just below the point where the Section (21. Then tear the peritoneum with your fingers to left and right, If necessary, extend the skin incision further down. If you use a Pfannenstiel incision, use your fingers aim your fingers in a more cephalic direction, so that the tear in a similar way for the tissues under the skin and above the in the peritoneum is curved (21-12J). Try to leave a bare fascia, even the fascia and also, now directed vertically, area about 2cm wide and 12cm long. Use two haemostats to pick up (2) Do not denude the lower segment for >5cm: if the cervix peritoneum near the upper end of the incision (21-12E). Make a small opening in it with a before opening it (21-12K), so as to prevent blood, liquor, scalpel (21-12F) or your finger, and then open the rest of it and meconium from soiling the peritoneal cavity, with scissors (21-12G) or tearing it with your fingers, and to keep the bowels out of the way. Meconium is irritant, longitudinally from above downwards to just above the and if it becomes infected peritonitis may follow. If you cut the bowel by mistake, Make a superficial incision over the full trajectory of the clamp it and close it later (11-5). This should be Clamp any active bleeding vessels if they are big, ≤2cm below the peritoneal reflection, and at least but postpone tying them until later in order to save time. They usually stop bleeding on their own anyway, although Do not make your transverse incision too low in the lower this does not always happen if you use a Pfannenstiel segment. Then go somewhat deeper in the midline because the current may cause foetal cardiac dysrhythmias. Do not try to aspirate the nose especially fingers bleed less and the extent of the opening is easy to with a big Yankauer sucker: it may push maternal blood into control. A major advantage is that you cannot in this way cut the nose and/or traumatise the nasal passages. Ergometrine occasionally makes a conscious patient sick, and may raise the blood pressure. Protect it with a finger will often not notice relaxation because bleeding will not be between the membranes and the uterine wall if you use overt. An oxytocin infusion at the end of the operation and scissors instead of tearing with your fingers. Also, when you because blood loss from the injured sinuses of the placenta suture it, you will be less likely to suture the ureters. Otherwise delayed cord clamping, placing the baby below table level and milking the cord all If there is a scar in the lower segment from a previous serve to increase the Hb level of a neonate, especially if Caesarean Section, make a shallow cut along it, where you pre-term. If you can feel the foetal vertex through the uterine wall, Now deliver the uterus by lifting the fundus out of the the placenta is probably lying in the fundus or posteriorly, abdomen; it is easier then to see what you are doing. If you are a quick operator, apply one Green-Armytage If you tear the placenta as you open the uterus, try to clamp (or sponge-holding forceps) at one angle of the detach it, and deliver the foetus around it. There can be severe bleeding from a lacerated placenta, so clamp the umbilical cord If you are a slow operator, apply several Green-Armytage quickly (21. Make sure they do not If the ends of the opening in the lower segment bleed grasp the posterior wall of the empty uterus, as it lies on the severely, before the foetus has been delivered, quickly promontory of the sacrum; you can easily do this by mistake proceed with delivery, and then control bleeding as if bleeding has been brisk. Do not pull on the clamps during suturing as this will result in an asymmetric If there are large veins over the lower segment, closure. The veins will probably stop bleeding soon by a combination of controlled cord traction and fundal after. If necessary, help it to contract by massaging the fundus from inside the abdomen. If there is a placenta praevia grown into a previous Then put your hand outside the lower flap of the incision, Caesarean Section scar, there is serious danger of serious and lift the foetal head up (21-12P). If you cannot remove the placenta manually (the practical If the incision is not long enough to deliver the foetus definition of placenta accreta) then you may be forced to without a lateral tear, extend its ends upwards and laterally proceed to hysterectomy. Do not probe the cervix to improve drainage: on them: they tend to slip off or break and are costly! Do not use non cleaner if you have previously inserted abdominal packs absorbable sutures, particularly not on the inner wall. Wash out the abdominal cavity Ask your assistant to hold the lower edge of the uterus with copious warm water if there was soiling present. Start the first sutures just beyond the lateral greater omentum over the uterus: it will usually reach the extremity of the wound. Then re-start with the first suture and contact is important in developing the bond between them. Estimate the blood loss: it will probably be more than you Unless the sutures are tight, they will not stop the bleeding. Check and chart the (1);Start suturing just lateral to the wound extremity with an pulse, temperature, and respiration ½hrly, until she is awake, adequate bite through the whole uterine wall. So, before the first layer of sutures is completed, theatre in reasonable condition is now collapsed. Suture only the uterus, and not too deeply downwards towards the vault of the vagina. If you are in any If the membranes were ruptured for >24hrs before the doubt, put your fingers down behind the uterus before you operation, or there are other reasons for suspecting start to close the lateral extremities of the opening so that the infection, continue antibiotics for 3days. When the uterus is no longer bleeding, close the peritoneum of the vesico-uterine pouch with continuous sutures of If vomiting ensues with abdominal distension, non-absorbable (21-12V). Do not close the peritoneum until you have or add these details to the baby’s birth card. If there was obstructed labour and the urine is bloodstained, leave a catheter in the bladder for 10days. So, after repairing a tear, check visually that the ureter has not been caught in a stitch by mistake. Many difficulties attend Caesarean Section, and many If these measures fail, the only way to control bleeding disasters can follow it, so the list below is long. Torrential may be to tie the both uterine arteries, just after they bleeding when you cut through a placenta praevia can kill a have entered or branched into the uterus or cervix. Disasters with the urinary tract are usually If you are not able to repair the uterus, perform a subtotal the result of very poor technique. If catheterization before the If a patient has had a previous Caesarean Section, operation was impossible, empty the bladder now with a dense adhesions may have formed between the uterus and needle and syringe. Mobilize the bladder free from the Do not excise a keloid scar: the keloid will probably get lower segment as usual. Excise redundant push the foetal head up from below through the vagina, skin if you intend simultaneously to repair an incisional before you open the uterus. If the sides of the abdominal wall might may prolapse into the incision and make delivery more prove difficult to line up accurately, mark a transverse line difficult. If it is too high, delivery will be Open the parietal peritoneum beyond the end of the previous difficult; if it is too low, you may have technical difficulties scar. If you find a plane of loose connective tissue, closing the vagina or you may even incise the vagina. If dissecting the adhesions is very difficult (unusual), give up and make an If delivering the head is difficult, do not panic. Take time to push the uterine wall back (1) Stay close to the uterus to avoid the bladder. If she has had a previous classical Caesarean Section, (1) Do not lever the head out with your whole hand, because you would probably be wiser to perform a lower segment this can cause vertical downward tears in the lower segment. If the bladder has stuck to the lower segment, Administer antibiotics for at least 5days. Lift the lower edge If there is a breech presentation, feel for a leg, or better, in forceps to stretch the adhesions between the bladder and both legs, and deliver the foetus breech-first as if you the uterus.

