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Cortical spreading depression ( CSD ) or spreading depolarization ( SD ) is a wave of electrophysiological hyperactivity followed by a wave of inhibition. [ 3 ] Spreading depolarization describes a phenomenon characterized by the appearance of depolarization waves of the neurons and neuroglia [ 4 ] that propagates across the cortex at a velocity of 1.5–9.5 mm/min. [ 5 ] [ 6 ] [ 7 ] [ 8 ]
CSD can be induced by hypoxic conditions and facilitates neuronal death in energy-compromised tissue. [ 9 ] CSD has also been implicated in migraine aura , where CSD is assumed to ascend in well-nourished tissue and is typically benign in most cases, although it may increase the probability in migraine patients to develop a stroke . [ 10 ]
Spreading depolarization within brainstem tissues regulating functions crucial for life has been implicated in sudden unexpected death in epilepsy , by way of ion channel mutations such as those seen in Dravet syndrome , a particularly severe form of childhood epilepsy that appears to carry an unusually high risk of SUDEP (sudden unexpected death in epilepsy).
Although the terms cortical spreading depression and spreading depolarization are often used as synonyms, a study found spreading depolarizations can produce variable effects on cortical activity in humans and rats, ranging from depressed to booming activity depending on SD depth. [ 11 ]
Neuroscientists use the term cortical spreading depression to represent at least one of the following cortical processes: [ citation needed ]
The scintillating scotoma of migraine in humans may be related to the neurophysiologic phenomenon termed the spreading depression of Leão . [ 13 ]
Increased extracellular potassium ion concentration and excitatory glutamate contribute to the initiation and propagation of cortical spreading depression, which is the underlying cause of migraine aura . [ 14 ]
Chronic daily administration of migraine prophylactic drugs ( topiramate , valproate , propranolol , amitriptyline , and methysergide ) dose-dependently suppressed frequency of CSD induced by continuous cortical application of 1 M KCl solution. [ 15 ] However lamotrigine (a drug with specific anti-aura action, but no efficacy in migraine in general) has a marked suppressive effect which correlates with its rather selective action on the migraine aura. Valproate and riboflavin were shown to have no effect on the triggering of cortical spreading depression though they are effective in migraine without aura. [ 16 ] Taken together, these results are compatible with a causal role of cortical spreading depression in migraine with aura, but not in migraine without aura. [ citation needed ]
The folded structure of the cerebral cortex is capable of irregular and complex CSD propagation patterns. The irregularities of the folded cortex and the vasculature promote the presence of re-entrance waves, such as spirals and reverberating waves. [ 7 ] The expansion of the wave then is less predictable and it is affected by the concentration of different molecules and gradients on the cortex. [ citation needed ]
Its triggers and propagation mechanisms, as well as clinical manifestations of CSD, are a therapeutic target to reduce brain damage after a stroke or brain lesion. [ 17 ] [ 18 ] [ 19 ]
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Cortical stimulation mapping ( CSM ) is a type of electrocorticography that involves a physically invasive procedure and aims to localize the function of specific brain regions through direct electrical stimulation of the cerebral cortex . [ 1 ] It remains one of the earliest methods of analyzing the brain and has allowed researchers to study the relationship between cortical structure and systemic function. [ 2 ] Cortical stimulation mapping is used for a number of clinical and therapeutic applications, and remains the preferred method for the pre-surgical mapping of the motor cortex and language areas to prevent unnecessary functional damage. [ 3 ] There are also some clinical applications for cortical stimulation mapping, such as the treatment of epilepsy . [ 4 ]
The history of cortical stimulation mapping dates back to the late 19th century. Neurologist David Ferrier and neurosurgeon Victor Horsley were some of the first to utilize this technique. [ 2 ] Ferrier and Horsley employed CSM to further grasp the structure and function of the pre-Rolandic and post-Rolandic areas, also known as the pre central gyrus and post central gyrus . Prior to the development of more advanced methods, in 1888 C.B. Nancrede utilized a battery operated bipolar probe in order to map the motor cortex . [ 2 ] In 1937, Wilder Penfield and Boldrey were able to show that stimulating the precentral gyrus elicited a response contralaterally ; a significant finding given that it correlated to the anatomy based on which part of the brain was stimulated. [ 2 ] In the early 1900s Charles Sherrington began to use monopolar stimulation in order to elicit a motor response. [ 2 ] This technique allowed Sherrington to determine that the precentral gyrus (pre-Rolandic area) is a motor cortex and the postcentral gyrus (post-Rolandic area) is a sensory cortex . These findings, which were repeated by Harvey Cushing through the early 1900s, show that the Rolandic fissure is the point of separation between the motor and sensory cortices. Cushing's work with CSM moved it from an experimental technique to one that became a staple neurosurgery technique used to map the brain and treat epilepsy. [ 5 ] Cushing took work that had previously been done on animals, specifically chimpanzees and orangutans, and was able to utilize cortical stimulation mapping to account for the differences between these species and humans. [ 5 ] Cushing's work dramatically increased the effectiveness of the treatment utilizing cortical stimulation mapping, as neurosurgeons were now utilizing a more updated picture of the brain. [ citation needed ]
Cortical stimulation mapping is an invasive procedure that has to be completed during a craniotomy . Once the dura mater is peeled back, an electrode is placed on the brain to test motor, sensory, language, or visual function at a specific brain site. The electrode delivers an electric current lasting from 2 to 10 seconds on the surface of the brain, causing a reversible lesion in a particular brain location. This lesion can prevent or produce a testable response, such as the movement of a limb or the ability to identify an object. The electric current from the electrode stimulates whatever function that site in the brain is responsible for, in essence telling the surgeon or examiner what a specific locale in the brain does. [ 6 ]
Electrodes are usually made of stainless steel or platinum-iridium embedded in a silastic material, and are usually circular with diameters of 2 to 3 mm. Electrode positioning varies from patient to patient, and electrodes can come in rows, in a grid array, or can be individually arranged. The number of electrodes necessary and their exact spatial arrangement is often determined in the operating room. [ 1 ] Cortical stimulation mapping allows electrodes to be placed in exact locations to test brain function and identify if stimulation of the brain location causes a functional impairment in the patient. [ 7 ] CSM can be completed using anesthetized patients or awake patients. [ 1 ]
Electrodes can either be placed directly on brain areas of interest or can be placed in the subdural space of the brain. Subdural electrodes can shift slightly and can be affected by cerebrospinal fluid in the subdural space, which could interfere with the current used to stimulate the brain from the electrodes and possibly cause shunting and dissipate the current, making the stimulation's effect less accurate. However, an advantage of subdural electrode grids is that they can be left in the brain for multiple days, and allow functional testing during stimulation outside the operating room. [ 1 ]
Current levels and density are an important consideration in all cortical stimulation mapping procedures. Current density , that is the amount of current applied to a defined area of the brain, must be sufficient to stimulate neurons effectively and not die off too quickly, yet low enough to protect brain tissue from damaging currents. Currents are kept at levels that have been determined safe and are only given as short bursts, typically bursts that slowly increase in intensity and duration until a response (such as a muscle movement) can be tested. Current intensity is usually set around bursts of 1 mA to begin and gradually increased by increments of 0.5 to 1 mA, and the current is applied for a few seconds. If the current applied causes afterdischarges, nerve impulses that occur after stimulation, then the levels are lowered. Studies on patients who have received cortical stimulation mapping have found no cortical damage in the tested areas. [ 1 ]
The different types and administration techniques for anesthesia have been shown to affect cortical stimulation mapping. CSM can be done performed on awake patients, called an awake craniotomy or in patients who have been placed under general anesthesia. If the patient is under general anesthesia , the depth of the anesthesia can affect the outcome because if the levels of muscle relaxation are too high due to neuromuscular blocking drugs, then the results from the mapping can be incorrect. [ 8 ] For the awake procedure there are different considerations for patient care that the anesthesiologist must take into account. Rather than simply ensuring that the patient is asleep, the doctor can follow what is called the asleep-awake-asleep technique. In this technique the patient is anesthetized using a general anesthesia during the opening and closing portions of the procedure, but during the interim the patient is maintained utilizing local anesthesia. [ 4 ] The local anesthesia techniques can be either a local field block or a regional nerve block of the scalp. [ 4 ] The more common technique for the awake craniotomy is conscious sedation. In conscious sedation, the patient is only sedated during the opening and closing process, but never fully anesthetized, eliminating the need for breathing tubes, lessening the chances of complications, and lessening the chances of problems with motor response. [ 4 ] Patients who undergo the procedure with an awake craniotomy instead of general anesthesia have better preservation of language function, a prediction of their seizure-free outcome based on corticography, a shorter hospitalization (which corresponds to a reduced cost of care), a decreased usage of invasive monitors, and decreased number of postoperative complications due to anesthesia such as nausea and vomiting. [ 4 ]
Cortical stimulation mapping is used for somatotopy to determine the areas of the cerebral cortex that connect through nerve fibers with different body parts. Cortical stimulation identifies which regions of the brain are vital for certain functions, thereby allowing a 'map' to be made which can be used to decide if brain areas are safe to remove. Cortical stimulation mapping led to the development of a homunculus for the motor and sensory cortices, which is a diagram showing the brain's connections to different areas of the body. An example is the cortical homunculus of the primary motor cortex and the somatosensory cortex , which are separated by the central sulcus . The diagram starts in the longitudinal fissure and continues out laterally from the center of the brain, representing the general pattern from lower extremities and genitals in the fissure up to the hands and face on outer edges of the brain. [ 2 ]
Functional testing of movement during cortical stimulation includes looking for active movement and inhibition of movement. When the precentral gyrus of the frontal lobe is stimulated, specific muscles in the body will contract based on the location of the brain that receives the electric signal. Stimulation on one side of the brain will cause a contraction on the contralateral , or opposite, side of the body. [ 2 ]
More recent studies using CSM have shown that the motor cortex is more complex than the arrangement pictured traditional homunculus, and that motor responses occur in the frontal lobe further away from the narrow strip next to the central sulcus. [ 1 ]
Areas of the cortex that inhibit movement upon stimulation have been found in some cases to be supplemental and not vital to motor function. These areas have been removed without compromising a patient's ability to move post-operation. [ 1 ]
During stimulation various language tasks are used to check brain function such as reading sentences, auditory comprehension, and spontaneous speech such as naming objects. [ 1 ] Cortical stimulation in language areas of the brain typically tests for the inhibition of some language capability, rather than a defined motor or sensory response. This can make language mapping require more complex language-related tasks to be assessed during testing, in order to determine if the site that is stimulated is essential to a certain language ability. [ 6 ]
Language mapping is normally done in the left hemisphere of the brain where most language areas are located, such as Broca's and Wernicke's areas. Cortical stimulation mapping has also identified a language area in the basal temporal cortex that was previously unknown. [ 6 ]
Cortical stimulation mapping in patients with epilepsy has shown that critical language areas of the brain vary greatly in patients, highlighting the need to perform accurate mapping prior to surgeries in language areas. [ 9 ] Traditional landmarks such as Broca's and Wernicke's areas cannot be relied on to distinguish essential language cortex. Rather, experiments that have tested for vital language sites are variable, and the exact role of a specific cortex area in a language task is difficult to judge. A further complication is that many patients who have undergone language mapping have epilepsy, which often alters the localization of cortical areas due to the neuroplastic response to cortical insult caused by the patient's seizures. [ 10 ] Since the procedure is so invasive, cortical stimulation mapping for language organization is not done on healthy individuals. Additionally the distribution and abundance of specific task-related language sites have shown variation based on IQ and gender. [ 6 ]
Somatosensory mapping involves measuring electrical responses on the surface of the brain as the result of the stimulation of peripheral nerves , such as mechanoreceptors that respond to pressure on the skin, and stimulating the brain directly to map sensory areas. Sensation has been tested in patients through the stimulation of the postcentral gyrus, with a drop in amplitude of sensory responses occurring towards the central sulcus. [ 2 ]
CSM is an effective treatment for focal epilepsy and bilateral or multiple seizure foci. [ 11 ] It is an effective treatment option when resective surgery to remove the affected area is not an option, generally seen with bilateral or multiple seizure foci. [ 11 ] CSM is routinely utilized for patients with epilepsy in order to pin point the focal point of the seizures . It is used once there is a testable hypothesis regarding brain location for the epileptogenic zone, determined through a less invasive procedure, electroencephalography . Once the focal point of the seizures is determined, this information allows aids neurosurgeons with knowing what portions of the brain could potentially be resected without any negative post-operative neurological deficits. [ citation needed ]
CSM will be considered for a patient with epilepsy when two conditions are met: the trial of anti-epileptic drugs has not controlled seizures and there is a likelihood that the surgery will benefit the patient. [ 4 ] Due to the nature of the procedure, CSM is only utilized after noninvasive procedures have not been able to fully localize and treat the patient. [ 12 ]
The invasive electrodes are stereotaxically placed electrodes or a subdural strip or grid electrode. [ 12 ] Utilizing the information obtained through CSM, limited resection of epileptogenic brain can be performed. [ 4 ] For focal epilepsy, resective surgery is one of the mainstay treatment options for medication resistant epilepsy. [ 11 ] Through the technique of CSM, generally using awake craniotomies, the neurosurgeon has the ability to monitor the functioning of the patient during the resection and stimulation of the brain.
Cortical stimulation mapping may be used in neuro-oncology as a tool to identify the areas of a patient's brain that are critical for functions such as the language and motor pathways. [ 13 ] This procedure is considered standard for operations involving gliomas in order to reduce loss of motor function and overall morbidity. Pre-surgical planning allows for the physician to avoid these high-risk areas as much as possible during a tumor resection, minimizing potential loss of function and development of sequelae . [ 14 ]
Patients whose surgeon uses cortical stimulation mapping to assess the anatomy and function of rolandic areas have a greater chance and faster rate of regaining baseline function post-operatively than those who undergo surgeries that avoid this technique. [ 15 ] The same may be said for the benefits of mapping language areas with the cortical stimulation technique before a glioma resection. Assessing and minimizing the damage of operating on language-involved regions leads to the greater and faster return of overall language function. [ 16 ]
Despite the functional gain from preserving these eloquent cortical areas, benefit-to-risk factors are still considered. More complete tumor resection has been shown to possibly expand the life expectancy of glioma patients; however, increasing the amount of brain tissue removed may also cause a debilitating decrease in function. As such, cortical stimulation mapping aids in determining the maximum amount of tissue that can be removed while still maintaining the patient's quality of life. [ 17 ]
Mapping of the occipital cortex has possible use in the development of a prosthesis for the blind. Electrical stimulation in the occipital lobe has been found to cause visual illusions called phosphenes such as light, colors, or shadows, which were observed in the early experiments of Penfield and Jasper . [ 1 ] The first recorded production of artificial sight was in experiments done by Brindley and Dobelle, where they were able to allow blind patients to 'see' small characters through cortical stimulation. [ 18 ] Electrical stimulation in the occipital lobe has also been known to produce small colored circles usually in the center of the patient's field of vision. [ 1 ] Visual hallucinations, such as moving geometric patterns and moving colored phosphenes have also been observed with cortical stimulation. Electrodes at the occipital cortex surface tend to produce flickering phosphenes, while electrodes inserted deeper within the cortex produce steady colors. [ 19 ] The primary visual cortex , which is responsible for generating more complex images, is located deeper within the calcarine fissure of the occipital lobe, so intracortical stimulation is needed to stimulate these areas effectively. Intracortical stimulation uses an electrode that goes deeper into the brain to more effectively stimulate the primary visual cortex, as opposed to trying to work only from the surface of the brain, which can cause unintended visual signals, pain, and damage to the nervous tissue. [ 18 ]
For patients with glaucoma and optic nerve atrophy, existing retinal prostheses are not an option since the optic nerve is damaged, therefore a prosthesis using cortical stimulation is a remaining hope to offer some vision function. A cortical visual prosthesis is a promising subject of research because it targets neurons past the site of disease in most blind patients. However, significant challenges remain such as reproducibility in different patients, long-term effects of electrical stimulation, and the higher complexity of visual organization in the primary visual cortex versus that in the retina . [ 18 ]
Another site of research for a vision prosthesis using cortical stimulation is the optic nerve itself, which contains the nerve fibers responsible for the complete visual field. Research is still ongoing in this area and the small size of the optic nerve and the high density of nerve fibers are continuing challenges to this approach [ 18 ]
Cortical stimulation mapping (CSM) is considered the gold standard for mapping functional regions of the brain to create a presurgical plan that maximizes the patient's functional outcome. [ 3 ] The history of beneficial outcomes and the amount of information already established about the CSM technique makes it advantageous in clinical and research applications. However, because it has the drawback of being an intraoperative technique, there is growing debate about its status as the preferred method. Instead, transcranial magnetic stimulation (TMS), a new [ when? ] procedure that does not carry the same amount of surgical risk, is being considered. [ by whom? ]
Transcranial magnetic stimulation has been gaining increasing interest as an alternative tool for studying the relationships between specific cortical areas and brain function, particularly because its non-invasive nature is advantageous over CSM. [ 20 ] Additionally, because of the increasing body of research focused on investigating the many medical uses of TMS, it could eventually have more applications than CSM. For example, this procedure been successfully used to measure the speed of conduction in central motor pathways, making it a useful tool for those studying multiple sclerosis . [ 21 ] Similarly, TMS is also being researched for its possibilities as a long-term and possibly more cost-effective therapeutic alternative for treating chronic psychiatric disorders such as major depression [ 22 ] as well as its use as a means of in aiding in stroke recovery. [ 23 ] However, although therapeutic TMS is promising overall, its success is still unclear and has not been upheld in a number of studies. This is true relating to studies of Parkinson's patients who were given long-term TMS therapy. Although it initially appeared as if these subjects gained improved performance in motor coordination tests, these results are inconsistently reproducible. [ 24 ] The same type of results are seen in studies in schizophrenia where it has been shown that cognitive performance in schizophrenic patients treated with TMS is highly variable. Such results suggest that evidence of the effects of TMS are lacking and this technique's neurobiological mechanisms are still not well understood. [ 25 ] Because of these uncertainties, research on this method is ongoing and much is still to be determined about its exact effect on the activation state of the brain. Comparatively, CSM, having the advantages of the more researched technique, is often still preferred. [ by whom? ]
Safety must also be considered with respect to both methods. So far, [ when? ] Food and Drug Administration (FDA) guidelines have only approved the use of TMS for the treatment of depression. [ 26 ] Although this technique has no known lasting side effects except for a few reported cases of induced seizures, it is still treated with caution due to its relative novelty in clinical use. [ 27 ] CSM has gained U.S. FDA approval for its uses regarding cortical stimulation mapping, especially in cases of seizure and glioma treatments, and for aiding in the placement of electrodes within the brain. [ 28 ]
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Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates , as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids , are involved in a wide range of physiological processes, including stress response , immune response , and regulation of inflammation , carbohydrate metabolism , protein catabolism , blood electrolyte levels, and behavior. [ 1 ]
Some common naturally occurring steroid hormones are cortisol ( C 21 H 30 O 5 ), corticosterone ( C 21 H 30 O 4 ), cortisone ( C 21 H 28 O 5 ) and aldosterone ( C 21 H 28 O 5 ) (cortisone and aldosterone are isomers ). The main corticosteroids produced by the adrenal cortex are cortisol and aldosterone. [ 1 ]
The etymology of the cortico- part of the name refers to the adrenal cortex , which makes these steroid hormones. Thus a corticosteroid is a "cortex steroid". [ citation needed ]
Synthetic pharmaceutical drugs with corticosteroid-like effects are used in a variety of conditions, ranging from hematological neoplasms [ 3 ] to brain tumors or skin diseases . Dexamethasone and its derivatives are almost pure glucocorticoids, while prednisone and its derivatives have some mineralocorticoid action in addition to the glucocorticoid effect. Fludrocortisone (Florinef) is a synthetic mineralocorticoid. Hydrocortisone (cortisol) is typically used for replacement therapy, e.g. for adrenal insufficiency and congenital adrenal hyperplasia . [ citation needed ]
Medical conditions treated with systemic corticosteroids: [ 2 ] [ 4 ]
Topical formulations are also available for the skin , eyes ( uveitis ), lungs ( asthma ), nose ( rhinitis ), and bowels . Corticosteroids are also used supportively to prevent nausea, often in combination with 5-HT 3 antagonists (e.g., ondansetron ). [ citation needed ]
Typical undesired effects of glucocorticoids present quite uniformly as drug-induced Cushing's syndrome . Typical mineralocorticoid side-effects are hypertension (abnormally high blood pressure), steroid induced diabetes mellitus, psychosis, poor sleep, hypokalemia (low potassium levels in the blood), hypernatremia (high sodium levels in the blood) without causing peripheral edema , metabolic alkalosis and connective tissue weakness. [ 5 ] Wound healing or ulcer formation may be inhibited by the immunosuppressive effects.
A variety of steroid medications, from anti-allergy nasal sprays ( Nasonex , Flonase ) to topical skin creams, to eye drops ( Tobradex ), to prednisone have been implicated in the development of central serous retinopathy (CSR). [ 6 ] [ 7 ]
Corticosteroids have been widely used in treating people with traumatic brain injury . [ 8 ] A systematic review identified 20 randomised controlled trials and included 12,303 participants, then compared patients who received corticosteroids with patients who received no treatment. The authors recommended people with traumatic head injury should not be routinely treated with corticosteroids. [ 9 ]
Corticosteroids act as agonists of the glucocorticoid receptor and/or the mineralocorticoid receptor . [ citation needed ]
In addition to their corticosteroid activity, some corticosteroids may have some progestogenic activity and may produce sex-related side effects. [ 10 ] [ 11 ] [ 12 ] [ 13 ]
Patients' response to inhaled corticosteroids has some basis in genetic variations. Two genes of interest are CHRH1 ( corticotropin-releasing hormone receptor 1 ) and TBX21 ( transcription factor T-bet ). Both genes display some degree of polymorphic variation in humans, which may explain how some patients respond better to inhaled corticosteroid therapy than others. [ 14 ] [ 15 ] However, not all asthma patients respond to corticosteroids and large sub groups of asthma patients are corticosteroid resistant. [ 16 ]
A study funded by the Patient-Centered Outcomes Research Institute of children and teens with mild persistent asthma found that using the control inhaler as needed worked the same as daily use in improving asthma control, number of asthma flares, how well the lungs work, and quality of life. Children and teens using the inhaler as needed used about one-fourth the amount of corticosteroid medicine as children and teens using it daily. [ 17 ] [ 18 ]
Use of corticosteroids has numerous side-effects, some of which may be severe:
The corticosteroids are synthesized from cholesterol within the adrenal cortex . [ 1 ] Most steroidogenic reactions are catalysed by enzymes of the cytochrome P450 family. They are located within the mitochondria and require adrenodoxin as a cofactor (except 21-hydroxylase and 17α-hydroxylase ). [ citation needed ]
Aldosterone and corticosterone share the first part of their biosynthetic pathway. The last part is mediated either by the aldosterone synthase (for aldosterone ) or by the 11β-hydroxylase (for corticosterone ). These enzymes are nearly identical (they share 11β-hydroxylation and 18-hydroxylation functions), but aldosterone synthase is also able to perform an 18-oxidation. Moreover, aldosterone synthase is found within the zona glomerulosa at the outer edge of the adrenal cortex ; 11β-hydroxylase is found in the zona fasciculata and zona glomerulosa . [ citation needed ]
In general, corticosteroids are grouped into four classes, based on chemical structure. Allergic reactions to one member of a class typically indicate an intolerance of all members of the class. This is known as the "Coopman classification". [ 43 ] [ 44 ]
The highlighted steroids are often used in the screening of allergies to topical steroids. [ 45 ]
Hydrocortisone , hydrocortisone acetate , cortisone acetate , tixocortol pivalate , prednisolone , methylprednisolone , and prednisone .
Amcinonide , budesonide , desonide , fluocinolone acetonide , fluocinonide , halcinonide , triamcinolone acetonide , and Deflazacort (O-isopropylidene derivative)
Beclometasone , betamethasone , dexamethasone , fluocortolone , halometasone , and mometasone .
Alclometasone dipropionate , betamethasone dipropionate , betamethasone valerate , clobetasol propionate , clobetasone butyrate , fluprednidene acetate , and mometasone furoate .
Ciclesonide , cortisone acetate , hydrocortisone aceponate , hydrocortisone acetate , hydrocortisone buteprate , hydrocortisone butyrate , hydrocortisone valerate , prednicarbate , and tixocortol pivalate .
For use topically on the skin, eye, and mucous membranes .
Topical corticosteroids are divided in potency classes I to IV in most countries (A to D in Japan). Seven categories are used in the United States to determine the level of potency of any given topical corticosteroid.
For nasal mucosa, sinuses, bronchi, and lungs. [ 46 ]
This group includes:
There also exist certain combination preparations such as Advair Diskus in the United States, containing fluticasone propionate and salmeterol (a long-acting bronchodilator), and Symbicort , containing budesonide and formoterol fumarate dihydrate (another long-acting bronchodilator). [ 47 ] They are both approved for use in children over 12 years old.
Such as prednisone, prednisolone, methylprednisolone , or dexamethasone . [ 48 ]
Available in injectables for intravenous and parenteral routes. [ 48 ]
Tadeusz Reichstein , Edward Calvin Kendall , and Philip Showalter Hench were awarded the Nobel Prize for Physiology and Medicine in 1950 for their work on hormones of the adrenal cortex, which culminated in the isolation of cortisone . [ 55 ]
Initially hailed as a miracle cure and liberally prescribed during the 1950s, steroid treatment brought about adverse events of such a magnitude that the next major category of anti-inflammatory drugs, the nonsteroidal anti-inflammatory drugs (NSAIDs), was so named in order to demarcate from the opprobrium. [ 56 ]
Lewis Sarett of Merck & Co. was the first to synthesize cortisone, using a 36-step process that started with deoxycholic acid, which was extracted from ox bile . [ 57 ] The low efficiency of converting deoxycholic acid into cortisone led to a cost of US$200 per gram in 1947. Russell Marker , at Syntex , discovered a much cheaper and more convenient starting material, diosgenin from wild Mexican yams . His conversion of diosgenin into progesterone by a four-step process now known as Marker degradation was an important step in mass production of all steroidal hormones, including cortisone and chemicals used in hormonal contraception . [ 58 ]
In 1952, D.H. Peterson and H.C. Murray of Upjohn developed a process that used Rhizopus mold to oxidize progesterone into a compound that was readily converted to cortisone. [ 59 ] The ability to cheaply synthesize large quantities of cortisone from the diosgenin in yams resulted in a rapid drop in price to US$6 per gram [ when? ] , falling to $0.46 per gram by 1980. Percy Julian's research also aided progress in the field. [ 60 ] The exact nature of cortisone's anti-inflammatory action remained a mystery for years after, however, until the leukocyte adhesion cascade and the role of phospholipase A2 in the production of prostaglandins and leukotrienes was fully understood in the early 1980s. [ citation needed ]
Corticosteroids were voted Allergen of the Year in 2005 by the American Contact Dermatitis Society. [ 61 ]
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In bone surgery , a corticotomy is a cutting of the bone that may or may not split into two pieces ( bone fracture ). It involves only the cortex , leaving intact the medullary vessels and periosteum . Corticotomy is particularly important in distraction osteogenesis or surgically facilitated orthodontic therapy .
This surgery article is a stub . You can help Wikipedia by expanding it .
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The cortisol awakening response ( CAR ) is an increase between 38% and 75% in cortisol levels peaking 30–45 minutes after awakening in the morning in some people. [ 1 ] This rise is superimposed upon the late-night rise in cortisol which occurs before awakening. While its purpose is uncertain, it may be linked to the hippocampus ' preparation of the hypothalamic-pituitary-adrenal axis (HPA) in order to face anticipated stress. [ 2 ]
Shortly after awakening, a sharp 38–75% (average 50%) increase occurs in the blood level of cortisol in about 77% [ 3 ] of healthy people of all ages. [ 4 ] The average level of salivary cortisol upon waking is roughly 15 nmol/L; 30 minutes later it may be 23 nmol/L, though there are wide variations. [ 3 ] The cortisol awakening response reaches a maximum approximately 30 minutes after awakening though it may still be heightened by 34% an hour after waking. [ 3 ] The pattern of this response to waking is relatively stable for any individual. [ 3 ] [ 5 ] Twin studies show its pattern is largely genetically determined since there is a heritability of 0.40 for the mean cortisol increase after awakening and 0.48 for the area under the cortisol rise curve. [ 6 ]
Normally, the highest cortisol secretion happens in the second half of the night with peak cortisol production occurring in the early morning. Following this, cortisol levels decline throughout the day with lowest levels during the first half of the night. [ 7 ] Cortisol awakening response is independent of this circadian variation in HPA axis activity; it is superimposed upon the daily rhythm of HPA axis activity, and it seems to be linked specifically to the event of awakening. [ 8 ] [ 9 ]
Cortisol awakening response provides an easy measure of the reactivity capacity of the HPA axis. [ 10 ]
Cortisol awakening response is larger for those:
Cortisol is released from the adrenal glands following activation by ACTH release from the pituitary . The ACTH release creating the cortisol awakening response is strongly inhibited after intake of a low-dose dexamethasone . [ 31 ] This is a synthetic glucocorticoid and this inhibition allows the detection of the presence of negative feedback from circulating cortisol that controls to ACTH -secreting cells of the pituitary.
In the hypothalamic-pituitary-adrenal axis the pituitary release of ACTH is regulated by the hypothalamus . This occurs through the hypothalamus's production of the hypophysiotropic hormone corticotropin-releasing hormone , the production of which is subject to circadian influence and the day/night cycle. [ 32 ] In the cortisol awakening response, the hypothalamic-pituitary-adrenal axis is controlled by the hippocampus . For example, cortisol awakening response is absent in those with bilateral and unilateral hippocampus damage [ 33 ] and hippocampal atrophy . [ 34 ] Those with severe amnesia , and thus with presumed damage to the temporal lobe , also do not have it. [ 35 ] Those with a larger hippocampus have a greater response. [ 36 ]
It's plausible also that the suprachiasmatic nucleus , the light-sensitive biological clock, plays a role in cortisol awakening response regulation. [ 4 ]
The function of cortisol awakening response is unknown but it has been suggested to link with a stress-related preparation in regard to the upcoming day by the hippocampus. [ 37 ] One hypothesis is: "that the cortisol rise after awakening may accompany an activation of prospective memory representations at awakening enabling individual's orientation about the self in time and space as well as anticipation of demands of the upcoming day... it is tempting to speculate that for the CAR, anticipation of these upcoming demands may be essential in regulating the CAR magnitude for the particular day. The hippocampus is, besides its established role in long-term memory consolidation, involved in the formation of a cohesive construct and representation of the outside world within the central nervous system processing information about space, time and relationships of environmental cues. This puts the hippocampus in a pivotal position for the regulation of the CAR." [ 4 ]
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Cosmesis is the preservation, restoration, or bestowing of bodily beauty . [ 1 ] In the medical context, it usually refers to the surgical correction of a disfiguring defect, or the cosmetic improvements made by a surgeon following incisions . Its use is generally limited to the additional, usually minor, steps that the surgeon (who is generally operating for noncosmetic indications ) takes to improve the aesthetic appearance of the scars associated with the operation. Typical actions include removal of damaged tissue, mitigation of tension on the wound, and/or using fine (thin) sutures to close the outer layer of skin.
Cosmetic surgery is the portion of plastic surgery that concerns itself with the elective improvement of cosmesis.
The practice of cosmesis, the creation of lifelike limbs made from silicone or PVC [ citation needed ] , has grown in popularity. Such prosthetics , such as artificial hands, can now be made to mimic the appearance of real limbs, complete with freckles , veins, hair, fingerprints , and even tattoos . Custom-made silicone cosmeses are generally more expensive, costing thousands of US dollars depending on the level of detail. Standard cosmeses come ready-made in various sizes, though they are often not as realistic as their custom-made counterparts. Another option is the custom-made silicone cover, which can be made to match a person's skin tone , but not details such as freckles or wrinkles. Cosmeses are attached to the body using an adhesive, suction, form-fitting, stretchable skin, or a skin sleeve. Cosmeses act as a barrier from dirt, water and other particles, thus protecting the technology inside the glove.
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Cosmetic dentistry is generally used to refer to any dental work that improves the appearance (though not necessarily the functionality) of teeth, gums and/or bite. It primarily focuses on improvement in dental aesthetics in color, position, shape, size, alignment and overall smile appearance. [ 1 ] Many dentists refer to themselves as "cosmetic dentists" regardless of their specific education, specialty, training, and experience in this field. This has been considered unethical with a predominant objective of marketing to patients. [ 2 ] The American Dental Association does not recognize cosmetic dentistry as a formal specialty area of dentistry. [ 3 ] However, there are still dentists that promote themselves as cosmetic dentists.
Reliable Cosmetic Dentistry in Phoenix, AZ
There are primarily two dental specialties that predominantly focus on dental aesthetics: prosthodontics [ 4 ] and orthodontics . [ 5 ]
Cosmetic dentistry may involve:
Whitening , or "tooth bleaching", is the most common cosmetic dental procedure. Whitening is a safe process that is effective for most patients. Multiple whitening options are available, including over the counter products such as Crest Whitestrips , as well as dentist-supervised methods such as in-office treatments or at-home treatments involving trays with a peroxide gel.
Laser whitening is a teeth whitening technique in which gums are covered with a rubber dam and a bleaching chemical is applied on the teeth. A beam of argon laser, which is intended to accelerate the process of bleaching, is then projected upon the teeth. This laser activates the bleaching chemical and lightens the teeth color. [ 7 ] Laser whitening is said to be six times more effective in teeth whitening compared to other procedures.
