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After 37 months of exposure, the females were mated with untreated males, and dosing was continued throughout breeding and gestation and into the first part of the lactation period. Study end points included numbers of impregnations, live infants, postpartum deaths, abortions, suspected resorptions, stillbirths, and gestation length. On the day of parturition all infants were x-rayed to ascertain osseus development. Body weight, clinical health, hematology, and serum biochemistry were periodically evaluated in the infants and maternal animals during the lactation period, and subsequently in the dams until the infants were 78 weeks old and in the infants until they were 122 weeks old. The offspring were also evaluated for changes in tooth eruption and anthropometric measurements throughout the study, and immunological changes when they were 20 and 60 weeks old. Because this effect occurred in the adult animals that were mated after 37 months of exposure, 0. Exposure during gestation and lactation resulted in both fetal toxicity and postnatal effects in the offspring. Incidence rates for fetal mortality (combined abortions, suspected resorptions, and stillbirths) were 2/11, 5/10, 3/4, 2/6, and 4/5 in impregnated monkeys in the 0, 0. Statistical comparison of the treated and control groups showed that the fetal mortality incidence rates were increased at 0. The precision of this statistical comparison is limited by the small numbers of animals, which obscures the high response rate in the 0. The major clinical signs in the surviving exposed offspring were inflammation and/or enlargement of the tarsal (Meibomian) gland, nail lesions, and gum recession. Although evaluation of the offspring data is complicated by the small number of animals, it is highly relevant that the clinical and immunological effects in the infants are similar to those observed in their chronically exposed dams at the same dose levels as low as 0. As indicated below in the other pertinent information section, clinical health findings (Arnold et al. Interpretation of the adversity of this effect is complicated by a lack of data on immunocompetence and the essentially inconclusive findings in the other tested end points; however, support for the 0. As indicated below in the other pertinent information section, eyelid and toe/finger nail changes were observed in some monkeys at doses as low as 0. Effects in the non-primate species occurred at relatively high doses (generally $4 mg/kg/day) and included decreased thymus and spleen weights in rats, mice, and guinea pigs exposed to Aroclors 1260, 1254, or 1248 (Allen and Abrahamson 1973; Bonnyns and Bastomsky 1976; Smialowicz et al. Additionally, results of studies in infant monkeys are consistent with the data in adults showing immunosuppressive effects of Aroclor 1254 at doses as low as 0. Evaluation of in utero and lactationally exposed offspring from the monkeys in the Tryphonas et al. Statistical analyses found significant increasing dose-related trends in incidence rates, total frequency of observed occurrences and/or onset times for these effects, with some treated and control group comparisons showing significant differences at doses as low as 0. Additionally, monkeys from this study that were mated after 37 months of exposure and continued to be exposed to $0. Conception rate, adjusted for the total number of matings, was significantly lower than controls at 0. Similar results were noted after adjustment for the number of matings with positive sires. The major headings in the Public Health Statement are useful to find specific topics of concern. Chapter 2 Relevance to Public Health the Relevance to Public Health section provides a health effects summary based on evaluations of existing toxicologic, epidemiologic, and toxicokinetic information. This summary is designed to present interpretive, weight-of-evidence discussions for human health endpoints by addressing the following questions. The section covers endpoints in the same order they appear within the Discussion of Health Effects by Route of Exposure section, by route (inhalation, oral, dermal) and within route by effect. In vitro data and data from parenteral routes (intramuscular, intravenous, subcutaneous, etc. If data are located in the scientific literature, a table of genotoxicity information is included. Limitations to existing scientific literature that prevent a satisfactory evaluation of the relevance to public health are identified in the Data Needs section. Each profile reflects a comprehensive and extensive evaluation, summary, and interpretation of available toxicologic and epidemiologic information on a substance. Primary Chapters/Sections of Interest Chapter 1: Public Health Statement: the Public Health Statement can be a useful tool for educating patients about possible exposure to a hazardous substance. Chapter 2: Relevance to Public Health: the Relevance to Public Health Section evaluates, interprets, and assesses the significance of toxicity data to human health.