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The condition was treated with paracetamol and there was a reaction to the treatment, liver failure. Disregard the condition unlikely to cause death and select the reaction to the treatment, liver failure, as the starting point. It is in the table of conditions considered unlikely to cause death, but in this case it caused complications that are not considered unlikely to cause death. A complication is reported, headache, but it is in the table of ill-defined conditions. There may be special coding instructions on this tentative underlying cause, or other reasons to modify the tentative underlying cause. Check whether the tentative underlying cause should be modified by applying the modification rules described in steps M1 to M3 (Modification rule 1 to Modification rule 3). At each step, there is a description of the modification rule itself and what to do next. If a special coding instruction applies, assign a new tentative underlying cause according to the instruction. Next, check whether any special instructions apply to this new tentative underlying cause. Repeat until you have found a tentative underlying cause that is not affected by any further special coding instruction. If there are several such combinations that would apply to the tentative underlying cause, then apply the combination with the first-mentioned of these other conditions (the first-mentioned linkage). Use the combination code only if the code title clearly indicates the etiology of the condition. There is a special instruction on ischaemic heart disease reported with myocardial infarction, and, according to this instruction, myocardial infarction is the new tentative underlying cause. Rules and guidelines for mortality and morbidity coding reported with ischaemic heart disease, and another one on atherosclerosis reported with myocardial infarction. Ischaemic heart disease is reported first on the certificate, so apply the instruction on atherosclerosis reported with ischaemic heart disease and select ischaemic heart disease as the new starting point. Next, there is a special instruction on ischaemic heart disease reported with myocardial infarction. Apply this instruction and select myocardial infarction as the new tentative underlying cause. There is a special instruction on atherosclerosis reported with ischaemic heart disease, and another one on atherosclerosis reported with cerebral infarction. Ischaemic heart disease is reported first on the certificate, so apply the instruction on atherosclerosis reported with ischaemic heart disease and select ischaemic heart disease as the new tentative underlying cause. There are special instructions on hypertension reported with cerebrovascular infarction and with myocardial infarction. Cerebrovascular infarction is reported first on the certificate, so apply the instruction on hypertension reported with cerebrovascular infarction and select cerebrovascular infarction as the new tentative underlying cause. There is a special instruction on atherosclerosis reported as the cause of dementia. Although there is a special instruction on dementia reported as caused by atherosclerosis, this instruction does not apply here because dementia is reported in Part 2 and not as caused by atherosclerosis. Step M2 – Specificity If the tentative underlying cause describes a condition in general terms and a term that provides more precise information about the site or nature of this condition is reported on the certificate, this more informative term is the new tentative underlying cause. Next, check whether this new tentative underlying cause can be specified even further by other terms on the death certificate. Repeat until you have found a tentative underlying cause that cannot be specified further. Do not disregard a generalized condition such as atherosclerosis because a more specific but unrelated condition is reported on the certificate (see also Example 9). If several other expressions on the certificate provide more precise information on the tentative underlying cause, start with the first mentioned of these other conditions. There is a special instruction on atherosclerosis reported with cerebrovascular accident; apply this instruction and select cerebrovascular accident as the new starting point according to Step M1. The type of cerebrovascular accident is described more precisely in Part 2 as an arterial embolism to brain stem. There is a special instruction on atherosclerosis reported with cerebrovascular accident; apply this instruction and select cerebrovascular accident as the new tentative underlying cause. There is no more specific description of the type of cerebrovascular accident on the certificate, and cerebrovascular accident remains the tentative underlying cause. The manifestation is described as meningitis, and the two terms combine into tuberculous meningitis, which is the tentative underlying cause. Arterial embolism of left leg, reported as the second condition on line 1(b), is a specific type of arterial disease. Therefore, select arterial embolism of left leg as the tentative underlying cause in Step M2. But colon cancer is an obvious cause of arterial embolism, and colon cancer is the new starting point. There is a special instruction on atherosclerosis reported as the cause of arterial disease, and, according to this instruction, arterial disease is the new starting point according to Step M1. Arterial embolism of left leg, reported as the second condition on line 1(b), is a more specific description of the type of arterial disease and is selected as the tentative starting point in Step M2. Therefore, always check whether any such restrictions apply to the underlying cause you selected. Thus, whether a sequence is listed as ‘rejected’ or ‘accepted’ may reflect interests of importance for public health rather than what is acceptable from a purely medical point of view. Individual countries should not correct what is assumed to be an error, since changes at the national level will lead to data that are less comparable to data from other countries, and thus less useful for analysis. Accept Type 2 diabetes mellitus (E11) as due to conditions that cause insulin resistance. Accept Other specified and unspecified diabetes mellitus (E13–E14) as due to conditions that cause damage to the pancreas. Accept cerebrovascular embolism, thrombosis and unspecified stroke (I63– I66, I69. Rules and guidelines for mortality and morbidity coding (d) Diabetes due to other conditions Do not accept Type 1 diabetes mellitus (E10. Do not accept Type 2 diabetes mellitus (E11) as due to any other cause except conditions causing insulin resistance. Do not accept Other and Unspecified diabetes mellitus (E13 and E14) as due to any other cause except conditions causing damage to the pancreas. Enterocolitis due to Clostridium difficile Consider enterocolitis due to Clostridium difficile as an obvious consequence of antibiotic therapy. Sepsis and systemic inflammatory response syndrome Consider conditions that impair the immune system, wasting diseases (such as malignant neoplasms and malnutrition), diseases causing paralysis (such as cerebral haemorrhage and thrombosis), serious respiratory conditions and serious injuries (grade 1–4 according to the injury priority list in Annex 7. Complications of diabetes Consider Diabetes mellitus (E10–E14) as the obvious cause of the following conditions. Dehydration Consider any intestinal infectious disease as an obvious cause of Volume depletion (dehydration) (E86) F. Dementia Consider conditions that typically involve irreversible brain damage as obvious causes of dementia, if no other cause of the dementia is stated. Mental retardation (F70–F79) Consider the following conditions as obvious causes of mental retardation. Disorders related to short gestation and low birth weight, not elsewhere classified (P07). Heart failure and unspecified heart disease Consider other heart conditions as the obvious cause of Heart failure (I50. Embolism Consider venous thrombosis, phlebitis or thrombophlebitis, valvular heart disease, childbirth or any operation as the obvious cause of diseases described as ‘embolic’. However, there must be a clear route from the place where the thrombus formed and the place of the embolism. Consider conditions that impair the immune system, wasting diseases (such as malignant neoplasms and malnutrition), diseases causing paralysis (such as cerebral haemorrhage and thrombosis), serious respiratory conditions, communicable diseases, conditions that affect the process of swallowing, other diseases that limit the ability to care for oneself, including dementia and degenerative diseases of the nervous system, poisoning and serious injuries (grade 1–4 according to the injury priority list in Annex 7. Pulmonary oedema Consider the following conditions as obvious causes of Pulmonary oedema (J81). Rules and guidelines for mortality and morbidity coding respiratory distress syndrome high altitude circulating toxins. Nephritic syndrome Consider any streptococcal infection (scarlet fever, streptococcal sore throat, etc.


  • Santavuori disease
  • Dobrow syndrome
  • Nystagmus with congenital zonular cataract
  • Ichthyoallyeinotoxism
  • Pulmonary fibrosis /granuloma
  • Carpal deformity migrognathia microstomia
  • Anotia
  • Faciocardiorenal syndrome

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It is impor tant to note that no deduction as to the amount of vision can Toxic, Nutritional and Hereditary Optic be made from the ophthalmoscopic appearances, for the Neuropathy presence of all the signs of atrophy is not inconsistent with a certain, sometimes a considerable, amount of vision. Aetiopathogenesis No treatment is effective for optic atrophy; the prognosis Many nutritional defciencies, toxic and hereditary optic depends on the possibility of early control of the causal factor. Vitamin def of the Optic Nerve ciencies associated with poor diet may be compounded by the ingestion of cassava and elevated levels of cyanide. Vitamins such as B12 and folic acid are crucial are likely to cause optic atrophy. Agents such as cyanide or formate (a meta the internal carotid artery or the ophthalmic artery can also bolic product of methanol) block this electron transport. Neurones involvement occurs if the posterior optic nerve or chiasma is with very low, very thin or unmyelinated axons, such as the affected. The critical signs include visual loss, feld defcits papillomacular bundle, are at a great disadvantage and and a relative afferent pupillary defect. Other signs may include proptosis and opticociliary Clinical Features shunt vessels (Fig. These are small vessels around the Usually, there is a sudden or rapid painless bilateral vision loss. Simultaneous involvement of both eyes is more com mon with nutritional defciency, toxic and some hereditary disorders, but monocular onset and fellow eye involvement occurring later (days, weeks or months) is more common with Leber hereditary optic neuropathy. Other clinical signs include dis turbed colour perception and feld defects typically charac terized by a centrocaecal scotoma (Fig. Associated neurological features such as paraesthesiae, ataxia and im paired hearing may be seen. However, visual loss is perma nent in chronic, long-standing nutritional or toxic optic neuropathy. Toxic Optic Neuropathies these include a number of conditions in which the optic nerve fbres are damaged by exogenous poisons. Previ ously, these were called the toxic amblyopias, which is a A misnomer going by the modern defnition of amblyopia. The most common of these poisons are tobacco, ethyl alco hol, methyl alcohol, arsenic, lead, thallium, quinine, ergot, carbon disulphide, stramonium and Cannabis indica. In some of them (tobacco, methyl alcohol), the disease is primarily retinal and follows poisoning of the ganglion cells of the retina which results in degeneration of the nerve fbres. The neuropathy produced by diabetes, carbon disul phide (seen in the rayon industry), and iodoform resembles that of tobacco. Methyl alcohol, lead, nitro and dinitrobenzol produce more serious optic atrophy than the agents mentioned ear B lier. There is probably always a stage at which a central scotoma is present, but it is often missed. More interesting, however, is the Tobacco-induced Optic Neuropathy: this results from loss of the nerve fiber layer in the papillomacular bundle. This patient, the excessive use of tobacco, either pipe smoking or chew who had tobacco-alcohol amblyopia (mixed toxic and nutritional defi ciency optic neuropathy), also had visual acuities of 20/400 (6/120) in ing, and occasionally from the absorption of dust in tobacco each eye, which recovered to only 20/100 (6/30) after changes in habit factories. In this class of optic neuropathies, relatively cigars suffer the most; cigarette smokers are rarely affected. Various substances have been ily involve the centrocaecal area between the fxation point regarded as the toxic agent, but a potent factor may be poi and the blind spot. Here, occupying a horizontally oval soning with