Biaxin

Jessica Berrios, MD

• Department of Emergency Medicine
• Nassau University Medical Center
• East Meadow, New York

The diversity benefit: How does diversity among health professionals address public needs Department of Health and Human Services gastritis symptoms remedy purchase biaxin mastercard, Health Resources and Services Administration gastritis diet ëàéâ discount biaxin 500mg amex. National standards for culturally and linguistically appropriate services in health care: Final report gastritis symptoms of purchase generic biaxin on-line. Program evaluation for organizational cultural competence in mental health practices chronic gastritis shortness of breath order biaxin with a visa. Ongoing education and staff training ensures that governance gastritis duodenitis buy generic biaxin 250mg online, leadership gastritis loss of appetite buy biaxin 250 mg line, and the workforce are equipped with adequate knowledge, tools, and skills to appropriately manage cross-cultural encounters with individuals (Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003). For example, health profession students should learn about culturally specific information regarding disease incidence and prevalence or the effect of current and historical events on certain groupsinteractions with the health and health care system (Betancourt et al. In addition, training of governance, leadership, and workforce could include review of, and emphasis on, honing existing communication or other related skills necessary to work effectively in cross-cultural encounters. For training, a knowledge-based, skill-based, or attitude-based approach should be adopted, based upon the needs and weaknesses of the organization, with the goal of ensuring the success of the training (Rose, 2011). Specific topics for training should be based on the responsibilities of each member of the workforce, leadership, or governance. Thus, training must be accompanied by coordinated initiatives to support data collection, performance improvement, and accountability. Curriculum for culturally responsive health care: the step-by-step guide for cultural competence training. Training and continuing education online: Health literacy for public health professionals (web based) [Online training course summary]. Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Components of the Standard Offer Language Assistance Language assistance services are mechanisms used to facilitate communication with individuals who do not speak English, those who have limited English proficiency, and those who are deaf or hard of hearing. By facilitating conversations regarding prevention, symptoms, diagnosis, treatment, and other issues, language assistance improves the quality of services and patient safety. Language assistance services may be required by law for organizations that receive federal funds. In 2000, the President signed Executive Order 13166, which requires all federal agencies, as well as all recipients of federal financial assistance, to take reasonable steps to ensure meaningful access for limited English proficient persons to the services and care provided by their agency or organization (Executive Order no. Interpretation and translation can be delivered through a variety of means, depending upon the setting and the services being delivered. The following table compares and contrasts the acts of interpreting and translating. As with all culturally and linguistically appropriate services, it is important to monitor the quality and utilization of services. Table 3: Interpreting and Translating Question Interpreting Translating Interpreting overcomes language barriers Translating allows individuals who cannot read Why to make communication possible. Quality interpreting reflects cultural terms, Quality translating must reflect cultural terms, expressions, and idioms that have bearing expressions, and idioms that have bearing on on the meaning of the content. A translation must Interpreting must capture any capture any expression or nuances in meaning expressions or nuances in meaning to to maintain the impact of the original message. What maintain the impact of the original A translation is a product that is permanent message. Interpreters must with advanced levels of proficiency in both have an advanced level of proficiency in languages and with exceptional research skills both languages and must possess to ensure accuracy in work. Translation teams exceptional listening and memory skills include proofreaders and editors (and in some for accuracy and completeness in verbal cases, desktop publishers, and project expression. Who Special language aptitude is required in Special language aptitude is required in both both the language of medical terminology the language of medical terminology and in and in health care systems. Translation teams also interpreters prepare and conduct research rely on dictionaries, consultation with prior to the encounter, using resources professionals in a specific field, and other such as dictionaries and consultation with resources to complete their work. Interpreters may consult comprehension before starting the translation, dictionaries or utilize other resources, but often consulting dictionaries and other the time between each exchange is only a resources for correct grammar and matter of seconds or minutes. Interpreters work bidirectionally, going Most translators usually translate into their back and forth between two languages. The interpreter functions as a conduit, Translation is a process that requires analysis, clarifier, cultural broker, and advocate. Interpreters must be able to perform each Translators must be sensitive and considerate role appropriately throughout the of both cultures. The goal is consideration differences in culture as well as to have the listener understand the language, whether that product is software, an message as if it were heard directly from Internet site, or a manufactured product. Health Care has published a Code of Ethics and Standards of Practice for the American Translators Association has interpreters (National Council on issued a Code of Ethics and Professional Interpreting in Health Care, 2004, 2005). As discussed in Standard 1, individuals may have communication needs not related to a language barrier, such as those who are deaf or hard of hearing, visually impaired, or disabled or those with low health literacy. If family members or caregivers also have limited English proficiency and/or other communication needs, their linguistic needs should also be met to ensure the best outcomes for the individual receiving care. Addressing language access issues in your practice: A toolkit for physicians and their staff members. Safer use of physicianssecond language skills in caring for patients with limited English proficiency: A report of the Commission to End Health Care Disparities with recommendations for clinicians, organizations, and policymakers. Components of the Standard Inform all individuals of the availability of language assistance services the provision of language assistance services is critical to ensuring quality, safety, satisfaction, and improved outcomes, and informing individuals that such services are available helps ensure their use. Organizations should take the appropriate steps to notify individuals of the availability of language assistance services and that they are available free of cost. Individuals in need of communication and language assistance may not know such services are available to them upon request. Commonly reported barriers to services among individuals who are limited English proficient include the lack of availability of