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Some vegetable oils, such as peanut, corn, sunflower and safflower oils, have a much lower phylloquinone content (1­10 µg/100 g). The great differences between vegetable oils obviously presents problems for calculating the phylloquinone contents of oil-containing foods when the type of oil (or its storage condition) is not known. Menaquinones seem to have a more restricted distribution in the diet than does phylloquinone. In the Western diet nutritionally significant amounts of long-chain menaquinones have been found in animal livers and fermented foods such as cheeses. Yeasts do not synthesise menaquinones and menaquinone-rich foods are those with a bacterial fermentation stage. The Japanese food natto (fermented soybeans) has a menaquinone content even higher than that of phylloquinone in green leafy vegetables. Knowledge of the vitamin K content of human milk has been the subject of methodologic controversies with a 10-fold variation in reported values of phylloquinone concentrations of mature human milk (38). Where milk sampling and analytical techniques have met certain criteria for their validity, the phylloquinone content of mature milk have generally ranged between 1 and 4 µg/l, with average concentrations near the lower end of this range (28, 29, 38). However, there is considerable intra- and inter-subject variation, and levels higher are in colostral milk than in mature milk (28). Menaquinone concentrations in human milk have not been accurately determined but appear to be much lower than those of phylloquinone. Phylloquinone concentrations in infant formula milk range from 3 to 16 µg/l in unsupplemented formulas and up to 100 µg/l in fortified formulas (26). Nowadays most formulas are fortified; typical phylloquinone concentrations are about 50 µg/l. Bio-availability of vitamin K from foods Very little is known about the bio-availability of the K vitamins from different foods. It has been estimated that the efficiency of absorption of phylloquinone from boiled spinach (eaten with butter) is no greater than 10 percent (39) compared with an estimated 80 percent when phylloquinone is given in its free form (10, 11). This poor absorption of phylloquinone from green leafy vegetables may be explained by its location in chloroplasts and tight association with the thylakoid membrane, where this naphthoquinone plays a role in photosynthesis. The poor extraction of phylloquinone from leafy vegetables, which as a category represents the single greatest food source of phylloquinone, may place a different perspective on the relative importance of other foods with lower concentrations of phylloquinone. No data exist on the efficiency of intestinal absorption of dietary long-chain menaquinones. Because the lipophilic properties of menaquinones are greater than those of phylloquinone, it is likely that the efficiency of their absorption, in the free form, is low, as suggested by animal studies (18, 21). Importance of intestinal bacterial synthesis as a source of vitamin K Intestinal microflora synthesise large amounts of menaquinones, which are potentially available as a source of vitamin K (42). Quantitative measurements at different sites of the human intestine have demonstrated that most of these menaquinones are present in the distal colon (42). The most promising site of absorption is the terminal ileum, where there are some menaquinone-producing bacteria as well as bile salts. The evidence overall suggests that the bio-availability of bacterial menaquinones is poor because they are mostly tightly bound to the bacterial cytoplasmic membrane and the largest pool is present in the colon, which lacks bile salts for their solubilisation (19, 23). Evidence on which recommendations can be based Assessment of vitamin K status Conventional coagulation assays are useful for detecting overt vitamin K-deficient states which are associated with a risk of bleeding. However, they offer only a relatively insensitive insight into vitamin K nutritional status and the detection of sub-clinical vitamin K-deficient states. A more sensitive measure of vitamin K sufficiency can be obtained from tests that detect under-carboxylated species of vitamin K-dependent proteins. In states of vitamin K deficiency, under-carboxylated species of the vitamin K-dependent coagulation proteins are released from the liver into the blood; their levels increase with the degree of severity of vitamin K deficiency. Other criteria of vitamin K sufficiency that have been used are plasma measurements of phylloquinone and the measurement of urinary Gla. It is expected and found that the excretion of urinary Gla is decreased in vitamin K deficiency. Dietary intakes in infants and their adequacy the average intake of phylloquinone in infants fed human milk during the first 6 months of life has been reported to be less than 1 µg/day; this is approximately 100-fold lower than the intake in infants fed a typical supplemented formula (29). Factors of relevance to classical vitamin K deficiency bleeding the liver stores of vitamin K in the newborn infant differ both qualitatively and quantitatively from that in adults. First, phylloquinone levels at birth are about one-fifth those in adults and second, bacterial menaquinones are undetectable (14). The resistance to placental transport of vitamin K to the human foetus is well-established (19, 22).

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If the opacity is still moving or floating, it is located within the vitreous (eg, small hemorrhage). If it is stationary, it is probably in the lens (eg, focal cataract) or on the cornea (eg, scar). Fundus Examination 90 the primary value of the direct ophthalmoscope is in examination of the fundus (Figure 2­11). The view may be impaired by cloudy ocular media, such as a cataract, or by a small pupil. Darkening the room usually causes enough natural pupillary dilation to allow evaluation of the central fundus, including the disk, the macula, and the proximal retinal vasculature. Pharmacologically dilating the pupil greatly enhances the view and permits a more extensive examination of the peripheral retina. If the pupil is 91 well dilated, the large spot size of light affords the widest area of illumination. For this reason, the smaller spot size of light is usually better for undilated pupils. As the patient fixates on a distant target with the opposite eye, the examiner first brings retinal details into sharp focus. Since the retinal vessels all arise from the disk, the latter is located by following any major vascular branch back to this common origin. The width of the central cup divided by the width of the disk is the "cup-to-disk ratio. The normal disk tissue is compressed into a peripheral thin rim surrounding a huge pale cup. This is surrounded by a more darkly pigmented and poorly circumscribed area called the foveola. The