Tooth reshaping removes parts of the enamel to improve the appearance of the tooth. It may be used to correct a small chip, or to alter the length, shape or position of teeth, as well as when there is tooth size discrepancy ; [ 8 ] [ 9 ] it can be used to correct crooked or excessively long teeth. The removed enamel is irreplaceable, and may sometimes expose dentin . It is also known as enameloplasty, odontoplasty, contouring , recontouring, cosmetic contouring, slenderizing, stripping. This procedure offers fast results and can even be a substitute for braces under certain circumstances. [ 10 ]
Bonding is a process in which an enamel -like dental composite material is color matched, applied to a tooth's surface, sculpted into proper tooth contour, hardened and then polished. This process utilizes dental adhesives, which are solutions of resin monomers that make the resin dental substrate interaction possible. They are mainly classified into two techniques: self-etch or etch-and-rinse. [ 11 ] An examples of a bonded restorations are inlays and onlays , which are used to repair decayed & cracked teeth. Teeth damaged by small to moderate decay, erosion, or small fractures can be repaired with direct composite restorations bonded to the teeth. Aesthetics are especially critical in anterior composite restorations .
Dental bridges are used to replace one or more missing teeth. Teeth on both sides of the space left by the missing teeth are prepared. [ 12 ] A bridge is made up of abutments, the teeth that are prepped, and the missing, false teeth, which are called pontics . [ 13 ] This procedure is used to replace one or more missing teeth and is cemented in. Bridges can consist of more than three teeth in total and the viability of any bridge is usually determined by applying Ante's Law and assessing where in the mouth the teeth are. [ citation needed ] Most bridges are fixed, they can not be removed. Fixed bridges cannot be taken out in the same way that partial dentures can. In areas of the mouth that are under less stress, such as the front teeth, a cantilever bridge may be used. Cantilever bridges or Maryland Bridges are used to replace anterior or front missing teeth, are minimally invasive but do have a reputation for failure. [ 14 ] Bridges require commitment to serious oral hygiene and carry risk. [ 15 ] The average life of bridges is similar to that of crowns which is nearly ten years. [ 16 ]
Veneers are ultra-thin, custom-made porcelain laminates that are bonded directly to the teeth. They are an option for closing gaps, enhance the shape, or change the color of teeth that do not respond well to whitening procedures. In the majority of the cases, some level of tooth reduction is necessary for optimal results. To achieve a pleasing smile, dentists fabricate diagnostic mock-ups, which act as a tooth preparation guide before the fabrication of veneers, [ 17 ] it allows the dentist to visualize the changes needed to be done on the patient's teeth with respect to size, shape and proportion, its relation with gingival-contour, lip contour and smile line. [ 18 ] Mock ups can be a great aid in fabricating pre-evaluation temporaries, which can give a preliminary evaluation to the esthetics, phonetics and teeth occlusion, in addition, it gives an opportunity to the clinicians to check if they need to do any corrections.
Dental implants are prosthetic replacements for missing teeth. According to ICOI ( International Congress of Oral Implantologists ) there are commonly three parts to what it is described as an implant: the implant device which is predominantly made of titanium (which is inserted into the bone), the abutment, and a dental crown or a denture which are connected to the implant through the abutment.
A gum lift is a cosmetic dental procedure that raises and sculpts the gum line. The procedure involves reshaping the tissue and/or underlying bones to create the appearance of longer or more symmetrical teeth. [ 19 ]
Metal braces are used primarily to correct crowded or misaligned teeth. While correcting issues such as jaw alignment are the primary purpose, they can also improve aesthetics. [ 20 ]
Clear aligners are used as an alternative to traditional metal braces. Clear aligners produce comparable results to metal braces and are preferred by some patients as they are less noticeable to others than traditional braces. [ 20 ]
Bite reclamation is for patients who have had years of excessive wear to their teeth due to grinding or acid reflux can alter their vertical dimension. This gives them a closed or shorter look to their face and smile. By opening up their bite, a qualified professional can reclaim their vertical dimension.
In the past, dental fillings and other tooth restorations were made of gold , amalgam and other metals—some of which were veneered with porcelain . [ citation needed ] Now, dental work can be made entirely of porcelain or composite materials that more closely mimic the appearance of natural tooth structure. These tooth-colored materials are bonded to the underlying tooth structure with resin adhesives. Unlike silver fillings (amalgams) they are entirely free of mercury. Cosmetic dentistry has evolved to cover many new procedures and new dental materials are constantly introduced.
The American Dental Association does not recognize cosmetic dentistry as a specialty. [ 21 ] Prosthodontics is the only dental specialty under which the concentration of cosmetic/esthetic dentistry falls. General dentists may perform some simple cosmetic procedures. Consequently, there are questions regarding whether it is ethical for general dentists to treat "smile makeovers" or complex cosmetic and full-mouth reconstruction cases, as they are not qualified to address the complex needs of the patient. [ 21 ] [ 22 ]
The American College of Prosthodontists is a not-for-profit organization representing prosthodontists within organized dentistry and to the public, with more than 3,700 members worldwide. Prosthodontics is one of the twelve dental specialties defined by the American Dental Association, which recognizes the American College of Prosthodontists as the national organization representing the prosthodontic specialty- the dental specialty of cosmetic / esthetic dentistry, implant dentistry and reconstructive dentistry.
Membership is open to individuals who have graduated from or are currently enrolled in an ADA-accredited advanced prosthodontics program. The ACP is the only prosthodontic specialty association where membership is based solely on education credentials. Certified dental laboratory technician and members of the prosthodontic academic community may become Alliance members of the college.
The American Academy of Cosmetic Dentistry (AACD) is the largest international dental organization in the world, composed of general dentists, specialists, and lab technicians focused on the art and science of cosmetic dentistry. Founded in 1984, the AACD has over 7,000 members in the United States and more than 70 countries around the globe. Members of the academy include dentists, dental laboratory technicians, educators, researchers, students, hygienists, corporations and dental auxiliaries. AACD members seek out continuing education through lectures, workshops, and publications in order to keep up-to-date with all of the advancements in cosmetic dental techniques and technology. In 1984, the AACD was formed and has filled the dire need for credentialing in cosmetic dentistry. The purpose of the American Board of Cosmetic Dentistry (ABCD) is the testing, analyzing, and evaluation of the services of dentists and laboratory technicians for the purpose of awarding AACD Accreditation in cosmetic dentistry. [ 23 ] However, this certification is not approved or recognized by the American Dental Association .
American Society For Dental Aesthetics:
Conceived in 1976, the American Society for Dental Aesthetics was developed with a single purpose in mind: continuing dental education to teach dental health professionals the most advanced aesthetic and restorative techniques available. To become a member of the ASDA, a dentist must show a minimum of five years in dental practice, or postgraduate training of two years in an approved program; attendance to at least two ASDA sponsored continuing dental education seminars; nomination by a member accompanied by two letters of recommendation by Society members; presentation of five (5) cases illustrating the concepts of aesthetic dentistry. [ 24 ]
Newell Sill Jenkins (1840–1919) was an American dentist who practiced most of his life in Dresden , Germany. [ 25 ] He developed the Jenkins porcelain enamel and improved, thus making a composition of the porcelain paste, porcelain inlays, dental crowns and bridges. Hence, he is regarded as the founder of aesthetic dentistry.
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Introduced in 1983, Cotrel–Dubousset Instrumentation is a treatment approach to scoliosis . Unlike Harrington rods , this treatment is more than just an osteodistraction mechanism and allows correction of some of the features of scoliosis untreatable by Harrington rods, such as rib hump. [ 1 ] [ 2 ]
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https://en.wikipedia.org/wiki/Cotrel–Dubousset_instrumentation
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Cotton wool consists of silky fibers taken from cotton plants in their raw state. Impurities, such as seeds, are removed and the cotton is then bleached using hydrogen peroxide or sodium hypochlorite and sterilized. It is also a refined product ( absorbent cotton in U.S. usage) which has medical , cosmetic and many other practical uses.
The first medical use of cotton wool was by Joseph Sampson Gamgee at the Queen's Hospital (later the General Hospital) in Birmingham , England . Although cotton wool is called cotton wool it is actually not wool at all. It is from the cotton plant. Most cotton comes from India, the United States, or China. Cotton plants prefer heavy soil to grow well.
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https://en.wikipedia.org/wiki/Cotton_wool
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Cough CPR is the subject of a hoax email that began circulating in 1999. [ citation needed ] It is described as a "resuscitation technique" in which through prolonged coughing and deep breathing every 2 seconds, a person suffering a cardiac dysrhythmia immediately before cardiac arrest can keep conscious until help arrives (or until the person can get to the nearest hospital). Neither the American Heart Association nor the American Red Cross endorses cough CPR during a heart attack. [ 1 ]
This confusion appears to revolve primarily over the public's failure to discriminate between a heart attack , cardiac arrest , and cardiac dysrhythmias. A heart attack occurs when an occlusion (e.g. blood clot) of an artery in the heart slowly causes tissue to die. This can result in chest pain and discomfort, and requires immediate medical attention to resolve the occlusion by emergency surgery or cardiac clot-busting drugs . A cardiac dysrhythmia is primarily an electrical problem within the heart, and is sometimes treated with electrolytes, vagal maneuver , or electrical cardioversion. Many dysrhythmias may herald an impending heart attack. [ medical citation needed ]
Cough CPR has been the subject of a series of chain email campaigns. These emails are typically of the following format: [ citation needed ] (See Snopes for this and other citation issues.) [1]
HOW TO SURVIVE A HEART ATTACK WHEN ALONE
Since many people are alone when they suffer a heart attack, this article seemed in order. Without help the person whose heart stops beating properly and who begins to feel Faint, has only about 10 seconds left before losing consciousness. However, these victims can help themselves by coughing repeatedly and very vigorously. A deep breath should be taken before each cough, and the cough must be deep and prolonged, as when producing sputum from deep inside the chest. A breath and a cough must be repeated about every two seconds without let up until help arrives, or until the heart is felt to be beating normally again. Deep breaths get oxygen into the lungs and coughing movements squeeze the heart and keep the blood circulating.
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https://en.wikipedia.org/wiki/Cough_CPR
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Council of Interstate Testing Agencies (CITA) is one of five examination agencies for dentists in the United States . The other examination agencies are, Central Regional Dental Testing Service , West Regional Examining Board , Northeast Regional Board of Dental Examiners , and Southern Regional Testing Agency . These were organized to standardize clinical exams for licensure.
The CITA examination is recognized for licensure in a total of twenty-six (26) states/territories.
Member states that help create the exam are: Alabama , Kentucky , Louisiana , North Carolina , West Virginia , and Puerto Rico .
Other states that accept the exam for licensure: Colorado , Kansas , Illinois , Maine , Massachusetts , Minnesota , Mississippi , Missouri , Montana , Nebraska , New Hampshire , New Mexico , North Dakota , Oregon , Pennsylvania , Puerto Rico , Texas , Vermont (dental only), Virginia , Washington (dental only), and Wisconsin
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https://en.wikipedia.org/wiki/Council_of_Interstate_Testing_Agencies
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A counterirritant is a substance which creates irritation or mild inflammation in one location with the goal of lessening discomfort and/or inflammation in another location. [ 1 ] This strategy falls into the more general category of counterstimulation .
Topical counter-irritants are non-analgesic, non-anesthetic substances or treatments used to treat pain. Capsaicin , menthol (mint oil), methyl salicylate , and camphor are examples of counterirritants. Heat and cold therapy and massage relieve pain by counterstimulation. [ citation needed ]
The US Food and Drug Administration defines a counterirritant as "An externally applied substance that causes irritation or mild inflammation of the skin for the purpose of relieving pain in muscles, joints and viscera distal to the site of application. They differ from the anesthetics , analgesics , and antipruritic agents, however, in that the pain relief they produce results from stimulation—rather than depression—of the cutaneous sensory receptors and occurs in structures of the body other than the skin areas to which they are applied as for example, in joints, muscles, tendons and certain viscera. The use of these products dates from antiquity." [ 2 ]
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https://en.wikipedia.org/wiki/Counterirritant
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A counterstain is a stain with colour contrasting to the principal stain, making the stained structure easily visible using a microscope .
Examples include the malachite green counterstain to the fuchsine stain in the Gimenez staining technique and the eosin counterstain to haematoxylin in the H&E stain . [ 1 ] In Gram staining , crystal violet stains only Gram-positive bacteria, and safranin counterstain is applied which stains all cells, allowing the identification of Gram-negative bacteria as well. An alternative method uses dilute carbofluozide. Counterstains are sometimes used to separate animals from organic detritus in microbiology studies.
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https://en.wikipedia.org/wiki/Counterstain
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Counterstimulation is a treatment for pain based on distraction.
A basic example is the practice of rubbing a fresh bruise, so that attention is paid to the sense of touch and pressure, rather than to the pain of the injury. [ 1 ] Liniment and "medicated" products containing menthol work in the same way, producing sensations such as heat or cold or strong odors.
Counterstimulation can also be applied to a remote part of the body.
Pain control can also be achieved by the use of electronic media , such as television or virtual reality .
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https://en.wikipedia.org/wiki/Counterstimulation
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Coupland's elevators (also known as chisels ) [ 1 ] [ 2 ] are instruments commonly used for dental extraction . They are used in sets of three each of increasing size and are used to split multi-rooted teeth and are inserted between the bone and tooth roots and rotated to elevate them out of the sockets. [ 3 ] The instruments were designed by Dr Douglas C W Coupland who qualified as a dental surgeon in Toronto in 1922 and spent most of his career practising dentistry in Ottawa where he specialised in dental extraction. [ 4 ] Coupland designed the instruments in the 1920s; they were manufactured by the Hu-Friedy company and sold from the early 1930s initially as sets of eight or twelve which were later reduced to three. [ 2 ] Coupland also designed a set of dental suckers with interchangeable tips. [ 2 ]
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https://en.wikipedia.org/wiki/Coupland's_elevators
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In medicine the term course generally takes one of two meanings, both reflecting the sense of " path that something or someone moves along...process or sequence or steps ":
A patient may be said to be at the beginning, the middle or the end, or at a particular stage of the course of a disease or a treatment. A precursor is a sign or event that precedes the course or a particular stage in the course of a disease, for example chills often are precursors to fevers. [ 5 ]
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https://en.wikipedia.org/wiki/Course_(medicine)
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Mialy Rajoelina
Covid-Organics (CVO) is an Artemisia -based drink that Andry Rajoelina , president of Madagascar , claims can prevent and cure Coronavirus disease 2019 (COVID-19). The drink is produced from a species under the Artemisia genus [ 1 ] [ 2 ] [ 3 ] from which artemisinin is extracted for malaria treatment. [ 4 ] [ 5 ] No publicly available clinical trial data supports the safety or efficacy of this drink.
Covid-Organics was developed and produced in Madagascar by the Malagasy Institute of Applied Research . Madagascar was the first country to decide to integrate Artemisia into COVID-19 treatment when the NGO Maison de l'Artemisia France contacted numerous African countries during the COVID-19 pandemic . At least one researcher from another part of Africa, Dr. Jérôme Munyangi of the Democratic Republic of the Congo , contributed. Some of the research on Artemisia , led by African scientists, had been carried out in France and Canada. [ 6 ] On 20 April 2020, Rajoelina announced in a television broadcast that his country had found "preventive and curative" cure for COVID-19. [ 7 ] [ 8 ] [ 9 ] Rajoelina publicly sipped from a bottle of Covid-Organics and ordered a nation-wide distribution to families. [ 10 ] In 2022, Covid-Organics is not recommended by the WHO . [ 11 ]
On 20 May 2020, Rajoelina announced on his Twitter account that the World Health Organization (WHO) will sign a confidentiality agreement with Madagascar regarding the formulation of CVO in order to perform clinical observation . On 21 May 2020, WHO director general Tedros Adhanom confirmed his video conference with Rajoelina, and that the WHO will cooperate with Madagascar on research and development of COVID-19 therapy. [ 12 ] The WHO does not recommend the use of non-pharmaceutical Artemisia plant matter. [ 13 ] The official position of WHO is that it "supports scientifically-proven traditional medicine" [ 14 ] and "recognizes that traditional, complementary and alternative medicine has many advantages". [ 15 ]
A wide range of scientific criticism followed the launch of Covid-Organics from within and outside Africa. Before cooperating with Madagascar, the World Health Organization (WHO) issued a warning against use of an untested COVID-19 remedy and said Africans deserve medicine that went through proper scientific trials. At the time, Covid-Organics efficacy and safety was tested on fewer than 20 people within a period of three weeks. [ 16 ] [ 17 ] [ 18 ] In order to meet established scientific standards, the two parties later agreed on a partnership for Covid-Organics to be registered for WHO's Solidarity trials , an international program for fast tracking clinical trials on COVID-19 treatment candidates. [ 19 ] The African Union (AU) demanded detailed scientific data on Covid-Organics for analysis by Africa CDC after it had been briefed by Madagascar authorities about the herbal remedy. [ 20 ] [ 21 ] [ 22 ] Africa Centres for Disease Control and Prevention expressed its interest in data for Covid-Organics for the purpose of quickly scaling up an effective and safe remedy. [ 23 ] In April, the Economic Community of West African States (ECOWAS) denied ordering a package of CVO after media reports that it had ordered for CVO and said the West Africa Health Organization (WAHO) would only endorse products shown to be effective and safe for use through well-known scientific procedure. [ 24 ] [ 25 ] [ 26 ] As concerns about the safety of CVO grow, South Africa offered to help Madagascar conduct a clinical trial on the herbal tonic. [ 27 ]
There are concerns over widespread usage of Artemisia accelerating drug resistance toward ACTs for malaria treatment. [ 28 ]
More than 19 African and Caribbean countries have taken delivery of CVO as of May 2020 to combat COVID-19. [ 29 ] [ 30 ] On 20 May, Ghanaian government finally placed an order for CVO for testing after weeks of pressure from Ghanaians that the herbal remedy be used to halt the spread of Coronavirus. [ 31 ] [ 32 ] At the end of April, Equatorial Guinea , among the first to express support for the remedy, sent a special envoy to Madagascar for a donated shipment of CVO. [ 33 ] Madagascar sent quantities of the product to at least 10 African countries in 2020. [ 34 ]
On 2 October 2020, President Andry Rajoelina inaugurated a medical factory named "Pharmalagasy" and officially started to produce CVO pills named "CVO-plus". [ 35 ] [ 36 ]
On 5 July 2021, WHO issued a statement announcing the completion of phase 3 clinical trials of the CVO+ dry capsule at the National Center for the Application of Pharmaceutical Research (CNARP) of Madagascar, indicating that the results will be reviewed by the Regional Expert Advisory Committee formed in partnership with Africa CDC . The committee will advise the manufacturer on the next steps to take. [ 15 ]
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The Cox maze procedure , also known as maze procedure , is a type of heart surgery for atrial fibrillation .
"Maze" refers to the series of incisions arranged in a maze -like pattern in the atria . Today, various methods of minimally invasive maze procedures, collectively named minimaze procedures , are used.
James Cox is an American cardiothoracic surgeon. Cox received his medical degree at University of Tennessee Medical Center and completed his training in both General and Cardiothoracic Surgery at Duke University Hospital . Cox and his associates at Duke, and later at Washington University School of Medicine developed the "maze" or "Cox maze" procedure, an "open-heart" cardiac surgery procedure intended to eliminate atrial fibrillation (AF).
Incidence of stroke in patients with AF who are anticoagulated is still around 2-5% per year. The first such procedure was performed by Dr. Cox at St. Louis' Barnes Hospital—now Barnes-Jewish Hospital —in 1987. [ 1 ]
The intention was to eliminate AF by using incisional scars to block abnormal electrical circuits (atrial macroreentry) that initiate and perpetuate the abnormal electrical waves of AF. This required an extensive series of full-thickness incisions through the walls of both atria, a median sternotomy (vertical incision through the sternum), and cardiopulmonary bypass (heart-lung machine; extracorporeal circulation ). After the introduction of the initial procedure, a series of improvements were made, culminating in 1992 in the Cox maze III procedure, which is now considered to be the "gold standard" for effective surgical cure of AF. It was quite successful in eliminating AF but had drawbacks as well. [ 2 ] The Cox maze III is sometimes referred to as the "traditional maze", the "cut-and-sew maze", or simply the "maze." [ citation needed ] Damiano and colleagues have described a Cox-Maze IV procedure in 2002 in which they modified the Cox-Maze III technique using a combination of bipolar radiofrequency and cryothermal ablation lines. [ 3 ] Since then, the Cox-Maze IV procedure is the gold standard surgical treatment for AF with conversion to normal sinus rhythm and freedom from AF at 1 year postoperatively of 93%, [ 4 ] [ 5 ] but the results are institution dependent. [ 6 ]
During the past 10 years, [ when? ] several energy sources, such as unipolar radiofrequency, bipolar radiofrequency, microwave, laser, high-intensity focused ultrasound, and cryothermia, were incorporated into various devices in order to create some of the lesions of the Cox maze III procedure without actually cutting into the atrial walls . Microwave and laser therapy have both been withdrawn from the market, but the other devices continue to be utilized to treat AF surgically. [ citation needed ]
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Coxsackie B is a group of six serotypes of coxsackievirus (CVB1-CVB6), a pathogenic enterovirus , that trigger illnesses ranging from a mild febrile rash to full-fledged pericarditis and myocarditis ( coxsackievirus-induced cardiomyopathy ). [ 1 ] [ 2 ]
The genome of Coxsackie B virus consists of approximately 7,400 base pairs. [ 3 ]
The various members of the Coxsackie B group were discovered almost entirely in the United States, appearing originally in Connecticut , Ohio , New York , and Kentucky , although a sixth member of the group has been found in the Philippines . [ 1 ] However, all six serotypes have a global distribution and are a relatively common cause of gastrointestinal upset. The name reflects the first isolation from Coxsackie, New York . [ citation needed ]
Infections are most commonly spread by the Fecal-oral route , emphasizing the importance of good hygiene, especially hand-washing. [ 2 ] Oral-oral and respiratory droplets can also be means of transmission. [ 4 ]
Coxsackie B infections have been reported to account for nearly a quarter of all enterovirus infections. [ 5 ] Nearly half of all reported cases of Coxsackie B infections occur before the age of five. [ 5 ] For the CBV1 serotype, two-thirds of Centers for Disease Control and Prevention reported infections in the United States were for children under one year of age. [ 4 ]
Symptoms of infection with viruses in the Coxsackie B grouping include fever , headache , sore throat , gastrointestinal distress, extreme fatigue as well as chest and muscle pain . It can also lead to spasms in arms and legs. This presentation is known as pleurodynia or Bornholm disease in many areas. Patients with chest pain should see a doctor immediately—in some cases, viruses in the Coxsackie B family progress to myocarditis or pericarditis, which can result in permanent heart damage or death. Coxsackie B virus infection may also induce aseptic meningitis . As a group, they are the most common cause of unexpected sudden death , and may account for up to 50% of such cases. [ 6 ] The incubation period for the Coxsackie B viruses ranges from 2 to 6 days, and illness may last for up to 6 months in extreme cases, but may resolve as quickly as two days. Infection usually occurs between the months of May and June, but do not show symptoms until October in temperate Northern Hemisphere regions. People should ideally spend 1 month resting during the height of infection. Another cause of this virus is from a dirty wound from an accident. [ 1 ]
Enterovirus infection is diagnosed mainly via serological tests such as ELISA [ 7 ] and from cell culture . [ 1 ] Because the same level and type of care is given regardless of type of Coxsackie B infection, it is mostly unnecessary for treatment purposes to diagnose which virus is causing the symptoms in question, though it may be epidemiologically useful. [ citation needed ]
Coxsackie B infections usually do not cause serious disease, although for newborns in the first 1–2 weeks of life, Coxsackie B infections can easily be fatal. [ 2 ] The pancreas is a frequent target, which can cause pancreatitis . [ 2 ]
Coxsackie B3 (CB3) infections are the most common enterovirus cause of myocarditis and sudden cardiac death . [ 8 ] CB3 infection causes ion channel pathology in the heart, leading to ventricular arrhythmia . [ 8 ] Studies in mice suggest that CB3 enters cells by means of toll-like receptor 4 . [ 9 ] Both CB3 and CB4 exploit cellular autophagy to promote replication . [ 9 ]
The B4 Coxsackie viruses (CB4) serotype was suggested to be a possible cause of diabetes mellitus type 1 (T1D). [ 10 ] An autoimmune response to Coxsackie virus B infection upon the islets of Langerhans may be a cause of T1D. [ 2 ]
Other research implicates strains B1, A4, A2 and A16 in the destruction of beta cells , [ 11 ] [ 12 ] with some suggestion that strains B3 and B6 may have protective effects via immunological cross-protection.
As of 2008 [update] , there is no well-accepted treatment for the Coxsackie B group of viruses. [ 1 ] Palliative care is available, however, and patients with chest pain or stiffness of the neck should be examined for signs of cardiac or central nervous system involvement, respectively. Some measure of prevention can usually be achieved by basic sanitation on the part of food-service workers, though the viruses are highly contagious. Care should be taken in washing ones hands and in cleaning the body after swimming. In the event of Coxsackie-induced myocarditis or pericarditis, anti-inflammatories can be given to reduce damage to the heart muscle. [ citation needed ]
Enteroviruses are usually only capable of acute infections that are rapidly cleared by the adaptive immune response. [ 13 ] [ 14 ] However, mutations which enterovirus B serotypes such as coxsackievirus B and echovirus acquire in the host during the acute phase can transform these viruses into the non-cytolytic form (also known as non-cytopathic or defective enterovirus). [ 15 ] This form is a mutated quasispecies [ 13 ] of enterovirus which is capable of causing persistent infection in human tissues, and such infections have been found in the pancreas in type 1 diabetes, [ 16 ] [ 17 ] in chronic myocarditis and dilated cardiomyopathy , [ 18 ] [ 13 ] [ 19 ] in valvular heart disease, [ 20 ] in myalgic encephalomyelitis , [ 21 ] [ 22 ] and in Sjögren's syndrome. [ 23 ] In these persistent infections, viral RNA is present at very low levels, and some researchers believe it is just a fading remnant of the acute infection [ 14 ] although others scientists believe this persistent viral RNA may have pathological effects and cause disease. [ 24 ]
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Coxsackieviruses -induced cardiomyopathy are positive-stranded RNA viruses in picornavirus family and the genus enterovirus , acute enterovirus infections such as Coxsackievirus B3 have been identified as the cause of virally induced acute myocarditis , resulting in dilated cardiomyopathy . [ 1 ] Dilated cardiomyopathy in humans can be caused by multiple factors including hereditary defects in the cytoskeletal protein dystrophin in Duchenne muscular dystrophy (DMD) patients). A heart that undergoes dilated cardiomyopathy shows unique enlargement of ventricles, and thinning of the ventricular wall that may lead to heart failure. In addition to the genetic defects in dystrophin or other cytoskeletal proteins, a subset of dilated cardiomyopathy is linked to enteroviral infection in the heart, especially coxsackievirus B. Enterovirus infections are responsible for about 30% of the cases of acquired dilated cardiomyopathy in humans. [ 2 ]
Coxsackievirus shows a cardiac tropism partly due to the high expression of coxsackievirus and adenovirus receptors (CAR) in cardiomyocytes. [ 3 ] Coxsackievirus B genome is approximately 7.4 Kb and translated as a polycistronic polyprotein. Upon translation, the polyprotein is cleaved by two essential viral proteases, 2A and 3C. The viral protease 2A cleaves the proteins in a sequence specific manner. These viral proteases can also act on host proteins exerting negative effects on the residing cell. Enteroviral protease 2A can cleave the cytoskeletal dystrophin protein in cardiomyocytes disrupting the dystrophin glycoprotein (DCG) complex. The cleavage site of dystrophin by protease 2A occurs in the hinge 3 region of the protein resulting a disruption of DCG complex and loss of sarcolemma integrity and increasing myocyte permeability. This eventually results in similar cardiac deformities observed in dilated cardiomyopathy caused by hereditary defects in dystrophin in DMD patients. Additionally, dystrophin deficiency has been shown to increase the severity in dilated cardiomyopathy in a mouse model for DMD. The increased susceptibility of dystrophin deficient heart to coxsackievirus-induced dilated cardiomyopathy is attributed to more efficient release of the virus from infected cells resulting an increase in viral-mediated cytopathic effects. [ 4 ]
Viral-induced dilated cardiomyopathy can be characterized using different methods. A 2011 study showed in coxsackievirus infected heart proteome , increased levels of fibrotic extracellular matrix proteins and reduced amounts of energy-producing enzymes can be observed suggesting they could be characteristic in enteroviral cardiomyopathy. [ 5 ]
There are notable differences between the hereditary dilated cardiomyopathy in DMD and acute coxsackieviral-mediated cardiomyopathy. [ 6 ]
Coxsackie-induced cardiomyopathy is a potential result of virally induced myocarditis. This cardiomyopathy may present with symptoms such as chest pain, fatigue, heart failure, cardiogenic shock, arrhythmias or sudden death. [ 7 ] These symptoms are a by-product of sustained cardiac muscle damage.
If Coxsackie-induced cardiomyopathy worsens to heart failure, this may result in systolic dysfunction, with further complications including mitral and tricuspid valve regurgitation and arrhythmias. [ 8 ]
A wide variety of treatment modalities are currently recommended including Immunosuppressive agents , intravenous immunoglobulins (IVIG) , and antiviral agents although the effectiveness of these treatments are not well established and no specific treatment is available. [ 9 ]
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https://en.wikipedia.org/wiki/Coxsackievirus-induced_cardiomyopathy
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Cramp fasciculation syndrome (CFS) is a rare [ 1 ] peripheral nerve hyperexcitability disorder. It is more severe than the related (and common) disorder known as benign fasciculation syndrome ; it causes fasciculations , cramps, pain, fatigue, and muscle stiffness similar to those seen in neuromyotonia (another related condition). [ 2 ] Patients with CFS, like those with neuromyotonia, may also experience paresthesias .
Most cases of cramp fasciculation syndrome are idiopathic , [ 3 ] although some research points to an autoimmune component that may be partly genetic in etiology. [ 4 ] Cramp fasciculation syndrome is diagnosed by clinical examination and electromyography (EMG). [ 5 ] Fasciculation is the only abnormality [ 6 ] (if any) [ 7 ] seen with EMG.
Cramp fasciculation syndrome is a chronic condition. [ 8 ] Treatment options include anti-seizure medications such as carbamazepine , immunosuppressive drugs and plasmapheresis .
Symptoms are very similar to those found in benign fasciculation syndrome and include: [ 9 ]
The procedure of diagnosis for Cramp Fasciculation Syndrome (CFS) is closely aligned with the diagnosis procedure for benign fasciculation syndrome (BFS). The differentiation between a diagnosis of BFS versus CFS is usually more severe and prominent pain, cramps and stiffness associated with CFS. [ citation needed ]
Treatment is similar to treatment for benign fasciculation syndrome . [ citation needed ]
Carbamazepine therapy has been found to provide moderate reductions in symptoms. [ 9 ]
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https://en.wikipedia.org/wiki/Cramp_fasciculation_syndrome
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Auscultation , a medical neurological procedure , can be performed upon the skull to check for intracranial bruits . Such a bruit may be found in such conditions as cerebral angioma, tumour of the glomus jugulare , intracranial aneurysm , meningioma , occlusion of the internal carotid artery, or increased intracranial pressure . [ citation needed ]
The following extract details a method of performing cranial auscultation:
A bruit should be listened for, in quiet surroundings, over the skull and eyeballs, the latter situation being the most favourable for hearing the softest ones. The patient should be asked to close both eyes gently and the stethoscope firmly applied over one eye. During auscultation the other eye should be opened as in this way there is considerable diminution of eyelid flutter, which may cause confusion if rhythmical. Auscultation is then carried out over the other eye in a similar manner. If a murmur is not readily heard the patient should be asked to hold his breath. Finally auscultation should be carried out over the temporal fossæ and mastoid processes . [ 1 ]
This neuroscience article is a stub . You can help Wikipedia by expanding it .
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https://en.wikipedia.org/wiki/Cranial_auscultation
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A cranial drill , also known as a craniotome , is a tool for drilling simple burr holes (trepanation) or for creating larger openings in the skull . This exposes the brain and allows operations like craniotomy and craniectomy to be done. The drill itself can be manually or electrically driven, and primarily consists of a handpiece and a drill bit , which is a sharp tool that has a form similar to Archimedes' screw ; this instrument must be inserted into the drill chuck to perform holes and remove materials. The trepanation tool is generally equipped with a clutch which automatically disengages once it touches a softer tissue, thus preventing tears in the dura mater . For larger openings, the craniotome is an instrument that has replaced manually pulled saw wires in craniotomies from the 1980s.
The oldest evidence of a hole being applied on a human's brain with a drill dates from c. 4000 B.C. [ 1 ] The oldest cranial drilling instrument was found in France, and subsequent use was evidenced by the Ancient Romans, Egyptians, and in Trepanation in Mesoamerica . The practice of trepanning is also evidenced in Ancient Greece , North and South America , Africa , Polynesia and the Far East . The conceivable reasons why ancient humans developed the technique of drilling the head could be religious, ritual or medical factors. [ 2 ] The first trepanning procedure consisted of different types of tools and techniques: at the beginning the only material that was available for use, it was a sharp and carved rock. The development of The Hippocratic Corpus , written in the fifth century B.C., is the first written source that can be found about trepanning. The aim of the procedure described in "On Wounds in the Head" was to allow the stagnant blood to escape from the head through a hole. The drill that was used at the time is similar to modern ones but was operated by hand rotation. [ 3 ]
In the 15th century, people began to believe that drilling was a cure for mental problems due to a magical stone of madness or stone of folly in the head, which had to be removed. Paintings that portray this practice exist, the most significant ones include The Extraction of the Stone of Madness c. 1488–1516 by Hieronymus Bosch and A Surgeon Extracting the Stone of Folly by Pieter Huys . [ 4 ]
From the Renaissance ages, cranial drilling continued to evolve and surgical practice was used less due to the high mortality rate. It was used only for some interventions, such as the treatment of hemorrhages, depressed fractures and penetrating the head. Also, the name for the surgery changed from trepanning to craniotomy.