language services or the lack of awareness that such services exist (Barr & Wanat, 2005; Flores, 2006). Thus, organizations should provide notification of the availability of language assistance services at various points of contact and by various means. Staff and providers speaking to individuals, whether in person or over the phone, should provide notification of the communication and language assistance available. All members of the organization should be fully aware of the communication and language assistance services available, as well as all related organizational policies and procedures. To achieve this, all members of the organization should be trained in how to access communication and language assistance and work with language assistance personnel in order to support requests that come from individuals seeking health care and services (see Standard 4). Research conducted by the National Health Law Program identified staff training as essential to ensuring that available language services are appropriately utilized (Youdelman, Perkins, Brooks, & Reid, 2007), and another study demonstrated that more effective staff training is associated with significantly higher ratings on patient-reported quality of care and trust in the organization (Wynia et al. These trainings may be conducted in person onsite (as a part of existing training), or they may be a part of online training and information dissemination (Youdelman et al. It may be important to consider the following questions: o What factors are enablers and barriers to notifying individuals about available language assistance A cultural mediator can act as a liaison between the culture of the organization and the culture of the individual. An additional strategy for notifying individuals of language services through mediation is by developing a health promotion program. It may be appropriate to provide staff with a script to ensure that they inform individuals of the availability of language assistance and to inquire whether they will need to utilize any of the available services. A functional manual for providing linguistically competent health care services as developed by a community health center. A patient-centered guide to implementing language access services in healthcare organizations. Providing language services in state and local health-related benefits offices: Examples from the field (Commonwealth Fund Publication No. Components of the Standard Ensure the competence of individuals providing language assistance Before one can be considered qualified to interpret, translate, or provide other communication assistance, he/she must be assessed to determine his/her competence. Language ability alone does not qualify an individual to provide language assistance. For service providers, using an ad hoc interpreter may appear to be advantageous because there may be little or no upfront financial cost associated with using untrained individuals and/or minors, and there may be little to no interruption in service delivery, since the untrained individual is likely readily available. Grave errors have occurred when untrained individuals have been used as interpreters, including misdiagnoses and significant medical errors (Flores, 2005; Flores et al. Untrained family, friends, minors, and staff often do not possess the necessary skills to provide meaningful language services. For example, research conducted in an emergency department found that the use of trained interpreters resulted in reduced return rates to the emergency department, increased clinic utilization, and lower 30 day discharges, with no concurrent increase in length of stay or cost of visit (Bernstein et al. The primary role of the interpreter is to act as the conduit of information between the provider and the recipient of care or services. Family and friends should be present as a means of support and shared decision-making if the individual so chooses. However, a loved one should not assume the additional burden and risk of interpretation errors. Children, especially minor children, may not have the cognitive or emotional maturity to function in the role of interpreter (Wilson-Stronks & Galvez, 2007). In addition, the use of children as interpreters has been found not only to place unnecessary tension in the parent-child relationship but also to place stress and emotional strain on the child (Flores, 2005, 2006; Jacobs, Kroll, Green, & David, 1995; Schenker, Lo, Ettinger, & Fernandez, 2008). Parents or caregivers may not want to share sensitive information with their children, and, therefore, health professionals may not be able to gather an accurate history. It can also be quite distressing for a friend, family member, or child to have to deliver poor prognostic information to the individual. Research has shown that when clinicians speak a non-English language, or when untrained bilingual staff is available, an important set of potential barriers can arise and hinder the effective and appropriate use of trained interpreters (Maul, Regenstein, Andres, Wright, & Wynia, 2012). Organizations may opt to provide interpretation services through in-person interpreters and bilingual staff and providers or through technological or electronic means, including telephonic or video remote interpreting. Translation may be conducted primarily internally or may be contracted to external organizations. The American Translators Association upholds standards of practice for translation services (n. Similarly, the National Council on Interpreting in Health Care has issued standards of practice that define expectations of performance and outcomes for health care interpreters (2005). In addition, the Certification Commission for Healthcare Interpreters and the National Board for Certification of Medical Interpreters provide national certification for interpreters. The standards of practice identified by these professional organizations may offer promising practices in the provision of linguistically appropriate services. Keeping these standards at the core of hiring, training, and evaluating individuals will help ensure their competence in providing language assistance. Organizations may provide language assistance according to a variety of models, including bilingual staff or dedicated language assistance. Under a multifaceted model, for example, telephonic interpreting will supplement the language assistance provided by bilingual staff to ensure that at all times, language assistance is being provided by competent individuals. Trained medical interpreters in the emergency department: effects on services, subsequent charges, and follow-up. The impact of medical interpreter services on the quality of health care: A systematic review. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Using a risk assessment approach to determine which factors influence whether partially bilingual physicians rely on their non-English language skills or call an interpreter Components of the Standard Provide easy-to-understand print and multimedia materials and signage Print and multimedia materials offer an effective way of communicating with large numbers of people, supplementing information provided by clinicians, service providers, and other staff, and reinforcing key messages from a health care or service encounter. Therefore, ensuring that an individual can read, comprehend, and act upon written materials is essential. Minority populations are disproportionately represented among those with basic or below basic health literacy skills (Kutner et al. Health literate organizations design and distribute print, audiovisual, and social media content that is easy to understand and act on (Brach et al.