retinal vascular branches approach from all sides but stop short of the foveola. Thus, its location can be confirmed by the focal absence of retinal vessels or by asking the patient to stare directly into the light. They are examined and followed as far distally as possible in each of the four quadrants (superior, inferior, temporal, and nasal). The veins are darker and wider than their paired arteries (anatomically arterioles). The vessels are examined for color, tortuosity, and caliber, as well as for associated abnormalities, such as aneurysms, hemorrhages, or exudates. The green "redfree" filter assists in the examination of the retinal vasculature and the subtle striations of the nerve fiber layer as they course toward the disk (see Chapter 14). To examine the retinal periphery, which is greatly enhanced by dilating the pupil, the patient is asked to look in the direction of the quadrant to be examined. Thus, the temporal retina of the right eye is seen when the patient looks to the right, while the superior retina is seen when the patient looks up. Since it requires wide pupillary dilation and is difficult to learn, this technique is used primarily by ophthalmologists. As with direct ophthalmoscopy, the patient is told to look in the direction of the quadrant being examined. Using the preset head-mounted ophthalmoscope lenses, the examiner can then "focus on" and visualize this midair image of the retina. Comparison of Indirect & Direct Ophthalmoscopy Indirect ophthalmoscopy is so called because one is viewing an "image" of the retina formed by a hand-held "condensing lens. Compared with the direct ophthalmoscope (15Ч magnification), indirect ophthalmoscopy provides a much wider field of view (Figure 2­16) with less overall magnification (approximately 3. Thus, it presents a wide panoramic fundus view from which specific areas can be selectively studied under higher magnification using either the direct ophthalmoscope or the slitlamp with special auxiliary lenses. Comparison of view within the same fundus using the indirect ophthalmoscope (A) and the direct ophthalmoscope (B). The field of view with the latter is approximately 10°, compared with approximately 37° using the indirect ophthalmoscope. One is the brighter light source that permits much better visualization through cloudy media. A second advantage is that by using both eyes, the examiner enjoys a stereoscopic view, allowing visualization of elevated masses or retinal detachment in three dimensions.

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A new method of repairing type I endoleaks for thoracic aortic aneurysms was successfully performed using the T-Fix system. These injections have been reported to relieve coccydynia (tailbone pain), as well as other malignant and nonmalignant pelvic pain syndromes. A variety of techniques have been previously described for blocking this sympathetic nerve ganglion, which is located in the retrorectal space just anterior to the upper coccygeal segments. Prior techniques have included approaches through the anococcygeal ligament, through the sacrococcygeal joint, and through intracoccygeal joint spaces. This article presents a new, paracoccygeal approach whereby the needle is inserted alongside the coccyx and the needle is guided through three discrete steps with a rotating or corkscrew trajectory. Compared with some of the previously published techniques, this paracoccygeal corkscrew approach has multiple potential benefits, including ease of fluoroscopic guidance using the lateral view, ability to easily use a stylet for the spinal needle, and use of a shorter, thinner needle. While no single technique works best for all patients and each technique has potential advantages and disadvantages, this new technique adds to the available options. Simple and effective local anesthesia for transperineal extended prostate biopsy: application to threedimensional 26-core biopsy. Source Department of Urology, Tokyo Medical and Dental University, Graduate School, Tokyo, Japan. At first, a periapical triangle, confined by the levator ani, the rhabdosphincter and the external anal sphincter muscle, was made visible by transrectal ultrasound. Efficacy of peritubal local anesthetic infiltration in alleviating postoperative pain in percutaneous nephrolithotomy. However, the patient complains of pain around the nephrostomy tube and demands for good postoperative analgesia. Skin infiltration with bupivacaine around the nephrostomy tube is not effective, so we hypothesize that peritubal infiltration of bupivacaine from renal capsule to the skin along the nephrostomy tract may alleviate postoperative pain. Postoperative pain score and analgesic requirement for the first 24 hours were assessed by visual and dynamic visual analog scales second hourly. Rescue analgesia with injection tramadol Hcl 50-100 mg was given intravenously to a maximum total dose of 400 mg when pain score exceeded 4. This was preceded by a bolus of room temperature sterile water (10 ml) injected through a 26G curved spinal needle into the exit foramen and adjacent epidural space for neuroprotection. The age of the patient, sex, lesion location, biopsy results and complications were recorded. There was an 85% clinical success rate (6 of the 7 patients), with recurrence of a lesion at 6 months, necessitating a repeat procedure (successful). One procedure described in the literature is a transorbital approach performed using a spinal needle. Because past publications have been case reports with minimal definition of external landmarks, the present study was performed. This approach was performed following an axial section through the cranium that exposed the lateral ventricular system. Landmarks for the ideal placement of catheters into the ventricular system were then evaluated. Such refined landmarks as described in the present study may be of use to the neurosurgeon. Arthroscopic aspiration and labral repair for treatment of spinoglenoid notch cysts. In an attempt to limit potential suprascapular nerve injury during arthroscopic excision, we have used a technique of arthroscopic cyst aspiration followed by labral repair. Routine glenohumeral arthroscopy is performed in preparation for superior labral repair. A 17-gauge spinal needle is then inserted 1 cm lateral to the posterior portal directed just lateral to the labrum in the region of the cyst (usually posterior-superior quadrant of glenoid). The cyst material is aspirated (commonly 5-15 mL), and the labral tear is repaired without violating the glenohumeral capsule. For all 4 patients described in this report, magnetic resonance imaging showed complete cyst resolution at a minimum of 6 months after surgery. Cyst aspiration followed by labral repair limits the potential for nerve injury while increasing the likelihood of complete cyst resolution during arthroscopic treatment of spinoglenoid notch cysts.