In the late 1860s, the archaeologist E.G. Squier discovered a skull in an ancient Inca cemetery. This specific skull was anticipated to be of the pre-Columbian era . The skull exhibited a large rectangle-shaped hole on the top. The skull was brought it back to the United States , and his findings were presented to the New York Academy of Medicine . Squier argued that the brain was injected with a tool called a burin which was used on woods and metals before. Traces showed human hand prints. He concluded that the skull and brain evidenced recovery from prehistoric brain surgery, potentially prolonging the patient's life. [ 5 ]
Metallurgy was a technique that allowed the use of saws and scalpels . Other cultures came about experimenting through the usage of glass. [ 4 ]
A cranial drill is currently used for neurosurgery operations. The procedure of trepanning is applied to patients who suffer, for example, a traumatic brain injury or a stroke . In these cases, it might be necessary to drill a hole in the skull to be able to access the dura mater or the brain itself, and to relieve brain pressure or blood clots. [ 6 ] With the use of modern types of cranial drills, surgeons are able to create holes in the bone structure without traumatizing underlying brain tissue. [ 7 ] The drill's working tooltip consists of a spiral blade that is framed by a guard device with an angled cranium guide that rests against the inner layer of the skull bone. The dura guard pushes the dura mater downward while the craniotome is moved forward thus preventing dural tearing. [ 8 ]
A cranial drill is an essential instrument used by surgeons to drill into the skull bone.
Various types of drills are used by surgeons for the craniotomy, or oral surgeries . The cranial drill can be differentiated by the examinations of what kind of surgery have to be performed. They can be manually operated, operated by electricity, or by pneumatic motors .
The rotating crank is typically connected to several cogs that set pressure on the skull. This specific drill is not connected to any external power and is used very little in today's operations. [ 9 ] The manual cranial drill is the most used and predominant type of drill in surgery , and performs manually. It has an adjusted stopper based on the setting and where the bone is thickest to prevent plunging. Surgeons use this drill manually without any other procedures, and can require substantial upper-body strength.
The electric cranial drill is powered either by a battery or by electricity via wall sockets .
The pneumatic motor is known for its great speed, which makes surgery much easier and faster. It is driven by expanding compressed air. The use of this kind of mechanism has many advantages such as the ease of use through high peak velocities. Thanks to superior torque, this system has great performance and it is essential for complex revision operations. The surgical procedure is shorter than usual, so patients spend less time under anesthesia . [ 10 ] Pneumatic high-speed craniotomes usually run at 40,000 to 80,000 rpm and have greatly facilitated intracranial approaches in neurosurgery . They are also employed to temporarily remove the vertebral arch in laminotomy . [ 10 ]
Technological progress to reduce surgery time and minimize risks for patients during surgery have been introduced in the field of cranial drills, primarily from machining .
CAD/CAM stands for computer-aided design/computer-aided manufacturing . In the medical field, as well, it is used by surgeons to simplify and ease surgeries: in the case of trepanning, a processor collects information from 2D images and then turns them into 3D images. The processor codifies this information so that the drill can, without any trouble, pierce the correct portion of the skull. [ 11 ]
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https://en.wikipedia.org/wiki/Cranial_drill
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The cranial nerve exam is a type of neurological examination . It is used to identify problems with the cranial nerves by physical examination . It has nine components. Each test is designed to assess the status of one or more of the twelve cranial nerves (I-XII). These components correspond to testing the sense of smell (I), visual fields and acuity (II), eye movements (III, IV, VI) and pupils (III, sympathetic and parasympathetic), sensory function of face (V), strength of facial (VII) and shoulder girdle muscles (XI), hearing and balance (VII, VIII), taste (VII, IX, X), pharyngeal movement and reflex (IX, X), tongue movements (XII).
The first test is for the olfactory nerve . Smell is tested in each nostril separately by placing stimuli under one nostril and occluding the opposing nostril. The stimuli used should be non-irritating and identifiable. Some example stimuli include cinnamon , cloves , and toothpaste . Loss of the sense of smell is called anosmia and can be either unilateral or bilateral. Bilateral loss can occur with rhinitis , smoking , or aging . Unilateral loss indicates a possible nerve lesion or deviated septum. This test is usually skipped on a cranial nerve exam. [ 1 ]
The short axons of the first cranial nerve regenerate on a regular basis. The neurons in the olfactory epithelium have a limited life span, and new cells grow to replace the ones that die off. The axons from these neurons grow back into the CNS by following the existing axons—representing one of the few examples of such growth in the mature nervous system. If all of the fibers are sheared when the brain moves within the cranium, such as in a motor vehicle accident, then no axons can find their way back to the olfactory bulb to re-establish connections. If the nerve is not completely severed, the anosmia may be temporary as new neurons can eventually reconnect. [ 2 ]
Vision via the optic nerve is examined both in fields of vision, and in clarity of vision.
The three nerves that control the extraocular muscles are the oculomotor nerve (CN III), the trochlear nerve (CN IV), and the abducens nerve (CN VI). As the name suggests, the abducens nerve is responsible for abducting the eye, which it controls through contraction of the lateral rectus muscle . The trochlear nerve controls the superior oblique muscle to rotate the eye along its axis in the orbit medially, which is called intorsion , and is a component of focusing the eyes on an object close to the face. The oculomotor nerve controls all the other extraocular muscles, as well as a muscle of the upper eyelid. Movements of the two eyes need to be coordinated to locate and track visual stimuli accurately. When moving the eyes to locate an object in the horizontal plane, or to track movement horizontally in the visual field, the lateral rectus muscle of one eye and medial rectus muscle of the other eye are both active. The lateral rectus is controlled by neurons of the abducens nucleus in the superior medulla, whereas the medial rectus is controlled by neurons in the oculomotor nucleus of the midbrain. [ 2 ]
Testing the trigeminal nerve involves testing its three branches.
The facial nerve is tested by
inspecting for facial asymmetry and involuntary movements. The individual is asked to:
The sensory component is tested for taste. Testing this is as simple as introducing salty, sour, bitter, or sweet stimuli to either side of the tongue. The patient should respond to the taste stimulus before retracting the tongue into the mouth. Stimuli applied to specific locations on the tongue will dissolve into the saliva and may stimulate taste buds connected to either the left or right of the nerves, masking any lateral deficits. [ 2 ]
The vestibulocochlear nerve is tested for hearing and balance.
More sensitive hearing tests are Rinne test and Weber test . The Rinne test involves using a tuning fork to distinguish between conductive hearing and sensorineural hearing. Conductive hearing relies on vibrations being conducted through the ossicles of the middle ear. Sensorineural hearing is the transmission of sound stimuli through the neural components of the inner ear and cranial nerve. A vibrating tuning fork is placed on the mastoid process and the patient indicates when the sound produced from this is no longer present. Then the fork is immediately moved to just next to the ear canal so the sound travels through the air. If the sound is not heard through the ear, meaning the sound is conducted better through the temporal bone than through the ossicles, a conductive hearing deficit is present. [ 2 ]
The Weber test also uses a tuning fork to differentiate between conductive versus sensorineural hearing loss. In this test, the tuning fork is placed at the top of the skull, and the sound of the tuning fork reaches both inner ears by travelling through bone. In a healthy patient, the sound would appear equally loud in both ears. With unilateral conductive hearing loss, however, the tuning fork sounds louder in the ear with hearing loss. This is because the sound of the tuning fork has to compete with background noise coming from the outer ear, but in conductive hearing loss, the background noise is blocked in the damaged ear, allowing the tuning fork to sound relatively louder in that ear. With unilateral sensorineural hearing loss, however, damage to the cochlea or associated nervous tissue means that the tuning fork sounds quieter in that ear. [ 2 ]
The glossopharyngeal nerve (CN IX) and vagus nerve (CN X) are tested for:
The accessory nerve is tested for:
The hypoglossal nerve has a sole motor function for most of the muscles of the tongue:
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https://en.wikipedia.org/wiki/Cranial_nerve_examination
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Cranial ultrasound is a technique for scanning the brain using high-frequency sound waves. It is used almost exclusively in babies because their fontanelle (the soft spot on the skull) provides an "acoustic window".
A different form of ultrasound-based brain scanning, transcranial Doppler , can be used in any age group. This uses Doppler ultrasound to assess blood flow through the major arteries in the brain, and can scan through bone. It is not usual for this technique to be referred to simply as "cranial ultrasound". Additionally, cranial ultrasound can be used for intra-operative imaging in adults undergoing neurosurgery once the skull has been opened, for example to help identify the margins of a tumour. [ 1 ]
Premature babies are especially vulnerable to certain conditions involving the brain. These include intraventricular hemorrhage (IVH), which often occurs during the first few days, [ 2 ] and periventricular leukomalacia (PVL), which tends to occur later on. [ 3 ] One of the main purposes of routine cranial ultrasound scanning in neonatal units is to identify these problems as they develop. If severe intraventricular haemorrhage is noted then the baby will need to be scanned more frequently in case post-hemorrhagic hydrocephalus (swelling of the ventricles as the natural flow of the cerebrospinal fluid is blocked by blood-clots) develops. [ 4 ]
Other indications include babies that requires ventilatory support, neonatal encephalopathy , and signs and symptoms that suggests central nervous system disorder such as seizures, microcephaly, macrocephaly, hypotonia, and unexplained poor feeding at term. [ 5 ]
Most neonatal units in the developed world routinely perform serial cranial ultrasound scans on babies who are born significantly premature . A typical regimen might involve performing a scan on the first, third and seventh day of a premature baby's life, and then at regular intervals until the baby reaches term. [ 6 ]
A 5 to 7.5 MHz probe is used to scan deeper structures in the brain. A 7 to 12 MHz probe is used for scanning superficial structures for detecting lesions between the brain and the skull, superior sagittal sinus thrombosis, cerebral oedema, and evaluating the structures of sulci and gyri . [ 4 ]
A water-based gel is applied to the infant's head, over the anterior fontanelle , to aid conduction of ultrasound waves. Ideally scans are performed during sleep or when the infant is calm. The operator then uses an ultrasound probe to examine the baby's brain, viewing the images on a computer screen and recording them as necessary. [ citation needed ]
A standard cranial ultrasound examination usually involves recording of approximately 11 views of the brain from different angles, six in the coronal plane and five in the sagittal and parasaggital planes. [ 7 ] This allows all parts of the ventricles and most of the rest of the brain to be visualised. [ citation needed ]
Who performs the scans varies between different health systems. In many hospitals in the United Kingdom paediatricians or neonatologists usually perform cranial ultrasound; in other systems advanced nurse practitioners , radiologists or sonographers may perform most scans. [ citation needed ]
While the anterior fontanelle is the most commonly used acoustic window for cranial ultrasounds, more advanced operators may gain additional views, especially of posterior fossa structures, by using the mastoid fontanelle , the posterior fontanelle and/or the temporal window. [ 8 ]
Other refinements of cranial ultrasound technique include serial measurement of the width of the lateral ventricles ("ventricular index") to monitor suspected ventricular dilatation and colour Doppler to assess blood flow. [ citation needed ]
Cranial ultrasound is a very safe technique as it is non-invasive and does not involve any kind of ionising radiation . However, it is subject to certain limitations.
Therefore, many neonatal services prefer to perform an MRI scan when the infant is near term, as well as routine cranial ultrasound, to avoid missing more subtle abnormalities.
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https://en.wikipedia.org/wiki/Cranial_ultrasound
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Craniocervical instability ( CCI ) is a medical condition characterized by excessive movement of the vertebra at the atlanto-occipital joint and the atlanto-axial joint located between the skull and the top two vertebra, known as C1 and C2 . [ citation needed ] The condition can cause neural injury and compression of nearby structures, including the brain stem , spinal cord , vagus nerve , and vertebral artery , resulting in a constellation of symptoms.
Craniocervical instability is more common in people with a connective tissue disease , including Ehlers-Danlos syndromes , [ 1 ] osteogenesis imperfecta , and rheumatoid arthritis . [ 2 ] It is frequently co-morbid with atlanto-axial joint instability, Chiari malformation , [ 3 ] or tethered spinal cord syndrome .
The condition can be brought on by physical trauma , including whiplash , laxity of the ligaments surrounding the joint, or other damage to the surrounding connective tissue.
The impact of craniocervical instability can range from minor symptoms to severe disability in which patients are bed-bound. The constellation of symptoms caused by craniocervical instability is known as "cervico-medullary syndrome" [ 4 ] and includes: [ 5 ] [ 6 ] [ 7 ]
Symptoms are frequently worsened by a Valsalva maneuver , or by being upright for long periods of time. The reason that being upright is problematic is that gravity allows increased interaction between the brain stem and the top of the spinal column, increasing symptoms.
Lying in the supine position can bring short-term relief. Lying supine eliminates the downward gravitational pull, reducing symptoms to some degree. Lying with the feet somewhat higher and head lower allows gravity can be helpful in symptom reduction.
Craniocervical instability is usually diagnosed through neuro-anatomical measurement using radiography . Digital Motion X-ray is considered the most accurate method. Upright magnetic resonance imaging , supine magnetic resonance imaging , CT scan , and flexion and extension x-rays may also be used but are far less accurate and have a much higher potential for false negatives.
The measurements to diagnose craniocervical instability are:
Alternatively, craniocervical instability can be diagnosed if a trial of cervical traction , typically using a halo fixation device , results in a significant alleviation of symptoms.
Conservative treatment of craniocervical instability includes physical therapy [ 10 ] [ 11 ] [ better source needed ] and the use of a cervical collar to keep the neck stable.
Cervical spinal fusion is performed on patients with more severe symptoms. [ citation needed ]
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https://en.wikipedia.org/wiki/Craniocervical_instability
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A cranioclast (from Greek κρανίον kranion "head, skull" and -κλάστης -klastes "breaker") is a surgical instrument akin to a strong forceps . It was once used to crush and then extract the skull of a fetus so as to facilitate delivery in cases of obstructed labour. [ 1 ]
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https://en.wikipedia.org/wiki/Cranioclast
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Craniofacial prostheses are prostheses made by individuals trained in anaplastology or maxillofacial prosthodontics who medically help rehabilitate those with facial defects caused by disease (mostly progressed forms of skin cancer , and head and neck cancer ), trauma ( outer ear trauma , eye trauma ) or birth defects ( microtia , anophthalmia ). They have the ability to replace almost any part of the face, but most commonly the ear , nose or eye / eyelids . An ocular prosthesis and hair prosthesis can also be classified as craniofacial prostheses. Prostheses are held in place either by biocompatible drying adhesives , osseointegrated implants , magnets , or another mechanical means (although rare) such as glasses or straps. Prostheses are designed to be as similar as possible to the natural anatomy of each individual. Their purpose is to cover, protect, and disguise facial disfigurements or underdevelopments.
When surgical reconstruction is not ideal, craniofacial prosthetics are favored when they can better restore the form and function of the absent facial feature. Craniofacial prosthetics are not wholly considered cosmetic [ 1 ] [ 2 ] because they replace the physical form and functional mechanics of the absent anatomy and serve a significant role in the emotional stability and rehabilitation of those with facial defects.
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https://en.wikipedia.org/wiki/Craniofacial_prosthesis
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Craniofacial surgery is a surgical subspecialty that deals with congenital and acquired deformities of the head , skull , face , neck , jaws and associated structures. Although craniofacial treatment often involves manipulation of bone, craniofacial surgery is not tissue-specific; craniofacial surgeons deal with bone, skin, nerve, muscle, teeth, and other related anatomy. [ 1 ] [ 2 ]
Defects typically treated by craniofacial surgeons include craniosynostosis (isolated and syndromic), rare craniofacial clefts , acute and chronic sequelae of facial fractures, cleft lip and palate , micrognathia, Treacher Collins Syndrome , Apert's Syndrome , Crouzon's Syndrome , Craniofacial microsomia, microtia and other congenital ear anomalies, and many others. Training in craniofacial surgery requires completion of a Craniofacial surgery fellowship. Such fellowships are available to individuals who have completed residency in oral and maxillofacial surgery , plastic and reconstructive surgery , or ear, nose, and throat surgery . Those who have completed residency in oral and maxillofacial surgery may be either single degree or dual-degree surgeons with no differences. There is no specific board for craniofacial surgery. In the US, cleft and craniofacial centers are found in many major academic centers.
The bones of the human skull are joined by cranial sutures (see figure 1). The anterior fontanelle is where the metopic, sagittal and coronal sutures meet. Normally the sutures gradually fuse within the first few years after birth. In infants where one or more of the sutures fuses too early the growth of the skull is restricted, resulting in compensation mechanisms which cause irregular growth patterns. Growth in the skull is perpendicular to the sutures. When a suture fuses too early, the growth perpendicular to that suture will be restricted, and the bone growth near the other sutures will be stimulated, causing an abnormal head shape. The expanding brain is the main stimulus for the rapid growth of the skull in the first years of life. Inhibited growth potential of the skull can restrict the volume, needed by the brain. In cases in which the compensation does not effectively provide enough space for the growing brain, craniosynostosis results in increased intracranial pressure. [ 3 ]
Craniosynostosis is called simple when one suture is involved, and complex when two or more sutures are involved. It can occur as part of a syndrome or as an isolated defect (nonsyndromic). [ 4 ]
In scaphocephaly, the sagittal suture is prematurely fused. The sagittal suture runs from the front to the back of the head. The shape of this deformity is a long narrow head, formed like a boat (Greek skaphe , "light boat or skiff"). The compensatory head-growth forward at the coronal suture gives a prominent forehead, frontal bossing and a prominent back of the head, called coning. [ 5 ] The incidence of scaphocephaly is 2.8 per 10,000 births in the Netherlands; therefore, it is the most common form of craniosynostosis. [ 6 ] [ 7 ]
In trigonocephaly, the metopic suture is prematurely fused. The metopic suture is situated in the medial line of the forehead. Premature fusion of this suture causes the forehead to become pointed, giving the head a triangular shape when viewed from above (Greek trigono , "triangle"). The incidence of trigonocephaly is 1 - 1.9 per 10,000 births in the Netherlands. [ 6 ]
In plagiocephaly, one of the coronal sutures is prematurely fused. The coronal sutures run over the top of the head, just in front of the ears. The shape of this deformity is an asymmetrical distortion (flattening of one side of the head) as you can see in figure 2. The incidence is 1 in 10,000 births. [ 6 ] [ 8 ]
In brachycephaly, both of the coronal sutures are prematurely fused. The shape of this deformity is a wide and high head. The incidence at birth is 1/20,000. [ 9 ]
Craniofacial surgery and follow-up care are usually conducted by a multidisclinary team of doctors, surgeons, nurses, and various therapists. [ 10 ] As of 2016, there is a new multidisciplinary care team of Neuroplastic Surgeons working with Neurosurgeons to prevent and/or correct neurosurgical-related deformities and to maximize outcomes in adult patients.
In cases where the forehead is involved (trigonocephaly and plagiocephaly), a technique called fronto-supraorbital advancement is used to correct the shape of the head. The procedure is performed at a young age in order to provide the brain with enough space to grow and prevent further abnormal growth of the skull. Fronto-orbital advancement literally means moving the front of the skull including the eye sockets forward. A section of the skull, ranging from the coronal sutures to the eye sockets is cut loose in order to correct the shape of the skull. The incision is cut in a zigzag shape from ear to ear so that the hair will cover the scar and make it less visible. The incision is made to the bone only, leaving the underlying meninges intact. The top half of the eye sockets is cut loose. Once the eye socket section has been cut loose, a vertical incision is made in the midline, and the whole section of the eye socket is bent outwards in order to correct the pointed shape of the forehead. Because the section is now too wide, a wedge needs to be cut on either side to allow the section to fit into the skull. Figure 4 shows the sections that are loosened and adjusted, and Figure 3 shows the location of the vertical incision (arrow A) and the two wedges (arrow B). [ citation needed ]
In scaphocephaly, the sagittal suture is prematurely fused, preventing the skull from growing perpendicular to the suture. Thus, the head becomes very narrow and long. If a scaphocephaly is diagnosed within 4 to 5 months after birth, it can be corrected with a relatively simple procedure whereby the sagittal suture is surgically reopened. Once the suture has been opened the bone segments will be able to grow again, and the head can regain its normal shape. This operation is only performed on patients younger than five months old with a scaphocephaly. This is due to the fact that the bone segments only have the ability to adapt so severely when the operation is performed at this young age. A scaphocephaly that is diagnosed and treated later in life requires a more extensive secondary operation than one that is treated before five months. [ citation needed ]
A major focus in craniosynostosis reconstruction is maintaining normalized aesthetics of temporal region, and avoiding temporal hollowing. Despite using overcorrection methods, autologous fat transfer, and bone grafts to prevent temporal hollowing, up to 50% of patients still experience post-operative depression in the temporal fossa.
Cranioplasty, or skull reconstruction, is the main concentration of a new field for adult neurosurgical patients known as Neuroplastic Surgery. There are now several centers around the world, including the United States and Israel. The first center of Neuroplastic Surgery was started at Johns Hopkins by Dr. Chad Gordon and the Department of Neurosurgery, which is where this new craniofacial subspecialty was born ( c. 2016 ). [ 11 ]
Some of the surgical complications in craniofacial surgery may include Death, Shock, Haemorrhage, visual loss, Intracranial collection of air/fluid, Epileptic seizures, Unexpected respiratory complications, etc. [ 12 ]
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https://en.wikipedia.org/wiki/Craniofacial_surgery
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Credé prophylaxis is the practice of washing a newborn's eyes with a 2% silver nitrate solution to protect against neonatal conjunctivitis caused by Neisseria gonorrhoeae , thereby preventing blindness. [ 1 ]
The Credé procedure was developed by the German physician Carl Siegmund Franz Credé who implemented it in his hospital in Leipzig in 1880. [ 1 ] Between 1881 and 1883, Credé published three papers in Archiv für Gynäkologie , each titled "Die Verhütung der Augenentzündung der Neugeborenen" (Prevention of inflammatory eye disease in the newborn), describing his method and its results. [ 1 ] [ note 1 ] The original procedure called for a 2% silver nitrate solution administered immediately after birth, as Credé erroneously believed that a 1% solution was ineffective due to a previous study by Hecker; however, this was eventually corrected and reduced back down to a 1% solution to reduce chemical irritation to the newborn's eyes. [ 2 ] As neonatal conjunctivitis used to occur in around 10% of newborns and cause about half of all cases of blindness in Europe, the treatment is credited with saving the eyesight of millions. [ 1 ] [ 2 ]
In the 1980s, silver nitrate was replaced by erythromycin and tetracycline treatments, which are better tolerated by the eye and more effective against Chlamydia trachomatis in addition to N. gonorrhea . [ 3 ]
The works "Archiv für Gynäkologie" are freely available in the public domain.
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https://en.wikipedia.org/wiki/Credé's_prophylaxis
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Creola bodies are a histopathologic finding indicative of asthma . Found in a patient's sputum , they are ciliated columnar cells sloughed from the bronchial mucosa of a patient with asthma. Other common findings in the sputum of asthma patients include Charcot-Leyden crystals , Curschmann's Spirals , and eosinophils (and excessive amounts of sputum).
Yoshihara et al. reported 60% of pediatric asthmatic patients demonstrating acute symptoms were found to have creola bodies in their sputum. These patients had increased levels of neutrophil -mediated cytokine activity concluding that "epithelial damage is associated with a locally enhanced chemotactic signal for and activity of neutrophils, but not eosinophils, during acute exacerbations of paediatric asthma." [ 1 ]
Ogata et al. found significant correlations among the CrB score, the concentration of sputum ECP and %FEV1.0 (p less than 0.001). The CrB score on the day of clinical appraisal significantly correlated with the number of days of treatment needed for remission. These results were in keeping with the hypothesis that eosinophils cause desquamation of respiratory epithelial cells resulting in prolongation of asthmatic attacks. Observation of CrB seemed to be useful as a marker of duration of asthmatic attacks. [ 2 ]
This article related to pathology is a stub . You can help Wikipedia by expanding it .
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https://en.wikipedia.org/wiki/Creola_bodies
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Cricopharyngeal myotomy is a surgical sectioning of the cricopharyngeus muscle , also known as the upper esophageal sphincter , that has been advocated for the treatment of cricopharyngeal spasm , or cricopharyngeal achalasia, that leads to cervical dysphagia in the clinical setting. [ 1 ]
This surgery can be used for retrograde cricopharyngeal dysfunction (R-CPD), a complication causing the inability to burp. [ 2 ] [ 3 ]
This surgery article is a stub . You can help Wikipedia by expanding it .
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https://en.wikipedia.org/wiki/Cricopharyngeal_myotomy
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A crisis actor (aka actor-patient or actor victim ) is a trained actor , role player, volunteer, or other person engaged to portray a disaster victim during emergency drills to train first responders such as police , firefighters or EMS personnel. Crisis actors are used to create high-fidelity simulations of disasters in order to allow first responders to practice their skills and help emergency services to prepare and train in realistic scenarios as part of full-scale disaster exercises. [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ] The term has also been used by conspiracy theorists who claim that some mass shootings and other terror events are staged for the advancement of various political objectives such as to advance gun control measures. [ 7 ]
Actors take on the role of mock victims and simulate specific injuries from a disaster to add life-like realism to an emergency exercise. Theatrical makeup and cosmetics, plus rubber and latex appliances, are often used to simulate a variety of wounds or medical conditions that realistically portray victim's injuries, a practice known as medical moulage . [ 8 ] [ 9 ] [ 10 ]
Actors who portray news reporters, relatives of victims, and concerned citizens are also used during drills to train emergency operations center personnel to cope with a variety of emotionally-charged demands and requests. [ 11 ]
In the United States , the term has been used by conspiracy theorists who claim that some mass shootings and other terror events are staged for the advancement of various political objectives such as to advance gun control measures. [ 7 ] Conspiracy theorists' use of the term is thought to have originated in 2012, when a blog post by former professor and conspiracy theorist James Tracy suggested that the government could have hired an acting agency named Visionbox to help stage the Sandy Hook Elementary School shooting . Visionbox offered dramatic training "in criminal and victim behavior" to actors intended to help "bring intense realism to simulated mass casualty incidents in public places". [ 12 ]
Tracy also promoted a crisis actor conspiracy theory of the Boston Marathon bombing . [ 12 ] [ 13 ] Conspiracy theorists have falsely claimed such attacks are " false flag operations" staged by conspirators, usually government or corporate forces, in order to achieve some goal such as justifying increased government surveillance , disarmament of the population, or military action against blamed nations or groups. Crisis actors are claimed in this context to play the part of bystanders or witnesses, emergency response personnel, and (with the aid of stage makeup) wounded victims of the attack.
Advocates of the conspiracy theory include Alex Jones and outlets such as True Pundit . [ 14 ] [ 15 ] [ 13 ] [ 16 ] In April 2018, the parents of two children killed in the Sandy Hook shooting launched a lawsuit against Jones for defamation "accusing him and his website InfoWars of engaging in a campaign of 'false, cruel, and dangerous assertions'". [ 17 ] In November 2021, Jones was found liable by default after failing to provide documents to the court and announced he would appeal the decision. [ 18 ] In August 2022, the Heslin v. Jones jury ordered that Jones pay $4.1M in compensatory damages and $45.2M in punitive damages. [ 19 ] [ 20 ] [ 21 ] During the trial, Jones admitted that the Sandy Hook shooting was "100% real", and he agreed with his own attorney that it was "absolutely irresponsible" to push falsehoods about the shooting and its victims. [ 22 ]
During the Gaza war , accusations of victims on both sides of the war being "crisis actors" have circulated on social media. [ 23 ] [ 24 ] [ 25 ]
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The Critical Psychiatry Network (CPN) is a psychiatric organization based in the United Kingdom . It was created by a group of British psychiatrists who met in Bradford , England in January 1999 in response to proposals by the British government to amend the Mental Health Act 1983 . They expressed concern about the implications of the proposed changes for human rights and the civil liberties of people with mental health illness. Most people associated with the group are practicing consultant psychiatrists in the United Kingdom's National Health Service (NHS), among them Dr Joanna Moncrieff . A number of non-consultant grade and trainee psychiatrists are also involved in the network.
Participants in the Critical Psychiatry Network share concerns about psychiatric practice where and when it is heavily dependent upon diagnostic classification and the use of psychopharmacology . These concerns reflect their recognition of poor construct validity amongst psychiatric diagnoses and scepticism about the efficacy of anti-depressants, mood stabilisers and anti-psychotic agents. [ 1 ] According to them, these concerns have ramifications in the area of the use of psychiatric diagnosis to justify civil detention and the role of scientific knowledge in psychiatry, and an interest in promoting the study of interpersonal phenomena such as relationship, meaning and narrative in pursuit of better understanding and improved treatment.
CPN has similarities and contrasts with earlier criticisms of conventional psychiatric practice, for example those associated with David Cooper , R. D. Laing and Thomas Szasz . Features of CPN are pragmatism and full acknowledgment of the suffering commonly associated with mental health difficulties. As a result, it functions primarily as a forum within which practitioners can share experiences of practice, and provide support and encouragement in developing improvements in mainstream NHS practice where most participants are employed.
CPN maintains close links with service user or survivor led organisations such as the Hearing Voices Network , Intervoice and the Soteria Network , and with like-minded psychiatrists in other countries. It maintains its own website. The network is open to any sympathetic psychiatrist, and members meet in person, in the UK, twice a year. It is primarily intended for psychiatrists and psychiatric trainees and full participation is not available to other groups.
The other involved the introduction of community treatment orders (CTOs) to make it possible to treat people against their wishes in the community. CPN submitted evidence to the Scoping Group set up by the government under Professor Genevra Richardson . [ 2 ] This set out ethical and practical objections to CTOs, and ethical and human rights objections to the idea of reviewable detention. It was also critical of the concept of personality disorder as a diagnosis in psychiatry. In addition, CPN's evidence called for the use of advance statements, crisis cards and a statutory right to independent advocacy as ways of helping to sustain autonomy at times of crisis. CPN also responded to government consultation on the proposed amendment, [ 3 ] and the white paper. [ 4 ]
The concern about these proposals caused a number of organizations to come together under the umbrella of the Mental Health Alliance [ 5 ] to campaign in support of the protection of patients' and carers' rights, and to minimise coercion. CPN joined the Alliance's campaign, but resigned in 2005 when it became clear that the Alliance would accept those aspects of the House of Commons Scrutiny Committee's report that would result in the introduction of CTOs. [ 6 ] Psychiatrists not identified with CPN shared the Network's concern about the more coercive aspects of the government's proposals, so CPN carried out a questionnaire survey of over two and a half thousand (2,500) consultant psychiatrists working in England seeking their views of the proposed changes. The responses (a response rate of 46%) indicated widespread concern in the profession about reviewable detention [ 7 ] and CTOs. [ 8 ]
The CPN was paid attention by Thomas Szasz who wrote: "Members of the CPN, like their American counterparts, criticize the proliferation of psychiatric diagnoses and 'excessive' use of psychotropic drugs, but embrace psychiatric coercions." [ 9 ]
There is a strong view by CPN that contemporary psychiatry relies too much on the medical model , and attaches too much importance to a narrow biomedical view of diagnosis. [ 10 ] This can, in part, be understood as the response of an earlier generation of psychiatrists to the challenge of what has been called 'anti-psychiatry'. Psychiatrists such as David Cooper , R. D. Laing and Thomas Szasz (although the latter two rejected the term) were identified as part of a movement against psychiatry in the 1960s and 1970s. Stung by these attacks, as well as accusations that in any case psychiatrists could not even agree who was and who was not mentally ill, [ 11 ] academic psychiatrists responded by stressing the biological and scientific basis of psychiatry through strenuous efforts to improve the reliability of psychiatric diagnosis based in a return to the traditions of one of the founding fathers of the profession, Emil Kraepelin . [ 12 ]
The use of standardized diagnostic criteria and checklists may have improved the reliability of psychiatric diagnosis, but the problem of its validity remains. The investment of huge sums of money in Britain, America and Europe over the last half-century has failed to reveal a single, replicable difference between a person with a diagnosis of schizophrenia and someone who does not have the diagnosis. [ 13 ] [ 14 ] [ 15 ] The case for the biological basis of common psychiatric disorders such as depression has also been greatly over-stated. [ 16 ] This has a number of consequences:
First, the aggrandisement of biological research creates a false impression both inside and outside the profession of the credibility of the evidence used to justify drug treatments for disorders such as depression and schizophrenia. Reading clinical practice guidelines for the treatment of depression, for example, such as that produced for the UK National Health Service by the National Institute for Health and Clinical Excellence (NICE), one might be fooled into believing that the evidence for the efficacy of selective serotonin reuptake inhibitors (SSRIs) is established beyond question. In reality this is not the case, as re-examinations of drug trial data in meta-analyses, especially where unpublished data are included (publication bias means that researchers and drug companies do not publish negative findings for obvious commercial reasons), have revealed that most of the benefits seen in active treatment groups are also seen in the placebo groups. [ 17 ] [ 18 ] [ 19 ]
As far as schizophrenia is concerned, neuroleptic drugs may have some short-term effects, but it is not the case that these drugs possess specific 'anti-psychotic' properties, and it is impossible to assess whether or not they confer advantages in long-term management of psychoses because of the severe disturbances that occur when people on long-term active treatment are withdrawn to placebos. These disturbances are traditionally interpreted as a 'relapse' of schizophrenia when in fact there are several possible interpretations for the phenomenon. [ 1 ]
Another consequence of the domination of psychiatry by biological science is that the importance of contexts in understanding distress and madness is played down. [ 20 ] [ 21 ] This has a number of consequences. First, it obscures the true nature of what in fact are extremely complex problems. For example, if we consider depression to be a biological disorder remediable through the use of antidepressant tablets, then we may be excused from having to delve into the tragic circumstances that so often lie at the heart the experience. This is so in adults and children. [ 22 ]
There is a common theme, here, with the work of David Ingleby whose chapter in Critical Psychiatry: The Politics of Mental Health [ 23 ] sets out a detailed critique of positivism (the view that epistemology, or knowledge about the world is best served by empiricism and the scientific method rather than metaphysics). A common theme running through Laingian antipsychiatry, Ingleby's critical psychiatry, contemporary critical psychiatry and postpsychiatry is the view that social, political and cultural realities play a vital role in helping us to understand the suffering and experience of madness. Like Laing, Ingleby stressed the importance of hermeneutics and interpretation in inquiries about the meaning of experience in psychiatry, and (like Laing) he drew on psychoanalysis as an interpretative aid, but his work was also heavily influenced by the critical theory of the Frankfurt School . [ 24 ]
The most forceful critic of this view was R. D. Laing, who famously attacked the approach enshrined by Jaspers' and Kraepelin's work in chapter two of The Divided Self, [ 25 ] proposing instead an existential-phenomenological basis for understanding psychosis. Laing always insisted that schizophrenia is more understandable than is commonly supposed. Mainstream psychiatry has never accepted Laing's ideas, but many in CPN regard The Divided Self as central to twentieth century psychiatry. Laing's influence continued in America through the work of the late Loren Mosher, who worked at the Tavistock Clinic in the mid-1960s, when he also spent time in Kingsley Hall witnessing Laing's work. Shortly after his return to the US, Loren Mosher [ 26 ] was appointed Director of Schizophrenia Research at the National Institute of Mental Health, and also the founding editor of the journal Schizophrenia Bulletin.