Partial laryngeal surgery often requires intensive vocal rehabilitation gastritis shoulder pain cheap biaxin 500 mg without a prescription, and full functionality may never be regained gastritis symptoms getting worse generic biaxin 500mg without prescription. Total laryngectomy results in aphonia gastritis diet ÿíäêñ generic biaxin 250 mg otc, and there are several communication options to replace this function gastritis cheap biaxin 500mg. N Epidemiology the annual incidence of diagnosed head and neck cancer in the United States is! Cancers diagnosed in the first or second stage are more likely to be treated with local surgical excision or chemoradiation therapy; cancers of the larynx in the third or fourth stage are more likely to result in a total removal of the larynx in combination with chemotherapy and radiotherapy gastritis diet or exercise discount 250mg biaxin overnight delivery. Of the three communication options postlaryngectomy gastritis kronik aktif adalah buy biaxin with mastercard, 55% of individuals use an electrolarynx as a primary communication method, 31% use a tracheoesophageal puncture prosthesis, and 6% use the esophageal speech method (8% remain nonvocal). N Clinical Signs and Symptoms Following partial laryngeal surgery, patients often present with dysphonia characterized by a weak, strained, or breathy vocal quality. Patients who have had a total laryngectomy have a total inability to phonate postopera tively secondary to removal of the larynx, including the vocal folds. Differential Diagnosis In patients with partial laryngeal surgery, it is important to determine whether the current vocal qualities are a result of surgical treatment versus an advancement or recurrence of the carcinoma. Any change in previous alaryngeal communication abilities of individuals following a total laryngectomy can indicate recurrence of cancer and should be care fully evaluated. N Evaluation Evaluation for communication methods following total laryngectomy include an evaluation of physical changes from surgery and chemoradia tion therapy to assess for the ability for electronic larynx placement either transcervically (neck-type) or intraorally (mouth-type), stoma size and placement for stomal occlusion with tracheoesophageal puncture voicing. Additionally, manual dexterity, motivation level, and financial/insurance resources should be considered. After Total Laryngectomy Electrolarynx A battery-powered electronic device called an electrolarynx is used. Depending on anatomic changes following surgery, an electrolarynx can be placed either transcervically (neck-type) or intraorally (mouth-type). The electrolarynx produces a vibration that is transmitted intraorally through a straw attached to the device or through the tissues of the neck or cheek. The electrolarynx offers a communication option immediately after surgery, is relatively easy to use, and has a lower one-time cost (when compared with the tracheoesophageal puncture voice prosthesis). Disadvantages include a mechanical sound quality, requirement for one free hand during communica tion, and unfamiliarity of the sound by most listeners. Tracheoesophageal Puncture Voice Prosthesis For the tracheoesophageal puncture voice prosthesis, a small fistula is surgically placed in the tracheoesophageal wall,! Voicing is then achieved by passing air from the trachea to the esophagus via stomal occlusion with either manual finger occlusion or a hands-free stomal attachment. The voice prosthesis allows for an esophageal sound production, which is then shaped by the oral cavity for speech production. Individuals with a laryngectomy often feel this method allows for speech to be most comparable to preoperative speech in terms of quality, fluency, and ease of production. Anatomic variations include hypertonicity or flaccidity of the pharyngoesophageal muscle segment, stomal stenosis, or stoma irregularity. Mechanical problems include size, fit, and prosthesis breakdown secondary to Candida infection or gastroesophageal reflux disease, or dislodgement. Other disadvantages include the cost of the prosthesis (which must be replaced every few months), accessibility to a speech-language pathologist or otolaryngologist trained to change and maintain indwelling valves, and manual dexterity for cleaning and management. Esophageal Speech S p e e c h i s p r o d u c e d f r o m a l e a r n e d m e t h o d o f v i b r a t i n g t h e p h a r y n g o e sophageal muscle segment. Air is introduced into the esophagus through the oral cavity and is then passed back out of the esophagus past the 5. T h i s c a n b e d o n e u s i n g e i t h e r a g l o s s o p h a ryngeal press method or an inhalation method. Esophageal speech allows for communication without the use of mechan ical or prosthetic devices and allows for more natural sound production. Disadvantages include an increased time period for learning this method (estimated 4 to 6 months of regular speech therapy and daily practice), limited success rates, and decreased ability to control volume. N Outcome and Follow-Up Any patient with laryngeal carcinoma must follow up with an otolaryngologist for at least 5 years postoperatively. A patient with an indwelling tracheoe sophageal puncture voice prosthesis must follow up with a speech-language pathologist or otolaryngologist trained in prosthesis management for all changes, approximately every 3 months. Additionally, follow-up should occur immediately for prosthesis dislodgement or significant change in sound quality, as this can indicate a more significant problem, recurrence, aspiration, or may allow tract stenosis or closure. Compliance, quality of life and quantitative voice quality aspects of hands-free speech. Looking Forward: the Speech and Swallowing Guidebook forPeople with Cancer of the Larynx or Tongue. G If no otic source for otalgia can be identified malignancy must be investigated and excluded. By definition, referred otalgia is the sensation of ear pain originating from a source outside the ear. Many remote anatomic sites share innervations with the ear, and noxious stimuli to these areas may be perceived as otalgia. N Evaluation the evaluation of a patient with otalgia begins with a detailed history and a thorough head and neck examination. Head and Neck 403 timing of the otalgia, exacerbating and alleviating factors of the otalgia, the patients past otologic history, the associated symptoms with the otalgia (tinnitus, hearing loss, vertigo), the presence of constitutional symptoms (to detect malignancies), and sinus and dental questions. A thorough otologic examination, with a tuning fork test at two frequencies (256 and 512 Hz), is important. The nose, sinuses, oral cavity, oral pharynx, and neck are inspected and palpated to look for sources of referred otalgia. In assessing otalgia in the setting of a normal otologic examination, a fiberoptic nasopharyngolar yngoscopy is mandated to look for lesions that can be potentially noxious to the trigeminal, facial, glossopharyngeal, or vagus nerves. Attention should be directed to the endolarynx to examine the mucosa for signs ofmalignancy and gastroesophageal reflux. N Treatment Options Appropriate treatment of the source of otalgia in combination with pain management. G Neck dissection or lymphadenectomy is a surgical procedure in which the fibrofatty contents of the neck are removed for the prevention or treatment of cervical metastasis. G Most commonly used in the treatment of cancers of the upper aerodi gestive tract, skin of the head and neck, thyroid, and salivary glands. The term neck dissectionrefers