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The table in Appendix 4 describes the terms used in Rohingya/Ruбingga to describe a core set of psychological and emotional reactions to adversity and potentially traumatic events. Drawing on extensive ethnographic research conducted with the Rohingya in Bangladesh and Malaysia, we identified a wide array of indigenously salient terms that Rohingya commonly use to describe their Review emotions and distress in general and specifically related to psychological trauma. In qualitative interviews conducted with 20 Rohingya informants and focus group participants living in Malaysia, symptoms of internal avoidance (such as avoiding distressing thoughts and feelings) and external avoidance (in the form of social detachment, avoiding people, places, and activities when feeling upset) (ba-ci-ta-kon or doray ta-kon) were described and recognized by all participants as a way to mitigate stress and mental distress. Words commonly used by the Rohingya people to describe symptoms of depression include monmora or cinta lager (feeling sad), mon horaf lager or dil hous kous lager (feeling low mood), chhoit lager (not feeling well, losing interest in things, and restless mind), and gaa cisciyaar or gaa bish lager (pain in the body) and gaa zoler or gaa furer (burning sensation in the body). The terms dishahara, hatfau aridiya, and maayus are also used to describe depression and hopelessness, as is a feeling of suffocation, or unniyashi lager. These locally recognized terms can correspond to the psychovegetative and somatic symptoms associated with major depressive disorder. These self-described suicide plans mirrored information from informal key informant interviews with primary health care staff in Kutupalong and Nayapara camps on prior suicide attempts they were aware of. Individuals who reported these syndromes also reported visual or auditory hallucinations and delusional ideas. Appendix 5 presents Rohingya terminology related to severe mental disorders including words indicating psychosis (foul and matбhorбf) and manic states (demag-chуut/horбf, soudou) and arsu-khasu. Thoughts about suicide are reportedly common among Rohingya in Myanmar and Bangladesh and are linked to a strong sense of hopelessness regarding their situation, the lack of prospects for the future, and the loss of identity [90, 151]. As suicide is strongly condemned in Islam, Rohingya will often hide these ideas out of shame and fear for being judged. Field workers in Myanmar reported that Rohingya women with suicidal ideation told them that when they disclosed their thoughts to their friends and family, the reaction was often judgmental (being told that they would go to hell) which further increased their agony and shame. Appendix 6 summarizes Rohingya terminology related to intellectual and developmental disabilities. In these cases, according to the Quran, the traditional belief is that the person is under possession by supernatural forces or sprits (Gin e payee or challan utty). Other common Rohingya terms (and synonyms) used to describe physical manifestations of seizures include khйzani, dourrforani (convulsion), atikkya-bйhouсj, haaf-chuзa, hafani, demagi, haaf/chуit (epileptic fit) and kйzarai or asa-hasn. Malignant spirits are attracted to dirt and since menstruation blood is considered dirty, a woman is considered particularly vulnerable to attacks by jinn during menstruation, during delivery and the forty days after delivery. Rohingya people usually do not seek medical or psychological treatment if they believe a person is possessed by a spirit but approach traditional healers who perform traditional rituals, religious practices and prayers. In a clinical context, a culturally informed assessment with a basic understanding of the explanatory models of illness and relevant cultural practices is needed to enable clinicians to distinguish jinn possession from psychotic presentation or epileptic seizures particularly in the Rohingya people. In 2013 survey among Rohingya refugees in Bangladesh the respondents indicated that they were feeling or believing that they were under a spell (10%), possessed by a bad spirit or demon (10%), or that they were controlled by an unidentified black shadow or black magic (6%) [90]. Koro-like syndrome Koro is a cultural syndrome in parts of Asia involving the belief that there is shrinking of the male genitals into the abdomen which is thought to ultimately result in death [154]. Koro-like symptoms have been recorded in a case report of a Rohingya male refugee in Malaysia, who presented with major depressive disorder accentuated by extreme feelings of religious guilt [155]. Spirit possession A prevailing folk diagnosis is possession by a spirit (jinn in Arabic and fawri in Rohingya) or ghost (saysee). Jinn are supernatural creatures (made of fire) capable of metamorphosing into human, ghost, or animal appearances. In traditional Islamic folklore and the Quranic literature [156], individuals possessed by the jinn are frequently seen as acting erratically, experiencing visual hallucinations and paranoid delusions. Jinn possession is widely described in clinical observations amongst Muslim patients [156, 157]. Both benign and malignant sprits are thought to be active at night and exist in different locations. Benign spirits are thought to be found in Islamic sacred religious places such as mosques. Malignant spirits are believed to manifest themselves especially in remote areas, rivers, latrines, Review 31 Figure 1. A schematic diagram of an explanatory model of psychological idioms of distress among Rohingya refugees affected by mass violence and displacement (adapted from Tay et al. These constituent components represent concrete aspects of the person (the brain and the body) and abstract aspects (the mind and the soul) and together they provide important insights into how mental health and psychosocial problems are expressed and understood in the Rohingya context. Most Rohingya have limited familiarity with international concepts of mental health and may express terms related to the mind-soul in ways that mental health practitioners find confusing. Traditional practices, however, are increasingly difficult to observe for Rohingya in Myanmar due to restricted freedom of movement and lack of available religious services.