One of his most notable contributions to this area was setting up and evaluating the first Soteria House , an environment modeled on Kingsley Hall in which people experiencing acute psychoses could be helped with minimal drug use and a form of interpersonal phenomenology influenced by Heidegger. He also conducted evaluation studies of the effectiveness of Soteria. [ 27 ] A recent systematic review of the Soteria model found that it achieved as good, and in some areas, better, clinical outcomes with much lower levels of medication (Soteria House was not anti-medication) than conventional approaches to drug treatment. [ 28 ]
One comparison study showed 34% of patients of a 'medical model' team were still being treated after two years, compared with only 9% of patients of a team using a 'non-diagnostic' approach (less medication, little diagnosis, individual treatment plans tailored to the person's unique needs). However the study comments that cases may have left the system in the 'non-diagnostic' approach, not because treatment had worked, but because (1) multi-agency involvement meant long-term work may have been continued by a different agency, (2) the starting question of 'Do we think our service can make a positive difference to this young person's life?' rather than 'What is wrong with this young person?' may have led to treatment not being continued, and (3) the attitude of viewing a case as problematic when no improvement has occurred after five sessions may have led to treatment not being continued (rather than the case 'drifting' on in the system). [ 29 ]
Peter Campbell first used the term 'postpsychiatry' in the anthology Speaking Our Minds , which imagines what would happen in a world after psychiatry. [ 30 ] Independently, Patrick Bracken and Philip Thomas coined the word later and used it as the title of a series of articles written for Openmind. This was followed by a key paper in the British Medical Journal and a book of the same name. [ 21 ] This culminated with the publication by Bradley Lewis, a psychiatrist based in New York, of Moving Beyond Prozac, DSM, and the New Psychiatry: The Birth of Postpsychiatry . [ 31 ]
According to Bracken, progress in the field of mental health is presented in terms of 'breakthrough drugs', 'wonders of neuroscience', 'the Decade of the Brain' and 'molecular genetics'. These developments suited the interests of a relatively small number of academic psychiatrists, many of whom have interests in the pharmaceutical industry, although so far the promised insights into psychosis and madness were yet to be realized. Some psychiatrists have turned to another form of technology, Cognitive Behavioural Therapy , although this does draw attention to the person's relationship with their experiences (such as voices or unusual beliefs), and focuses on helping them to find different ways of coping, it however, it is based on a particular set of assumptions about the nature of the self, the nature of thought, and how reality is constructed. The pros and cons of this have been explored in some detail in a recent publication. [ 32 ] [ 33 ]
Framing mental health problems as 'technical' in nature involves prioritising technology and expertise over values, relationships and meanings, the very things that emerge as important for service users, both in their narratives, and in service user-led research. [ 34 ] For many service users these issues are of primary importance. Recent meta-analyses into the effectiveness of antidepressants and cognitive therapy in depression confirm that non-specific, non-technical factors (such as the quality of the therapeutic relationship as seen by the patient, and the placebo effect in medication) are more important than the specific factors. [ 17 ] [ 18 ] [ 35 ] [ 36 ] [ 37 ]
Postpsychiatry tries to move beyond the view that we can only help people through technologies and expertise. Instead, it
prioritises values, meanings and relationships and sees progress in terms of engaging creatively with the service user movement, and communities. This is especially important given the considerable evidence that in Britain, Black and Minority Ethnic (BME) communities are particularly poorly served by mental health services. For this reason an important practical aspect of postpsychiatry is the use of community development in order to engage with these communities. [ 38 ] The community development project Sharing Voices Bradford is an excellent example of such an approach. [ 39 ]
There are many commonalities between critical psychiatry and postpsychiatry, but it is probably fair to say that whereas postpsychiatry would broadly endorse most aspects of the work of critical psychiatry, the obverse does not necessarily hold. In identifying the modernist privileging of technical responses to madness and distress as a primary problem, postpsychiatry has looked to postmodernist thought for insights. Its conceptual critique of traditional psychiatry draws on ideas from philosophers such as Heidegger , [ 40 ] Merleau-Ponty , [ 41 ] [ 42 ] Foucault [ 43 ] and Wittgenstein . [ 44 ]
The word anti-psychiatry is associated with the South African psychiatrist David Cooper , who used it to refer to the ending of the 'game' the psychiatrist plays with his or her victim (patient). [ 45 ] [ page needed ] It has been widely used to refer to the writings and activities of a small group of psychiatrists, most notably R.D. Laing , Aaron Esterson , Cooper, and Thomas Szasz (although he rejects the use of the label in relation to his own work, as did Laing and Esterson), and sociologists (Thomas Scheff). Szasz discards even more what he calls the quackery of 'antipsychiatry' than the quackery of psychiatry. [ 46 ] [ page needed ]
Anti-psychiatry can best be understood against the counter-cultural context in which it arose. The decade of the 1960s was a potent mix of student rebellion, anti-establishment sentiment and anti-war (Vietnam) demonstrations. It saw the rise to prominence of feminism and the American civil rights movement and the Northern Ireland civil rights movement. Across the world, formerly colonised peoples were throwing off the shackles of colonialism. Some of these themes emerged in the Dialectics of Liberation, a conference organized by Laing and others in the Round House in London in 1968. [ 47 ]
CPN is involved in four main areas of work, writing and the publication of academic and other papers, organizing and participating in conferences, activism and support. A glance at the members' publication page on the CPN website reveals in excess of a hundred papers, books and other articles published by people associated with the network over the last twelve years or so. These cover a wide range of topics, from child psychiatry, psychotherapy, the role of diagnosis in psychiatry, critical psychiatry, philosophy and postpsychiatry, to globalization and psychiatry. CPN has also organized a number of conferences in the past, and continues to do so in collaboration with other groups and bodies. It has run workshops for psychiatrists and offers peer supervision face to face and via videolink. It also supports service user and survivor activists who campaign against the role of the pharmaceutical industry in psychiatry, and the campaign for the abolition of the schizophrenia label. The CPN has published a statement in support. [ 48 ]
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Critical Reviews in Oncogenesis is a quarterly scientific journal published by Begell House covering the field of oncology . The editor-in-chief is Ragnhild A. Lothe .
This article about an oncology journal is a stub . You can help Wikipedia by expanding it .
See tips for writing articles about academic journals . Further suggestions might be found on the article's talk page .
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Critical emergency medicine ( CREM ) refers to the acute medical care of patients who have medical emergencies that pose an immediate threat to life, irrespective of location. In particular, the term is used to describe the role of anaesthesiologists in providing such care. [ 1 ]
The term was introduced in 2010 in a position paper by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine , who defined it as "immediate life support and resuscitation of critically ill and injured patients in the pre-hospital as well as hospital settings". [ 1 ] It describes the roles and competencies of anaesthesiologists and intensive care physicians in caring for patients with life-threatening illness or injury who require resuscitation or support of their vital functions, particularly in Scandinavia and other parts of Europe. One reason the term was introduced was to distinguish these core activities from the broader internationally recognised medical specialty of emergency medicine ; the latter deals with the acute care of a broad range of minor to major medical problems that present to an emergency department ,. [ 1 ]
The European Board of Anaesthesiology and European Society of Anaesthesiology formally adopted the term in 2016 "to define anaesthesiologists’ competencies and role in the acute management of life-threatening emergencies", which had previously been referred to in the anaesthesiology speciality European training requirements simply as "emergency medicine". [ 2 ] The European Training Requirement curriculum for anaesthesiology was updated in 2018 to state that knowledge, clinical skills and specific attitudes for CREM should form part of postgraduate training for doctors specialising in anaesthesiology. [ 3 ]
The scope of CREM is broad, ranging from providing high-level clinical skills and decision making in the pre-hospital setting, through assisting in rescue work, managing life-threatening medical and surgical emergencies and participating in multidisciplinary in-hospital medical emergency teams and resuscitation teams, through to declaration of death at the site of an incident. [ 3 ] Anaesthesiologists specialised in CREM may have additional experience in organising healthcare responses to mass-casualty incidents and disasters, as well as training in management of CBRN defence , hyperbaric medicine , or organisation and coordination of emergency departments , burn centres , poison control centres , or emergency medical services . [ 3 ]
Internationally, there are two primary models of emergency medicine: the Anglo-American model, which relies on "bringing the patient to the hospital", and the Franco-German model, which operates through "bringing the hospital to the patient". [ 4 ] In the Anglo-American model, the patient is rapidly transported by non-physician providers to definitive care, typically an emergency department in a hospital. Conversely, the Franco-German approach has a physician, traditionally an anesthesiologist but now more so an emergency physician, come to the patient and provide stabilizing care in the field. The patient is then triaged directly to the appropriate specialist department of a hospital. [ 4 ] As such, CREM specialists must be expert in the principles of patient transfer, often by helicopter or aeroplane as well as by land ambulance, and should exhibit appropriate knowledge, skills and attitudes for working safely in the pre-hospital setting and managing the attendant risks, and communicating with firefighters, police and rescue workers. [ 3 ]
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Critical illness polyneuropathy ( CIP ) and critical illness myopathy ( CIM ) are overlapping syndromes of diffuse, symmetric, flaccid muscle weakness occurring in critically ill patients and involving all extremities and the diaphragm with relative sparing of the cranial nerves. CIP and CIM have similar symptoms and presentations and are often distinguished largely on the basis of specialized electrophysiologic testing or muscle and nerve biopsy . [ 1 ] [ 2 ] The causes of CIP and CIM are unknown, though they are thought to be a possible neurological manifestation of systemic inflammatory response syndrome . [ 3 ] Corticosteroids and neuromuscular blocking agents , which are widely used in intensive care, may contribute to the development of CIP and CIM, [ 4 ] as may elevations in blood sugar , which frequently occur in critically ill patients. [ 5 ]
CIP was first described by Charles F. Bolton in a series of five patients. [ 6 ]
Combined CIP and CIM was first described by Nicola Latronico in a series of 24 patients. [ 7 ]
People with CIP/CIM have diffuse, symmetric, flaccid muscle weakness . CIP/CIM typically develops in the setting of a critical illness and immobilization, so patients with CIP/CIM are often receiving treatment in the intensive care unit (ICU). [ citation needed ]
Weakness (motor deficits) occurs in generalized fashion, rather than beginning in one region of the body and spreading. Limb and respiratory (diaphragm) muscles are especially affected. The muscles of the face are usually spared, but in rare cases, the eye muscles may be weakened, leading to ophthalmoplegia . [ 8 ]
Respiratory difficulties can be caused by atrophy of the muscles between the ribs (intercostals), atrophy of the diaphragm muscle , and degeneration of the nerve that stimulates the diaphragm ( phrenic nerve ). [ 8 ] This can prolong the time it takes to wean a person off of a breathing machine ( mechanical ventilation ) by as much as 7 – 13 days. [ 9 ]
Deep tendon reflexes may be lost or diminished , and there may be bilateral symmetric flaccid paralysis of the arms and legs. The nervous system manifestations are typically limited to peripheral nerves , as the central nervous system is usually unaffected. [ citation needed ]
The causes of CIP and CIM are unknown, though they are thought to be a possible neurological manifestation of systemic inflammatory response syndrome . [ 3 ] [ 10 ]
Nerve biopsy would show axonal neuropathy, [ 7 ] but it is no longer indicated. A muscle biopsy of critical illness myopathy would show selective loss of thick filaments in muscle, demonstrating the loss of myosin and the presence of muscle cell death ( necrosis ). [ 1 ] [ 11 ] When muscles lose stimulation from neurons, they can undergo degeneration. However, when critical illness myopathy occurs, it is not solely due to loss of innervation of the muscle. [ 11 ] With critical illness myopathy, no other cause of the muscle degeneration can be found. [ citation needed ]
Unlike Guillain–Barre syndrome , another neurological disorder that causes weakness, patients with critical illness polyneuropathy do not have loss of the myelin sheath that normally surrounds neurons ( demyelination ). [ 11 ]
CIP and CIM are a major cause of ICU-acquired weakness (ICUAW). Current guidelines recommend a clinical diagnosis of ICUAW, made by manually testing the muscle strength with the use of the Medical Research Council (MRC) sum score or handgrip dynamometry. [ 12 ]
CIP/CIM is often not identified until a patient is unable to be successfully weaned from a mechanical ventilator. Early detection of the condition is difficult, because these patients are often sedated and intubated, and thus unable to cooperate with a thorough neuromuscular physical examination. [ 11 ] The use of conventional nerve conduction studies is time-consuming and requires specialized personnel; however, simplified electrophysiologic tests can be used as screening tools in the critically ill to confirm or exclude CIP/CIM. [ 13 ] [ 14 ] The peroneal nerve test is a validated, high-sensitivity, minimally invasive, non-volitional and quick diagnostic test which can accurately exclude CIP/CIM if the result is normal. [ 13 ] Moreover, patients with disuse atrophy and muscle deconditioning have normal electrophysiological tests even if muscle strength is severely reduced [ 14 ] Hence, these tests are important to define the cause of muscle weakness and can be helpful to refine the prognosis. [ 15 ]
The serum creatine phosphokinase (CPK) can be mildly elevated. [ 11 ] While the CPK is often a good marker for damage to muscle tissue, it is not a helpful marker in CIP/CIM, because CIP/CIM is a gradual process and does not usually involve significant muscle cell death ( necrosis ). Also, even if necrosis is present, it may be brief and is therefore easily missed. If a lumbar puncture (spinal tap) is performed, the protein level in the cerebral spinal fluid would be normal. [ citation needed ]
Initial screening for CIP/CIM may be performed using an objective scoring system for muscle strength. The Medical Research Council (MRC) score is one such tool, and sometimes used to help identify CIP/CIM patients in research studies. The MRC score involves assessing strength in 3 muscle groups in the right and left sides of both the upper and lower extremities. Each muscle tested is given a score of 0–5, giving a total possible score of 60. An MRC score less than 48 is suggestive of CIP/CIM. However, the tool requires that patients be awake and cooperative, which is often not the case. Also, the screening tool is non-specific , because it does not identify the cause a person's muscle weakness. [ citation needed ]
Once weakness is detected, the evaluation of muscle strength should be repeated several times. If the weakness persists, then a muscle biopsy , a nerve conduction study (electrophysiological studies), or both should be performed. [ 11 ]
CIP/CIM can lead to difficulty weaning a person from a mechanical ventilator , and is associated with increased length of stay in the ICU and increased mortality (death). [ 9 ] It can lead to impaired rehabilitation. Since CIP/CIM can lead to decreased mobility (movement), it increases the risk of pneumonia , deep vein thrombosis , and pulmonary embolism .
Critically ill people that are in a coma can become completely paralyzed from CIP/CIM. [ 8 ] Improvement usually occurs in weeks to months, as the innervation to the muscles are restored. About half of patients recover fully. [ 8 ]
While the exact incidence is unknown, estimates range from 33 - 57 percent of patients staying in the ICU for longer than 7 days. [ 9 ] More exact data is difficult to obtain, since variation exists in defining the condition.
The three main risk factors for CIP and CIM are sepsis and systemic inflammatory response syndrome (SIRS), and multi-organ failure . Reported rates of CIP/CIM in people with sepsis and SIRS range from 68 to 100 percent. [ 9 ] Additional risk factors for developing CIP/CIM include: female gender, high blood sugar ( hyperglycemia ), low serum albumin , and immobility. A greater severity of illness increases the risk of CIP/CIM. Such risk factors include: multi-organ dysfunction, kidney failure , renal replacement therapy, duration of organ dysfunction, duration of ICU stay, and central neurologic failure. [ citation needed ]
Certain medications are associated with CIP/CIM, such as corticosteroids , neuromuscular blocking agents , vasopressors , catecholamines , and intravenous nutrition ( parenteral nutrition ). Research has produced inconsistent results for the impact of hypoxia, hypotension, hyperpyrexia, and increased age on the risk of CIP/CIM. The use of aminoglycosides is not an independent risk for the development of CIP/CIM. [ citation needed ]
CIP was first described in 1984 by Charles F. Bolton in a series of five patients. [ 16 ] The condition used to be described as "Bolton's neuropathy.". [ 9 ] In 1996, Latronico and colleagues first described that CIP and CIM often coexist in the same patient. [ 7 ]
A number of terms are used to describe critical illness polyneuropathy, partially because there is often neuropathy and myopathy in the same person, and nerve and muscle degeneration are difficult to distinguish from each other in this condition. Terms used for the condition include: critical illness polyneuromyopathy, critical illness neuromyopathy, and critical illness myopathy and neuropathy (CRIMYNE). [ 17 ] [ 18 ] [ 13 ] Bolton's neuropathy is an older term, which is no longer used.
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Cross-circulation is a medical technique in which the circulatory system of one individual is temporarily connected to and shared with that of another, typically to support or maintain physiological function in cases where one system alone would be insufficient. Initially pioneered in the 1950s by cardiac surgeon C. Walton Lillehei , cross-circulation allowed surgeons to perform open-heart surgery on infants and children before the development of reliable heart-lung machines. More recently, the concept has been adapted to rehabilitate injured donor organs and bioengineer transplantable grafts ex vivo.
In the early 1950s, open-heart surgery was limited by the lack of extracorporeal circulation technologies. In 1954, Dr. C. Walton Lillehei at the University of Minnesota introduced cross-circulation as a method to provide oxygenated blood to patients undergoing complex intracardiac repairs. In this procedure, the patient's circulation was temporarily connected to that of a healthy donor (often a parent), whose heart and lungs would maintain oxygenation and perfusion for both individuals during surgery. [ 1 ] This technique allowed for successful repair of congenital heart defects before the widespread availability of cardiopulmonary bypass machines. [ 2 ]
Although revolutionary, cross-circulation in its original form raised ethical and safety concerns due to the risks posed to healthy donors. It was largely replaced by mechanical heart-lung machines by the early 1960s. [ 3 ] Nevertheless, it marked a major milestone in the history of cardiac surgery and contributed to the evolution of extracorporeal support systems.
Beginning in the 2010s, cross-circulation was re-envisioned as a platform to rehabilitate and regenerate donor organs outside the body. Drawing inspiration from the historic role of cross-circulation in cardiac surgery, researchers at Columbia University and Vanderbilt University pioneered a modern adaptation of the technique to support and recover ex-vivo organs using a living swine host as physiologic support. [ 4 ] [ 5 ] In this system, an extracorporeal circuit is established between an ex-vivo organ (e.g., lung, liver) and a swine host, allowing systemic regulation from the host to maintain organ homeostasis. This approach provides dynamic hormonal, immune, and metabolic regulation and support that cannot be replicated by conventional mechanical perfusion systems. [ 6 ]
Initial studies led by cardiothoracic surgeon Matthew Bacchetta and biomedical engineer Gordana Vunjak-Novakovic demonstrated normothermic support and preservation of ex-vivo lungs for 4 days [ 7 ] and the functional repair of ex-vivo lungs with ischemic, aspiration, or infectious injury that would otherwise be deemed unsuitable for transplant. [ 4 ] [ 8 ] Innovations in cannulation strategies and circuit design were developed to optimize platform safety and scalability. [ 9 ] Through durable physiologic support and targeted therapeutic intervention, this platform actively facilitates organ recovery, immune modulation, and functional regeneration.
In later work, researchers extended the technique to human donor organs using xenogeneic cross-circulation, where a swine host served as a systemic ‘xeno-support’ animal for an ex-vivo human donor organ. [ 10 ] [ 11 ] These trailblazing studies garnered the attention of several mainstream media outlets. [ 12 ] [ 13 ] Further studies examined immune interactions within this xenogeneic context, revealing an attenuated immune response and permissive environment for donor organ recovery. [ 14 ] [ 15 ] Additional studies confirmed that the platform enables rehabilitation of donor lungs using xeno-support without triggering hyperacute rejection in a human lung transplantation model, laying the groundwork for clinical translation. [ 16 ] The platform has since been refined with advanced ex-vivo organ assessment capabilities, integrating real-time monitoring, functional imaging, and molecular diagnostics to guide intervention and clinical decision-making. [ 17 ]
As of the mid-2020s, cross-circulation is emerging as a novel tool for organ recovery. [ 18 ]
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Cross-cultural psychiatry (also known as ethnopsychiatry or transcultural psychiatry or cultural psychiatry ) is a branch of psychiatry concerned with the cultural context of mental disorders and the challenges of addressing ethnic diversity in psychiatric services. It emerged as a coherent field from several strands of work, including surveys of the prevalence and form of disorders in different cultures or countries; the study of migrant populations and ethnic diversity within countries; and analysis of psychiatry itself as a cultural product. [ 1 ]
The early literature was associated with colonialism and with observations by asylum psychiatrists or anthropologists who tended to assume the universal applicability of Western psychiatric diagnostic categories. A seminal paper by Arthur Kleinman in 1977 [ 2 ] followed by a renewed dialogue between anthropology and psychiatry, is seen as having heralded a "new cross-cultural psychiatry". However, Kleinman later pointed out that culture often became incorporated in only superficial ways, and that for example 90% of DSM-IV categories are culture-bound to North America and Western Europe, and yet the " culture-bound syndrome " label is only applied to "exotic" conditions outside Euro-American society. [ 3 ] Reflecting advances in medical anthropology, DSM-5 replaced the term " culture-bound syndrome " with a set of terms covering cultural concepts of distress: cultural syndromes (which may not be bound to a specific culture but circulate across cultures); cultural idioms of distress (local modes of expressing suffering that may not be syndromes); causal explanations (that attribute symptoms or suffering to specific causal factors rooted in local ontologies); and folk diagnostic categories (which may be part of ethnomedical systems and healing practices).
Cultural psychiatry looks at whether psychiatric classifications of disorders are appropriate to different cultures or ethnic groups. It often argues that psychiatric illnesses represent social constructs as well as genuine medical conditions, and as such have social uses peculiar to the social groups in which they are created and legitimized. It studies psychiatric classifications in different cultures, whether informal (e.g. category terms used in different languages) or formal (for example the World Health Organization's ICD , the American Psychiatric Association 's DSM , or the Chinese Society of Psychiatry 's CCMD ). [ 4 ] The field has increasingly had to address the process of globalization . [ 5 ] It is said every city has a different culture and that the urban environment, and how people adapt or struggle to adapt to it, can play a crucial role in the onset or worsening of mental illness. [ 6 ]
However, some scholars developing an anthropology of mental illness (Lézé, 2014) [ 7 ] consider that attention to culture is not enough if it is decontextualized from historical events, and history in more general sense. An historical and politically informed perspective can counteract some of the risks related to promoting universalized 'global mental health' programs as well as the increasing hegemony of diagnostic categories such as PTSD ( Didier Fassin and Richard Rechtman analyze this issue in their book The Empire of Trauma ). [ 8 ] Roberto Beneduce, who devoted many years to research and clinical practice in West Africa ( Mali , among the Dogon ) and in Italy with migrants, strongly emphasizes this shift. Inspired by the thought of Frantz Fanon , Beneduce points to forms of historical consciousness and selfhood as well as history-related suffering as central dimensions of a 'critical ethnopsychiatry' or 'critical transcultural psychiatry'. [ 9 ] [ 10 ]
As a named field within the larger discipline of psychiatry, cultural psychiatry has a relatively short history. [ 1 ] In 1955, a program in transcultural psychiatry was established at McGill University in Montreal by Eric Wittkower from psychiatry and Jacob Fried from the department of anthropology.
In 1957, at the International Psychiatric Congress in Zurich , Wittkower organized a meeting that was attended by psychiatrists from 20 countries, including many who became major contributors to the field of cultural psychiatry: Tsung-Yi Lin (Taiwan), Thomas Lambo (Nigeria), Morris Carstairs (Britain), Carlos Alberto Seguin (Peru) and Pow-Meng Yap (Hong Kong). The American Psychiatric Association established a Committee on Transcultural Psychiatry in 1964, followed by the Canadian Psychiatric Association in 1967. H.B.M. Murphy of McGill founded the World Psychiatric Association Section on Transcultural Psychiatry in 1970. By the mid-1970s there were active transcultural psychiatry societies in England , France , Italy and Cuba .
There are several scientific journals devoted to cross-cultural issues: Transcultural Psychiatry [ 11 ] (est. 1956, originally as Transcultural Psychiatric Research Review , and now the official journal of the WPA Section on Transcultural Psychiatry), Psychopathologie Africaine (1965), Culture Medicine & Psychiatry (1977), Curare (1978), and World Cultural Psychiatry Research Review (2006). The Foundation for Psychocultural Research at UCLA [ 12 ] has published an important volume on psychocultural aspects of trauma [ 13 ] and more recently landmark volumes entitled Formative Experiences: the Interaction of Caregiving, Culture, and Developmental Psychobiology edited by Carol Worthman, Paul Plotsky, Daniel Schechter and Constance Cummings, [ 14 ] Re-Visioning Psychiatry: Cultural Phenomenology, Critical Neuroscience, and Global Mental Health edited by Laurence J. Kirmayer, Robert Lemelson and Constance Cummings, [ 15 ] and Culture, Mind, and Brain: Emerging Concepts, Models, and Applications edited by Laurence J. Kirmayer , Carol Worthman, Shinobu Kitayama , Robert Lemelson and Constance A. Cummings. [ 16 ]
It is argued that a cultural perspective can help psychiatrists become aware of the hidden assumptions and limitations of current psychiatric theory and practice and can identify new approaches appropriate for treating the increasingly diverse populations seen in psychiatric services around the world. [ 17 ] The recent revision of the nosology of the American Psychiatric Association , DSM-5 , includes a Cultural Formulation Interview that aims to help clinicians contextualize diagnostic assessment. A related approach to cultural assessment involves cultural consultation which works with interpreters and cultural brokers to develop a cultural formulation and treatment plan that can assist clinicians. [ 18 ]
The main professional organizations devoted to the field are the WPA Section on Transcultural Psychiatry, the Society for the Study of Psychiatry and Culture, and the World Association for Cultural Psychiatry. Many other mental health organizations have interest groups or sections devoted to issues of culture and mental health.
There are active research and training programs in cultural psychiatry at several academic centers around the world, notably the Division of Social and Transcultural Psychiatry at McGill University , [ 19 ] Harvard University , the University of Toronto , and University College London . Other organizations are devoted to cross-cultural adaptation of research and clinical methods. In 1993 the Transcultural Psychosocial Organization (TPO) was founded. The TPO has developed a system of intervention aimed at countries with little or no mental health care. They train local people to become mental health workers, often using people who previously have provided mental health guidance of some kind. The TPO provides training material that is adapted to local culture, language and distinct traumatic events that might have occurred in the region where the organization is operating. Avoiding Western approaches to mental health, the TPO sets up what becomes a local non-governmental organization that is self-sustainable, as well as economically and politically independent of any state. The TPO projects have been successful in both Uganda and Cambodia.
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Cross education is a neurophysiological phenomenon where an increase in strength is witnessed within an untrained limb following unilateral strength training in the opposite, contralateral limb. [ 1 ]
Cross education can also be seen in the transfer of skills from one limb to the other.
A resistance trainer witnesses strength gains in her left and right biceps after participating in a strength training program for only her right biceps. This phenomenon is due to factors at the muscular , spinal and neural levels.
A basketball player learns to dribble a basketball with his right hand and then successfully performs the task with his left hand even though he had undergone no previous training with his left side.
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https://en.wikipedia.org/wiki/Cross_education
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In dentistry, the crown is the visible part of the tooth above the gingival margin and is an essential component of dental anatomy. Covered by enamel , the crown plays a crucial role in cutting, tearing, and grinding food. Its shape and structure vary depending on the type and function of the tooth ( incisors , canines , premolars , or molars ), and differ between primary dentition and permanent dentition . The crown also contributes to facial aesthetics, speech, and oral health.
The anatomical crown refers to the portion of the tooth covered by enamel, regardless of whether it is visible. The clinical crown is the part of the tooth that is visible in the mouth. In a healthy young adult, the gums typically follow the contour where enamel meets the root, so the clinical and anatomical crowns are similar in size. However, with age or periodontal disease , this may change. [ 1 ]
To describe the location and orientation of the crown’s surfaces, dental professionals use several standard terms.
The surface of the tooth that faces the lips or cheeks is referred to as the facial surface. In anterior teeth, such as incisors and canines, this surface is more specifically known as the labial surface, while in posterior teeth, such as premolars and molars, it is termed the buccal surface. [ 1 ]
The lingual surface is the side of the tooth that faces the tongue. In the upper jaw or maxillary arch, this surface may also be referred to as the palatal surface due to its proximity to the palate. [ 1 ]
The occlusal surface is the chewing surface found on posterior teeth (premolar and molars), whereas anterior teeth have an incisal edge, which is a sharp cutting edge used for biting. [ 1 ]
The sides of a tooth that make contact with neighbouring teeth are called proximal surfaces. If the surface faces toward the midline of the dental arch, it is known as the mesial surface. Conversely, if it faces away from the midline, it is termed the distal surface. [ 1 ]
The crown contributes to multiple functions, including mastication , speech, aesthetics, and protection of supporting oral structures. Incisors, positioned at the front of the mouth, have sharp edges for cutting food and aiding in speech. Canines have pointed cusps to tear food and support the bite . Premolars combine tearing and grinding functions, while molars, with their broad surfaces, are specialised for crushing and grinding food. [ 2 ]
The anatomical crown refers to the portion of a tooth covered by enamel, it includes three main layers: enamel, dentine , and the pulp chamber. [ 3 ]
Enamel is the outermost and hardest tissue in the human body. [ 4 ] It consists of approximately 96% inorganic material, primarily in the form of carbonated hydroxyapatite crystals, with the remainder composed of organic matrix and water. [ 5 ] Its main function is to protect the underlying dentine and aid in food breakdown through mastication. [ 6 ]
Enamel is formed during amelogenesis , a two-stage process beginning with the secretion of an organic matrix by ameloblasts near the dentinoenamel junction (DEJ). [ 5 ] Once mineralisation reaches 96%, enamel formation is complete, and no further deposition occurs due to the degeneration of ameloblasts. [ 7 ] [ 5 ]
At the microscopic level, enamel has a complex structure composed of enamel rods and interrod enamel, arranged in a prism-like pattern which contributes to its density and mechanical strength. [ 5 ]
Dentine lies beneath the enamel and forms the bulk of the anatomical crown. It supports the enamel and protects the innermost pulp chamber. [ 7 ] [ 6 ] Composed of 70% inorganic material, 20% organic matrix (mainly collagen ), and 10% water, dentine is resilient and capable of absorbing functional stresses. [ 8 ]
The structure of dentine includes dentinal tubules that extend from the enamel-dentine junction to the pulp. These tubules are surrounded by peritubular and intertubular dentine, contributing to its mechanical properties and sensitivity. [ 5 ] [ 8 ]
The pulp chamber is the innermost part of the anatomical crown and contains blood vessels, nerves, lymphatics, and odontoblasts. [ 3 ] It plays a role in dentine formation, nutrient delivery, and pain response.