to the systematic removal of lymph nodes in the neck. To eradicate cancer in the cervical lymph nodes and to help determine the need for additional therapy (staging) when no lymph nodes are clinically identified, neck dissection may be performed. Although used most commonly for the management of cancers of the upper aerodigestive tract, neck dissection is also used for malignancies of the skin of the head and neck, the thyroid, and the salivary glands. More recently, a shift toward more conservative surgical procedures has been adopted. This shift aims at removing lymphatic tissue but preserving adjacent nonlymphatic struc tures. In addition, specific nodal groups at risk for metastatic disease as predicted by the size, location, and other features of the primary tumor are addressed in a selective fashion in certain cases. N Classification of Neck Levels the evaluation of the drainage pattern of the primary tumor site in the upper aerodigestive tract has led to the understanding and identification of nodal groups at risk for cervical metastases. Level 1: the Submandibular and Submental Triangles L e v e l 1 c o n s i s t s o f t h e s u b m a n d i b u l a r a n d s u b m e n t a l t r i a n g l e s. T h e s u b mandibular triangle is bordered by the mandible superiorly, the posterior belly of the digastric muscle posteroinferiorly, and the anterior belly of the digastric muscle anteroinferiorly. The submental triangle is the region between the bilateral anterior bellies of the digastric muscle and the hyoid bone. Level 2: the Jugular Digastric Region Level 2 is known as the jugular digastric region. Its boundaries are the skull base superiorly, the carotid bifurcation inferiorly, posterior border of the sternocleidomastoid muscle, and the lateral border of the sternohyoid and sternothyroid muscles medially. Level 3: the Middle Jugular Region L e v e l 3 i s t h e m i d d l e j u g u l a r r e g i o n. I t i s b o r d e r e d b y t h e c a r o t i d b i f u r c a tion superiorly, the junction of the omohyoid and sternocleidomastoid muscle at the jugular vein inferiorly, the posterior border of the sterno mastoid muscle laterally, and the lateral border of the sternohyoid muscle medially. Head and Neck 405 Level 4: the Lower Jugular Region Level 4 is the lower jugular region and extends from the omohyoid superiorly to the clavicle inferiorly. It extends to the posterior border of the sternomastoid muscle and the lateral border of the sternohyoid muscle medially. The fascia overlying the phrenic nerve and the brachial plexus is the deep boundary. It includes the lymph nodes between the posterior border of the sternomastoid muscle and the anterior border of the trapezius muscle. Level 6: the Anterior Compartment Level 6 is the anterior compartment and includes the midline lymph nodes adjacent to the trachea and thyroid gland. The borders of this region are the hyoid bone superiorly, the sternal notch inferiorly, and the carotid sheath laterally. N Classification of Neck Dissections the c u r r e n t c l a s s i f i c a t i o n o f n e c k d i s s e c t i o n h a s b e e n d e v e l o p e d b y t h e C o m m i t tee of Head and Neck Surgery & Oncology of the American Academy of Otolar yngologyHead and Neck Surgery and is based on the following principles: 1. It is defined as the en block removal of the nodal groups between the mandible and the clavicle. The procedure is usually performed if there is no palpable neck disease (clinically N0 neck), but the risk of occult metastases to the cervical lymph nodes is likely "20%. G Supraomohyoid neck dissection involves removal of levels 1 through 3 and is usually performed in the setting of oral cavity tumors and N0 neck disease. Posterior lateral neck dissection is typically performed for cutaneous malignancies of the scalp and face. G Anterior compartment or central compartment neck dissection includes level 6 and is used for tumors found in the larynx, the hypo pharynx, the subglottis cervical esophagus, and the thyroid. Anterior neck dissection is commonly performed for papillary thyroid cancer with metastases to the lymph nodes. An extended neck dis section may involve the retropharyngeal lymph nodes, the hypoglossal nerve, portions of the prevertebral musculature and the carotid artery. Also, certain parotid gland malignancies may require total parotidec tomy combined with neck dissection. N Complications of Neck Dissection Complications may be divided into intraoperative or postoperative. It is important to remember that certain medical conditions such as postra diation treatment, poor nutritional status, hypothyroidism, alcoholism, and diabetes may increase the risk of intraoperative and postoperative complications. During a submandibular submental dissection, the marginal mandibular branch of the facial nerve, the hypoglossal nerve, and the lingual nerve are all at risk. Injury to the phrenic nerve may cause hemidiaphragm paresis, but is typically only symptomatic in patients with significant pulmonary disease. Injury to the brachial plexus is rare but can occur, causing upper extremity weakness. Postoperative complications include hematoma, shoulder dysfunction, wound infection, salivary or chylus fistula, and carotid artery blowout. Occupations such as farmers, construc tion workers, and others who spend many hours in the sun have a skin cancer risk. Other Tests No imaging or laboratory tests are necessary, but suspicious lesions should be biopsied. The lesions appear as waxy papules with central depression or rolled edges, and a pearly translu cency. Often, telangiectasias appear over the surface, which can lead to bleeding and crusting, especially with ulceration. It appears commonly on the face as a sclerotic, sometimes depressed, plaque with yellowish color and irregular borders. These tumor cells express collagenases, which allow them to travel along peripheral nerves and embryonic fusion planes. Pigmented: this type is very similar to the nodular type, but with the additional characteristic of pigmentation, which may resemble a benign 5. Superficial: this type appears commonly on the trunk (rarely on the head and neck) as scaly, indurated patch with an irregular border, often mimicking psoriasis or eczema or resembling actinic keratosis. External beam radiation can be used effectively and has gained favor over superficial x-rays by many radiation oncologists. Ionizing radiation is a good treatment option for patients who are not surgical candidates, especially those patients who have facial tumors. The most effective procedure (9699% cure rate) is Mohs micrographic excision. In this technique, the tumor is removed and the margin mapped and color coded, then examined thoroughly for remaining cancer. If there is remnant cancer, the surgeon returns to that specifically mapped area and removes tissues, repeating this process until all margins are clear. This procedure is best used for cosmetically or functionally sensitive areas in which wide margins cannot be easily removed, or for aggressive, recur ring, or large tumors. N Outcome and Follow-Up P a t i e n t s w h o a r e d i a g n o s e d w i t h B C C h a v e a 3 5 t o 4 0 % c h a n c e o f d e veloping another tumor within 3 years and a 50% chance of developing another (not recurrent) basal cell carcinoma within 5 years. Wearing hats to protect the head and neck from sun exposure and sun-block usage should be encouraged. Stuttgart/New York: Thieme; 2009:675702 R u b i n A I, C h e n E H, R a t n e r D. In addition to sun exposure, chronic damage to skin and immunosuppressive states are risk factors.