the cyanide in tobacco smoke associated with a area, there is a relative scotoma to white and colours, par deficiency of vitamin B12. The scotoma the ganglion cells of the retina, particularly of the macular gradually extends to involve the fxation area itself so that area where the cells show vacuolation and Nissl degenera central vision may be lost but the peripheral feld remains tion. Clinically, the patient complains of increasing foggi Treatment consists of abstaining from or severely cur ness of vision, usually least marked in the evening and in tailing the use of tobacco and alcohol. Central vision is greatly diminished, so that read prognosis is eventually good although visual improvement ing and near work become diffcult. Although the condition may not be evident for a period of some months; thereafter is bilateral, one eye is usually more affected. Improvement may be hastened by intramus the fundus is normal or a slight temporal pallor may be cular injections of 1000 mg hydroxycobalamine. Lead: Lead poisoning is rarely seen nowadays since pre Ethyl Alcohol Although alcohol is usually an adju cautions have been taken to eliminate salts of this metal vant in tobacco-induced optic neuropathy, it may cause from pottery glazes, children’s paints, painted toys, etc. Such patients However, it may still be a major problem due to vehicular frequently suffer from alcoholic peripheral neuritis. The dis pollution in some areas of the world and in countries where ease, characterized by a central scotoma, may be due essen indigenous systems of medicine may include therapy with tially to avitaminosis owing to chronic lack of nourishment. General measures such Adults develop abdominal pain, anaemia, renal disease, as stopping alcohol intake, improved diet and injections of headache, peripheral neuropathy with demyelination, ataxia hydroxycobalamine as outlined above can be tried. Childhood poisoning is manifested by therapy has not been found to be of any beneft. This syndrome is almost always Methyl Alcohol Poisoning from drinking wood alcohol associated with a high dose exposure to lead, pica and has always been common in countries during prohibition, malnutrition, with iron, calcium and zinc defciency. The subclinical form of childhood plumbism includes se Individual susceptibility is marked. It may occur in an acute lective defects in language, cognitive functions and behaviour. In the acute form there may be severe meta the ocular signs are optic neuritis or optic atrophy, bolic acidosis with nausea, headache and giddiness followed which may be primary or post-neuritic. If the patient survives, vision fails very rapidly, velop a retinopathy which may be due directly to lead or of passing through the stages of contracted fields and absolute the renal type, secondary to lead nephritis. The vision may improve, but Laboratory tests to establish the diagnosis include a usually relapses, becoming gradually abolished by progres haemogram, measurement of the blood lead levels (normal sive optic atrophy. Later there are signs of optic atrophy, and the use of chelating agents such as the calcium salt of usually of the primary type. The largest gradual, progressive loss of vision with the development of doses were usually taken for malaria, but quinine was also optic atrophy. Ophthalmoscopically, Arsenic: this is especially liable to cause optic atrophy, the retinal vessels are extremely contracted and the disc is usually total, when administered in the form of pentavalent very pale; oedema of the retina has been described in the compounds such as atoxyl or soamin. Occasionally blindness is permanent and optic attacking the trypanosome of sleeping sickness, but have atrophy ensues. The discs throat, diffculty in swallowing, nausea, vomiting, diar may remain pale for years or become normal. Manifestations of chronic Ethambutol: this is an oral chemotherapeutic agent used poisoning include erythroderma, hyperkeratosis, hyperpig in the treatment of tuberculosis and may produce an optic mentation, exfoliative dermatitis, skin carcinoma, bronchi neuritis resulting in reduced visual acuity and colour vision, this and polyneuritis. The neuritis is reversible the condition is diagnosed by the detection of arsenic when the drug is discontinued but patients should be exam in the hair and nails and the measurement of arsenic levels ined monthly during the early stages of therapy. A dose of in the blood (normal,3 mg/dl) and urine (normal,100 15 mg/kg/day is the upper limit of safety with regard to eye mg/L). Gradual recovery to a variable extent has induced optic neuropathy has no correlation with duration, been known to occur. Optic nerve related to the corneal deposits, but fundus examination and involvement is rarely directly related, but is more commonly an evaluation of optic nerve function are indicated. A mild pigmentary life-threatening situations, which respond only to amioda disturbance in the macular area leads to visual field defects, rone, the drug may have to be continued; fortunately, com most commonly a central scotoma and a characteristic plete blindness is rare. Eventually there is a widespread retinal atro Other Drugs: To complete the list, antibiotics such as phy with pigment clumping and attenuated retinal vessels. In the past, the fears of toxicity are a combination of progestogens and oestrogens, may were based on the total accumulated dosage the patient had play a part in the production of occlusive vascular disease, ingested over his lifetime. It now appears that this is not a particularly in women who suffer from vascular hyperten problem if the actual effective doses are adhered to, and the sion, migraine or other vascular syndromes. Infarction of daily dosage is considered the most critical factor in pre the brain or of the optic nerve head occurs more commonly venting eye damage. In such cases the Hydroxychloroquine, which has a lower risk of ocular drug must be discontinued. Nutritional Defciency the maximum dose allowed for chloroquine is 6 mg/kg in A defciency of vitamins in the diet, particularly thiamine, 24 hours while for hydroxychloroquine it is 4. The may be responsible for the development of an optic neuritis, latter is more commonly used nowadays (300–400 mg/ usually of the axial type, resulting in the loss of central vi day). Similar lesions in the mid-brain cause various types of term therapy are reversible on stopping the drug. Keratopa ophthalmoplegia (acute haemorrhagic anterior encephalitis thy produced by long-term use and seen in up to 90% cases, of Wernicke).