Though mainly associated with root canal treatments, the pulp chamber's position within the crown is important in clinical practice. Several anatomical "laws" have been described to aid in locating the pulp chamber during restorative or endodontic procedures:
Primary teeth are the first set of teeth in the human dentition. It comprises 20 teeth, known as primary teeth or milk teeth. Primary teeth begin to erupt in infancy and are eventually replaced by permanent teeth. Premature loss of primary teeth can result in malocclusion or crowding of the permanent successors. [ 11 ]
Primary teeth differ from permanent teeth in several anatomical and structural ways. The crowns of primary teeth are generally shorter and broader, with a thinner layer of enamel, making them more susceptible to wear. This enamel also gives them a whiter appearance compared to permanent teeth. [ 11 ] In anterior teeth, mamelons , small bumps on the incisal edge of newly erupted permanent incisors, are absent in the primary dentition. The cervical ridges are more pronounced, particularly in molars, and the crowns are more bulbous with a distinct cervical constriction. [ 11 ]
Structurally, the roots of primary teeth are thinner and more widely spread, with short or absent root trunks. These adaptations facilitate natural exfoliation as the underlying permanent teeth erupt. [ 11 ]
Functionally and morphologically, primary molars have narrower occlusal tables and flatter buccal and lingual surfaces, whereas anterior primary teeth are proportionally wider mesiodistally compared to their crown height. These distinctions are important during dental assessments and restorative procedures. [ 12 ] [ 13 ]
In the permanent dentition, maxillary central incisors have broad, rectangular crowns with a straight incisal edge. Newly erupted incisors often display three mamelons, which wear down with time. The lingual surface contains a distinct cingulum bordered by mesial distal marginal ridges, enclosing a shallow lingual fossa. [ 12 ] Maxillary lateral incisors are smaller, with rounded incisal angles and a deeper lingual fossa that may include developmental grooves. [ 12 ] Mandibular central incisors are the smallest teeth and exhibit a symmetrical crown with a straight incisal edge and smooth lingual surface. Mandibular lateral incisors are slightly larger and possess a distally sloping incisal edge. [ 12 ] [ 14 ]
Primary maxillary central incisors have crowns wider mesiodistally than inciso-cervically, a feature not found in any other tooth. They lack mamelons and display a prominent cingulum and marginal ridges with a deeper lingual fossa. [ 15 ] Primary lateral incisors are smaller with more rounded incisal angles. In the mandible, primary central incisors are symmetrical with a tapered crown and smooth lingual surface, while lateral incisors are slightly larger with a distally sloped incisal edge. [ 15 ]
Permanent maxillary canines are characterised by a prominent labial ridge, a well-developed cingulum , and a pronounced pointed cusp. The crown appears diamond-shaped from the incisal view, with strong mesial and distal slopes. The lingual anatomy includes a central ridge flanked by shallow fossae and prominent marginal ridges. [ 12 ] [ 16 ] Mandibular canines are narrower mesiodistally, with a less prominent cingulum and smoother lingual surface. Their crowns are generally flatter and less pointed than those of maxillary canines. [ 16 ]
In the primary dentition, maxillary canines maxillary canines have prominent, sharp cusps with longer mesial slopes. The crown is constricted cervically and appears more bulbous. [ 12 ]
Maxillary premolars usually have two cusps–buccal and lingual. The first premolars show sharp buccal cusp and a smaller lingual cusp separated by a central groove. They often exhibit a pronounced buccal ridge and occlusal sulcus. [ 12 ] [ 13 ] The second premolars are smaller with cusps of more equal height and display more supplemental grooves on the occlusal surface.
Mandibular first premolars have a dominant buccal cusp and a much smaller lingual cusp, often giving the appearance of a single cusp. The crown tapers sharply towards the lingual side. [ 13 ] Second premolars typically have two lingual cusps and a broader, square, or round occlusal table. Their occlusal groove pattern may vary from Y, H, to U shapes. [ 13 ]
Maxillary first permanent molars have four main cusps, and sometimes a fifth cusp known as the cusp of Carabelli . The occlusal surface typically has a rhomboidal shape and includes a distinct oblique ridge connecting the mesiopalatal and distobuccal cusps. [ 12 ] Second maxillary molars are smaller, and the distopalatal cusp may be reduced or absent, giving rise to a heart-shaped occlusal form. Third molars are highly variable in anatomy, often smaller and more rounded, with numerous accessory grooves and ridges. [ 12 ]
Mandibular first molars have five cusps and a pentagonal occlusal outline. They include three buccal and two lingual cusps, separated by distinct grooves. The mesiobuccal cusp is typically the largest. [ 17 ] Second molars have four cusps of nearly equal size and a rectangular occlusal outline, with grooves forming a cross pattern. Third molars exhibit significant anatomical variation and often have wrinkled occlusal surfaces due to supplemental grooves. [ 12 ]
Primary molars differ in shape and size from permanent molars. Maxillary first molars have a prominent mesiopalatal cusp and a smooth buccal surface with minimal grooves. Second molars resemble permanent maxillary first molars and include a cusp of Carabelli. [ 18 ] Mandibular first molars are unique in shape and do not resemble any permanent teeth, featuring a strong mesial marginal ridge and pronounced curvature at the cervical third. [ 18 ] Second mandibular molars resemble the permanent mandibular first molars but are smaller in all dimensions. [ 18 ]
On radiographs, enamel appears as the most radiopaque (white) structure due to its high mineral content. [ 19 ] Dentine and cementum are less radiopaque and are usually indistinguishable from each other. [ 19 ] The pulp chamber and root canals are radiolucent (dark), centrally located within the tooth structure. The periodontal ligament appears as a thin, radiolucent line between the root and the lamina dura. [ 19 ]
Developmental anomalies that affect the crown of a tooth can lead to changes in its shape, size, and structure, affecting both appearance and function. These anomalies typically arise during the early stages of tooth formation , and can result in irregularities such as extra cusps, fused teeth, or abnormal indentations. Such variations in crown morphology can cause difficulties in maintaining oral hygiene, occlusal issues, and increase the risk of caries and periodontal problems.
Fusion occurs when two developing teeth merge, forming a large crown that may have one or two roots. [ 21 ] Complete fusion affects both crown and roots, while incomplete fusion affects only the crown. [ 22 ] The crown may have a groove or notch that increases plaque retention. [ 22 ] Management includes sealants, reshaping, or extraction if necessary. [ 23 ]
Gemination results from a single tooth attempting to divide. It presents as a bifid crown with a single root and root canal. [ 22 ] Unlike fusion, gemination does not reduce tooth count. [ 23 ] Deep grooves increase caries risk. Treatment may include sealants, restorations, or orthodontic correction. [ 23 ]
Clinically, geminated teeth can cause aesthetic concerns, spacing issues, and malocclusion. Depending on its impact, treatment may include sealants, restorations, orthodontic correction, or extraction in severe cases. [ 23 ]
Dens invaginatus (DI), or dens in dente, is a condition where part of the tooth crown folds inward before hardening, during development, forming a deep groove or pocket lined with enamel. [ 21 ] [ 24 ] This anomaly most commonly affects upper lateral incisors, followed by central incisors, and premolars. [ 24 ]
Oehlers (1957) classified DI into three types based on how far the invagination extends within the tooth: [ 25 ]
Only Type I and Type III directly affect the crown, altering its shape and surface features.
Affected teeth may appear barrel-shaped or conical and are prone to caries. [ 26 ] Treatment ranges from sealing to extraction, depending on severity. [ 24 ]
Dens evaginatus presents as an extra cusp on the occlusal or palatal surface, also known as talon cusp in anterior teeth. [ 21 ] [ 24 ] It contains enamel, dentine, and sometimes pulp. It may interfere with occlusion and increase caries risk. [ 24 ] Management includes grinding, sealing, or root canal therapy if pulp is exposed. [ 27 ] [ 28 ]
Microdontia is a developmental anomaly where one or more teeth appear smaller than normal, often leading to aesthetic concerns, spacing issues, and difficulty chewing. [ 29 ] The most commonly affected teeth are upper lateral incisors, often presenting as peg-shaped teeth with a conical appearance. [ 29 ] [ 30 ] Therefore, microdontia may contribute to functional issues such as food trapping due to improper spacing, leading to caries and periodontal issues. [ 29 ] Management may include orthodontics and restorations. [ 29 ]
Macrodontia , or megalodontia, is a condition where one or more teeth are abnormally large, while still having normal crown, root, and pulp morphology. [ 22 ] [ 30 ] Isolated macrodontia usually occurs in isolation, but generalised macrodontia (affecting all teeth) may be linked to systemic conditions such as otodental syndrome, insulin-resistant diabetes, and hypophyseal gigantism. [ 21 ] Not to be mistaken for gemination or fusion, macrodontia does not involve tooth splitting or merging. [ 22 ] [ 23 ] Clinically, macrodontia may cause crowding, misalignment, and aesthetic concerns. [ 22 ] Treatment may include size reduction, orthodontics, or extraction. [ 22 ] [ 30 ]
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Crown lengthening is a surgical procedure performed by a dentist , or more frequently a periodontist , where more tooth is exposed by removing some of the gingival margin (gum) and supporting bone. [ 1 ] Crown lengthening can also be achieved orthodontically (using braces) by extruding the tooth.
Crown lengthening is done for functional and/or esthetic reasons. Functionally, crown lengthening is used to: 1) increase retention and resistance when placing a fabricated dental crown , [ 2 ] 2) provide access to subgingival caries , 3) access accidental tooth perforations, and 4) access external root resorption . [ citation needed ] Esthetically, crown lengthening is used to alter gum and tooth proportions, such as in a gummy smile . There are a number of procedures used to achieve an increase in crown length. [ 3 ]
The remaining crown of the natural tooth needs to be sufficiently long to have adequate retention and resistance to withstand occlusal (biting) forces. Without adequate retention and resistance, a prosthetic crown can be dislodged and/or damaged. Suggested characteristics are: 1) 10-20° of occlusal convergence, 2) minimum height of 4 mm for molars and 3 mm for other teeth, 3) a height:width ratio of 0.4 or greater, and 4) proximal line angles should be conserved. When these characteristics are lacking, auxiliary retention (e.g. axial grooves) are needed. [ 4 ]
Previously known as biologic width, [ 5 ] supracrestal tissue attachment (STA) consists of the junctional epithelium and connective tissue attachment above the alveolar crest . [ 6 ] On average, STA is 2.04 mm, with the junctional epithelium and connective tissue constituting 0.97 and 1.07 mm, respectively. [ 2 ] [ 7 ] However, the STA has been observed to vary between 0.75 - 4.33 mm. [ 8 ]
It is important to avoid invading the STA when fabricating dental restorations . If a dental restoration invades the STA, chronic inflammation is likely to occur which then causes pain, gum recession, and unpredictable loss of alveolar bone. [ 9 ] [ 10 ] [ 11 ]
Due to the variation in STA and limits of precisely restoring a tooth to the coronal edge of the junctional epithelium, it is often recommended to remove enough bone to place restorative margins such that they maintain at least 3 mm of tooth and gum tissue above the alveolar crest. [ 12 ] [ 13 ] [ 14 ]
In dentistry, the ferrule effect is, a "360° collar of the crown surrounding the parallel walls of the dentin extending coronal to the shoulder of the preparation". [ 15 ] This circumferential collar should have a height of ~2 mm and width of ~1 mm. [ 16 ] Presence of adequate ferrule helps resist tooth fracture by minimizing stress concentration at the junction of tooth structure and the dental restoration. [ 17 ] This has been shown to significantly reduce the incidence of fracture in the endodontically treated tooth. [ 18 ] Because beveled tooth structure is not parallel to the vertical axis of the tooth, it does not properly contribute to ferrule height; thus, a desire to bevel the crown margin by 1 mm would require an additional 1 mm of bone removal in the crown lengthening procedure. [ 19 ] Frequently, however, restorations are performed without such a bevel.
Recent studies suggest that, while adequate ferrule is desirable, it should not come at the expense of removing too much remaining tooth and root structure. [ 20 ] However, as little as 1 mm of additional tooth structure, when encased by a ferrule, provides great protection. If adequate ferrule cannot be achieved without significant tooth structure removal, tooth extraction should be considered. [ 21 ]
The alveolar bone surrounding a tooth also surrounds adjacent teeth. Removing bone for a crown lengthening procedure will effectively decrease the bony support available for surrounding teeth and unfavorably increase the crown-to-root ratio . Additionally, once alveolar bone is removed, it is almost impossible to restore it to previous levels. This has implications for a patient's future treatment options. For example, there might not be enough alveolar bone to support an implant in an area where a crown lengthening procedure has been completed. Thus, it would be prudent for patients to thoroughly discuss all of their treatment options with their dentist before undergoing an irreversible procedure such as crown lengthening. [ 22 ] [ 23 ] [ 24 ] [ 25 ] [ 26 ]
Crown lengthening is often done in conjunction with a few other expensive and time-consuming dental procedures (e.g. post and core , endodontic treatment ) with the ultimate goal of saving the tooth. The prognosis for a tooth should be considered carefully. If multiple treatment procedures are necessary, each procedure costs time and money with potential for failures/complications. Thus, tooth extraction may be a reasonable treatment option. The tooth could then be replaced with a dental implant .
Alternatively, orthodontic extrusion can be used to achieve crown lengthening. Using brackets, light forces can be used to pull the tooth away from the gums within a few months. A fiberotomy is performed after crown lengthening and is easily performed by the general dentist.
Source: [ 27 ]
An apically repositioned flap is a widely used procedure that involves flap elevation with subsequent osseous contouring. The flap is designed such that it is replaced more apical to its original position and thus immediate exposure of sound tooth structure is gained. As discussed above, when planning a crown lengthening procedure consideration must be given to maintenance of the supracrestal tissue attachment.
As a general rule, at least 4 mm of sound tooth structure must be exposed at the time of surgery. This, allows for proliferation of the supracrestal soft tissues, which are estimated to cover 2– 3 mm of the coronal root structure thereby leaving 1–2 mm of sound tooth structure supragingivally. Additionally, gingiva tends to regrow over abrupt changes in the bone contour. Therefore, the bone underlying the gingiva and adjacent teeth may need to be recontoured to prevent this.
Consequently, substantial amounts of attachment may have to be sacrificed when crown lengthening is accomplished with an apically positioned flap technique. Importantly, for esthetic reasons, symmetry of tooth length must be maintained between the right and left sides of the dental arch. This may, in some situations, call for the inclusion of even more teeth in the surgical procedure. [ 28 ]
Crown lengthening of multiple teeth in a quadrant or sextant of the dentition
Single teeth in the aesthetic zone becomes increasingly destructive.
Source: [ 27 ]
Immediate increase in sound tooth structure can be achieved.
Difficult procedure for patients to tolerate, increased post-operative pain [ 28 ]
Source: [ 27 ]
Orthodontic tooth movement can be used to erupt teeth in adults. If moderate eruptive forces are applied, the entire eruptive apparatus will move in unison with the tooth. As such, the units required must be extruded a distance equal to or slightly longer than the portion of sound tooth structure that will be exposed in the following surgical treatment. Once stabilized, a full-thickness flap is then elevated and osseous recontouring is performed to expose the required tooth structure. To restore aesthetic proportions correctly, the hard and soft tissues of adjacent teeth should remain unchanged.
Forced tooth eruption is indicated where crown lengthening is required, but attachment and bone from adjacent teeth must be preserved.
Forced tooth eruption requires a fixed orthodontic appliance. This poses problems in patients with reduced dentitions; in such instances alternative crown lengthening procedures must be considered [ citation needed ]
Source: [ 27 ]
Orthodontic brackets are bonded to the teeth requiring crown lengthening surgery and then to adjacent teeth, these are then combined within an archwire. A power elastic band is then tied from the bracket to the archwire (or the bar), which pulls the tooth coronally. The direction of the tooth movement must be carefully checked to ensure no tilting or movement of adjacent teeth occurs. [ citation needed ]
Forced tooth eruption can also be performed with fiberotomy. This technique is adopted when gingival margins and crystal bone height are to be maintained at their pretreatment locations. Fiberotomy is performed at 7-10 day intervals during treatment. A scalpel is used to sever supracrestal connective tissue fibres, thereby preventing crystal bone from following the root in a coronal direction. [ citation needed ]
Preserves osseous structure around adjacent teeth [ citation needed ]
Procedure requires fixed wire placement. Treatment time can be prolonged.
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A crownlay is a type of dental restoration.
A crownlay is a hybrid dental restoration typically placed over an endodontically treated tooth that is more conservative than a normal full coverage crown , but less conservative than a normal only. Crownlays incorporate an extension of extra restorative material on the underside of the restoration into the excavated pulp chamber following root canal therapy , taking advantage of the extra surface area afforded in this space on the interior aspect of the preparation, thereby sparing the external walls from needing as much tooth reduction. The use of a crownlay results in the conservation of more healthy, natural tooth structure than is otherwise possible.
Crownlays are typically used in place of traditional post and core restorations. Post and core buildups are essentially rods of restorative material made out of titanium, stainless steel or resin that glean extra surface area against the internal walls of root canal-treated teeth when there is little to no teeth left above the gumline to hold a normal crown or onlay in place. The post and core buildup serve to aid in retention of a traditional crown but increase the likelihood of root fracture because chewing forces are directed vertically along the hollowed out and subsequent weaker remnants of the internal surfaces of an endodontically-treated (root-canal-treated) tooth. Crownlays are typically constructed from milled, monolithic blocks of solid porcelain which not only very intimately fit the prepared tooth, but are acid etched and bonded into place using very strong resin materials, decreasing the need for physical retention.
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Crutch paralysis is a form of paralysis which can occur when either the radial nerve or part of the brachial plexus , containing various nerves that innervate sense and motor function to the arm and hand, is under constant pressure, such as by the use of a crutch . [ 1 ] This can lead to paralysis of the muscles innervated by the compressed nerve. [ 2 ] Generally, crutches that are not adjusted to the correct height can cause the radial nerve to be constantly pushed against the humerus . This can cause any muscle that is innervated by the radial nerve to become partially or fully paralyzed. An example of this is wrist drop , in which the fingers, hand, or wrist is chronically in a flexed position because the radial nerve cannot innervate the extensor muscles due to paralysis. This condition, like other injuries from compressed nerves, normally improves quickly through therapy. [ 3 ] [ 4 ]
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Cryoablation is a process that uses extreme cold to destroy tissue . Cryoablation is performed using hollow needles (cryoprobes) through which cooled, thermally conductive fluids are circulated. Cryoprobes are positioned adjacent to the target in such a way that the freezing process will destroy the diseased tissue. Once the probes are in place, the attached cryogenic freezing unit removes heat from ("cools") the tip of the probe and by extension from the surrounding tissues.
Ablation occurs in tissue that has been frozen by at least three mechanisms:
The most common application of cryoablation is to ablate solid tumors found in the lung, liver, breast, kidney and prostate. The use in prostate and renal cryoablation are the most common. Although sometimes applied in cryosurgery through laparoscopic or open surgical approaches, most often cryoablation is performed percutaneously (through the skin and into the target tissue containing the tumor) by a medical specialist, such as an interventional radiologist . The term is from cryo- + ablation .
This offers distinct advantages and disadvantages when compared to other pain management modalities. Unlike chemical neurolysis (e.g., alcohol or phenol), cryoanalgesia is non-neurolytic and maintains the nerve's architectural integrity, facilitating regeneration and reducing the risk of deafferentation pain. Compared to radiofrequency ablation (RFA), cryoanalgesia often results in a less painful procedure and a lower incidence of neuroma formation. However, RFA may offer longer-lasting pain relief in some cases. Traditional local anesthetic nerve blocks provide immediate but short-lived relief, whereas cryoanalgesia provides extended pain control without permanent nerve destruction
The equipment for cryoanalgesia typically consists of a cryoanalgesia unit (console) and specialized cryoprobes. The console regulates the flow of a cryogen (e.g., nitrous oxide or carbon dioxide gas) to the tip of the cryoprobe. Cryoprobes vary in size and design, featuring a small, insulated shaft and a uninsulated tip that forms an ice ball upon activation. Different probe sizes are chosen based on the target nerve's diameter and location.
Cryoanalgesia is indicated for a wide range of chronic pain conditions where a temporary but prolonged nerve block is desired. Common indications include post-thoracotomy pain syndrome, intercostal neuralgia, trigeminal neuralgia (peripheral branches), occipital neuralgia, neuropathic pain following surgery or trauma, phantom limb pain, and pain associated with spasticity. It is also used for managing acute pain in certain surgical procedures, such as rib fractures or sternotomy.
Prostate cryoablation is moderately effective but, as with any prostate removal process, also can result in impotence. Prostate cryoablation is used in three patient categories:
Cryoablation has been explored as an alternative to radiofrequency ablation in the treatment of moderate to severe pain in people with metastatic bone disease . The area of tissue destruction created by this technique can be monitored more effectively by CT than RFA, a potential advantage when treating tumors adjacent to critical structures. [ 1 ]
Cryoablation has similar outcomes to radiofrequency ablation when treating renal cell carcinoma . [ 2 ]
Cryoablation for breast cancer is typically only possible for small tumors. [ 3 ] Often surgery is used following cryoablation. [ 3 ] As of 2014 more research is required before it can replace lumpectomy . [ 3 ]
Another type of cryoablation is used to restore normal electrical conduction by freezing tissue or heart pathways that interfere with the normal distribution of the heart’s electrical impulses. Cryoablation is used in two types of intervention for the treatment of arrhythmias : (1) catheter -based procedures and (2) surgical operations.
A catheter is a very thin tube that is inserted into a vein in the patient’s leg and threaded to the heart where it delivers energy to treat the patient’s arrhythmia. In surgical procedures, a flexible probe is used directly on an exposed heart to apply the energy that interrupts the arrhythmia. By cooling the tip of a cryoablation catheter ( cardiology ) or probe ( heart surgery ) to sub-zero temperatures, the cells in the heart responsible for conducting the arrhythmia are altered so that they no longer conduct electrical impulses.
Cryoablation is also currently being used to treat fibroadenomas of the breast. Fibroadenomas are benign breast tumors that are found in approximately 10% of women (primarily ages 15–30). [ 4 ]
In this procedure which has been approved by the U.S. Food and Drug Administration (FDA), an ultrasound-guided probe is inserted into the fibroadenoma and extremely cold temperatures are then used to destroy the abnormal cells. [ 5 ] Over time the cells are reabsorbed into the body. The procedure can be performed in a doctor's office setting with local anesthesia and leaves very little scarring compared to open surgical procedures. [ 5 ]
Different catheter-based ablation techniques may be used and they generally fall into two categories: (1) cold-based procedures where tissue cooling is used to treat the arrhythmia, and (2) heat-based procedures where high temperature is used to alter the abnormal conductive tissue in the heart.
Cold temperatures are used in cryoablation to chill or freeze cells that conduct abnormal heart rhythms. The catheter removes heat from the tissue to cool it to temperatures as low as -75 °C. This causes localized scarring, which cuts undesired conduction paths.
This is a much newer treatment for supraventricular tachycardia (SVT) involving the atrioventricular (AV) node directly. SVT involving the AV node is often a contraindication for using radiofrequency ablation because of the risk of injuring the AV node, forcing patients to receive a permanent pacemaker. With cryoablation, areas of tissue can be mapped by limited, reversible, freezing (e.g., to -10 C). If the result is undesirable, the tissue can be rewarmed without permanent damage. Otherwise, the tissue can be permanently ablated by freezing it to a lower temperature (e.g., -73 C).
This therapy has revolutionized AV nodal reentrant tachycardia (AVNRT) and other AV nodal tachyarrhythmias. It has allowed people who were otherwise not a candidate for radiofrequency ablation to have a chance at having their problem cured. This technology was developed at The Montreal Heart Institute in the late 1990s. The therapy was successfully adopted in Europe in 2001, and in the US in 2004 following the "Frosty Trial". [ 6 ]
In 2004, the technology was pioneered in the midwest United States at Miami Valley Hospital in Dayton, Ohio, by Mark Krebs, MD, FACC, Matthew Hoskins, RN, BSN and Ken Peterman, RN, BSN. These electrophysiology experts were successful in curing the first 12 candidates in their facility. [ citation needed ]
Cryoablation for AVNRT and other arrhythmias do have some drawbacks. A recent study [ 7 ] concluded that procedure times are slightly higher on average for cryoablation than for traditional radio-frequency (heat-based) ablations. Also, higher rate of equipment failures were recorded using this technique. Finally, even though short term success rate is equivalent to RF treatments, cryoablation appears to have a significantly higher long term recurrence rate.
Cryoanalgesia can be performed using various techniques, primarily categorized into percutaneous and intraoperative approaches. The percutaneous approach involves inserting a cryoprobe through the skin under imaging guidance (e.g., fluoroscopy, ultrasound, or CT) to precisely target the nerve. This is common for intercostal or occipital nerve blocks. The intraoperative approach involves direct visualization and application of the cryoprobe to nerves exposed during surgery, often utilized during thoracotomy or other procedures where nerves are easily accessible.
Cryotherapy is able to produce a temporary electrical block by cooling down the tissue believed to be conducting the arrhythmia. This allows the physician to make sure this is the right site before permanently disabling it. The ability to test a site in this way is referred to as site testing or cryomapping .
When ablating tissue near the AV node (a special conduction center that carries electrical impulses from the atria to the ventricles), there is a risk of producing heart block – that is, normal conduction from the atria cannot be transmitted to the ventricles. Freezing tissue near the AV node is less likely to provoke irreversible heart block than ablating it with heat.
As in catheter-based procedures, techniques using heating or cooling temperatures may be used to treat arrhythmias during heart surgery. Techniques also exist where incisions are used in the open heart to interrupt abnormal electrical conduction ( Maze procedure ). Cryosurgery involves the use of freezing techniques for the treatment of arrhythmias during surgery.
A physician may recommend cryosurgery being used during the course of heart surgery as a secondary procedure to treat any arrhythmia that was present or that may appear during the primary open-chest procedure. The most common heart operations in which cryosurgery may be used in this way are mitral valve repairs and coronary artery bypass grafting . During the procedure, a flexible cryoprobe is placed on or around the heart and delivers cold energy that disables tissue responsible for conducting the arrhythmia.
Cryoablation has recently been used to treat low-flow vascular malformations such as venous malformations (VM) and fibroadipose vascular anomalies (FAVA). Cryoablation has proved effective for treating these disorders both as primary treatment and after sclerotherapy . [ 8 ]
Cryoimmunotherapy is an oncological treatment for various cancers that combines cryoablation of tumor with immunotherapy treatment. [ 9 ] In-vivo cryoablation of a tumor alone can induce an immunostimulatory, systemic anti-tumor response, resulting in a cancer vaccine – the abscopal effect . [ 10 ] However, cryoablation alone may produce an insufficient immune response, depending on various factors, such as high freeze rate. Combining cryotherapy with immunotherapy enhances the immunostimulating response and has synergistic effects for cancer treatment. [ 11 ]
The use of cold for pain relief and as an anti-inflammatory has been known since the time of Hippocrates (460–377 BC). [ 12 ] Since then there have been numerous accounts of ice used for pain relief including from the Ancient Egyptians and Avicenna of Persia (AD 982–1070). [ 13 ] Since 1899, Dr. Campbell White used refrigerants for treating a variety of conditions, including: lupus erythematosus, herpes zoster, chancroid, naevi, warts, varicose leg ulcers, carbuncles, carcinomas and epitheliomas. De Quervain successfully used of carbonic snow to treat bladder papillomas and bladder cancers in 1917. Dr. Irving S. Cooper, in 1913, progressed the field of cryotherapy by designing a liquid nitrogen probe capable of achieving temperatures of -196 °C, and utilizing it to treat of Parkinson's disease and previously inoperable cancer. Cooper's cryoprobe advanced the practice of cryotherapy, which led to growing interest and practice of cryotherapy. In 1964, Dr. Cahan successfully used his liquid nitrogen probe invention to treat uterine fibroids and cervical cancer. Cryotherapy continued to advance with Dr. Amoils developing a liquid nitrogen probe capable of achieving cooling expansion, in 1967. [ 14 ] [ 15 ] [ 16 ]
With the technological cryoprobe advancements in the 1960s came wider acceptance and practice of cryotherapy. Since the 1960s, liver, prostate, breast, bone, and other cancers have been treated with cryoablation in many parts of the world. Japanese physician Dr. Tanaka began treating metastatic breast cancer with cryoablation in 1968. [ 17 ] For the next three decades, Dr. Tanaka successfully treated small and localized as well as advanced and unresectable breast cancer with minimally invasive cryoablation. All of Dr. Tanaka's breast cancer cases were considered incurable: advanced, unresectable, and resistant to radiotherapy, chemotherapy, and endocrine therapy. [ 17 ] At the same time, physicians, including Dr. Ablin and Dr. Gage, started utilizing cryoablation for the treatment of prostate and bone cancer . [ 18 ] [ 19 ] Dr. Paul J. Wang MD and Dr. Peter L. Friedman MD, PhD invented cryoablation for the heart and cardiac arrhythmia in 1988. Their patents were for the cryoablation catheter and cryogenic mapping (US Patents 5147355A and 5423807A).