Each radiation treatment is called a fraction because for most situations the total radiation dose is given over multiple sessions gastritis erosiva buy generic biaxin. Fractionation is biologically advanta geous because of the processes of tumor reoxygenation and reassortment into more radiosensitive parts of the cell cycle gastritis diet quick discount biaxin 500mg overnight delivery. Increasing the number of fractions preferentially spares normal tissues by giving them more time to repair sublethal damage gastritis problems biaxin 250 mg on-line. Accelerated radiation delivers treatment faster than standard fractionation ("10 Gy per week) gastritis diet 100 discount 250mg biaxin otc. N Methods of Radiation Delivery Radiation is broadly divided into brachytherapy and teletherapy gastritis diet íùãåãèó buy biaxin 500 mg. The exposure time ranges from over 2 to 3 days in low-dose rate applications diet plan for gastritis sufferers buy biaxin canada, most commonly with cesium 137, to 10 to 30 minutes in high-dose rate applications, most commonly with iridium-192. With differentiated thyroid cancer, orally administered iodine-131 (131I) preferentially binds to tumor cells, with ablative doses of 100 to 150 mCi delivering 250 to 300 Gy. Teletherapy, or external beam radiation, is the delivery of radiation by pointing an external source of radiation at the target. The most common source in modern radiotherapy is the linear accelerator, which can generate high energy (4 to 25 MeV) photons and electrons. Intraopera tive radiation can be focally delivered to internal structures with a linear accelerator or portable x-ray generator in the operating room. C o n v e n t i o n a l r a d i a t i o n p l a n n i n g u s e s x r a y f i l m s t o d e f i n e t h e t a r g e t v o l u m. P l a n s a r e g e n e r a l l y l i m i t e d t o a s m a l l n u m b e r o f a n g l e s a n d r a d i a t i o n beams are shaped by fabricating Cerrobend blocks. This in creases dose conformality to the target by making it easier to use more fields from virtually any beam angle. A gamma knife uses cobalt-201 sources aimed at the same point in space to produce a small area with a high dose and sharp dose drop-off. Head and Neck 357 trait of all modern systems is that increased dose conformality to the target requires a high level of patient set-up consistency, and this is achieved using custom masks or external frames that connect to the patient couch. N Rationale for Definitive (Curative) Radiotherapy P r i m a r y r a d i o t h e r a p y i n t h e t r e a t m e n t o f S C C o f t h e n a s o p h a r y n x, o r o p h a r y n x, oral cavity, and glottis has long been considered an option even in resect able disease. The primary justification for this is not increased efficacy over surgery but organ and functional preservation without compromising long term efficacy. For patients with advanced disease, defini tive radiation with chemotherapy with or without planned neck dissection, with surgery to the primary reserved for salvage, had an equivalent survival compared with surgery followed by radiation in randomized trials of cancers of the larynx, hypopharynx, and other areas of the pharynx. For patients with early-stage lesions of the larynx, no randomized trials of laryngectomy versus other modalities exist, but a large series of mature data exists regarding the long-term efficacy of definitive radiation. The results of these trials cannot be extrapolated to all cases, and it is likely that surgery should be the primary modality in some patient subsets. Definitive radiation, with or without chemotherapy depending upon the histology, is also used in mucosal melanoma, skin cancer, salivary gland cancer, lymphoma, and plasmacytoma. N Rationale for Adjuvant Radiotherapy Postoperative radiotherapy is used if there is residual disease or a significant risk of occult residual disease. The addition of current chemotherapy to adjuvant radiation has proven to be better than radiation alone in large randomized trials. Ran domized data for other tissue types does not exist, but postoperative radiation is commonly given in high-risk cases of Merkel cell carcinoma, salivary gland carcinoma, skin cancer, and thyroid cancer. Preoperative radiation is generally reserved for marginally unresectable disease, but is more standard in esthe sioneuroblastomas to make the definitive surgery smaller and less morbid. N Rationale for Palliative Radiotherapy I n t h e n o n c u r a t i v e s e t t i n g, r a d i o t h e r a p y i s u s e d t o t r e a t a r e a s t h a t a r e c a u s i n g local symptoms or at a high risk to cause local symptoms. Common indica tions in head and neck cancer to treat the primary lesion include uncontrolled bleeding, pain, dysphagia, and a compromised airway. Metastatic disease to the bone, brain, and lung can also be palliated effectively using radiation. Acute effects occur during or within the first few weeks after radiotherapy and tend to be transient. Common acute side effects include dermatitis, mucositis, taste changes, xerostomia, fatigue, facial hair loss, decreased sweating, anorexia, and weight loss. Common late effects include xerostomia, trismus, hypothyroidism, soft tissue fibrosis, dysphagia, and taste changes. Less com mon late effects include soft tissue necrosis, osteoradionecrosis, laryngeal edema, spinal cord myelopathy, carotid stenosis, and second malignancy. Acute effects are generally managed supportively because of their transient nature. Aggressive dental support, stretching exercises, and proper skin care can minimize some late effects. Routine evaluation for hypothyroidism and xerostomia should also be performed, as pharmacologic interventions can improve these conditions. N Improving the Therapeutic Ratio of Radiation Radiation can be improved by sensitizing tumor cells preferentially or by decreasing radiation damage to normal tissues. Radiation sensitizers with proven efficacy in randomized trials include concurrent platinum agents, mitomycin C, and cetuximab. Future improvements are expected as imaging, radiation delivery, and new agents continue to be further developed. Tumors of the ethmoid sinuses are less common (20%), and cancers of the sphenoid and frontal sinuses are rare ($1%). N Epidemiology Chemical carcinogens such as chromium, nickel, thorium dioxide, and tanning chemicals have been implicated in the development of carcinoma