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Always take appropriate specimens before starting treatment (except in suspected meningococcaemia if this would delay potentially life saving treatment). Most infections do not require treatment beyond the resolution of signs and symptoms. Early review of treatment will lower side effects, cost and selection of resistance. Prolonged treatment is required for neonatal meningitis, endocarditis, bone and joint infections and systemic Staphylococcus aureus infections. For other infections not listed or for more information please consult the Consultant Microbiologist or Paediatric Infectious Disease physician. In particular, hands must be decontaminated before and after contact with a patient or their surroundings. Further advice on infection prevention and control in the Trust is available from: Infection Prevention and Control Nurses ext. In addition, other agents are kept in stock for second line or more complex clinical conditions. For advice on antimicrobial agents, other than antibacterials, please contact Pharmacy, the Microbiologist, or the Consultant in Infectious Diseases. Acute Bone Osteomyelitis Seek Co-amoxiclav and Joint Septic Arthritis Cefuroxime advice or Treat acute osteomyelitis for 6 weeks minimum. Infection (over 3 months old) before flucloxacillin Chronic osteomyelitis for 12 weeks minimum. Cefotaxime Seek specialist advice from Orthopaedics, Paediatrics and Microbiology/Infectious Diseases. Second Line Preferred Type of Infection First Line Antibacterial Route Oral Switch Comment Antibacterial Empyema see Pneumonia Ophthalmia Eye Infections Neonatorum 1. Chlamydial Clarithromycin Oral Treat for 14 days conjunctivitis Contact tracing mandatory 2. Second Line Preferred Type of Infection First Line Antibacterial Route Oral Switch Comment Antibacterial Salmonellosis and Shigellosis Only treat with antibiotics if If treatment with antibiotics required consult systemically unwell. Relapses are not due to antibiotic resistance – colitis re-treatment with metronidazole is acceptable. Presence of Clostridium difficile toxin is not usually clinically significant in children under 2 years old. Type of Surgery 1st line Antibiotic Alternative Number of Doses If allergic to 1st and 2nd line drug, contact Microbiologist or Pharmacist for advice Appendicectomy Cefuroxime 50mg/kg (max 1. Type of Surgery 1st line Antibiotic Alternative Number of Doses If allergic to 1st and 2nd line drug, contact Microbiologist or Pharmacist for advice Neuro Neurosurgery Cefuroxime 50mg/kg (max 1. Osteomyelitis & septic (Dosage based on co arthritis (oral switch) amoxiclav content) Birth – 3months 30mg/kg every 12 hours 3 month 18 years 30mg/kg (max 1. Target trough level is 10-15mg/L in most circumstances – discuss with Microbiology if further advice required. This outlines the empirical antibiotic regimen appropriate for that patient (based upon their previous isolates) and should be followed. Removal of the line is not usually necessary but should be considered in severe sepsis and/or failure to respond to optimal antibiotic therapy. If cultures are negative, and clinical suspicion of infection had not been high then stop antibiotics (Section 2. Max 4 regular dosing 3 – 6 months 50micrograms/kg micrograms/kg doses/24 hours Following major plus 7 days for surgery or more when required 6months – 2 years – 100micrograms/kg prolonged inpatient usage. See Tables the 1600 microgram/actuation Nasal Spray is only suitable for children weighing between 30kg and 50kg. For patients from 12kg to 30kg the 720 micrograms/actuation strength should be used. Administration: A new tip should be used for any new patient to avoid risk of microbial contamination and soiling of the tip. Ensure that the dip tube remains in the solution during priming and re-priming to avoid air entering the pump spray and affecting dose uniformity. It is recommended that the patient sits in a semi-recumbent position at about 45 degrees when the nasal spray is being administered. The patient should then be monitored for at least 30 minutes following administration D. Weight (kg) Approximate age Number of Dose of (years) sprays diamorphine (mg) 720 micrograms/actuation strength 12 18 2 5 2 1. Maximum dose depends on age Age 1-3 yrs 2 ml Age > 3 yrs 3 ml Each bottle is single patient use only and should be discarded within 24 hours of opening. Notes for successful local anaesthesia:  Digital nerve this requires the gaining and keeping of confidence: it is blocks. Touch and pressure sensation are frequently preserved despite adequate pain block; this does not represent inadequate anaesthesia but may be an unsettling surprise to a patient who is not prepared. Minimal sedation is a drug induced state during which patients are awake and calm, and respond normally to verbal commands. Although cognitive function and co-ordination may be impaired, ventilatory and cardiovascular functions are unaffected. Moderate sedation is a drug induced depression of consciousness during which patients are sleepy but respond purposefully to verbal commands (also known as conscious sedation). By definition, loss of verbal contact (with appropriate stimuli) by the patient constitutes ‘deep sedation’ or even general anaesthesia, so verbal contact must be maintained. It is not general anaesthesia, but can be used in conjunction with other techniques. Procedural sedation is used for “elective” or “semi-elective procedures” and has no role in the emergency management of patients with life-threatening complaints. Other priorities, especially attention to Airway, Breathing and Circulation must take precedence. It may be used however, when balanced against risks of starvation status, in limb-threatening trauma. If sedation remains inadequate after this dose, it may then be possible to site an I. Ideally, three practitioners would be present, one to perform sedation and manage the airway, another to perform the procedure and a third person (nursing) to support and monitor the patient and support the parents. If they are happy, give info leaflet no 369 explaining the procedure fully and the consent process. Calculate doses / have nearby all drugs that may be required during the procedure. Consequently, monitoring should include pulse oximetry but not blood pressure monitoring, unless indicated. This is achieved safely by placing your free arm along the infant’s back and encircling the occiput with your hand. These are similar to chest compressions, but sharper in nature and delivered at a slower rate. To use the phrase ‘life-threatening’ can be misunderstood that the event was more serious than it often was. The aim of this is to help clinicians use evidence-based management recommendations in evaluating the risk of future similar events for ‘low risk’ patients where history and examination are normal. It does not extend to managing more complex ‘high risk’ patients where history and/or examination indicate a more severe pathology for which specific guidelines (local or National) exist. It is more specific in terms of addressing whether there had been cyanosis or pallor; not just ‘colour change’, absent or reduced breathing; not just ‘apnoea’, hypo or hypertonia; not just ‘change in tone’. Environment sleeping arrangement, temperature, bedding Potential for accidental ingestion Illness in preceding days? Infants being discharged and stratified as ‘low risk’ should have at least 2 normal observations; on triage and assessment. They will require a period of continuous pulse-oximetry and investigations guided by the history and examination findings and relevant guidelines. Brief Resolved Unexplained Events (Formally Apparent Life-Threatening Events) and evaluation of low risk infants. The majority of the work is carried out by the Paediatric Liaison team and health visitors. It is therefore important to take a thorough history and examine fully, and provide adequate reassurance and explanations. This pathway is discussed on the enrolment visit at the family home, usually when the mum is 34 weeks pregnant.