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Treatment of ocular surface myiasis is by mechanical removal of the larvae after topical anesthesia. In most cases, there is a history of allergy to pollens, grasses, animal danders, or other allergens. The patient complains of itching, tearing, and redness of the eyes and often states that the eyes seem to be "sinking into the surrounding tissue. There may be a small amount of ropy discharge, especially if the patient has been rubbing the eyes. Treatment consists of the instillation of topical preparations, such as emedastine and levocabastine, which are antihistamines; cromolyn, lodoxamide, nedocromil, and pemirolast, which are mast cell stabilizers; alcaftadine, azelastine, bepotastine, epinastine, ketotifen, and olopatadine, which are combined antihistamines and mast cell stabilizers; and diclofenac, flurbiprofen, indomethacin, ketorolac, and nepafenac, which are nonsteroidal antiinflammatory drugs (see Chapter 22). Mast cell stabilization takes longer to act than antihistamine and nonsteroidal anti-inflammatory effects but is useful for prophylaxis. Topical vasoconstrictors, such as ephedrine, naphazoline, tetrahydrozoline, and phenylephrine, alone or in combination with antihistamines such as antazoline and pheniramine, are available as over-the-counter medications but are of limited efficacy in allergic eye disease and may produce rebound hyperemia and follicular conjunctivitis. Cold compresses are helpful to 227 relieve itching, and antihistamines by mouth, such as loratadine 10 mg daily, are of some value. The immediate response to treatment is satisfactory, but recurrences are common unless the antigen is eliminated. Fortunately, the frequency of the attacks and the severity of the symptoms tend to moderate as the patient ages. The specific allergen or allergens are difficult to identify, but patients with vernal keratoconjunctivitis usually show other manifestations of allergy known to be related to grass pollen sensitivity. The disease is less common in temperate than in warm climates and is almost nonexistent in cold climates. It is almost always more severe during the spring, summer, and fall than in the winter. There is often a family history of allergy (hay fever, eczema, etc), and sometimes, there is a history of allergy in the young patient as well. The conjunctiva has a milky appearance with many fine papillae in the lower palpebral conjunctiva. The upper palpebral conjunctiva often has giant papillae that give a cobblestone appearance (Figure 5­10). Each giant papilla is polygonal, has a flat top, and contains tufts of capillaries. A stringy conjunctival discharge and a fine, fibrinous pseudomembrane (Maxwell-Lyons sign) may be noted, especially on the upper tarsus on exposure 228 to heat. In some cases, especially in persons of black African ancestry, the most prominent lesions are located at the limbus, where gelatinous swellings (papillae) are noted (Figure 5­11). A pseudogerontoxon (arcus-like haze) is often noted in the cornea adjacent to the limbal papillae. Conjunctival scarring usually does not occur unless the patient has been treated with cryotherapy, surgical removal of the papillae, irradiation, or other damaging procedure. Superficial corneal ("shield") ulcers (oval and located superiorly) may form and may be followed by mild corneal scarring. Treatment Since vernal keratoconjunctivitis is a self-limited disease, it must be recognized that the medication used to treat the symptoms may provide short-term benefit but long-term harm. Topical and systemic corticosteroids, which relieve the itching, affect the corneal disease only minimally, and their side effects (glaucoma, cataract, and other complications) can be severely damaging. Newer mast cell stabilizer­antihistamine combinations, such as epinastine, ketotifen, 229 and olopatadine (see Chapter 22) are useful prophylactic and therapeutic agents in moderate to severe cases. Vasoconstrictors, cold compresses, and ice packs are helpful, and sleeping (and, if possible, working) in cool, air-conditioned rooms can keep the patient reasonably comfortable. Patients able to do so benefit from a marked reduction in symptoms, if not a complete cure. The acute symptoms of an extremely photophobic patient who is unable to function can often be relieved by a short course of topical or systemic corticosteroids followed by vasoconstrictors, cold packs, and regular use of histamine-blocking eye drops. Topical nonsteroidal anti-inflammatory agents, such as ketorolac, mast cell stabilizers, such as lodoxamide, and topical antihistamines (see Chapter 22) may provide significant symptomatic relief but may slow the reepithelialization of a shield ulcer.

Syndromes

  • Alkalosis
  • Itching
  • How bad is it?
  • Nausea
  • Hypertelorism (abnormally wide space between the eyes)
  • CT scan to look at the bones in the foot
  • Does the swelling appear to be fluid?