The 1980s and 1990s saw dramatic advancement in apparatus and imaging techniques, with the introduction of CMS Cryoprobe, and Accuprobe. [ 20 ] CT -, MRI -, and ultrasound -guided cryoprobes became available and improved the capabilities of cryoprobes in treatment. Excited by the latest advancements in cryotherapy, China embraced cryotherapy in the 1990s to treat many oncological conditions. [ 21 ] With the benefits well-established, the FDA approved the treatment of prostate cancer with cryoablation in 1998. [ 22 ]
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After the 1959 Cuban Revolution , Cuba established a program to send its medical personnel overseas, particularly to Latin America , Africa , and Oceania , and to bring medical students and patients to Cuba for training and treatment respectively. In 2007, Cuba had 42,000 workers in international collaborations in 103 countries, of whom more than 30,000 were health personnel, including at least 19,000 physicians. [ 1 ] Cuba provides more medical personnel to the developing world than all the G8 countries combined. [ 1 ] The Cuban missions have had substantial positive local impacts on the populations served. [ 2 ] It is widely believed that medical workers are a vital export commodity for Cuba. [ 3 ] According to Granma , the Cuban state newspaper, the number of Cuban medical staff abroad fell from 50,000 in 2015 to 28,000 in 2020. [ 4 ]
A major criticism of Cuban medical internationalism is that the doctors involved that are sent by Cuba are sometimes sent against their will, and with little to no compensation for their services—as opposed to medical international aid from nearly any other country. [ 5 ] [ 6 ] [ 7 ]
A 2007 academic study on Cuban internationalism surveyed the history of the program, noting its broad sweep: "Since the early 1960s, 28,422 Cuban health workers have worked in 37 Latin American countries, 31,181 in 33 African countries, and 7,986 in 24 Asian countries. Throughout a period of four decades, Cuba sent 67,000 health workers to structural cooperation programs, usually for at least two years, in 94 countries ... an average of 3,350 health workers working abroad every year between 1960 and 2000". [ 8 ] In November 2019, the United Nations estimated that there were around 30,000 Cuban doctors active in 67 countries. Since 1963, more than 600,000 Cuban health workers have provided medical services in more than 160 countries. [ 9 ] In 2020, Cuban doctors were active in over 60 countries. [ 10 ]
The term "disaster tourism" arose in response to a growing number of large-scale natural disasters. The phrase refers to individuals, governments and organisations who travel to a disaster area with the primary goal of having an "experience" rather than providing meaningful aid. Such aid is often short-lived, and may even get in the way of more serious rescue efforts. Cuban medical internationalism represents a polar opposite to this disaster tourism mentality, with a focus on large-scale, sustained aid targeting the most marginalised and under-served populations across the globe. [ 11 ]
In 1960, Cuba sent an emergency brigade to Chile to assist the recovery from the Valdivia earthquake . [ 12 ] The program was officially initiated in 1963 as part of Cuba's foreign policy of supporting anti-colonial struggles. It began when Cuba sent a small medical brigade to Algeria , which suffered from the mass withdrawal of French medical personnel during the Algerian War of Independence Some wounded soldiers and war orphans were also transported back to Cuba for treatment. [ 13 ] [ 14 ] Cuba was able to put this program in place despite half the country's 6,000 doctors fleeing after the Cuban revolution. [ 1 ] Between 1966 and 1974, Cuban doctors worked alongside Cuban artillery in Guinea-Bissau during its war of independence against Portugal. [ 1 ] Cuba's largest foreign campaign was in Angola where, in 1977, two years after the campaign's commencement, only one Angolan province out of sixteen was without Cuban health technicians. [ 15 ] After 1979, Cuba also developed a strong relationship with Nicaragua . [ 16 ]
In addition to the internationalism which was driven by foreign policy objectives, humanitarian objectives also played a role in Cuba's overseas medical program, with medical teams despatched to countries governed by ideological foes. For example, in 1960, 1972 and 1990 Cuba dispatched emergency assistance teams to Chile, Nicaragua, and Iran following earthquakes. [ 1 ] Similarly, Venezuela's Mission Barrio Adentro program grew out of the emergency assistance provided by Cuban doctors in the wake of the December 1999 mudslides in Vargas state, which killed 20,000 people. [ 17 ]
Cuban medical missions were sent to Honduras , Guatemala and Haiti following 1998's Hurricane Mitch and Hurricane Georges , and remained there semi-permanently. [ 13 ] From 1998 onwards, Cuba expanded its international cooperation in health dramatically. [ 18 ] The number of Cuban doctors working abroad jumped from about 5,000 in 2003 to more than 25,000 in 2005. [ 18 ]
In Honduras the medical personnel had a substantial impact: "In the areas they served, infant mortality rates were reduced from 30.8 to 10.1 per 1,000 live births and maternal mortality rates from 48.1 to 22.4 per 1,000 live births between 1998 and 2003." [ 1 ] However, as one academic paper noted, "The idea of a nation saving lives and improving the human condition is alien to traditional statecraft and is therefore discounted as a rationale for the Cuban approach." [ 1 ] In 2004 the 1700 medical personnel in Guatemala received the Order of the Quetzal , the country's highest state honour. [ 1 ] A 2005 attempt by Honduras to expel the Cuban mission on the basis that it was threatening Honduran jobs was successfully resisted by trade unions and community organisations. [ 13 ]
Following the 2004 Asian tsunami , Cuba sent medical assistance to Banda Aceh and Sri Lanka . [ 8 ] In response to Hurricane Katrina , Cuba prepared to send 1500 doctors to New Orleans , however, the offer was refused. Several months later a mission was dispatched to Pakistan following the 2005 Kashmir earthquake . Ultimately, Cuba sent "more than 2,500 disaster response experts, surgeons, family doctors, and other health personnel", who stayed through the winter for more than 6 months. [ 8 ] [ 19 ] Cuba helped during the medical crisis in Haiti after the 2010 Haiti earthquake . [ 20 ] All 152 Cuban medical and educational personnel in the Haitian capital Port-au-Prince at the time of the earthquake were reported to be safe, with two suffering minor injuries. [ 21 ] In 2014, Cuba sent 103 nurses and 62 doctors to help fight the Ebola virus epidemic in West Africa , the biggest contribution of health care staff by any single country. [ 22 ]
In the first year of the COVID-19 pandemic , Cuba sent 57 brigades of medical specialists and abroad. [ 23 ] These specialists treated 1.26 million COVID patients in 40 countries. A Cuban medical team consisting of over 50 medical personnel was dispatched to Italy at the request of the worst-affected region Lombardy . [ 24 ] [ 25 ] Cuban medical teams also assisted in Andorra and in Latin America, the Caribbean, Africa, Asia and the Middle East. [ 12 ] [ 26 ]
Cuban doctors, accustomed to working under resource-constrained conditions, have been requested to assist in the pandemic response abroad. Despite the international demand for these professionals, there are concerns regarding the working conditions and the distribution of their salaries when they work abroad, as a significant portion is retained by the Cuban government. [ 27 ] Reports surfacing in early 2022 revealed that the doctors that travel abroad on behalf of the Cuban government, often do so against their will and without monetary compensation similar to doctors from other countries. Another report found that nearly 7,000–8,000 doctors since 2006 have gone into hiding or failed to return to Cuba after having gone on abroad as part of the Cuban government's "volunteering" them to provide healthcare to foreign nationals without remuneration. While Cuban doctors are sent abroad to assist in medical missions, domestically, although wages in the health sector have increased in recent years, they are still considered low compared to the prices of basic goods in Cuba. [ 27 ]
In the 2000s, Cuba began establishing or strengthening relations with Pacific Island countries, and providing medical aid to those countries. Cuba's medical aid to Pacific countries has involved sending its doctors to Oceania, and providing scholarships for Pacific students to study medicine in Cuba at Cuba's expense. [ citation needed ]
In 2007, there were sixteen Cuban doctors providing specialised medical care in Kiribati , and an additional sixteen scheduled to join them. [ 28 ] Cuba also offered training to Kiribati doctors. [ 29 ] Cuban doctors have reportedly provided a dramatic improvement to the field of medical care in Kiribati, reducing the child mortality rate in that country by 80%, [ 30 ] and winning the proverbial hearts and minds in the Pacific. In response, the Solomon Islands began recruiting Cuban doctors in July 2007, while Papua New Guinea and Fiji considered following suit. [ 30 ]
In 2008, Cuba was due to send doctors to the Solomon Islands, Vanuatu , Tuvalu , Nauru and Papua New Guinea, [ 31 ] while seventeen medical students from Vanuatu would study in Cuba. [ 32 ] It was reported that it might also provide training for Fiji doctors. [ 33 ]
As of September 2008, fifteen Cuban doctors were serving in Kiribati, sixty-four Pacific students were studying medicine in Cuba, and Cuban authorities were offering "up to 400 scholarships to young people of that region". [ 34 ] Among the sixty-four students were twenty-five Solomon Islanders, twenty I-Kiribati , two Nauruans and seventeen ni-Vanuatu. [ 35 ] Pacific Islanders have been studying in Cuba since 2006. [ 36 ]
In June 2009, Prensa Latina reported that Cuban doctors had "inaugurated a series of new health services in Tuvalu". One Cuban doctor had been serving in Tuvalu since October 2008, and two more since February 2009. They had reportedly "attended 3,496 patients, and saved 53 lives", having "opened ultrasound and abortion services, as well as specialized consultations on hypertension, diabetes, and chronic diseases in children". They had visited all the country's islands, and were training local staff in "primary health care, and how to deal with seriously ill patients, among other subjects". [ 37 ]
Cuba's largest and most extensive medical aid effort is with Venezuela . The program grew out of the emergency assistance provided by Cuban doctors in the wake of the December 1999 mudslides in Vargas state , [ 38 ] : 131 which killed 20,000 people. Under this bilateral effort, also known as the "oil for doctors" program, Cuba provided Venezuela with 31,000 Cuban doctors and dentists and provided training for 40,000 Venezuelan medical personnel. [ 39 ] In exchange, Venezuela provided Cuba with 100,000 barrels of oil per day. Based in February 2010 prices, the oil was worth $7.5 million per day, or nearly $3 billion per year. [ 3 ]
Following the development of cooperation with Venezuela through Mission Barrio Adentro, Mission Milagro/ Operación Milagro was set up to provide ophthalmology services to Cuban, Venezuelan and Latin American patients, both in Cuba and in other countries. As of August 2007, Cuba had performed over 750,000 eye surgeries, at no cost, including 113,000 surgeries for its own citizens. [ 1 ] [ 40 ] Cuba continued to grow the program and by 2017 had established 69 Operación Milagro clinics in 15 countries. [ 41 ] By 2019, over 4 million people in 34 countries had received free surgery through the program. [ 41 ]
In 2017, The Miami Herald reported that groups of Cuban health care workers who had defected from the program stated that due to the daily quotas of patients, they would often feel pressured to fake paperwork and throw away medicine, since regular audits of their supplies meant they needed them to match their patient count. If Cuban medical personnel did not meet their quotas, they were threatened with having their pay cut or being sent back to Cuba. [ 42 ]
Since 1990, Cuba has provided long-term care for 24,000 victims of the Chernobyl disaster , [ 43 ] : 277 "offering treatment for hair loss, skin disorders, cancer, leukemia, and other illnesses attributed to radioactivity", free of charge. [ 1 ] [ 43 ] : 277
Cuba has also sent notable missions to Bolivia (particularly after the 2005 election of Evo Morales ) and South Africa , the latter in particular after a post- apartheid brain drain of white doctors. [ 44 ] Since 1995, a co-operation agreement with South Africa has seen hundreds of Cuban doctors practice in South Africa, while South Africa sends medical students to Cuba to study. [ 45 ] In 2012, the two governments signed another deal, increasing numbers on both sides. Under the deal, South African could send 1,000 students to Cuba for training which, South Africa believed, will help train the doctors it desperately needs for the implementation of its National Health Insurance Scheme. [ 46 ] After the 1999 violence in East Timor , the country of a million people was left with only 35 physicians and 75% of its population displaced. The number later increased to 79 physicians by 2004, and Cuba sent an additional 182 physicians and technicians. [ 47 ]
"From 1963 to 2004, Cuba was involved in the creation of nine medical faculties in Yemen, Guyana, Ethiopia, Guinea-Bissau, Uganda, Ghana, Gambia, Equatorial Guinea, and Haiti." [ 8 ]
In 2023 Cuba sent 171 doctors to aid Italian hospitals in the poor region of Calabria , which are severely understaffed. [ 48 ]
Cuba's overseas medical missions are intended to provide services at low cost to the host country. "Patients are not charged for services, and the recipient countries are expected to cover only the cost of collective housing, air fare, and limited food and supplies not exceeding $200 a month. While Cuban doctors are abroad, they continue to receive their salaries as well as a stipend in the foreign currency". [ 1 ] In 2008, the pay for Cuban doctors abroad was $183 per month, whereas the pay for doctors working domestically was $23 per month. [ 44 ]
However, during the COVID-19 pandemic there was concern in South Africa about the relatively high salaries to be paid for Cuban medical assistance even as many South African doctors and nurses remained unemployed. [ 49 ] [ 50 ] [ 51 ] [ 52 ]
In response to Hurricane Mitch in 1998, Cuba set up the Escuela Latinoamericana de Medicina (abbreviated as ELAM, and in English the Latin American School of Medicine) outside Havana, converted from a former naval base. It accepts around 1500 students per year. [ 1 ] ELAM forms part of a range of medical education and training initiatives; "Cubans, with the help of Venezuela, are currently educating more doctors, about 70,000 in all, than all the medical schools in the United States, which typically have somewhere between 64,000 to 68,000 students enrolled in their programs". [ 13 ] ELAM selects students from a working-class background who would not be able to afford university otherwise. [ 43 ] : 279
Both humanitarian and ideological factors were prominent in Cuba's "doctor diplomacy", particularly during the Cold War . Subsequently, its continuation has been seen as a vital means to promote Cuba's image abroad and prevent international isolation. Cuba's health missions in Honduras were "undoubtedly a deciding factor" in the re-establishment of diplomatic relations between the two countries in 2002; [ 1 ] Guatemala re-established diplomatic relations with Cuba in 1998. [ 8 ]
It has also been suggested that Cuban medical internationalism promotes exports of Cuban medical technology, and may be a source of hard currency. However, the targeting of poor countries reduces the hard currency potential of missions abroad. [ 1 ] In 2006, Cuba's earnings from medical services, including the export of doctors, amounted to US$2,312M – 28% of total export receipts and net capital payments. This exceeded earnings from both nickel and cobalt exports and from tourism. [ 44 ] These earnings were achieved despite the fact that a substantial part of Cuba's medical internationalism since 1998 has been organised within the framework of the "Integrated Health Program" (Programa Integral de Salud, PIS); this cooperation program is free for the receiving country. [ 8 ] Cuba's co-operation with Venezuela provides Cuba with cheap oil in exchange for its medical support to Mission Barrio Adentro. [ 8 ] Bloomberg reported in March 2014 that Cuban state-controlled media forecasted revenue of $8.2 billion that year from the program. [ 53 ]
It has also been argued that the program has, particularly in the 1980s and 1990s, "perform[ed] a critical function in consolidating socialist consciousness" within Cuba. [ 54 ]
Although Cuba's large-scale medical training programs and high doctor-patient ratios give it much latitude, the expansion of doctor diplomacy since 2004, particularly with the Barrio Adentro program, has been dramatic: the number of Cuban doctors working abroad jumped from about 5000 in 2003 to more than 25,000 in 2005. [ 18 ] This has had some impact on the domestic health system, for example there have been increased waiting times, particularly with regard to family doctors. [ 44 ] The number of patients per doctor rose from 139 to 179. [ 47 ] In March 2008 Cuba announced a reorganisation of its domestic family doctor program for greater efficiency. [ 44 ]
A 2010 article by Laurie Garrett in Foreign Affairs warned that lifting the United States trade and travel restrictions on Cuba could have dire consequences for Cuba's health care system, leading to an exodus of thousands of well-trained Cuban health-care professionals. U.S. companies could also transform the remaining health care system into a destination for medical tourism . Garrett concluded that, if politicians do not take great care, lifting of the restrictions would rob Cuba of its greatest triumph. [ 3 ]
According ADN Cuba , the Cuban government keeps between 70 and 90% of their additional salary paid by the host country and those who break the mission are punished for 8 years, without allowing them to return to Cuba. [ 55 ] [ better source needed ]
According to a 2019 The New York Times article, sixteen Cuban doctors from Mission Barrio Adentro in Venezuela denied medicine and other treatments in order to secure votes for the United Socialist Party of Venezuela (PSUV) during elections through coercion. The report said this occurred during 2018 Venezuelan presidential election in which Nicolás Maduro won reelection. Cuban doctors would have been instructed to go door to door warning residents that medical treatments would be cut off if they did not vote for Maduro. They also were asked to register people into the Venezuelan government homeland card, to secure medical services, and refuse treatment to those who did not apply for it. Some doctors report to have provided counterfeit ID cards to patients to be able to vote. According to four doctors, Maduro administration established electoral command centers next to clinics led by members of the PSUV to dispatch doctors to pressure residents. [ 6 ]
According to Human Rights Watch "the Cuban government imposes draconian rules on doctors deployed in medical missions globally that violate their fundamental rights". [ 5 ]
In the summer of 2000, two Cuban doctors working in Zimbabwe denounced the Cuban government and declared their intention to defect to Canada. After submitting their applications they were assigned to a Zimbabwean refugee camp near Harare. The doctors left the camp nine days later, unaware that this was illegal under Zimbabwean law. Zimbabwean police arrested the doctors and took them to the O. R. Tambo International Airport in South Africa for deportation back to Cuba. The doctors gave a note to the flight attendants stating that they were being kidnapped, leading South African authorities to demand the doctors and police return to Zimbabwe. The pair were briefly imprisoned upon returning to Harare but were allowed to continue their refugee application process. [ 56 ] They fled to Sweden in July and eventually received asylum in the United States. [ 57 ] The case drew attention from the international press and the United Nations High Commissioner for Refugees criticized Zimbabwe for violating the rights of the doctors as refugees. A spokesperson for the Cuban government said Cuba was not involved in the attempted deportation and has no "authority to extract people from one country and take them to another". [ 56 ]
According to a 2007 paper published in The Lancet medical journal, "growing numbers of Cuban doctors sent overseas to work are defecting to the USA", some via Colombia, where they have sought temporary asylum. [ 58 ] In February 2007, at least 38 doctors were requesting asylum in the U.S. embassy in Bogotá after asylum was denied by the Colombian government. [ 59 ] Cuban doctors who defected said that they were monitored by "minders" and subject to curfew. [ 58 ]
In August 2006 the United States under George W. Bush created the Cuban Medical Professional Parole program (CMPP), [ 60 ] specifically targeting Cuban medical personnel and encouraging them to defect while working outside Cuba. [ 13 ] From an estimated 40,000 eligible medical personnel, over 1000 had entered the United States under the program by October 2007, according to the chief of staff for U.S. Rep. Lincoln Díaz-Balart . [ 61 ] By 2017, more than 7000 had entered the program. [ 4 ] The promised fast-track visa was not always forthcoming, with at least one applicant having to wait a year for his visa; although according to Julio César Alfonso of the Cuban dissident organisation "Outside the Barrio," the U.S. government has rejected only a handful of the hundreds of applications for visas. [ 62 ] Critics of the US program described it as "immoral" because it takes medical professionals from the world's poorest nations to one of the world's wealthiest nations. [ 58 ] On 12 January 2017, President Obama announced the end of the program, saying that both Cuba and the US work to "combat diseases that endanger the health and lives of our people. By providing preferential treatment to Cuban medical personnel, the medical parole program contradicts those efforts, and risks harming the Cuban people". [ 63 ]
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Cuffitis is inflammation at the anal transition zone or "cuff" created as a result of ileal pouch-anal anastomosis (IPAA). [ 1 ] It is considered a variant form of ulcerative colitis that occurs in the rectal cuff. [ 2 ] Cuffitis is a common complication of IPAA, particularly when a stapled anastomosis without mucosectomy procedure has been used. [ 2 ]
Symptoms of cuffitis mimic those of pouchitis . [ 2 ] In addition, patients with cuffitis often present with small volume bloody bowel movements. [ 2 ] Often, cuffitis can produce the appearance of bright red blood on tissue. [ 1 ]
Surgery-associated ischemia may contribute inflammation at the anal transitional zone. [ 2 ]
Patients whose cuffitis is refractory to mesalamine and/or corticosteroids should be evaluated for other disease in the cuff area, such as fistula or anastomotic leaks. [ 2 ] Cuffitis that is refractory to medication can also be a sign of Crohn's disease of the pouch. [ 2 ]
Chronic cuffitis can also contribute to the development of anastomotic stricture . [ 2 ]
Cuffitis that is refractory, Crohn's-related, or is associated with surgical complications can contribute to pouch failure. [ 2 ]
Definitive diagnose of cuffitis is obtained by endoscopy . [ 2 ]
Cuffitis is treated with mesalamine suppositories or topical application of lidocaine or corticosteroid medications. [ 2 ] Systemic medications are rarely used. [ 2 ]
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The Cullen Medal , named for William Cullen , is awarded by the Royal College of Physicians of Edinburgh for “the greatest benefit done to Practical Medicine”. [ 1 ] [ 2 ] [ 3 ]
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A Cullenite is a follower of any person named Cullen . Notable Cullens to have followers referred to as Cullenites have included the Scottish physician William Cullen [ 1 ] and particularly Paul Cardinal Cullen , archbishop of Dublin and the first cardinal from Ireland.
Notable Cullenites who followed Cardinal Cullen included George Joseph Plunket Browne , Bishop of Elphin, [ 2 ] and Patrick Francis Moran , archbishop of Sidney and the first cardinal from Australia; indeed, "Cullenite" is used as an adjective in the phrases "Cullenite network" (used to describe a group of bishops who had been students of or were related to Cardinal Cullen, and many of whom became highly influential in the churches of Australia and New Zealand) [ 3 ] and "the Cullenite church", used to describe the Irish church until the 1960, a church strongly allied to the "rural bourgeoisie" and the rising class of what are called "strong-farmers". [ 4 ]
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This article about history of the Catholic Church is a stub . You can help Wikipedia by expanding it .
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Cultural competency training is an instruction to achieve cultural competence and the ability to appreciate and interpret accurately other cultures . In an increasingly globalised world, training in cultural sensitivity to others' cultural identities (which may include race , sexuality , religion and other factors) and how to achieve cultural competence is being practised in the workplace, particularly in healthcare , schools and in other settings.
Cultural competence refers to an ability to interact effectively with people of different cultures. Cultural competence comprises four components: (a) awareness of one's own cultural worldview, (b) attitude towards cultural differences, (c) knowledge of different cultural practices and worldviews, and (d) cross-cultural skills. Developing cultural competence results in an ability to understand, communicate with, and effectively interact with people across cultures and leads to a 15% decrease in miscommunication. [ 1 ] Cultural competence has a fundamental importance in every aspect of a work field and that includes school and government setting. [ 2 ] With the amalgamation of different cultures in American society, it has become imperative for teachers and government employees to have some form of cultural competency training. [ 3 ]
To attain the goal of cultural competence, cultural sensitivity must be understood. Cultural sensitivity is the knowledge, awareness, and acceptance of other cultures , [ 4 ] and includes "the willingness, ability and sensitivity required to understand people with different backgrounds", and acceptance of diversity. [ 5 ] Crucially, it "refers to being aware that cultural differences and similarities between people exist without assigning them a value ", [ 6 ] [ 7 ]
To cater to an increasingly globalized society , many hospitals, organizations, and employers may choose to implement forms of cultural competency training methods to enhance transparency between language, values, beliefs, and cultural differences. Training in cultural competence often includes careful consideration of how best to approach people's various forms of diversity. This new-found awareness helps military members, educators, medical practitioners , other workers and citizens to establish equity in their environments, and enhances interrelationships between one another for increased productivity levels. There are numerous theories as to how best to conduct cultural competency training, which are often dependent on the specific environment and type of work. [ citation needed ]
When defining the ideas that surround cultural competence training, defining what culture is can help to understand the ideas that shape the concept. Culture is defined as the set of shared attitudes, values, goals, and practices that characterizes an institution or organization. [ 8 ] When looking at culture in terms of cultural competence training, certain groups of individuals should be focused on because of their relevance to society. There are many groups that are marginalized and underrepresented; a few examples of concepts that make up one's cultural identity follow. The approach to identity helps to shape the ideas and themes that go into cultural competence training.
The initialism LGBTQIA stands for lesbian , gay , bisexual , transsexual , transgender , queer , intersex , and asexual . This particular group of individuals has faced numerous obstacles and has historical events to highlight the inequalities they face, such as the Stonewall riots . The Stonewall riots became a symbol for the gay liberation movement when police attempted a raid at the Stonewall Inn to arrest the gay and lesbian patrons and the gay community fought back. Numerous systemic oppressions historically and currently target LGBTQIA individuals. [ 9 ]
Race is a sensitive aspect of cultural competency training that requires professionals to be able to identify, acknowledge and value cultural differences. Training on this aspect of cultural competence teaches professionals that to ignore racial differences is a form of microaggression that can help exacerbate racial inequalities. In order to begin to understand intercultural communications , one must understand the historical and social context under which different cultural groups operate. For example, the history related to the cultural genocide of indigenous peoples in North America , understanding the said group's value system, their ways of learning, and logic is essential in being able to understand how certain aspects of their culture may be similar or different from our own. Such distinction must be approached with respect and without ascribing superiority or inferiority to the difference, that is, in a culturally sensitive fashion.
Religious differences can play a role in how professionals interact and communicate with others. Religiosity refers to the nature and extent of public and private religious activity, including belief in God, prayer, and place of worship attendance. Religiosity is usually linked to formal religious traditions (such as Christianity ), institutions (such as mosques), sacred texts (such as The Book of Mormon ), and a definitive moral code (such as the Decalogue). Spirituality can be an important part of religion but can also exist independent of extant faith traditions, involving a variety of more individual subjective beliefs and activities related to the sacred. In this aspect of cultural competence training professionals should learn how to have religious competence. Religious competence refers to skills, practices, and orientations that recognize, explore, and harness patient religiosity to facilitate diagnosis, recovery, and healing. Religious competence involves the learning and deployment of generic competencies, including active listening and a nonjudgmental stance. It is also an overarching orientation, providing a safe place for discussion of religious issues and identities received in a humble, respectful, and empathetic manner. [ 10 ]
In terms of nationality , particularly for people who are immigrants , the recent increase in global migration make them an increasingly common demographic everywhere. Though they will have varying cultures as well. It is important for those who are trained to understand both similarities and differences between themselves, and the individual they are helping. With this knowledge, it makes the process of aiding the individual more efficient and successful. [ 11 ] Both the past nation the individual has come from, and their journey of immigration as an experience, can shape their mentality. To have specialists with specific nationalities help explain some differences is a helpful strategy. [ 12 ]
School is considered to be the second learning home for children. Every year a large number of people come to the United States. These groups of people are often families, including small children. [ 13 ] In today's world, cultural competency plays a vital role in shaping the kids future. The United States is not the front runner in cultural competency training amongst children, with Canada and Australia apparently more progressive in this sector. [ 14 ] Cultural competency training can be a huge help for the families who are thinking of adopting a foster child, specifically, if that child was born outside of United States. [ 15 ] A school is a mixture of different races and cultures and as an educator, one must be sensitive to everyone's needs. Different cultures act uniquely to the different situations, and as an educator, one has to not only value diversity, but also have a strategy for everyone to feel welcomed. [ 16 ]
Over the years, there have been new developed ways of practicing cultural competency in the workforce. There are many different methods that would allow assistance in cultural competency such as: global leadership programs, international team building exercises and specific cross-cultural skills training for special executive positions. Having a good grasp on the many different cultures that exist is increasingly becoming a major principle in the workforce. The techniques for cultural competency training must be practiced more than just in class room lecture. Trainers must be extremely educated in this matter to be able to sufficiently train people. They must take notice of their own biases perspective and about the different types cultures that receive discrimination. [ citation needed ]
In the medical setting, effective communication between clinicians, patients, families and other health care providers is fundamental. [ citation needed ]
Health disparities refer to gaps in the quality of health and health care across racial, ethnic, and socioeconomic groups. Studies have demonstrated the multiple factors that contribute to health disparities. [ citation needed ]
Cultural Competence Online for Medical Practice (CCOMP) is an attempt in the United States to address one of the factors - the patient-doctor interaction. The CCOMP project is funded by a grant from the National Institutes of Health (NIH) through the National Heart Lung and Blood Institute (NHLBI). CCOMP offers a clinician's guide to reduce cardiovascular disparities, intended to create effective cross-cultural approaches to care for African-American patients with cardiovascular disease , especially hypertension . Videos with real patient scenarios and case-based modules are aimed at developing this increased awareness. [ citation needed ]
[ clarification needed ]
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Dwarfism has been showcased across many types of media. As popular media has become more prevalent, a greater number of works depicting dwarfism have popularized the condition.
Several works of literature treat dwarfism as a major theme, with varying degrees of realism:
Several works of visual arts treat dwarfism as a major theme, with varying degrees of realism:
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Breast cancer diagnosis and treatment is influenced by different cultural backgrounds . Factors include differences in beliefs, attitudes, and treatment options that impact diverse populations throughout the world.