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In addition, maintenance of a the presentation of hypochondriasis in an infec close alliance with the primary care physician tious disease setting will generally be in the con and consulting mental health provider may help text of excessive fear of a life-threatening to foster a team-based approach to the patient’s infectious disease [64]. Among those seeking treatment for obsessional thinking and hypochondriacal sexually transmitted diseases, there is increased behavior [60]. Patients may also report with con Cardiovascular diseases cerns of parasitic infection, called delusions of Cardiology is one of the clinical settings where parasitosis (see Dermatology), which is some hypochondriacal patients are most likely to times considered to be a psychotic disorder, present and at a relatively low threshold due to a although it conceptually fits well as an example perceived medical emergency. Atypical chest pain patient’s reported symptoms may be innocuous and chest pain without cardiac risk factors for or even absent [67]. Even when no lesions may partially account for their seeking medical were present, patients were concerned regarding consultation [69]. We matologist may apply a combination of benign propose the following clinical approach in the dermatologic therapies. First, empathic confronta bacterial creams for secondary bacterial infec tion of the excessive health-related anxiety is tions). Second, scheduled the dermatologist may prescribe psychiatric med follow-up examinations and the regular use of ications shown to be effective for a variety of dis noninvasive, low-risk procedures. Pimozide and newer second diogram or exercise treadmill test as tolerated) are generation antipsychotics. Antidepressants, sometimes should be shifted to risk reduction and cardiac chosen for their sedative or antihistamine effect rehabilitation. Dermatology Obstetrics & gynecology Studies have estimated the prevalence of psychi Although hypochondriasis is equally prevalent atric comorbidity to be 30–40% in patients among both genders, women reported with dermatological disorders [74,75]. The iety being out of proportion to the objective authors explained that women may have a future science group Treatment options include physical vigilance, leading to increased gynecologic and therapy, Thiele massage, pelvic floor exercise obstetric visits [81]. Women During pregnancy, women have more hypo with vulvodynia have more psychological distress chondriacal fears and conviction of disease than than women with other vulvar pathology. Fear of dying and bodily ment includes surgery, which results in complete preoccupations predominate during the third tri resolution in 72% of women, and pelvic floor mester [82]. The culmination Ophthalmology of these fears results in a fear of childbirth, which In ophthalmologic practice, hypochondriasis may leads women to request elective cesarean section present with a significant conviction of a vision for delivery. Cognitive therapy, group psycho threatening illness, either based on amplified education and relaxation exercises have been response to actual visual or ocular symptoms, or shown to be effective in treating fear of child based on no tangible symptoms [92]. In addition, such a patient may experience tion, intravenous fluid resuscitation and other benign visual and ocular symptoms as heralding psychological treatments, such as hypnosis. Several hypochondriacal concerns arise in the Similarly, a patient with hypochondriacal con gynecological setting. Following the Women’s cern of cataracts may present with obscure visual Health Initiative finding that unopposed estro complaints that he/she is convinced are due to gen-replacement therapy increased the risk of cataracts. Again, full functional assessment and endometrial cancer, a ‘pill scare’ erupted with examination of the crystalline lens may be at patients worrying about increased risk of disease least temporarily assuaging. As with glaucoma, with aging, especially among women with prior reassurance that even in the case of actual cata hysterectomy [202]. In a study of 1142 women ract development, the likelihood of a good surgi undergoing hysterectomy for benign conditions, cal result and good visual function 80% reported ‘a little fear’ and 29% reported ‘a postoperatively may be shared with the hypo lot of fear’ of developing gynecologic cancer chondriacal patient. Another common chondriasis score was associated with fear hypochondriacal fear comes from abnormal regarding having a cataract operation in a cohort Papanicolaou (Pap) smears. Such enced anxiety due to fear of cancer and/or col a patient is likely to present to the clinic with poscopy [87]. Consistent with our general benign complaints of ‘floaters’ and other visual management recommendations, increased symptoms, possibly referable to vitreous and reti patient education regarding Pap smears and col nal pathology. Thorough funduscopic examina poscopy, shorter wait times and mobilization of tion may serve to temporarily ameliorate these social support may help reduce patient anxiety. Other common gynecologic symptoms asso Hypochondriasis regarding the eye can be quite ciated with hypochondriasis include vulvodynia, severe. While there ment may assuage such fears and gentle confron are no established thresholds for the consider tation of the excessive illness concern may be ation of hypochondriasis, we propose that gradually introduced during each subsequent patients with more than three work-ups may be visit. Collaboration with either the primary care screened for hypochondriasis or