of the paranasal sinuses. Exposure to wood dust has been implicated specifically in adenocarcinoma of the ethmoid. Interestingly, tobacco use was previously thought not to play a role in sinonasal carcinogenesis. However, up to a fivefold increased risk of sinonasal carcinoma has been observed with heavy smoking. Rarely, sinonasal cancers may present as a second primary tumor in tobacco users with other head and neck cancers. N Clinical Signs and Symptoms Clinical presentation of sinus malignancies is nonspecific and often mimics benign disease, thus diagnosis is often delayed for months. Key indicators of malignancy are cranial neuropathies, proptosis, and pain of maxillary dentition; trismus, palatal, and alveolar ridge fullness; or frank erosion into the oral cavity. Symptoms include nasal obstruction, discharge, stuffi ness, congestion, epistaxis, unilateral tearing, diplopia, exophthalmos, infraorbital nerve hypesthesia, cheek swelling, facial asymmetry, hearing loss, and serous otitis media due to nasopharyngeal extension may occur. Differential Diagnosis the d i f f e r e n t i a l d i a g n o s i s i n c l u d e s b e n i g n s i n u s d i s e a s e, b e n i g n s i n u s t u m o r s, and metastatic tumors to the sinus. Physical Exam A complete head and neck examination, including nasal endoscopy, should be performed. Evidence of nerve hypesthesia, diplopia, proptosis, and loose dentition should be carefully evaluated. N Treatment Options Most stage T1 or T2 maxillary sinus carcinomas are treated by surgery alone, provided adequate resection margins are obtained. This may be en bloc surgical resection or endoscopic sinus surgery, depending on the extent of disease and experience of the surgeon. The specific approach is determined by the location of disease and histology. The issue regarding whether radiation is more effective before or after surgery remains controversial. Despite improvements in surgical ablative and reconstructive techniques, radiation delivery modalities, and imaging technologies, dis ease-free survival at 5 years remains $50%, independent of stage. Five-year disease-free survival for patients with advanced stage cancer drops to 25%. It divides the maxil lary sinus into a superoposterior part and an inferoanterior part. Malignant tumors of the nose and paranasal sinuses: a retrospective review of 291 cases. G the diagnosis must be excluded in patients with asymptomatic cervical lymphadenopathy and unilateral serous otitis media. N Anatomy the nasopharynx is bounded superiorly by the basiocciput and basisphenoid, posteriorly by the C1 and C2 cervical bodies, anteriorly by the choanae, and inferiorly by the soft palate. There is an interme diate incidence in Inuit Eskimos and in the populations of the Mediterranean basin. N Clinical Signs and Symptoms Early signs and symptoms are subtle and variable, and are often initially ignored by both patient and physician. Five to 7% of all patients have systemic metastases at presentation, most often to bone. Symptoms include unilateral nasal obstruction, unilateral hearing loss and otalgia, diplopia, facial or neck pain, and paresthesia. Differential Diagnosis G Minor salivary gland tumors G Juvenile nasopharyngeal angiofibroma G Adenoid hypertrophy G Tornwaldt cysts G Fibromyxomatous polyps G Choanal polyps, fibromas G Papillomas G Osseous/fibroosseous tumors G Craniopharyngiomas G Extracranial meningiomas G Chordomas N Evaluation History History should include questions about epistaxis, nasal obstruction and discharge, hearing loss or clogged ear, headache, diplopia, facial pain, and numbness. A chest x-ray, liver ultrasound, and a bone scan are recommended for all patients with nodal disease. Other Tests A dental examination is required before instituting radiotherapy to reduce the development of postradiotherapy complications. Type 1 may have an association with cigarette and alcohol consumption and accounts for up to 30% of cases in nonendemic areas and $5% in endemic areas. External beam is most commonly delivered by opposed lateral fields to encompass the primary tumor and upper neck. Because there is a high incidence of subclinical neck disease, radiation doses between 50 and 60 Gy are used to electively treat the neck. Recent data shows a clear role for concomitant chemoradiotherapy fol lowed by adjuvant chemotherapy, which provides statistically significant improvement in overall survival and disease free survival. Neck dissection for postradiation residual or recurrent nodal disease is the most common indication for surgery. For these patients, radiotherapy delivered in combination with chemotherapy has become the standard of care. A f i r s t c o m p l e t e e v a l u a t i o n s h o u l d b e p e r f o r m e d 2 t o 3 m o n t h s a f t e r c o m pletion of treatment. The next evaluations should be scheduled for 6 months after this first posttherapeutic workup and on a yearly basis thereafter. State-of-the-art management of nasopharyngeal carcinoma: current and future directions. The oral cavity extends from the skinvermilion junctions of the anterior lips to the junction of the hard and soft palates superiorly and to the line of circumvallate papillae posteriorly. N Epidemiology Thirty thousand people are diagnosed yearly with oral cancer in the United States, and it will cause "8000 deaths. For all stages combined, 370 Handbook of OtolaryngologyHead and Neck Surgery the 5-year relative survival rate is 59% and the 10-year survival rate is 44%. It typically occurs in those over the age of 45, and occurs in men twice as often as women. The number of new cases of this disease has been decreasing during the past 20 years. Smokeless tobacco in the Western world and paan (betel leaf with areca nut) in Asia are also risk factors for oral cancer. Recently there has been a growing number of young patients with oral cancers, particularly involving the tongue. N Clinical Signs Signs may include uncomfortable or poorly fitting dentures, loosening of the teeth, changes in articulation, a mass in the neck, weight loss, and persistent halitosis. Symptoms Symptoms depend on site and stage of the primary tumor and its effect on function of that area. They include a nonhealing white or red (leukoplakia, erythroplasia) patch or sore in the mouth (most common symptom), per sistent pain in the mouth, and a thickening in the cheek or floor of mouth. More advanced disease may cause