A study examining spirituality and breast cancer showed a positive correlation between spirituality and quality of life. [ 1 ] Religious practices, a belief in God or higher power, and a support system of family and friends were important among the African-American women studied. [ 1 ] In Chile , prayer and perceived dependence on God to intercede and guide them through this time in their life was important for women with breast cancer. They also had social support from their faith communities. [ 1 ] Muslim women studied commonly viewed their diagnoses as the will of God . They were also active in getting the medical treatment they needed. These women's quality of life was linked with their spiritual meaning. [ 1 ]
Religion or spirituality is often used to help frame the diagnosis in a new way that provides meaning and purpose. Health care providers can benefit by knowing the role spirituality plays in these patients' lives, leading to better awareness of the support networks needed to help cope with the diagnosis, leading to more empathetic care. [ 1 ]
The topic of breast cancer can be used to highlight the differences in treatment practices between Western countries and China . This is despite the fact that the incidence of breast cancer in China was approximately 215,600 patients in 2011, which compares closely to the incidence in the United States of America. [ 2 ] Even with the high incidence, there has been a lack of emphasis on diagnosis and detection of breast cancer in its early stages. [ 2 ]
In Western countries, there are many resources available for patient education and awareness of breast cancer detection as well as many therapeutic options. In China, the majority of breast cancer patients are diagnosed with Stage III/IV disease, which contrasts with Western countries, where patients are more likely to be diagnosed in the early stages. Proper diagnosis is not the only limiting factor. Patients with well-defined disease ( HER2-positive ) struggle with the ability to gain access to traditional chemotherapeutic options that are considered the standard of care for their Western counterparts. [ 2 ]
The other issue most often seen in emerging markets is lack of treatment options as patients relapse following first-line therapy. In China, only about 40% of metastatic breast cancer patients who receive first-line therapy will go on to receive a second line of therapy. The situation later becomes dire, where only one-quarter of patients will receive third-line therapy. Fourth- and fifth-line therapies are virtually non-existent in China. These reported frequencies of later lines of chemotherapy among Chinese patients are significantly lower than those in Japan and the United States, where 80% of patients continue to second-line and 65% of those patients continue to third line. The main reasons for low use of later-line treatments are the lack of good therapeutic options and the financial burden of more expensive drugs. As the disease progresses, patients are more likely to turn to traditional Chinese medicine . [ 2 ]
Stigma is one of the largest influences on the cultural perception of breast cancer within India . There is a widespread belief that breast cancer is contagious, even from casual contact. This often leads to the physical isolation of the patient at either the hands of the community or the patient's own. Isolation can go as far as total separation within households including rooms, food, and dinnerware in addition to cutting out close proximity with loved ones. Even with strong communication and intimate education from doctors, some patients still believe that cancer means an inevitable life of isolation and karmic justice. [ 3 ]
Beyond physical isolation, it is common within India for patients to feel a sense of shame with a diagnosis. This shame can come from a lot of places but tends to revolve around feelings of failure in one way or another. There is a general fear of death across the population but a fear of unfulfillment was recorded more amongst women. Women are seen to be more worried about their inability as a member of the household and to be inadequate as a mother, sexual partner, wife, and daughter. This fear can either come from the effects of the cancer, treatment, post recovery disabilities, or isolation. This sense of shame also extends to their children. It’s common for mothers to fear the social standing of their children due to their diagnosis, thinking about things like marriage prospects, career opportunities, and personal relationships. [ 3 ]
The aforementioned topic of karmic justice also played a role in the overarching feelings of shame that women with breast cancer have carried. Cancer is said to be a punishment for bad deeds both from past or present lives , breast and cervical cancer said to be a punishment for sexual transgression or sexual behavior considered deviant by the community. [ 3 ]
Human Papillomavirus (HPV) is a sexually transmitted disease, where certain strains have the risk of causing precancerous cell changes . Without proper screening and management, these cells can develop into cancers, such as vaginal , cervical , and vulvar . [ 4 ] Still the narrative pays focus to the moral standing of one's behavior surrounding sex as the cause of reproductive cancer rather than HPV as a sexually transmissible risk of cancer. [ 3 ]
The narrative given to cancer within Indian culture, hugely deters women from seeking early screening , proper diagnosis, and treatment as a whole. The fear of the unknown has led women further and further away from the doctor, many even admitting to ignoring present breast lumps and other concerns to a point of incurability. Even after a diagnosis women are particular in their disclosure to the community, if at all. This act protects them from discrimination, gossip, and isolation but, in parallel, isolates them from a community of support. [ 3 ]
Despite the fact that governments have passed policies and engage in outreach to provide equal access to healthcare and screenings, women who are intellectually disabled have lower rates of mammography than the general population. A study was done to discover reasons why women were still not taking advantage of the screenings that are now available to them. [ 5 ]
A group of women in Ireland had recently received a mammography; they were interviewed to see what they knew about breast cancer, signs or symptoms, if they had read any material prior to their screening or how they could help prevent breast cancer from occurring. The sample of women had little knowledge in any of these areas. The women explained that their experience was positive but prior to screening they had feelings of fear , anxiety and stress because they did not know what to expect. A low level of awareness and the fear of the unknown are barriers preventing women from getting screenings. [ 5 ] Three suggestions have been given: [ 6 ]
As in many parts of the world, breast cancer is the most prevalent form of cancer in Turkey . However, women are not attending regular screening, even in high-risk populations. Though women within Turkey fear cancer, the fear is usually what drives women to treatment, their lack in medical care comes from intimate uncomfortability. [ 7 ] The World Health Organization found that on average about 43% of OB/GYN’s were female across all provinces. Still that number varied widely based on the religious atmosphere with less conservative areas like Denizli having 21% female and more conservative provinces like Erzurum , Rize , and Giresun having 80% female OB/GYN. [ 8 ]
For many Turkish women, there is a profound disconnect between female patients and male doctors in intimate spaces such as gynecology . Due to personal, patriarchal, and religious reasons, there is hesitancy in women to seek healthcare in a way they would feel exposed, specifically in front of men. There is also a lack in proper education surrounding medical procedures like mammography , leaving women to rely on hearsay prior to experiencing it themselves, entering with a large amount of uncertainty and fear. With limiting options as to medical providers, privacy concerns, fears of potential pain, and uncertainty, women have found a sense of distrust and uncomfortability within obstetrics and gynecology fueling an avoidance of medical care. [ 7 ]
When women do seek care, this comes from familial support and encouragement, specifically from partners. It is common culture within Turkey for the needs of the family to be considered before the needs of the women, due to worries about financial and relational hardship influencing medical decision making. Women fear their cancer will negatively affect the relationship they've built with their husbands, possibly causing separation and insecurity. [ 7 ]
A woman's view of herself is also a battle. When asked many women associated breast cancer with losses to feminine traits such as hair, eyebrows, and breasts, causing a masculinization effect to the women. The loss of breasts is particularly a fear due to its permanent effects and perceived loss of femininity and sexual identity. [ 7 ]
Israel has maintained military control over Palestinian territories like the West Bank and Gaza , leaving the communities in a war zone due to a century long conflict began in 1917. Though efforts have been made for a two-state solution, Gaza and the people of Palestine, remain under fire, lacking access to necessary resources for survival, including medical care. [ 9 ]
Within Palestine, breast cancer makes up 34% of cancers in females and 18.7% of cancer across the population, the most common in both categories. For most communities, fear is a common barrier from receiving cancer care, however, within Palestine, the shortage of qualified professionals, medical centers, medication, and treatment play the biggest role in preventing aid. In 2022, there were only seven listed oncologists , two cancer centers, twenty mammography machines, zero cancer research centers and zero professional training facilities. Limited initiatives led to a lack of public education about detection and prevention, leaving Palestinians to unreliable and generalized education from television and the internet. [ 10 ]
Even when treatment is achieved, it is said that there is a significant inconsistency in treatments, timing, and medications. As resources thin, Palestinians fear their own death with poorer community members receiving the least. Hospitals are overcrowded with no privacy for health-related conversations or separation from others for physical exams. For Muslim women this is especially harmful due to cultural expectations surrounding modesty . Early detection finds its biggest barrier as women feel uncomfortable and exposed during breast examinations even from female medical providers, even without a lack of private rooms. [ 10 ]
Continued research and education on cancer care has no allocated budget and is restricted to an individual based responsibility such as college related education theses. The few trained professionals are said to be trained abroad as well as early direction initiatives being funded internationally. [ 10 ]
Policy makers and doctors are aware of the situation around cancer care and have reflected on gaps of education and access. They are working diligently as they continue to seek international aid and to recruit additional specialists to address the urgent needs of their people. [ 10 ]
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The Ebola virus epidemic in West Africa has had a large effect on the culture of most of the West African countries. In most instances, the effect is a rather negative one as it has disrupted many Africans’ traditional norms and practices. For instance, many West African communities rely on traditional healers and witch doctors , who use herbal remedies, massage, chant and witchcraft to cure just about any ailment. [ 1 ] [ 2 ] Therefore, it is difficult for West Africans to adapt to foreign medical practices. Specifically, West African resistance to Western medicine is prominent in the region, which calls for severe distrust of Western and modern medical personnel and practices. (see Ebola conspiracies below.) [ 3 ]
Similarly, some African cultures have a traditional solidarity of standing by the sick, which is contrary to the safe care of an Ebola patient. [ 1 ] [ 2 ] This tradition is known as "standing by the ill" in order to show one's respect and honor to the patient. According to the Wesley Medical Center, these sorts of traditional norms can be dangerous to those not infected with the virus as it increases their chances of coming in contact with their family member's bodily fluids. [ 2 ] In Liberia , Ebola has wiped out entire families, leaving perhaps one survivor to recount stories of how they simply could not be hands off while their loved ones were sick in bed, because of their culture of touch, hold, hug and kiss. [ 4 ]
Some communities traditionally use folklore and mythical literature, which is often passed on verbally from one generation to the next to explain the interrelationships of all things that exist. However the folklore and songs are not only of traditional or ancient historical origins, but are often about current events that have affected the community. Additionally, folklore and music will often take opposing sides of any story. Thus early in the Ebola epidemic, the song "White Ebola" was released by a diaspora based group and centers on the general distrust of "outsiders" who may be intentionally infecting people. [ 5 ] [ 6 ]
This initial misinformation increased the general distrust in foreigners, and the idea that Ebola was not in Africa before their arrival led to attacks on many health workers, as well as blockages of aid convoys blocked from checking remote areas. A burial team, which was sent in to collect the bodies of suspected Ebola victims from West Point in Liberia, was blocked by several hundred residents chanting: "No Ebola in West Point." Health ministries and workers started an aggressive Ebola information campaign on all media formats to properly inform the residents and allow aid workers safe access to the high risk areas. [ 7 ] [ 8 ] In Guinea , riots broke out after medics disinfected a market in Nzerekore . Locals rumored that the medics were actually spreading the disease. In nearby Womey , 8 people distributing information about Ebola were killed by the villagers. [ 9 ]
The Ebola epidemic of 2014 has forced West Africans to face numerous difficulties on a daily basis regarding their traditional norms and practices. In essence, their traditions have been severely disrupted due to the Ebola virus . For instance, West Africans have had the tendency to remain close to their sick family members to nurse them during illness for centuries. Unfortunately for West African communities, many have been encouraged to keep their distance from their infected family members as potential contact could be fatal. In addition, it is part of their culture to touch the deceased at funerals and for the sister of the deceased's father to bathe, clean, and dress the corpse in a favorite outfit. When there is not an aunt to perform this task, a female elder in their community is then held responsible. Not only is it customary to wash and touch the deceased, but also to kiss those that have passed. [ citation needed ]
Specifically, funerals are considered to be major cultural events for families and friends to gather around to celebrate the deceased. The funeral performances, which involve wailing and dancing, is done out of care and respect for the dead. Funerals in West Africa often last for several days, depending on the status of the person who died. In other words, the more important the person who died was while they were alive, the longer the mourning will last. More importantly, there is a common bowl used for ritual hand washing towards the end of the ceremony, including a final kiss or touch on the face, which is to be bestowed on the dead. This is commonly referred to as a "love touch." The Wesley Medical Center has confirmed that prohibiting West African families from performing such rites is a disgrace as it insults the deceased, putting the remaining family in danger. Specifically, it is believed that the dead person's spirit, also known as "tibo," will cause harm and bring illness to the family as a result of an improper burial. [ 2 ]
Resistance to Western medicine is considered to be a significant barrier to battling the Ebola virus. [ 3 ] The Wesley Medical Center claims that the interference with West African burial rituals caused by Western medical practices has prohibited them from properly honoring their loved ones. They believe that this may have been a reason for heightened distrust in medical professionals, and that the mistrust enhances each time family members of infected persons are prohibited from participating in the funeral or seeing the dead body in person. [ 2 ] Due to the mistrust, Ebola-stricken communities in Liberia reportedly hid family members with Ebola from health care providers and held secret burials. [ 10 ] In Sierra Leone, health workers made more progress because health measures were implemented according to WHO guidance, which advises health workers to heed the traditions of the threatened communities when attending to the dead. Therefore, funerals were held in agreement with the wishes of the families, but also gave health workers an opportunity to disinfect the bodies. [ 10 ] In many of the Ebola infected areas in Africa, Western medicine is also believed either to be ineffective or to be the actual origin of the virus. In other words, there is a belief among the African community that Western doctors are intentionally killing their patients with their treatments. A conspiracy theory also says that the medical professionals are planning to harvest the organs of those dying from Ebola. [ 3 ]
Resistance to Western medicine exists also because of the look of the hazmat suits, which are worn by healthcare workers to protect themselves from becoming infected with the Ebola virus. The protective equipment is said to frighten many West Africans and also believed to be hostile and intimidating to the West African families. [ 2 ] [ 3 ] Lastly, the interference in the family's care for the patient diminishes the honor of the patient as well as hindering the family's duty to provide comfort and care. [ 2 ] Regardless of the existing resistance towards Western medicine, handling the bodies of the deceased poses a high risk of contagion as Ebola is contracted through physical contact with an infected person's bodily fluids. This is mainly because preparation for burial includes touching, washing, and kissing as is mentioned above. Those that are preparing for the funeral can become easily infected as they can easily become exposed to the infected person's blood, vomit, diarrhea, and other bodily fluids as these are the main symptoms of the virus. [ 3 ]
Apart from the fact that traditional West African healers have been using ritual and herbal remedies for many centuries, the West African people also trust these treatments and find the costs more affordable. Traditional procedures include the following: magic, biomedical methods, fasting, dieting, herbal therapies, bathing, massage, as well as surgery. Surgical procedures often involve cutting a patient's skin with unsterilized knives. Sometimes, traditional healers apply blood to the skin to rid them of their sickness. [ 2 ] Despite the severe distrust of Africans in modern medicine, the Ebola virus has been said to spread rampantly across West Africa due to a shortage of healthcare workers and limited medical resources and facilities. The unsanitary conditions in the overall West African region have also made it easier for Ebola to spread. [ 3 ]
The Ebola virus, for which the primary host is suspected to be fruit bats , has been linked to bushmeat , which is commonly consumed in areas of West Africa that use it as a protein source. Although primates and other species may be intermediates, evidence suggests people primarily get the virus from bats. Hunters usually shoot, net, scavenge or catapult their prey, and butcher the bats without gloves, getting bites or scratches and coming in contact with their blood. [ 11 ] [ 12 ]
In 2014, the suspected index case for the Ebola outbreak in West Africa is a two-year-old child in Guéckédou in south-eastern Guinea, who was the child of a family that hunted two species of fruit bat, [ 12 ] Hypsignathus monstrosus and Epomops franqueti . [ 13 ] Some researchers suggested the case was caused by zoonotic transmission through the child playing with an insectivorous bat from a colony of Angolan free-tailed bats near the village. [ 14 ] [ 15 ]
Despite health organisations warning about risks of bushmeat, surveys pre-dating the 2014 outbreak indicate that people who eat bushmeat are usually unaware of the risks and view it as healthy food. Because of bushmeat's role as a protein source in Western Africa, it is traditionally associated with good nutrition, and efforts to outlaw the sale and consumption of bushmeat have been impossible to enforce and have met with suspicion from rural communities. [ 16 ] The UN Food and Agriculture Organization estimates that between 30 and 80 percent of protein intake in rural households in Central Africa comes from wild meat. [ 17 ]
One major Nigerian newspaper published a report about the widespread view that eating dog meat was a healthy alternative to bush meat. [ 18 ] Dog meat was implicated in a June 2015 Liberian outbreak of Ebola, where three villagers who had tested positive for the disease had shared a meal of dog meat. [ 19 ]
A number of Ebola-themed jokes circulated in West Africa, which were seen as a way to spread awareness of the virus. [ 78 ]
In July 2014, the Liberian Football Association made an announcement that all soccer related activities would be put on hold " indefinitely to protect players and fans ." [ 79 ] In September 2014, in a joint venture between FIFA and WHO , the Antoinette Tubman Stadium was converted into an Ebola treatment center. [ 80 ]
The 2015 African Cup of Nations (AFCON) was temporarily put on hold when the original hosts, Morocco , asked the Confederation of African Football (CAF) to postpone the final games till 2016, due to the Ebola outbreak. [ 81 ] CAF eventually moved the finals to Equatorial Guinea , which eliminated Morocco from the game as hosts, and brought Equatorial Guinea in, even though they had been eliminated prior. [ 82 ]
However the qualifiers for 2015 AFCON have been influenced by many countries' fear of Ebola, with many refusing to enter or allow entry of teams from affected countries. In July 2014, Seychelles refused entry to the Sierra Leone team. CAF ruled that Seychelles forfeited the game, giving Sierra Leone an automatic pass to the next stage. Lesotho refused to send the Under-20 team to Nigeria . CAF again ruled that Lesotho forfeited the game, sending Nigeria through to the finals. [ 83 ]
In August 2014, CAF also decided to forbid any official games in Guinea, Liberia and Sierra Leone. For Liberia, who had already been eliminated, this was not of concern. [ 83 ] Sierra Leone managed to move some home games to the visiting team's home; both home and away games against DR Congo were played in Lubumbashi , [ 84 ] and both games against Cameroon were played in Yaounde . [ 85 ] Guinea managed to get their home games moved to Casablanca , Morocco. [ 86 ]
Even after calls to have the 2015 AFCON postponed, the Equatorial Guinea government and CAF organisers have downplayed these concerns, and insisted that they would have ample measures in place, including: [ citation needed ]
On 7 August 2014, a social media hoax message was doing the rounds in Nigeria . It urged readers to " bath with hot water and salt before daybreak " and to drink as much of it as possible. On 8 August, the person who started the joke message to see how many of their friends would fall for it, identified it as such and posted an apology. [ 88 ] [ 89 ] The hoax message quickly went viral when " several gullible, unsophisticated opinion leaders " repeated the hoax message. [ 88 ] Within days many were hospitalized due to excessive salt intake, with 2 deaths in Jos , Plateau , [ 90 ] 2 deaths in Makurdi, Benue [ 91 ] and at least 3 deaths in Bauchi . [ 92 ] None of these deaths occurred in states that had known Ebola cases; only Lagos State and Rivers State had any. Eight people died as a result of the hoax cure, equaling the death toll from Ebola in Nigeria. [ 93 ] [ 94 ]
In two separate incidents in October 2014, flights were delayed from disembarking because passengers falsely claimed to have Ebola. On 8 October 2014, US Airways flight 845 from Philadelphia to Punta Cana , Dominican Republic was held up for two hours on the tarmac when an American passenger sneezed, then announced "I have Ebola. You're all screwed," during the flight. After landing, he was escorted off the plane by four emergency personnel wearing blue hazmat suits , and detained until medical tests cleared him. [ 95 ] On 30 October 2014, during the Aer Lingus flight EI 433, from Milan , Italy to Dublin , Ireland a passenger wrote "'Attenzione Ebola'" ("Attention Ebola") on a coffee lid before handing it to his daughter. The container and lid were discreetly disposed of, however a flight attendant noticed, and alerted the captain. The passenger was arrested, and later pleaded guilty to "engaging in threatening, abusive or insulting behavior on an airplane contrary to the Air Navigation and Transport Act ", and was fined 2500 euros . [ 96 ] [ 97 ]
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Culture conversion is a diagnostic criteria indicating the point at which samples taken from a person infected with a tuberculosis can no longer produce tuberculosis cell cultures . [ 1 ] [ 2 ] Culture conversion is a positive prognostic marker indicating that a person is cured of, or is recovering from, tuberculosis. [ citation needed ]
This medical diagnostic article is a stub . You can help Wikipedia by expanding it .
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A cure is a substance or procedure that resolves a medical condition. This may include a medication , a surgical operation , a lifestyle change, or even a philosophical shift that alleviates a person's suffering or achieves a state of healing. The medical condition can be a disease , mental illness , genetic disorder , or a condition considered socially undesirable, such as baldness or insufficient breast tissue.
An incurable disease is not necessarily a terminal illness , and conversely, a curable illness can still be fatal.
The cure fraction or cure rate —the proportion of people with a disease who are cured by a given treatment—is determined by comparing disease-free survival in treated individuals against a matched control group without the disease. [ 1 ]
Another method for determining the cure fraction and/or "cure time" involves measuring when the hazard rate in a diseased group returns to the hazard rate observed in the general population. [ 2 ] [ 3 ]
The concept of a cure inherently implies the permanent resolution of a specific instance of a disease. [ 4 ] [ 5 ] For example, a person who recovers from the common cold is considered cured , even though they may contract another cold in the future. Conversely, a person who effectively manages a disease like diabetes mellitus to prevent undesirable symptoms without permanently eliminating it is not considered cured.
Related concepts with potentially differing meanings include response , remission , and recovery .
In complex diseases like cancer, researchers use statistical comparisons of disease-free survival (DFS) between patients and matched, healthy control groups. This approach equates indefinite remission with a cure. [ 6 ] The Kaplan-Meier estimator is commonly used for this comparison. [ 7 ]
The simplest cure rate model was published by Joseph Berkson and Robert P. Gage in 1952. [ 7 ] In this model, survival at any given time equals the sum of those who are cured and those who are not cured but have not yet died or, in diseases with asymptomatic remissions, have not yet experienced a recurrence of signs and symptoms. Once all non-cured individuals have died or experienced disease recurrence, only the permanently cured population members remain, and the DFS curve becomes flat. The earliest point at which the curve flattens indicates when all remaining disease-free survivors are considered permanently cured. If the curve never flattens, the disease is formally considered incurable (with existing treatments).
The Berkson and Gage equation is S ( t ) = p + [ ( 1 − p ) t i m e s S ∗ ( t ) ] {\displaystyle S(t)=p+[(1-p)timesS^{*}(t)]}
where S ( t ) {\displaystyle S(t)} is the proportion of people surviving at any given time, p {\displaystyle p} is the proportion permanently cured, and S ∗ ( t ) {\displaystyle S^{*}(t)} is an exponential curve representing the survival of non-cured individuals.
Cure rate curves can be determined through data analysis. [ 7 ] This analysis allows statisticians to determine the proportion of people permanently cured by a treatment and the time needed post-treatment to declare an asymptomatic individual cured. [ 3 ]
Several cure rate models exist, including the expectation-maximization algorithm and Markov chain Monte Carlo model. [ 7 ] Cure rate models can be used to compare the efficacy of different treatments. [ 7 ] Generally, survival curves are adjusted for the effects of normal aging on mortality, especially in studies of diseases affecting older populations. [ 8 ]
From the patient's perspective, especially after receiving a new treatment, the statistical model can be frustrating. [ 6 ] It may take years to gather enough data to determine when the DFS curve flattens (indicating no further relapses are expected). Some diseases may be technically incurable but require infrequent treatment, making them practically equivalent to a cure. Other diseases may have multiple plateaus, leading to unexpected late relapses after what was initially considered a "cure." Consequently, patients, parents, and psychologists have developed the concept of psychological cure , the point at which the patient decides the treatment is sufficiently likely to be a cure to be considered one. [ 6 ] For example, a patient may declare themselves "cured" and choose to live as if the cure is confirmed immediately after treatment.
Cures can include natural antibiotics (for bacterial infections ), synthetic antibiotics like sulphonamides or fluoroquinolones , antivirals (for a few viral infections ), antifungals , antitoxins , vitamins , gene therapy , surgery, chemotherapy, radiotherapy, and so on. Despite the development of numerous cures, many diseases remain incurable.
Scurvy became curable (and preventable) with vitamin C (e.g., in limes) after James Lind published A Treatise on the Scurvy (1753). [ 10 ]
Emil Adolf von Behring and colleagues produced antitoxins for diphtheria and tetanus toxins from 1890. The use of diphtheria antitoxin to treat diphtheria was considered by The Lancet to be the "most important advance of the [19th] Century in the medical treatment of acute infectious disease." [ 11 ] [ 12 ]
Sulphonamides became the first widely available cure for bacterial infections. [ citation needed ]
Antimalarials were first synthesized, [ 13 ] [ 14 ] [ 15 ] making malaria curable. [ 16 ]
Bacterial infections became curable with the development of antibiotics. [ 17 ]
Hepatitis C , a viral infection, became curable through treatment with antiviral medications. [ 18 ] [ 19 ]
Signs and symptoms Syndrome Disease
Medical diagnosis Differential diagnosis Prognosis
Acute Chronic Cure
Eponymous disease Acronym or abbreviation Remission
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Curettage ( / ˌ k j ʊər ɪ ˈ t ɑː ʒ / or / k j ʊəˈr ɛ t ɪ dʒ / ), in medical procedures , is the use of a curette (French, meaning "scoop" [ 1 ] ) to remove tissue by scraping or scooping. [ 2 ] [ 3 ]
Curettages are also a method of abortion . It has been replaced by vacuum aspiration over the last decade. [ citation needed ]
Curettage has been used to treat teeth affected by periodontitis .
Gingival curettage is a surgical procedure designed to remove the soft tissue lining of the periodontal pocket with a curet, leaving only a gingival connective tissue lining. ... Gingival curettage, as originally conceived, was designed to promote new connective tissue attachment to the tooth, by the removal of pocket lining and junctional epithelium. Since there is no evidence that gingival curettage has any therapeutic benefit in the treatment of chronic periodontitis, the American Dental Association has deleted that code from the fourth edition of Current Dental Terminology (CDT-4). In addition, the American Academy of Periodontology, in its Guidelines for Periodontal Therapy, did not include gingival curettage as a method of treatment. This indicates that the dental community as a whole regards gingival curettage as a procedure with no clinical value. [ 4 ]
Curettage is also a major method used for removing osteoid osteoma and osteoblastoma .
Curettage with subsequent culture is more accurate than ulcer base swan culture or aspiration and culture for diabetic foot ulcers. [ citation needed ]
Curettage is also used when excising a chalazion of the eyelid.
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A curette is a surgical instrument designed for scraping or debriding biological tissue or debris in a biopsy , excision , or cleaning procedure. In form, the curette is a small hand tool , often similar in shape to a stylus ; at the tip of the curette is a small scoop, hook, or gouge . The verb to curette means "to scrape with a curette", and curettage ( / ˌ k ʊər ɪ ˈ t ɑː ʒ / or / ˌ k jʊər ɪ ˈ t ɑː ʒ / ) is treatment that involves such scraping.
Some examples of medical use of a curette include:
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Current Cancer Drug Targets is a peer-reviewed medical journal published by Bentham Science Publishers . The editor-in-chief is Ruiwen Zhang ( UH Drug Discovery Institute). The journal covers research on contemporary molecular drug targets involved in cancer , including medicinal chemistry , pharmacology , molecular biology , genomics , and biochemistry . Current Cancer Drug Targets publishes original research reports, review papers, and rapid communications ("letters"). [ 1 ]
Current Cancer Drug Targets is abstracted and indexed in: [ 2 ]
According to the Journal Citation Reports , the journal has a 2019 impact factor of 2.912. [ 3 ]
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Current Dental Terminology ( CDT ) is a code set with descriptive terms developed and updated by the American Dental Association (ADA) for reporting dental services and procedures to dental benefits plans. [ 1 ] [ 2 ] [ 3 ] Prior to 2010 many of the codes were published by Centers for Medicare and Medicaid Services (CMS) as HCPCS D-codes under arrangement with the ADA. Ownership and copyright of CDT remained with the ADA. [ 4 ] [ 5 ] In 2010 the ADA ended the CMS distribution of CDT codes, which can now be purchased from the ADA. [ citation needed ]
For the year 2013, the ADA began publishing the CDT codes on an annual basis. There are new codes, revised codes and deleted codes in each annual edition and dental professionals must update these codes to maintain compliance with HIPAA regulations. In addition, payment to dental professionals is based on the CDT code(s) reported on the ADA Claim Form, so using the most current codes helps to maximize reimbursement and minimize audit liability. [ 6 ]
In the near future, dental professionals will be required to use diagnosis codes in support of the procedures and services they provide. The 2012 edition of the Dental Claim Form includes fields for diagnosis codes and instructions covering the use of the ICD-9-CM and ICD-10-CM coding systems. In addition to ICD-9-CM and ICD-10-CM there are other dental diagnostic coding systems under consideration, including SNODENT and EZCODES . [ 7 ]
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Current Oncology is a bi-monthly peer-reviewed medical journal covering oncology . It was established in 1994 and was originally published quarterly by Multimed Inc. , a company founded in 1980 by Lorne Cooper. Its founders intended it to be a forum in which Canadian oncologists could publish their work. [ 1 ] The journal is now published bimonthly by MDPI . All issues published since December 2005 are available fully open access on the journal's website. [ 2 ] According to the Journal Citation Reports , the journal has a 2020 impact factor of 3.677. [ 3 ]
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Current Problems in Surgery is a monthly peer-reviewed academic journal of surgery published by Elsevier . According to the Journal Citation Reports , the journal has a 2021 impact factor of 2.815. [ 1 ]
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In anatomy , the Curve of Spee (also called von Spee's curve or Spee's curvature ) is defined as the curvature of the mandibular occlusal plane beginning at the canine and following the buccal cusps of the posterior teeth , continuing to the terminal molar . According to another definition the curve of Spee is an anatomic curvature of the occlusal alignment of the teeth, beginning at the tip of the lower incisor, following the buccal cusps of the natural premolars, and molars and continuing to the anterior border of the ramus. It is named for the German embryologist Ferdinand Graf von Spee (1855–1937), who was first to describe the anatomic relations of human teeth in the sagittal plane.
The pull of the main muscle of mastication, the masseter , is at a perpendicular angle with the curve of Spee to adapt for favorable loading of force on the teeth. The long axis of each lower tooth is aligned nearly parallel to their individual arch of closure. The Curve of Spee is, essentially, a series of sloped contact points. It is of importance to orthodontists as it may contribute to an increased overbite. A flat or mild curve of Spee was essential to an ideal occlusion. [ 1 ]
The Curve of Spee is distinct from the Curve of Wilson , which is the upward (U-shaped) curvature of the maxillary and mandibular occlusal planes in the coronal plane.
The Curve of Spee is basically a part of a circle (8-inch diameter) which has its circumference as the anterior ramus of mandible. Ideally, it is aligned so that a continuation of this arc would extend through the condyles. The curvature of this arc would relate, on average, to part of a circle with a 4-inch radius. It is the only Anteroposterior curve of occlusion.
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The curve of Wilson is the across arch, and across median plane, curvature or posterior occlusal plane.
Arc of the curve, which is concave for mandibular teeth and convex for maxillary teeth are defined by a line drawn from left mandibular first molar to right mandibular first molar. [ 1 ]
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In gynaecology , Cusco's self-retaining bivalved speculum is a kind of speculum used for vaginal and cervical examinations. It has a jaw that opens up like a duck bill.
The instrument was named after French surgeon Édouard-Gabriel Cusco (1819–1894). [ 1 ]
It comes in three models: side screw, centre screw, and special narrow virgin size. [ 2 ] Cusco's speculum is usually 80 millimeters (3.1 in) long and 22 millimeters (0.87 in) broad. However, smaller and larger sizes are available. Cusco's speculum is used for introducing an intrauterine contraceptive device , taking a Pap smear , cauterization of vaginal erosion, and colposcopic examination. [ 3 ] It is preferred in cryosurgery because it protects the anterior and posterior vaginal wall. The advantage of Cusco's speculum is that it is self-retaining. Therefore, an assistant's help is not needed to keep the speculum in place. It also acts as the vaginal wall retractor. However, it reduces the space in the vaginal cavity and therefore is not a preferred instrument for vaginal surgery . Because it covers most of the vaginal wall, small lesions on the vaginal wall may be masked by the blades of the device. [ 4 ]
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Cushing's syndrome disease , also known as hyperadrenocorticism and spontaneous hypercortisolism , is a condition resulting from an endocrine disorder where too much adrenocorticotropic and cortisol hormones are produced, causing toxicity. It may arise in animals as well as in humans . [ 1 ] Cushing's is an umbrella term for conditions caused by elevated cortisol and adrenocorticotropic hormone levels.
Cushing's disease most commonly refers to pituitary-dependent hyperadrenocorticism, the most common condition of Cushing's syndrome, but 'Cushing's' is used to refer to all hyperadrenocorticism conditions. [ 2 ]
Cats are less likely to be diagnosed than dogs. [ 2 ] Cushing's occurs infrequently in hamsters . It may be more common but due to hamsters not being routinely treated it may go undiagnosed. [ 3 ]
Cushing's syndrome is classified as either pituitary-dependent, adrenal-dependent, or iatrogenic . [ 2 ] Pituitary-dependent Cushing's is caused by an adrenocorticotropic hormone producing pituitary tumour. Adrenal-dependent Cushing's is caused by an adrenal tumour. [ 4 ] Pituitary-dependent Cushing's accounts for 80-85% of cases. [ 5 ] Other forms have been described but they appear to be rare. [ 1 ] Ectopic adrenocorticotropic hormone secretion has been described in a German Shepherd dog , those reviewing the case noted it could be the result of an abdominal neuroendocrine tumour. [ 6 ] In one case a Vizsla was diagnosed with food-dependent hypercortisolemia. [ 7 ]
Cortisol is a hormone produced in the adrenal glands. Cortisol is stored in these glands and released to help prepare the body for a fight-or-flight response . Cortisol makes the body mobilise fat and sugar stores and retain sodium and water by adjusting the metabolism. This allows the body to easily access stored resources. When the body is constantly exposed to this hormone the effects it results in Cushing's syndrome. [ 5 ] Blood levels of cortisol determine whether additional cortisol production is required via a negative feedback loop . An improper feedback loop due to a tumour or as a side effect of medication can result in an overproduction of adrenocorticotropic and cortisol hormones. Animals can only handle limited periods of elevated cortisol levels. [ 2 ]
Cushing's has a wide variety of symptoms and most gradually appear with a slow onset. [ 8 ] The reason for the wide variety is due to how cortisol affects many different systems of the body. [ 2 ]
Symptoms in dogs include: [ 8 ]
Dermatological symptoms include: [ 2 ]
Rare clinical signs of Cushings include: [ 2 ]
A potbelly appearance is present in 90% of dogs with Cushing's, the cause is a hormonal redistribution of body fat and the breakdown of abdominal muscles. This breakdown of muscle protein leads to muscle weakness and lethargy. [ 8 ]
Other potential complications from Cushing's in dogs include proteinuria , glomerulosclerosis , pancreatitis , and gallbladder mucocele . [ 4 ] A study of 66 dogs with Cushing's found 91% of dogs to have either polyuria or polydipsia, 79% to have polyphagia, and 77% to have alopecia. [ 4 ]
Signs of ectopic adrenocorticotropic hormone secretion that accompany the rapidly progressing physical changes are high plasma levels of adrenocorticotropic hormones and cortisol alongside hypokalaemia . [ 6 ]
The symptoms of Cushing's in cats is similar to that of dogs. [ 8 ] For cats the most common reason for referral resulting in a diagnosis is diabetes mellitus . Abnormal dermatological findings were the most common reason for referral after physical examination in cats. [ 9 ] 80% of cats with Cushing's develop diabetes mellitus compared to 10% of dogs. [ 8 ] One study of cats found all 30 to have dermatological lesions, 87% to have polyuria or polydipsia, and 70% to have polyphagia. [ 9 ] Curling of the tips of the ears may occur. [ 2 ]
Signs in hamsters include nonpruritic alopecia which will slowly progress to complete hair loss except for vibrissae , hyperpigmentation, polyuria , polydipsia, and polyphagia. [ 3 ]
Animals with Cushing's syndrome often have a co-morbidity such as: diabetes mellitus, chronic urinary tract infections , systemic hypertension , and pulmonary thromboembolism . [ 2 ] The prevalence of systemic hypertension in dogs with Cushing's ranges between 31%-86%; however the reasons for this are unknown but hypotheses include: increased mineralocorticoid activity, decreased concentrations of nitric oxide , and increased renal vascular resistance. Studies have not found a difference in prevalence nor severity of systemic hypertension in dogs with pituitary-dependent versus adrenal-dependent Cushing's. No correlation has been identified with systolic blood pressure , age, sex, and neuter status . A relationship between systolic blood pressure and urinary protein to creatinine ratio or base coritsol levels has been inconsistently identified in studies. [ 4 ]
Pituitary-dependent Cushing's is caused by production of too much adrenocorticotropic hormone by a functioning pituitary tumour. The tumour may be benign or malignant. Adrendal-dependent Cushing's is caused by a primary adrenal disorder . [ 10 ]
Iatrogenic Cushing's is caused by long term use of corticosteroid-type medicine which can produce the same effects as cortisol produced by the body. [ 2 ]
Older dogs are more likely to present with Cushing's syndromes. Greater prevalence has been observed in some breeds such as the Yorkshire Terrier , Poodle (miniature), Miniature Dachshund , Boxer , [ 1 ] Irish Setter , and Basset Hound . [ 11 ] One study found bitches to be 1.4 times more likely to be diagnosed than dogs. [ 11 ]
The presentation of clinical signs occurs with great variation due to the gradual onset of Cushing's. In cases where a tumour is the cause it may take months or years for a diagnosis to occur. [ 2 ] A study looking at 66 records of dogs with Cushing's found the duration of clinical signs before diagnosis to be between 1 and 36 months with a median of 8 months. [ 4 ]
Routine diagnostic testing for Cushing's includes: a complete blood count , urinalysis , and a serum biochemistry panel; however the abnormalities these tests detect are not specific to Cushing's. [ 2 ] Abnormalities that can be found in a complete blood count include: thrombocytosis , neutrophilia , lymphopenia , erythrocytosis , eosinopenia , and monocytosis . Abnormalities that can be found via serum biochemistry include: hyperglycaemia , hypercholesterolaemia , hypokalaemia , increased alkaline phosphatase concentration, alanine aminotransferase levels, creatinine concentration, lipase activity, and decreased urea concentration. [ 12 ]
Ultrasonography , CT scans , and MRI are used to identify any abnormality in the pituitary or adrenal gland. This helps diagnose if the patient has pituitary-dependent Cushing's or adrenal-dependent Cushing's. [ 2 ]
Cushing's may cause a breakdown of dermal proteins , causing shiny and thin skin, this can lead to secondary infection and is pathognomonic of Cushing's. [ 2 ]
Blood tests are not always practical for hamsters due to their small size; abdominal ultrasounds can be used to show adrenal gland enlargement. [ 3 ]
Hypothyroidism is a potential differential diagnosis. Glucocorticoids lower the serum concentration of thyroxine and triiodothyronine . 40-50% of dogs with Cushing's have lowered levels of these thyroid hormones . The cause of this is not known. When a dog has lowered serum levels of thyroid hormones and endocrine alopecia it is harder to differentiate between hypothyroidism and Cushing's. Signs of polydipsia, polyuria, and polyphagia help to differentiate as these symptoms do not occur in hypothyroidism. If Cushing's is suspected it can be confirmed via urinalysis of the creatine/cortisol ratio. L-thyroxine is the most common method of treating hypothyroidism in dogs, if used to treat a dog with Cushing's the dog will likely display polyuria and polydipsia and the condition may worsen. [ 13 ]
Prognosis varies based on the type of Cushing's, if the tumour is benign or malignant, and treatment method. [ 2 ] Median survival times for dogs of 662-900 days have been observed in pituitary-dependent cases treated with trilostane, and 353-475 days for adrenal-dependent cases treated with trilostane. [ 14 ] Survival rates of 72-79% have been observed in dogs with pituitary-dependent Cushing's four years after a hypophysectomy . Dogs affected by adrenal-dependent Cushing's that underwent an adrenalectomy had a median survival rate of 533-953 days. [ 14 ]
Treatment of Cushing's depends on the cause. It is possible to cure Cushing's if the tumour is small, benign, and located on the adrenal gland; however, this is not common. [ 2 ] [ 6 ] Hypophysectomy is an option for patients with good clinical signs and a high life expectancy. Inoperable pituitary tumours may be treated with radiation, this is therapeutic as can take up to 16 months for change to show. [ 6 ]
Mitotane , sold under the brand name Lysodren, erodes the layers of the adrenal gland which produce corticosteroid hormones. Whilst the pituitary tumour will still excrete excessive hormones, the adrenal gland will no longer be capable of excess production of hormones. Mitotane was historically the only treatment used for pituitary dependent Cushing's in dogs and is relatively cheap. Disadvantages of mitotane as a treatment include the side effects and the requirement for blood test monitoring. Issues can arise when too much of the adrenal cortex becomes eroded. Approximately 30% of dogs will experience a reaction in response to treatment with mitotane; prednisone may be used as an antidote . In the event of a reaction, mitotane treatment is discontinued until regrowth of the adrenal gland occurs. Occasionally the erosion is permanent and the dog will require treatment for cortisone deficiency. The risk of permanent or life-threatening reactions are between 2-5% based on two studies. Side effects of mitotane include diarrhoea , vomiting, anorexia , adipsia , and lethargy . [ 8 ]
Trilostane , sold under the brand name Vetoryl, inhibits the 3-beta-hydroxysteroid dehydrogenase enzyme. The enzyme is responsible for the production of cortisol and the inhibition of it will inhibit cortisol production. Trilostane has been identified by multiple studies as an effective treatment for Cushing's. Common side effects of trilostane include lethargy and anorexia. Addisonian reactions where the adrenal cortex dies have been reported, but the reasons for this reaction are not known. Most reactions can be reversed with the ceasing of treatment; however permanent reactions are possible. Permanent reactions from using trilostane are idiosyncratic , whereas permanent erosion caused by mitotane is dose-dependent. Therefore, blood testing monitoring is required. The risk of permanent or life-threatening reactions are between 2-3% based on two studies. [ 8 ]
L-Deprenyl , sold under the brand name anipryl, does not target cortisol production, instead it directly addresses the tumour. Research on L-Deprenyl has shown that adrenocorticotropic hormone secretion in the intermediate area of the pituitary gland is controlled by the neurotransmitter dopamine . High levels of dopamine production will shut down adrenocorticotropic hormone secretion. L-Deprenyl inhibits the enzymes responsible for the degradation of dopamine as well as stimulating the production of dopamine. Approximately 5% of dogs experience minor nausea, restlessness, and reduced hearing ability. The different mechanism of L-Deprenyl and that it breaks down into amphetamine and methamphetamine —which suppresses hunger— meaning the normal monitoring tests are not useful in dogs treated with L-Deprenyl. Independent studies showed roughly 20% of dogs to improve with L-Deprenyl compared to 80% with studies sponsored by the manufacturer. Advantages of L-Deprenyl include the lower risk of side effects and inability to cause hypoadrenocoritism. Disadvantages are the substantial cost and the comparatively longer time before improvements can be noticed compared to lysodren. Some veterinarians may use high doses of lysodren to induce hypoadrenocorticism (a deficiency of cortisone), as it is easier to treat. This is not a common method and is not used in some hospitals. [ 8 ]
The prevalence of hyperadrenocorticism in dogs is between 0.2% and 0.28%. [ 15 ] [ 16 ]
An English study comparing dogs with hyperadrenocorticism to general hospital cases found smaller breeds, overweight dogs, dogs over the age of 9, and neutered dogs to be more likely to be diagnosed. [ 17 ]
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Cutaneous lymphoma , also known as lymphoma cutis , is when lymphoma involves the skin. [ 1 ] It is characterized by a proliferation of lymphoid tissue. [ 2 ]
There are two main classes of lymphomas that affect the skin: [ citation needed ]
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A cutaneous sinus of dental origin is where a dental infection drains onto the surface of the skin of the face or neck. This is uncommon as usually dental infections drain into the mouth, typically forming a parulis ("gumboil").