referred for psy physician and/or a mental health provider is chiatric consultation. The clinician should exam socio not limited to, dizziness, vertigo, epistaxis, hali demographic variables and risk factors for dis tosis, pain, tinnitus, sense that the dental bite is ease. Subjects who well known [100] and age-appropriate factors for complain of tinnitus have more affective inhibi adolescents have been described [101]. If a patient tion, irritability and denial compared with sub is asked and screens positive for a history of sexual jects who can cope positively with the trauma, a psychiatric referral may be the next step symptoms. Therefore, prior to performing a fering presented higher levels of hypochondria, procedure to augment sexual function in males, it disease conviction and dysphoria [98]. Studies are limited in triaging these symptoms There is likely a psychological component in to underlying diagnoses, but it is likely that many patients with sexual complaints, whether mood, anxiety and somatoform disorders are diagnosed with hypochondriasis or not [102]. There is a spectrum between good start is setting a tone in which patients can normal and unhealthy presentation involving share concerns and feel understood, regardless of personality, help-seeking behavior, age and cul the problem or planned work-up. In addition, the presentation may be colored by the course of a true medical illness, Pulmonary medicine particularly if it presents in forme fruste fashion, the literature contains little information which confuses the clinician. This group made very frequent use of a range of Patients with more than three work-ups and a medical services and took a large amount of med negative family history for illnesses in the differ icine. Patients more negative opinion regarding their own with chronic airflow obstruction may have fear, health, despite being less ill. Psychological or psy anxiety or hypochondriasis superimposed on chiatric consultation was suggested as ‘necessary’ true illness [103]. In the latter case, some patients experi use of general treatment approaches (Table 1). Consistent with general matic behavior in the long-term if not principles of treatment (Table 1), sympathetic addressed [104]. Until more studies are per communication and treatment of psychiatric formed regarding hypochondriasis in the pul comorbidities have been recommended [114]. The exact We combined the sections of neurology and causes of hypchondriasis remain unclear but rheumatology as hypochondriasis in these two most likely involve multifactorial etiologies specialties may present similarly, most likely including psychological, social and neuro due to parallels in chronic evolution of symp biological origins. Patients with migraines [105], tension treatment process, use of reassurances, further headaches [106], chronic fatigue syndrome [107] investigations and specific treatments must be and fibromyalgia score higher on scales of hypo carefully selected. Judicious use of reassurance could be help ity, than chronic pain patients or healthy ful in the elderly and those who have suffered controls [108]. Again, the Individuals that seek medical attention for head patient–physician alliance should be utilized to aches score higher on hypochondriacal concerns guide therapy. Hypochondriasis ten Future perspective dencies also weigh heavily on osteoarthritis and As hypochondriasis has been aggravating rheumatoid arthritis severity ratings [110]. On the patients and their physicians since antiquity, it is other hand, scores of hypochondriasis increased unlikely to disappear from the clinical landscape in individuals after they developed low-back in the next 5–10 years. Greater use of noninvasive diag viduals with medically confirmed postpolio syn nostic procedures will allow for more thorough drome also score higher in depressive and evaluations while preserving safety. More pri hypochondriacal symptomatology when com mary consideration of hypochondriasis early in pared with controls without postpolio, but score the workup may allow for earlier treatment and the same on neuropsychological measures of psychiatric consultation. There is a tion for the etiologies of hypochondriasis could lack of specific recommendation for the treat improve educational efforts and the physi ment of hypochondriasis in the neurology and cian–patient alliance. Additional con foreseeable technical advancements, the physi trolled studies will in turn lead to more wide cian will continue to rely on his or her rapport spread adaptation of evidence-based specific with the patient to select the most suitable treatments in various practice settings. Hypochondriasis is a vexing somatoform disorder that most commonly presents in primary care and specialty medical settings in various ways. The primary care and specialty physician should consider consulting with and/or referring to a mental health provider, after establishing a mutual agreement with the patient. American Psychiatric Association: Diagnostic Psychosomatics 39(3), 263–272 (1998). Ferguson E: Hypochondriacal concerns, hypochondriasis: attention-induced Somatosensory Amplification Scale in symptom reporting and secondary gain physical symptoms without sensory general medical and general practice mechanisms. Psychiatry Hypochondriacal concerns: Management controlled study of hypochondriasis. Kellner R: Diagnosis and treatment of Rimer B, Lerman C: Excessive breast self hypochondriasis. Faravelli C, Salvatori S, Galassi F, Aiazzi L, illness behaviours in patients with cancer. Lindberg G, Smout A: Disorders of psychoeducational group approach to Pediatrics 108, E1 (2001).