  • Gas
  • Imaging tests, such as an MRI or CAT scan of the brain or neck

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Specific recommendations and grades of recommendations were made on the basis of published results and determined by the Levels of Evidence (4). Consensus of the committee determined the recommendations, which are found at the end of the chapter. Using conservative estimates from the literature, it is calculated that over 5,000 men will require treatment each year for post-prostatectomy strictures of the posterior urethra and bladder neck. Thus, further investigations are needed to understand the pathogenesis of post-prostatectomy stricture so that preventive measures can be introduced. Clinical risk factors include urinary extravasation, increased blood loss, current cigarette smoking, older age, and obesity (5­19). These factors may reflect poor wound healing and/or poor visualization during the vesico-urethral anastomosis, impairing epithelial-to-epithelial apposition. Both temporal reports of single surgeon experience and cross-sectional reports of Medicare data have shown contracture rates to be lower with increased case volume. Proposed mechanisms include anastomotic tension, inflammation from urinary extravasation, poor tissue handling, and ischemia. Treating acute post-operative urinary retention with a suprapubic rather than a trans-urethral catheter has been mentioned as another risk factor (18). This has occurred with acceptable acute toxicity (< 90 days post-radiotherapy) and shortterm adverse effects (90 days­5 years); however, the long-term adverse effects have been poorly documented. As a result, the general consensus is that patients with localized prostate cancer should receive at least 74 Gy (42). A high dose is administered to the prostate itself, with rapid dose fall-off beyond the gland. This not only serves to focus the dose to the prostate gland itself, but also protects surrounding adjacent tissue, including the urethra. The radiation dose from a permanent seed implant is delivered over months as the isotope decays. For iodine-125, with a half-life of 60 days, this results in a maximal dose rate of about 10 cGy/h. Given the degree of fall-off, the additional radiation is thought to treat any potential extra-capsular extension. The greatest advantage is optimizing dose distribution by varying source dwell times along the catheters. Similar trends were noted in a 2010 study evaluating patients with low-risk disease in the British Association of Urological Surgeons Cancer Registry (43). After a median follow-up of 5 years, they reported a 9% rate of urethral stenosis development. Cumulative Stricture Incidence Figure 2 Actuarial cumulative survival rate of diagnosis of bulbomembranous urethral stricture, according to the brachytherapy technique (67). This has occurred with acceptable acute toxicity (< 90 days post-radiotherapy) and short-term adverse effects (90 days­5 years); however, the long-term adverse effects have been poorly documented. Older age was not found to be a significant risk factor in the series of Pellizon et al. Most strictures occur at the membranous urethra, and early investigators noted the risk to be related to the dose delivered to the apex of the prostate (63,81,82). Others have countered that apical dose does not matter; however, a close read of more recent series demonstrates their apical dose to be much lower than in earlier series (48,51). The risk can be reduced with careful attention to technique and urethral dose, as well as patient selection. Figure 4 Actuarial cumulative rate of diagnosis of bulbomembranous urethral stricture divided by the presence or absence of a history of hypertension (A), or trans-urethral resection of the prostate (B) (67). The a value is related to unrepairable damage in cells, while the b value is related to repairable damage. A low a:b ratio implies more radioresistance, but this does not directly explain the site of the stricture being substantially inferior to the high-radiation dose area. One explanation for this may be needle slippage, with some centres reporting up to 20 mm of caudal movement of catheters between fractions (46,96­98).

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Product Name: Lithobid (brand only) [a] Approval Length Therapy Stage Guideline Type 12 month(s) Reauthorization Prior Authorization Approval Criteria 1 - Documentation of positive clinical response to therapy Notes [a] State mandates may apply. Indications Drug Name: Lokelma (sodium zirconium cyclosilicate), Veltassa (patiromer) Hyperkalemia Indicated for the treatment of hyperkalemia. Use of automated approval and re-approval processes varies by program and/or therapeutic class · Supply limits may be in place Background: Lokelma and Veltassa are indicated for the treatment of hyperkalemia. Lokelma and Veltassa should not be used as an emergency treatment for life threatening hyperkalemia because of its delayed onset of action. Non-emergent hyperkalemia is generally treated by addressing the reversible causes, such as removing drugs that may be causing impaired renal function, removing or adjusting medications that directly cause hyperkalemia, and initiating therapies for potassium removal. Managing hyperkalemia caused by inhibitors of the renin-angiotensinaldosterone system. Authorization will be issued for 24 months up to the dose allowed by s upply limit review (please refer to supply limit criteria). Product Name: [morphine sulfate controlled-release capsules (generic Avinza), Duragesic^, fentanyl transdermal patch (37. Any federal regulatory requirements an d the patient specific benefit plan coverage may also impact coverage criteria. Pain is moderate to severe and expected to persist for an extended period of time (chronic). Authorization will be issued for 6 months for non-cancer and non-end of life pain up to the dose allowed by supply limit review (please refer t o supply limit criteria). Before starting opioid therapy, treatment goals should be established with patients that include realistic goals for pain and function and should consider how therapy will be discontinued if benefits do not outweigh risks. Continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. When starting opioid therapy for chronic pain, clinicians should prescribe immediaterelease opioids instead of extended release/long-acting opioids. To avoid increased risk of respiratory depression, long-acting opioids should not be prescribed concurrently with benzodiazepines. Use a patient treatment agreement, signed by both the patient and prescriber that addresses risks of use and responsibilities of the patient. Clinicians should evaluate benefits and harms of continued therapy at least every 3 months. Long-acting opioids are not indicated for pain in the immediate postoperative period (the first Page 426 12-24 hours following surgery), or if the pain is mild, or not expected to persist for an extended period of time. They are only indicated for