a sore throat, difficulty chewing, dys phagia, trismus or tongue tethering, numbness of the tongue or mouth, and pain around the teeth or jaw. Differential Diagnosis G Oral and pharyngeal infections such as pharyngitis or stomatitis G Chancre G Benign oral or odontogenic lesions G Denture sores G Aphthous ulcers or herpetic sores G Lesion due to cheek biting G Oral manifestations of systemic diseases G Necrotizing sialometaplasia N Evaluation History Evaluation begins with a detailed history inquiring about tobacco and alco hol usage, oral pain, referred otalgia, dysphagia, articulation changes, and weight loss. Head and Neck 371 Physical Exam A physical exam should include a complete head and neck exam. The lesion size should be noted as should its infiltration and spread to adjacent oral cavity or oropharyngeal subsites such as floor of mouth, alveolus, and tongue base. A bimanual examination of the lesion, the surrounding floor of mouth, and the submandibular triangle should be performed. The main routes of lymph node drainage from the oral cavity are into the first echelon nodes. Tumor size and spread may be evaluated as well as discrete nodal disease, bony destruction, and vascular involvement. Other Tests Patients with suspected oral cancer must undergo a biopsy for pathologic diagnosis. The routine use of panendoscopy, which includes bronchoscopy, esophagoscopy, and laryngoscopy, is recommended. It allows for the complete evaluation of the upper aerodigestive tract and helps rule out the presence of a synchronous tumor. The mucous membranes of the upper aerodigestive tract are carefully evaluated, and biopsy samples of any abnormal-looking areas. Toluidine blue staining and photodynamic agents such as Foscan (Sigma Aldrich, St.

Bilateral nephrectomy before transplantation: indications gastritis symptoms heart palpitations discount 250 mg biaxin with visa, surgical approach gastritis cystica profunda definition buy 250mg biaxin amex, morbidity and mortality gastritis diet 101 purchase biaxin 500 mg line. Pretransplant native nephrectomy in patients with end-stage renal failure: assessment of the role of laparoscopy gastritis diet àâòî order biaxin canada. Outcome of patients with vesicoureteral reflux after renal transplantation: the effect of pretransplantation surgery on posttransplant urinary tract infections gastritis symptoms patient biaxin 250mg discount. Tuberculosis treatment and management-an update on treatment regimens chronic gastritis symptoms stress cheap biaxin generic, trials, new drugs, and adjunct therapies. Treatment outcomes from community-based drug resistant tuberculosis treatment programs: a systematic review and meta-analysis. 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The impact of periodontal disease on physical and psychological domains in long-term hemodialysis patients: a cross-sectional study. Human immunodeficiency virus infection and kidney transplantation in the era of highly active antiretroviral therapy and modern immunosuppression. Updated international consensus guidelines on the management of cytomegalovirus in solid-organ transplantation. Epstein-Barr virus and posttransplant lymphoproliferative disorder in solid organ transplantation. Retransplantation in patients with graft loss caused by polyoma virus nephropathy. Impact of human T-cell leukemia virus type 1 on living donor liver transplantation: a multi-center study in Japan. The accelerated hepatitis B virus vaccination schedule among hemodialysis patients, does it work Comparison of Accelerated and Standard Hepatitis B Vaccination Schedules in High-Risk Healthy Adults: A Meta-Analysis of Randomized Controlled Trials. Association of response to hepatitis B vaccination and survival in dialysis patients. Extra-high-dose hepatitis B vaccination does not confer longer serological protection in peritoneal dialysis patients: a randomized controlled trial. Challenges in containing the burden of hepatitis B infection in dialysis and transplant patients in India. Loss of hepatitis B immunity in hemodialysis patients acquired either naturally or after vaccination. Responses in children to measles vaccination associated with perirenal transplantation. Effectiveness of Herpes Zoster Vaccine in Patients 60 Years and Older With End-stage Renal Disease. Cancer screening in the United States, 2015: a review of current American cancer society guidelines and current issues in cancer screening. Chronic kidney disease and the risk of cancer: an individual patient data meta-analysis of 32,057 participants from six prospective studies. Cancer risk among elderly persons with end stage renal disease: a population-based case-control study. Knowledge, beliefs and attitudes of kidney transplant recipients regarding their risk of cancer. Screening for prostate, breast and colorectal cancer in renal transplant recipients. Health benefits and costs of screening for colorectal cancer in people on dialysis or who have received a kidney transplant. The health and economic impact of cervical cancer screening and human papillomavirus vaccination in kidney transplant recipients. Cancer Screening Recommendations for Solid Organ Transplant Recipients: A Systematic Review of Clinical Practice Guidelines. Cancer-Specific and All-Cause Mortality in Kidney Transplant Recipients With and Without Previous Cancer. Outcomes of Solid Organ Transplant Recipients With Preexisting Malignancies in Remission: A Systematic Review and Meta-Analysis. Association Between Pretransplant Cancer and Survival in Kidney Transplant Recipients. Prostate cancer prior to solid organ transplantation: the Israel Penn International Transplant Tumor Registry experience. The Novel Application of Genomic Profiling Assays to Shorten Inactive Status for Potential Kidney Transplant Recipients With Breast Cancer. Prediction of postoperative pulmonary complications in oesophagogastric cancer surgery. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Reversible and irreversible airflow obstruction as predictor of overall mortality in asthma and chronic obstructive pulmonary disease. Predictors of survival in patients receiving domiciliary oxygen therapy or mechanical ventilation. European Renal Best Practice Guideline on kidney donor and recipient evaluation and perioperative care. Cardiovascular events and investigation in patients who are awaiting cadaveric kidney transplantation. Cardiac disease evaluation and management among kidney and liver transplantation candidates: a scientific statement from the American Heart Association and the American College of Cardiology Foundation: endorsed by the American Society of Transplant Surgeons, American Society of Transplantation, and National Kidney Foundation. Cardiac testing for coronary artery disease in potential kidney transplant recipients. Prognostic value of cardiac tests in potential kidney transplant recipients: a systematic review. Prognostic value of cardiovascular screening in potential renal transplant recipients: a single-center prospective observational study. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Coronary revascularisation in insulin-dependent diabetic patients with chronic renal failure. Association of the pattern of use of perioperative beta blockade and postoperative mortality. Association of beta-blocker therapy with risks of adverse cardiovascular events and deaths in patients with ischemic heart disease undergoing noncardiac surgery: a Danish nationwide cohort study. Incidence, predictors and associated outcomes of rhabdomyolysis after kidney transplantation. Aspirin, beta-blocker, and angiotensin-converting enzyme inhibitor therapy in patients with end-stage renal disease and an acute myocardial infarction. Benefits of aspirin and beta-blockade after myocardial infarction in patients with chronic kidney disease. Effects of antiplatelet therapy on mortality and cardiovascular and bleeding outcomes in persons with chronic kidney disease: a systematic review and meta-analysis. Risk of elective major noncardiac surgery after coronary stent insertion: a population-based study. The incremental risk of noncardiac surgery on adverse cardiac events following coronary stenting. Task Force on Myocardial Revascularization of the European Society of C, the European Association for Cardio-Thoracic S, European Association for Percutaneous Cardiovascular I, et al. Survival of kidney transplantation patients in the United States after cardiac valve replacement. Do echocardiographic parameters predict mortality in patients with end-stage renal disease Evaluation and Management of Pulmonary Hypertension in Kidney Transplant Candidates and Recipients: Concepts and Controversies. Influence of ejection fraction on cardiovascular outcomes in a broad spectrum of heart failure patients. Systolic dysfunction portends increased mortality among those waiting for renal transplant. Prognostic value of reduced left ventricular ejection fraction at start of hemodialysis therapy on cardiovascular and all-cause mortality in end-stage renal disease patients. Carvedilol increases two-year survivalin dialysis patients with dilated cardiomyopathy: a prospective, placebo-controlled trial. Ankle Brachial Index and Subsequent Cardiovascular Disease Risk in Patients With Chronic Kidney Disease. Helical computed tomography angiography is the most efficient test to assess vascular calcifications in the iliac arterial sector in renal transplant candidates. Treatment of aortoiliac occlusive or dilatative disease concomitant with kidney transplantation: how and when Aortoiliac reconstruction with allograft and kidney transplantation as a one-stage procedure: long term results. Is severe atherosclerosis in the aortoiliac region a contraindication for kidney transplantation Can Kidney Transplantation Improve Arterial Stiffness in End-Stage Renal Patients Does kidney transplantation to iliac artery deteriorate ischemia in the ipsilateral lower extremity with peripheral arterial disease Peripheral vascular occlusive disease in renal transplant recipients: risk factors and impact on kidney allograft survival. Independent preoperative predictors of outcomes in orthopedic and vascular surgery: the influence of time interval between an acute coronary syndrome or stroke and the operation. Time elapsed after ischemic stroke and risk of adverse cardiovascular events and mortality following elective noncardiac surgery. Screening for asymptomatic carotid artery stenosis: a systematic review and meta-analysis for the U. Evaluation of Carotid Ultrasonography Screening Among Kidney Transplant Candidates: A Single-Center, Retrospective Study. Extended follow-up of unruptured intracranial aneurysms detected by presymptomatic screening in patients with autosomal dominant polycystic kidney disease. Screening for intracranial aneurysm in 355 patients with autosomal-dominant polycystic kidney disease. Prevalence of unruptured intracranial aneurysms, with emphasis on sex, age, comorbidity, country, and time period: a systematic review and meta-analysis. Autosomal Dominant Polycystic Kidney Disease and Intracranial Aneurysms: Is There an Increased Risk of Treatment Repeat imaging for intracranial aneurysms in patients with autosomal dominant polycystic kidney disease with initially negative studies: a prospective ten-year follow-up. A follow-up study of autosomal dominant polycystic kidney disease with intracranial aneurysms using 3. High frequency of ulcers, not associated with Helicobacter pylori, in the stomach in the first year after kidney transplantation. Upper gastrointestinal complications after renal transplantation: a 3-yr sequential study. Incidence, complications, treatment, and outcome of ulcers of the upper gastrointestinal tract after renal transplantation during the cyclosporine era. Advantage of eradication therapy for Helicobacter pylori before kidney transplantation in uremic patients. Laparoscopic sigmoid resection for diverticulitis decreases major morbidity rates: a randomized control trial: short-term results of the Sigma Trial. The utility of prophylactic laparoscopic cholecystectomy in transplant candidates. Management of asymptomatic cholelithiasis for patients awaiting renal transplantation. Inflammatory bowel disease after liver transplantation: risk factors for recurrence and de novo disease. Effect of liver transplantation on inflammatory bowel disease in patients with primary sclerosing cholangitis. Inflammatory bowel disease after liver transplantation: the effect of different immunosuppressive regimens. The factor V Leiden (R506Q) mutation and risk of thrombosis in renal transplant recipients. Frequency, potential risk and therapeutic intervention in end-stage renal disease patients with antiphospholipid antibody syndrome: a multicenter study.

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