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We requested and clinicians not offering routine screening and many patients received from the Editorial Board Manager a copy of the not wanting it. The following information addresses search strategies they use for cancer screening literature. Screening should not occur without an informed summaries, we accepted their strategy and results as the decision-making process. Informed decision making tools literature search we would use to update our guideline. The are available on-line from the Centers for Disease Control results available in the online summaries as of June 2010 and Prevention at the site: were used. Our conclusions were based on prospective randomized controlled trials if available, to the exclusion of other data; if Terminating screening. Screening sigmoidoscopy during the measurement year or the four prior and surveillance for early detection of colorectal cancer years, colonoscopy during the measurement year or the nine and adenomatous polyps, 2008. The University of Michigan Health System endorses the Guidelines of the Association of American Medical Colleges and the Standards of the Accreditation Council for Measures of Clinical Performance Continuing Medical Education that the individuals who present educational activities disclose significant National programs that have clinical performance measures relationships with commercial companies whose products or of cancer screening include the following. Screening for and by distribution for comment within departments and Breast Cancer, 2009. General Medicine, General Obstetrics & Gynecology, Breast Oncology, Breast Radiology, Gastroenterology, Gynecology Cervical cancer screening Oncology, and Urology. Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection Acknowledgments of cervical cancer. To provide feedback on its contents or on your experience of using the publication, please email publications. The information in this booklet has been compiled from professional sources, but its accuracy is not guaranteed. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise, without prior permission of the Publishers. This publication may not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in which it is published, without the prior consent of the Publishers. They can be subdivided into those may increase the risk of developing the disease. Anyone who has ever had sexual trimester) are more at risk of getting clear contact including penetrative, anal or oral sex, cell adenocarcinoma vaginal cancer. The reasons for these associations symptoms and are spontaneously cleared by the are as yet unknown. It is usually impossible to identify from whom the virus was initially contracted. It is also not known how long it takes for the virus to cause neoplasia (abnormal tissue growth or tumour), but it is thought to take many years. It is also recommended that they familiarise themselves the national cervical cancer screening with local polices and understand national programme is currently offered to women programmes. The registrant has a professional duty to inform their sample is acquired via cervical screening, which employer if they require training. The examination should Public Health Wales (2017) Cervical take place in a closed room that cannot be Screening Wales; Annual Statistical Report entered while the examination is in progress. Two thirds (70%) of young women don’t think cervical screening reduces a woman’s risk of cervical Chaperones, privacy, cancer (Jo’s Cervical Cancer Trust, 2017b). A health care All women attending for screening should be professional should be alert and sensitive to any offered the option of having a chaperone present issues that the woman may wish to discuss and during any consultation, examination, treatment all advice and information should be accurate, up or care (which may or may not include physical to date and evidence based. Record verbal consent and, if local policy the importance of regular screening checks. Reconsider the need for a chaperone and, if may have learning difficulties or mental health the woman declines, record this. In addition, when caring for women under the When explaining the examination procedure, age of 25 it is important to convey the rational ensure the language used is easily understood for not routinely screening, as this is a recurring and avoid unnecessary jargon. A paper sheet to preserve modesty should be provided to cover the full lower torso. Digital examination may only be necessary to assist in the location of the cervix and not as a means of physical assessment that will aid diagnosis. If it is still not possible to visualise the cervix then the procedure should be abandoned, and Diagram courtesy of referral made to a colposcopy clinic. Explain again what Health care practitioners should always reflect will happen if a result is abnormal and how on their practice and use every opportunity to her care will progress from here. Mention the learn and develop; regular and complete auditing possibility of vaginal bleeding and short-term of practice is considered obligatory. A named person, within each practice/ clinic where cervical samples are taken, should. Experienced information on understanding screening sample takers should also ensure objective peer results and abnormal cells review and critical appraisal of their service The challenge is in identifying those women who have the potential to progress to cancer and Types of cervical cancer those who do not. The staging colposcopist (a registered doctor or nurse trained for cervical cancer is as follows. Stage 0 (pre-cancer) – there are no images can be filed in the woman’s health care cancerous cells in the cervix, but there records for future reference (see Figure 2). Stage 3 – the cancer has spread into the woman will be shown to the examination room lower section of the vagina and/or into and offered assistance to help attain the correct the pelvic wall. Cell removal is preferred over cell destruction as this facilitates histological examination of the area. Destructive techniques are still Treatment options used widely including: laser therapy, cold Treatment for cervical cancer will depend on the coagulation and cryotherapy. Laser or cryotherapy may high-grade dyskaryosis (abnormal changes of also be used and, dependent on the management squamous epithelial cells), will be referred back required, treatment may include radiotherapy for a colposcopy (Fozzard and Greenwood, 2014). Usually, treatments are very effective at Other treatment methods may include cone removing the detected abnormality, with most biopsy and, in rare cases, hysterectomy (or women only needing one treatment before returning to normal cervical screening results. Women should always be offered information in a format suitable to their needs, ensuring a comprehensive understanding of the process. They should actively engage a woman’s participation and confidence in the screening programme, as it will offer peace of mind and a positive public health outlook. Prior to the sample being taken, women should be fully informed of the reason for the procedure and the implications for their future health and wellbeing. A screening test should be taken in such a way as to provide an adequate sample for assessment, with the minimum of distress or discomfort. The importance of action, regular screening and effective follow up cannot be over emphasised – early diagnosis and treatment saves lives, plus reduces stress and anxiety for the woman and her family. Access to services should be local and easily accessible to reduce service barriers that may restrict take-up to the national screening programme. Lichen sclerosis, a long-term skin condition that Chlamydia, a sexually transmitted infection mainly affects the skin of the genitals. Cold coagulation, a procedure to treat women with an abnormality on their cervix by Oncogenic, causing development of a tumour or destroying the abnormal cells through a heated tumours. Papillomas, a small wart-like growth on the Cryotherapy, a treatment that uses extreme cold skin or on a mucous membrane, derived from the to destroy cancer cells. Herd immunity, (also called herd effect, community immunity, population immunity or social immunity) is a form of indirect protection from infectious disease that occurs when a large percentage of a population has become immune to an infection, thereby providing a measure of protection for individuals who are not immune. Online information for the public on the colposcopy Cervical Screening Scotland procedure. The Society represents a common forum for the discussion and debate of all matters pertaining to the prevention of cancer of the cervix. General rights Unless other specific re-use rights are stated the following general rights apply: Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. Cervical screening programs can reduce the incidence by 50%, but are not common in the developing world. In Sweden there are approximately 400 new cases of cervical cancer yearly, despite the existence of a screening program. The aim of this thesis was to analyze the screening history of women with cervical cancer, to find new techniques to screen women for cervical cancer, and to find out why some women do not attend screening.


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