postoperative use if the patient is already receiving the drug prior to surgery or if the postoperative pain is expected to be moderate to severe and persist for an extended period of time. Physicians should individualize treatment, moving from parenteral to oral analgesics as appropriate. Physicians should individualize treatment in every case, initiating therapy at the appropriate point along a progression from non-opioid analgesics, such as non-steroidal anti-inflammatory drugs and acetaminophen to opioids in a plan of pain management such as those outlined by the World Health Organization, the Agency for Healthcare Research and Quality, the Federation of State Medical Boards Model Guidelines, or the American Pain Society. Standardizing the use of mental health screening instruments in patients with pain. Revision History Date 7/20/2021 Notes 5/2021 P&T - Removed products no longer on the market. Added requirements for documentation of treatment g oals and screening for underlying depression and anxiety. Criteria Product Name: Lonhala Magnair * [a] Approval Length Therapy Stage 12 month(s) Initial Authorization Page 429 Guideline Type Prior Authorization Approval Criteria 1 - All of the following: 1. Any federal regulatory requirements an d the member specific benefit plan coverage may also impact coverage Page 430 criteria. Notes Product Name: Lonhala Magnair*, Yupelri [a] Approval Length 12 month(s) Page 431 Therapy Stage Guideline Type Reauthorization Prior Authorization Approval Criteria 1 - Documentation of positive clinical response to therapy Notes [a] State mandates may apply. Revision History Date 12/21/2020 Notes Updated criteria/formatting for Lonhala Magnair to clarify that patient m ust meet diagnosis requirement, as well as have a hx of failure, contrai ndication or intolerance to the metered dose inhalers. Product Name: Lotronex* Approval Length Therapy Stage Guideline Type 12 month(s) Reauthorization Prior Authorization Approval Criteria 1 - Lotronex will be approved based on documentation of positive clinical response to Lotronex therapy Notes *Brand Lotronex is typically excluded from coverage.

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Since urine and bile are the major excretory routes for pyrethrin and pyrethroid metabolites, kidney and/or liver disease are likely to delay elimination of metabolites from the body. However, no studies were located in which metabolites of pyrethrins or pyrethroids were shown to exert toxic effects in humans or animals. Young animals may be more susceptible during stages when enzymes responsible for metabolizing absorbed pyrethroids are not fully developed (Cantalamessa 1993) or during critical stages of neonatal brain development (Ahlbom et al. A predisposition for asthma may contribute to pyrethrin- or pyrethroid-induced respiratory effects. Allergic reactions have been observed in a few individuals following exposure to products that contain pyrethrins or pyrethroids. However, such responses may be due, at least in part, to "inert ingredients" in such products. However, because some of the treatments discussed may be experimental and unproven, this section should not be used as a guide for treatment of exposures to pyrethrins. There is little information regarding the degree of absorption following inhalation exposure to pyrethrins or pyrethroids, although it is presumed that absorption will occur via diffusion across lipid membranes. However, there is no known effective way to reduce absorption following inhalation exposure to pyrethrins or pyrethroids. Pyrethrins and pyrethroids are rapidly absorbed following oral exposure and it is presumed that absorption occurs across the intestinal mucosa via diffusion. There is, however, very little information available regarding the rate or extent of absorption following oral administration in humans. Use of lavage and activated charcoal would likely result in reduced absorption following oral exposure, and charcoal may aid in removing compounds undergoing enterohepatic recirculation. It is also presumed that some absorption could occur in the mouth and stomach and, therefore, mouth rinsing may modestly contribute to decreasing absorption following oral exposure. Pyrethrins and pyrethroids are not well absorbed following dermal exposure, but limited absorption through the skin does occur. No information was located regarding the effectiveness of various methods intended to reduce peak absorption of pyrethrins or pyrethroids following exposure. Pyrethrins and pyrethroids are substantially detoxified through biotransformation reactions catalyzed by microsomal enzymes, although the specific enzymes involved have not been identified. It is anticipated that the body burden would be reduced more quickly if these enzymes are induced; however, until the specific enzymes involved are identified, it is not possible to specify protocols to reduce the body burden of pyrethrins or pyrethroids through induction of microsomal enzymes. Metabolites of pyrethrins and pyrethroids are excreted in urine and bile, but no specific information is available regarding the renal or hepatic handling of these metabolites. Increased fluid consumption, which increases the rate of urine production and excretion, may help to decrease the body burden of pyrethroid metabolites since they are water soluble and excreted in the urine. Activated charcoal might aid in removing pyrethrins or pyrethroids undergoing enterohepatic circulation. However, since pyrethrins and pyrethroids are rapidly metabolized by mammalian detoxification systems, such methods for reducing body burden might not effectively shorten the time during which pyrethrins and pyrethroids exert their toxic effects. Anticonvulsant drugs have varying degrees of therapeutic efficacy in various animal species treated with a variety of pyrethroids, and may not be regarded as specific antidotes for pyrethroid poisoning in general (Vijverberg and van den Bercken 1990). Atropine appears to be effective in reducing pyrethroid-induced effects such as salivation and choreoathetosis in animals (Ray and Cremer 1979). Agents such as ivermectin and pentobarbitone, which act as agonists at chloride channels, have been shown to reduce salivation and choreoathetosis, respectively, in animals (Forshaw and Ray 1997). Dermal applications of Vitamin E and local anesthetic creams have effectively reduced symptoms of paresthesia following dermal exposure to pyrethroids (Flannigan et al. The purpose of this figure is to illustrate the existing information concerning the health effects of pyrethrins and pyrethroids. Each dot in the figure indicates that one or more studies provide information associated with that particular effect. Available data regarding health effects in humans exposed to pyrethrins or pyrethroids largely concern occupational exposure during crop applications in which exposure was considered to have occurred primarily via dermal contact, although inhalation exposure could not be ruled out.

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Occult the initial lesion is a small area of alopecia that develops a crusted surface. Nodular Encapsulated discrete masses are contained within the dermis/epidermis (Figure 15. Distribution Sarcoids can be found on any part of the body; however, they are common around the head (particularly the verrucose type), eyes, groin, ventral midline and axilla. A biopsy can trigger further growth and should be avoided when a sarcoid is suspected. If the lesion is small and interfering with a harness, surgical excision is possible. There has been a varied success rate, and there is a small risk of anaphylactic shock (Knottenbelt et al. Sarcoids of the limbs and axilla are more difficult to treat and have a high recurrence rate. An abscess is an accumulation of white blood cells (predominantly neutrophils) in response either to an infectious process or to a foreign body. Lance with a scalpel blade in a vertical line from the centre to the most ventral part. Antibiotics are not a substitute for drainage and irrigation, and are not usually indicated unless there is evidence of systemic infection. Flushing to be continued, daily for 5 days, by the owner to ensure drainage continues. Hernias and ruptures A hernia is a swelling due to mesenteric fat and intestines protruding through a congenital opening in the body wall muscle (umbilical, inguinal). A rupture is a swelling due to mesenteric fat and intestines protruding through an acquired opening in the body wall muscle (accidents, trauma). If a rupture is suspected, bandaging may help to retain intestines within the abdomen while the defect heals. Surgical repair of ruptures and large hernias cannot be recommended in field conditions as there is high risk of wound breakdown and peritonitis. An imbricating suture pattern is used to draw one muscle layer over the top of the other. It is essential that hernias and ruptures are differentiated from an abscess prior to attempts to drain the latter. Haematoma A blunt trauma (fall/kick) ruptures small blood vessels under the skin, causing subcutaneous bleeding. This blood clots forming a lump over the next few days which eventually fibroses and shrinks to a small hard mass. Seromas present as a fluid-filled mass in the vicinity of a surgical incision or site of trauma. Treatment Remove one or two ventral sutures and allow to drain, or take out all sutures and allow to heal as an open wound. Drainage of a closed seroma is not worthwhile as the fluid will continue to accumulate. When suturing a wound ensure that the dead space is closed down by using a multi-layered closure. Distribution depends on the underlying cause although it is seen most often in dependent areas such as the ventral abdomen/chest, sheath and lower limbs (Figure 15. Generally, the swelling is diffuse and an indentation is left when the oedema is pressed (pitting). Causes Localised circulatory disturbances Lower-limb swelling due to standing for long periods Poor venous circulation and lymphatic drainage Unsuitable bandaging methods Major circulatory disturbances such as heart failure Hypo-proteinaemia as the result of liver disease, parasitism or malnutrition Inflammation of vessels which increases permeability to fluid Figure 15. Generalised oedema will require a thorough clinical examination for signs of underlying systemic disease or other causes of low blood protein. Cellulitis Cellulitis is an inflammation of the subcutaneous tissue, often associated with infection. Recommended protocol for treatment of cellulitis If microbial culture is available, a swab or aspirate of the fluid should be collected. Penicillin alone may be ineffective in 60% of cellulitis cases (Haggett and Wilson 2008, Fjordbakk et al. Skin diseases characterised by crusting and ulcerative lesions Sunburn and photosensitisation Sunburn is primary direct damage to the epidermis by intense ultraviolet light. Damage tends to be to non-pigmented skin which is more sensitive to the harmful rays.

References:

  • https://www.health.state.mn.us/communities/environment/risk/docs/guidance/cleaners.pdf
  • http://www.imm.org/Reports/rep048.pdf
  • https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/bariatric-surgery.pdf
  • https://bronchoscopy.org/wp-content/uploads/The-Essential-Intensivist-Bronchoscopist.pdf