Cutaneous sinuses of dental origin tend to occur under the chin or mandible . Without elimination of the source of the infection, the lesion tends to have a relapsing and remitting course, with healing periods and periods of purulent discharge.
Cutaneous sinus tracts may result in fibrosis and scarring which may cause cosmetic concern. Sometimes minor surgery is carried out to remove the residual lesion. [ 1 ]
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Cutaneous squamous-cell carcinoma ( cSCC ), also known as squamous-cell carcinoma of the skin or squamous-cell skin cancer , is one of the three principal types of skin cancer , alongside basal-cell carcinoma and melanoma . [ 10 ] cSCC typically presents as a hard lump with a scaly surface, though it may also present as an ulcer . [ 1 ] Onset and development often occurs over several months. [ 4 ]
Compared to basal cell carcinoma, cSCC is more likely to spread to distant areas . [ 11 ] When confined to the epidermis , the outermost layer of the skin, the pre-invasive or in situ form of cSCC is termed Bowen's disease . [ 12 ] [ 13 ]
The most significant risk factor for cSCC is extensive lifetime exposure to ultraviolet radiation from sunlight. [ 2 ] Additional risk factors include prior scars, chronic wounds, actinic keratosis , lighter skin susceptible to sunburn, Bowen's disease, exposure to arsenic , radiation therapy , tobacco smoking , poor immune system function , previous basal cell carcinoma, and HPV infection . [ 2 ] [ 14 ] [ 15 ] The risk associated with UV radiation correlates with cumulative exposure rather than early-life exposure. [ 16 ] Tanning beds have emerged as a significant source of UV radiation.
Genetic predispositions, such as xeroderma pigmentosum [ 17 ] and certain forms of epidermolysis bullosa , [ 18 ] also increase susceptibility to cSCC. The condition originates from squamous cells located in the skin 's upper layers. [ 19 ] Diagnosis typically relies on skin examination, and is confirmed through skin biopsy . [ 2 ] [ 3 ]
Research, both in vivo and in vitro , indicates a crucial role for the upregulation of FGFR2 , part of the fibroblast growth factor receptor immunoglobin family, in cSCC cell progression. [ 20 ] Mutations in the TPL2 gene leads to overexpression of FGFR2, which activates the mTORC1 and AKT pathways in primary and metastatic cSCC cell lines. Utilization of a "pan FGFR inhibitor" has shown to reduce cell migration and proliferation in cSCC in vitro studies. [ 20 ]
Preventive measures against cSCC include minimizing exposure to ultraviolet radiation and the use of sunscreen . [ 5 ] [ 6 ] Surgical removal is the typical treatment method, [ 2 ] employing simple excision for minor cases or Mohs surgery for more extensive instances. [ 2 ] Other options include cryotherapy and radiation therapy . [ 7 ] For cases with distant metastasis, chemotherapy or biologic therapy may be employed. [ 7 ]
As of 2015, approximately 2.2 million individuals globally were living with cSCC at any given time, [ 8 ] constituting about 20% of all skin cancer cases. [ 21 ] In the United States, approximately 12% of males and 7% of females are diagnosed with cSCC at some point in their lives. [ 2 ] While prognosis remains favorable in the absence of metastasis, upon distant spread the five-year survival rate is markedly reduced to ~34%. [ 4 ] [ 5 ] In 2015, global deaths attributed to cSCC numbered around 52,000. [ 9 ] The average age at diagnosis is approximately 66 years. [ 4 ] Following successful treatment of an initial cSCC lesion, there is a substantial risk of developing subsequent lesions. [ 2 ]
SCC of the skin begins as a small nodule and as it enlarges the center becomes necrotic and sloughs and the nodule turns into an ulcer, and generally are developed from an actinic keratosis. Once keratinocytes begin to grow uncontrollably, they have the potential to become cancerous and produce cutaneous squamous-cell carcinoma. [ 22 ]
Cutaneous squamous-cell carcinoma is the second-most common cancer of the skin (after basal-cell carcinoma, but more common than melanoma ). It usually occurs in areas exposed to the sun. Sunlight exposure and immunosuppression are risk factors for SCC of the skin, with chronic sun exposure being the strongest environmental risk factor. [ 26 ] There is a risk of metastasis starting more than 10 years [ citation needed ] after diagnosable appearance of squamous-cell carcinoma, but the risk is low, [ specify ] though much [ specify ] higher than with basal-cell carcinoma. Squamous-cell cancers of the lip and ears have high rates of local recurrence and distant metastasis. [ 27 ] In a recent study, it has also been shown that the deletion or severe down-regulation of a gene titled Tpl2 (tumor progression locus 2) may be involved in the progression of normal keratinocytes into becoming squamous-cell carcinoma. [ 28 ]
cSCC represents about 20% of the non-melanoma skin cancers; 80-90% of cSCCs with metastatic potential are located on the head and neck. [ 29 ]
Tobacco smoking also increases the risk for cutaneous squamous-cell carcinoma. [ 14 ] [ 30 ]
The vast majority of cSCC cases are located on exposed skin, and are often the result of ultraviolet exposure. cSCC usually occurs on portions of the body commonly exposed to the sun; the face, ears, neck, hands, or arms. The primary sign is a growing bump that may have a rough, scaly surface, and flat, reddish patches.
Unlike basal-cell carcinoma, cSCC carries a higher risk of metastasis than does basal-cell carcinoma, and may spread to the regional lymph nodes , [ 31 ]
Erythroplasia of Queyrat (SCC in situ of the glans or prepuce in males, [ 32 ] M [ 33 ] : 733 [ 34 ] : 656 [ 35 ] or the vulva in females. [ 36 ] ) may be induced by human papilloma virus . [ 37 ] It is reported to occur in the corneoscleral limbus . [ 38 ] Erythroplasia of Queyrat may also occur on the anal mucosa or the oral mucosa. [ 39 ]
Genetically, cSCC tumors harbor high frequencies of NOTCH and p53 mutations as well as less frequent alterations in histone acetyltransferase EP300 , subunit of the SWI/SNF chromatin remodeling complex PBRM1 , DNA-repair deubiquitinase USP28, and NF-κB signaling regulator CHUK. [ 40 ]
A significant proportion of cSCC and its precursor lesions carry UV -induced p53 mutations. In fact, these mutations are present in up to 90% of cSCC cases. The detection of p53 mutations in precursor lesions indicates that this could be an early event in the development of squamous cell carcinoma. [ 41 ]
People who have received solid organ transplants are at a significantly increased risk of developing squamous-cell carcinoma due to the use of chronic immunosuppressive medication. [ 42 ] While the risk of developing all skin cancers increases with these medications, this effect is particularly severe for cSCC, with hazard ratios as high as 250 being reported, versus 40 for basal cell carcinoma. [ 43 ] The incidence of cSCC development increases with time posttransplant. [ 44 ] Heart and lung transplant recipients are at the highest risk of developing cSCC due to more intensive immunosuppressive medications used. [ 45 ]
Cutaneous squamous-cell carcinoma in individuals on immunotherapy or who have lymphoproliferative disorders (e.g. leukemia ) tend to be much more aggressive, regardless of their location. [ 46 ] The risk of cSCC, and non-melanoma skin cancers generally, varies with the immunosuppressive drug regimen chosen. The risk is greatest with calcineurin inhibitors like cyclosporine and tacrolimus, and least with mTOR inhibitors, such as sirolimus and everolimus. The antimetabolites azathioprine and mycophenolic acid have an intermediate risk profile. [ 47 ]
Diagnosis is confirmed via skin biopsy of the tissue or tissues suspected to be affected by SCC.
The pathological appearance of a squamous-cell cancer varies with the depth of the biopsy. For that reason, a biopsy including the subcutaneous tissue and basilar epithelium, to the surface is necessary for correct diagnosis. The performance of a shave biopsy (see skin biopsy ) might not acquire enough information for a diagnosis. An inadequate biopsy might be read as actinic keratosis with follicular involvement. A deeper biopsy down to the dermis or subcutaneous tissue might reveal the true cancer. An excision biopsy is ideal, but not practical in most cases. An incisional or punch biopsy is preferred. A shave biopsy is least ideal, especially if only the superficial portion is acquired. [ citation needed ]
Histopathologically, the epidermis in cSCC in situ (Bowen's disease) will show hyperkeratosis and parakeratosis. There will also be marked acanthosis with elongation and thickening of the rete ridges. These changes will overly keratinocytic cells which are often highly atypical and may in fact have a more unusual appearance than invasive cSCC. The atypia spans the full thickness of the epidermis, with the keratinocytes demonstrating intense mitotic activity, pleomorphism, and greatly enlarged nuclei. They will also show a loss of maturity and polarity, giving the epidermis a disordered or "windblown" appearance. [ citation needed ]
Two types of multinucleated cells may be seen: the first will present as a multinucleated giant cell, and the second will appear as a dyskeratotic cell engulfed in the cytoplasm of a keratinocyte. Occasionally, cells of the upper epidermis will undergo vacuolization, demonstrating an abundant and strongly eosinophilic cytoplasm. There may be a mild to moderate lymphohistiocytic infiltrate detected in the upper dermis. [ 12 ]
Bowen's disease is essentially equivalent to and used interchangeably with cSCC in situ , when not having invaded through the basement membrane . [ 12 ] Depending on source, it is classified as precancerous [ 13 ] or cSCC in situ (technically cancerous but non-invasive). [ 48 ] [ 49 ] In cSCC in situ (Bowen's disease), atypical squamous cells proliferate through the whole thickness of the epidermis. [ 12 ] The entire tumor is confined to the epidermis and does not invade into the dermis. [ 12 ] The cells are often highly atypical under the microscope , and may in fact look more unusual than the cells of some invasive squamous-cell carcinomas. [ 12 ]
Erythroplasia of Queyrat is a particular type of Bowen's disease that can arise on the glans or prepuce in males, [ 32 ] [ 33 ] : 733 [ 34 ] : 656 [ 35 ] and the vulva in females. [ 36 ] It mainly occurs in uncircumcised males, [ 36 ] [ 50 ] over the age of 40. [ 39 ]
In invasive cSCC, tumor cells infiltrate through the basement membrane. The infiltrate can be somewhat difficult to detect in the early stages of invasion: however, additional indicators such as full thickness epidermal atypia and the involvement of hair follicles can be used to facilitate the diagnosis. Later stages of invasion are characterized by the formation of nests of atypical tumor cells in the dermis, often with a corresponding inflammatory infiltrate. [ 12 ]
Appropriate sun-protective clothing, use of broad-spectrum (UVA/UVB) sunscreen with at least SPF 50, and avoidance of intense sun exposure may prevent skin cancer . [ 51 ] A 2016 review of sunscreen for preventing cutaneous squamous-cell carcinoma found insufficient evidence to demonstrate whether it was effective. [ 52 ]
Most cutaneous squamous-cell carcinomas are removed with surgery. A few selected cases are treated with topical medication. Surgical excision with a free margin of healthy tissue is a frequent treatment modality. Radiotherapy, given as external beam radiotherapy or as brachytherapy (internal radiotherapy), can also be used to treat cSCC. There is little evidence comparing the effectiveness of different treatments for non-metastatic cSCC. [ 53 ] Cosibelimab (Unloxcyt) was approved for medical use in the United States in December 2024, for the treatment of adults with metastatic cutaneous squamous cell carcinoma or locally advanced cutaneous squamous cell carcinoma who are not candidates for curative surgery or curative radiation. [ 54 ]
Mohs surgery is frequently utilized; considered the treatment of choice for squamous-cell carcinoma of the skin, physicians have also utilized the method for the treatment of squamous-cell carcinoma of the mouth, throat, and neck. [ 55 ] An equivalent method of the CCPDMA standards can be utilized by a pathologist in the absence of a Mohs-trained physician. Radiation therapy is often used afterward in high risk cancer or patient types. [ 56 ] Radiation or radiotherapy can also be a standalone option in treating cSCC.
As a non-invasive option brachytherapy serves a painless possibility to treat in particular but not only difficult to operate areas like the earlobes or genitals. An example of this kind of therapy is the high-dose brachytherapy Rhenium-SCT which makes use of the beta rays emitting property of rhenium-188 . The radiation source is enclosed in a compound which is applied to a thin protection foile directly over the lesion. This way the radiation source can be applied to complex locations and minimize radiation to healthy tissue. [ 57 ]
After removal of the cancer, closure of the skin for patients with a decreased amount of skin laxity involves a split-thickness skin graft. A donor site is chosen and enough skin is removed so that the donor site can heal on its own. Only the epidermis and a partial amount of dermis is taken from the donor site which allows the donor site to heal. Skin can be harvested using either a mechanical dermatome or Humby knife. [ 58 ]
Electrodessication and curettage (EDC) can be done on selected squamous-cell carcinoma of the skin. In areas where cSCC is known to be non-aggressive, and where the patient is not immunosuppressed, EDC [ clarification needed ] can be performed with good to adequate cure rate. [ 59 ]
Treatment options for cSCC in situ (Bowen's disease) include photodynamic therapy with 5-aminolevulinic acid, cryotherapy , topical 5-fluorouracil or imiquimod, and excision. A meta-analysis showed evidence that PDT is more effective than cryotherapy and has better cosmetic outcomes. There is generally a lack of evidence comparing the effectiveness of all treatment options. [ 13 ]
High-risk squamous-cell carcinoma, as defined by that occurring around the eye, ear, or nose, is of large size, is poorly differentiated, and grows rapidly, requires more aggressive, multidisciplinary management.
Nodal spread:
In general, squamous-cell carcinomas have a high risk of local recurrence, and up to 50% do recur. [ 60 ] Frequent skin exams with a dermatologist is recommended after treatment.
The long-term outcome of squamous-cell carcinoma is dependent upon several factors: the sub-type of the carcinoma, available treatments, location and severity, and various patient health-related variables (accompanying diseases, age, etc.). Generally, the long-term outcome is positive, with a metastasis rate of 1.9-5.2% and a mortality rate of 1.5-3.4%. [ 25 ] [ 61 ] [ 62 ]
When it does metastasize, the most commonly involved organs are the lungs, brain, bone and other skin locations. [ 63 ] Squamous-cell carcinoma occurring in immunosuppressed people (such as those with organ transplant, human immunodeficiency virus infection, or chronic lymphocytic leukemia) the risk of developing cSCC and having metastasis is much higher than the general population. [ 64 ]
One study found squamous-cell carcinoma of the penis had a much greater rate of mortality than some other forms of squamous-cell carcinoma, that is, about 23%, [ 65 ] although this relatively high mortality rate may be associated with possibly latent diagnosis of the disease due to patients avoiding genital exams until the symptoms are debilitating, or refusal to submit to a possibly scarring operation upon the genitalia.
The incidence of cutaneous squamous-cell carcinoma continues to rise around the world. This is theorized to be due to several factors; including an aging population, a greater incidence of those who are immunocompromised and the increasing use of tanning beds. [ 25 ]
A recent study estimated that there are between 180,000 and 400,000 cases of cSCC in the United States in 2013. [ 67 ] Risk factors for cSCC varies with age, gender, race, geography, and genetics. The incidence of cSCC increases with age and with those 75 years or older being at a 5-10 times increased risk of developing cSCC as compared with those who are younger than 55 years old. [ 25 ] Males are affected with cSCC at a ratio of 3:1 in comparison to females. [ 25 ] Those who have light skin, red or blonde hair and light colored eyes are also at increased risk. [ 25 ]
Squamous-cell carcinoma of the skin can be found on all areas of the body but is most common on frequently sun-exposed areas, such as the face, legs and arms. [ 68 ] Solid organ transplant recipients (heart, lung, liver, pancreas, among others) are also at a heightened risk of developing aggressive, high-risk cSCC. There are also a few rare congenital diseases predisposed to cutaneous malignancy. In certain geographic locations, exposure to arsenic in well water [ 69 ] or from industrial sources may significantly increase the risk of cSCC. [ 26 ]
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Cutibacterium granulosum is a bacterium that may stimulate the immune system to fight cancer .
This article incorporates public domain material from Dictionary of Cancer Terms . U.S. National Cancer Institute .
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Cyclic vomiting syndrome ( CVS ) is a chronic functional condition of unknown pathogenesis . CVS is characterized as recurring episodes lasting a single day to multiple weeks. Each episode is divided into four phases: inter-episodic, prodrome , vomiting , and recovery. During the inter-episodic phase, which typically lasts one week to one month, there are no discernible symptoms and normal activities can occur. The prodrome phase is known as the pre-emetic phase, characterized by the initial feeling of an approaching episode but still being able to keep down oral medication . The emetic or vomiting phase is characterized by intense persistent nausea and repeated vomiting, typically lasting hours to days. During the recovery phase, vomiting ceases, nausea diminishes or is absent, and appetite returns. "Cyclic vomiting syndrome (CVS) is a rare abnormality of the neuroendocrine system that affects 2% of children." [ 1 ] This disorder is thought to be closely related to migraines and family history of migraines. [ 2 ] [ 3 ]
Affected people may vomit or retch 6–12 times per hour, and an episode may last from a few hours to over three weeks and in some cases months, with a median episode duration of 41 hours. [ 4 ] Stomach acid , bile and, if the vomiting is severe, blood may be vomited. Some with the condition drink water to reduce the irritation of bile and acid on the esophagus during emesis. Between episodes, the affected person is usually healthy but can be in a state of fatigue or experience muscle pain . In approximately half of cases, the attacks, or episodes, occur in a time-related manner. Each attack is stereotypical; that is, in any given person, the timing, frequency, and severity of attacks is similar. Some affected people experience episodes that progressively worsen when left untreated, occurring more frequently with reduced symptom-free phases. [ 5 ]
Episodes may happen every few days, every few weeks or every few months, for some happening at common uniform times, typically mornings. [ 5 ] For other affected people, there is not a pattern in time that can be recognized. Some with the condition have a warning of an episodic attack; they may experience a prodrome, some documented prodromal symptoms include: unusually intense nausea and pallor , excess salivation, sweating , flushing , rapid/irregular heartbeat, diarrhea , anxiety / panic , food aversion, restlessness/insomnia, irritability , depersonalization , fatigue/listlessness, intense feelings of being hot or chilled, intense thirst, shivering/shaking, retching, tachypnea , abdominal pain/cramping, limb paresthesias , hyperesthesia , photophobia , phonophobia , headache , and dyspnea , heightened sensitivity, especially to light, though sensitivity to smell, sound, pressure, and temperature, as well as oncoming muscle pain and fatigue, are also reported by some patients. Many experience a full panic attack when nausea begins and continue to panic once the vomiting has begun. Medications like Lorazepam , Alprazolam , and other benzodiazepines are prescribed by their doctors and instructed to take immediately at the onset of any of their CVS symptoms and/or triggers. Some prodromal symptoms are present inter-episodically as well as during acute phases of illness. The majority of affected people can identify triggers that may precede an attack. The most common are various foods, infections (such as colds ), menstruation , extreme physical exertion, lack of sleep, and psychological stresses , both positive and negative. [ citation needed ]
An affected person may also be light-sensitive (photophobic), sound-sensitive (phonophobic) or, less frequently, temperature- or pressure-sensitive during an attack. [ 6 ] Some people also have a strong urge to bathe in warm or cold water. In fact, many people with CVS experience a compulsion to be submerged in hot water, and end up taking several baths during the duration of an episode. For some the psychological compulsion to be in hot water is so extreme that they cannot stop themselves from taking very long baths in near scalding hot water several times per day. For some of these people, they may have just finished taking a lengthy bath in extremely hot water and immediately feel this compulsion again and end up taking another bath right after drying off. Some people with the condition experience insomnia , diarrhea (GI complications), hot and cold flashes, and excessive sweating before an episode. Some report that they experience a restless sensation or stinging pain along the spine, hands, and feet followed by weakness in both legs. Some of these symptoms may be due to dehydration or hypokalemia from excessive vomiting, rather than the underlying cause of CVS.
There is no known genetic pathogenesis for CVS. Recent studies suggest many affected individuals have a family history of related conditions, such as migraines, psychiatric disorders and gastrointestinal disorders. Inheritance is thought to be maternal, a possible genetic mitochondrial inheritance. Adolescents show higher possible mitochondrial inheritance and maternal inheritance than found in adults. Single base-pair and DNA rearrangements in the mitochondrial DNA (mtDNA) have been associated with these traits. [ 7 ] [ 8 ]
The cause of CVS has not been determined and there are no diagnostic tests for CVS. Several other medical conditions, such as cannabinoid hyperemesis syndrome (CHS), can mimic the same symptoms, and it is important to rule these out. If all other possible causes have been excluded, a diagnosis of CVS using Rome criteria by a physician may be appropriate. [ 5 ]
Once formal investigations to rule out gastrointestinal or other causes have been conducted, these tests do not need to be repeated in the event of future episodes. [ 6 ]
Due to the lack of specific biomarkers available for the disorder, and if all other possible causes can be ruled out (such as intestinal malrotation ), physicians rely on the Rome IV process criteria in order to diagnose patients. [ 5 ] Patients must meet all three of the following criteria to receive diagnosis:
Criteria must be fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. A history of family history of migraine headaches can also be used in facilitating diagnosis. [ 9 ]
Treatment for cyclic vomiting syndrome depends on the evident phase of the disorder. [ 10 ]
Because the symptoms of CVS are similar (or perhaps identical) to those of the disease well-identified as " abdominal migraine ," prophylactic migraine medications, such as topiramate and amitriptyline , have seen recent success in treatment for the prodrome and vomiting phases, reducing the duration, severity, and frequency of episodes. [ 11 ]
Therapeutic treatment for the prodromal phase, characterized by the anticipation of an episode, consists of sumatriptan (nasal or oral) an anti-migraine medication, anti-inflammatory drugs to reduce abdominal pain, and possible anti-emetic drugs. These options may be helpful in preventing an episode or reducing the severity of an attack. [ 12 ] [ 13 ]
The most common therapeutic strategies for those already in the vomiting phase are maintenance of salt balance by appropriate intravenous fluids. Sedation via high dose intravenous benzodiazepines , typically lorazepam , has been shown to shorten the length of emergency department stays for some patients. [ 14 ] Having vomited for a long period prior to attending a hospital, patients are typically severely dehydrated. For a number of patients, potent anti-emetic drugs such as ondansetron (Zofran) or granisetron (Kytril), and dronabinol (Marinol) may be helpful in either preventing an attack, aborting an attack, or reducing the severity of an attack. Many patients seek comfort during episodes by taking prolonged showers and baths typically quite hot. The use of a heating pad may also help reduce abdominal pain. [ 2 ]
Lifestyle changes may be recommended, such as extended rest, reduction of stress, frequent small meals, and to abstain from fasting . A diet change may be recommended avoid food allergens , eliminating trigger foods such as chocolates, cheese, beer, and red wine. [ 15 ] [ 3 ]
Some patients experience relief from inhaled isopropyl alcohol. [ 16 ]
Intravenous Haloperidol may be an effective treatment. [ 17 ]
Fitzpatrick et al. (2007) identified 41 children with CVS. The mean age of the sample was 6 years at the onset of the syndrome, 8 years at first diagnosis, and 13 years at follow-up. As many as 39% of the children had resolution of symptoms immediately or within weeks of the diagnosis. Vomiting had resolved at the time of follow-up in 61% of the sample. Many children, including those in the remitted group, continued to have somatic symptoms such as headaches (in 42%) and abdominal pain (in 37%). [ 18 ]
Most children who have this disorder miss on average 24 school days a year. [ 15 ] The frequency of episodes is higher for some people during times of excitement. [ 15 ] Charitable organizations to support affected people and their families and to promote knowledge of CVS exist in several countries.
A 2005 study by Fleisher et al. identified 41 adults who had been previously seen for complaints compatible with CVS. The average age at presentation of the sample was 34 years, and the mean age at onset was 21 years. The mean duration of the CVS at the time of consultation was 12 years. Of the 39 patients surveyed, 85% had episodes that were fairly uniform in length. Most patients reported these attacks in the morning hours. Of those 39 patients, 32% were completely disabled and required financial support due to CVS. Despite this, data suggests that the prognosis for CVS is generally favorable. [ 2 ]
Complications can include dehydration, dental caries , or an esophageal tear . [ 19 ]
The average age at onset is 3–7 years, with described cases as young as 6 days and as old as 73 years. [ 20 ] Typical delay in diagnosis from onset of symptoms is 3 years. [ 20 ] Females show a slight predominance over males. [ 20 ]
One study found that 3 in 100,000 five-year-olds are diagnosed with the condition. [ 21 ] Two studies on childhood CVS suggest nearly 2% of school-age children may have CVS. [ 22 ] [ 23 ]
Cyclic vomiting syndrome was first described in France by Swiss physician Henri Clermond Lombard [ 24 ] and first described in the English language by pediatrician Samuel Gee in 1882. [ 25 ]
It has been suggested that Charles Darwin's adult illnesses may have been due to this syndrome. [ 26 ] Darwin's illness had features seen in patients with cyclic vomiting, in particular his susceptibility to seasickness when onboard HMS Beagle, episodes being brought on by pleasurable events, and his periods of extreme lethargy dating back to his university student days. However in Darwin's case it is argued that his vomiting was due to an inherited mitochondrial disorder. [ 27 ]
See also
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https://en.wikipedia.org/wiki/Cyclic_vomiting_syndrome
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Cynanthropy (sometimes spelled kynanthropy ; from Ancient Greek : κύων / kúōn , 'dog' + ἄνθρωπος / ánthrōpos , 'man; human') is, in psychiatry , the pathological delusion of real persons that they are dogs [ 1 ] and in anthropology and folklore , the supposed magical practice of shape-shifting alternately between dog and human form, or the possession of combined canine and human anatomical features, a form of therianthropy .
The Greeks spoke of cynanthropy ( kyon , dog). The term existed by at least 1901, when it was applied to myths from China about humans turning into dogs, dogs becoming people, and sexual relations between humans and canines. [ 2 ] After lycanthropy , cynanthropy is the best known term for a specific variety of therianthropy.
Anthropologist David Gordon White called Central Asia the "vortex of cynanthropy" because races of dog-men were habitually placed there by ancient writers. Hindu mythology puts races of "Dog Cookers" to the far north of India, the Chinese placed the "Dog Jung" and other human/canine barbarians to the extreme west, and European legends frequently put the dog men called Cynocephali in unmapped regions to the east. Some of these races were described as humans with dog heads, others as canine shapeshifters. [ 3 ]
The weredog or cynanthrope is also known in Timor . It is described as a human/canine shapeshifter who is also capable of transforming other people into animals against their wills. These transformations are usually into prey animals such as goats, so that the cynanthrope can devour them without discovery of the crime. [ 4 ]
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https://en.wikipedia.org/wiki/Cynanthropy
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Cysteinyldopa , or 5- S -cysteinyldopa , is a catecholamine . Excessive cysteinyldopa in plasma and urine has been linked to malignant melanoma . [ 1 ] [ 2 ] [ 3 ] Cysteinyldopa is found in large amounts in the plasma and urine of patients with malignant melanoma. It is therefore used in the diagnosis of melanoma and for the detection of postoperative metastases. Cysteinyldopa is believed to be formed by the rapid enzymatic hydrolysis of 5-S-glutathionedopa found in melanin-producing cells.
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https://en.wikipedia.org/wiki/Cysteinyldopa
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Cystic fibrosis–related diabetes ( CFRD ) is diabetes specifically caused by cystic fibrosis , a genetic condition. Cystic fibrosis related diabetes mellitus (CFRD) develops with age, and the median age at diagnosis is 21 years. [ 1 ] It is an example of type 3c diabetes – diabetes that is caused by damage to the pancreas from another disease or condition. [ 2 ]
CFRD shares features of both type 1 diabetes and type 2 diabetes . The primary cause of CFRD is insulin deficiency due to pancreatic scarring. CFRD patients are typically young and are not obese, and lack metabolic syndrome features. The cause of CFRD is not autoimmune. [ 3 ] CFRD patients can also have insulin resistance, but ketosis is rare. [ 4 ]
The endocrine pancreatic function deterioration appears to be secondary to chronic pancreatitis and subsequent scarring associated with CF. [ 4 ] The thick mucus caused by CF is considered to block the pancreatic ducts causing chronic pancreatitis. The failure of the chloride channel leads to less salt and water in the mucus. It is also probable that the failed chloride channel leads to high chloride levels within cells which leads to increased cations (especially potassium and calcium) in those cells. This may also lead to abnormal functioning of the islets of Langerhans cells , the insulin-producing endocrine glands of the pancreas . Inflammation of the surrounding exocrine pancreatic cells is considered to affect the Islet cells but abnormal intracellular electrolytes may be a better explanation as to why CF persons (pwCF) have a high incidence of diabetes . Abnormal intracellular electrolytes may also the reason pwCF have a high incidence of Adrenal failure, osteoporosis and Hyperparathyroidism. Muscle function is also likely to be affected including heart muscle function. Research is needed into intracellular electrolytes in pwCF.
CFRD occurs in some 20% of adolescents and 40–50% of adults affected by CF. [ 3 ] Though rare in children, it has been described in CF patients of all ages, including infants. Beginning in the teenage years, CFRD has an annual incidence of ~3%, and may be more common in females. It is associated with more severe CF gene mutation types. [ 4 ]
As survival of CF patients has steadily increased in past decades, CFRD is an increasingly common – and currently the most common – complication of CF. [ 5 ]
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https://en.wikipedia.org/wiki/Cystic_fibrosis–related_diabetes
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Cystic lesions of the pancreas are a group of pancreatic lesions characterized by a cystic appearance. They can be benign or malignant. [ citation needed ]
Cystic lesions are found in 20.6% of all pancreatectomy specimens. Among this heterogeneous group, benign neoplasms predominate, particularly those with mucinous lining. Age at presentation, gender, location and tumor size are highly variable, with the exception of solid pseudopapillary tumor .
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https://en.wikipedia.org/wiki/Cystic_lesions_of_the_pancreas
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A cystocele , also known as a prolapsed bladder , is a medical condition in which a woman's bladder bulges into her vagina . [ 1 ] [ 5 ] Some may have no symptoms. [ 6 ] Others may have trouble starting urination, urinary incontinence , or frequent urination . [ 1 ] Complications may include recurrent urinary tract infections and urinary retention . [ 1 ] [ 7 ] Cystocele and a prolapsed urethra often occur together and is called a cystourethrocele. [ 8 ] Cystocele can negatively affect quality of life . [ 9 ] [ 10 ]
Causes include childbirth , constipation , chronic cough , heavy lifting, hysterectomy , genetics , and being overweight . [ 1 ] [ 2 ] [ 6 ] The underlying mechanism involves weakening of muscles and connective tissue between the bladder and vagina. [ 1 ] Diagnosis is often based on symptoms and examination. [ 1 ]
If the cystocele causes few symptoms, avoiding heavy lifting or straining may be all that is recommended. [ 1 ] In those with more significant symptoms a vaginal pessary , pelvic muscle exercises , or surgery may be recommended. [ 1 ] The type of surgery typically done is known as a colporrhaphy . [ 11 ] The condition becomes more common with age. [ 1 ] About a third of women over the age of 50 are affected to some degree. [ 5 ]
The symptoms of a cystocele may include:
A bladder that has dropped from its normal position and into the vagina can cause some forms of incontinence and incomplete emptying of the bladder. [ 1 ]
Complications may include urinary retention , recurring urinary tract infections and incontinence. [ 1 ] [ 7 ] The anterior vaginal wall may protrude though the vaginal introitus (opening). This can interfere with sexual activity. [ 6 ] Recurrent urinary tract infections are common for those who have urinary retention. [ 15 ] In addition, though cystocele can be treated, some treatments may not alleviate troubling symptoms, and further treatment may need to be performed. Cystoceles may affect the quality of life; women who have cystoceles tend to avoid leaving their homes and avoid social situations. The resulting incontinence puts women at risk of being placed in a nursing home or long-term care facility. [ medical citation needed ]
A cystocele occurs when the muscles, fascia , tendons and connective tissues between a woman's bladder and vagina weaken, or detach. [ 2 ] [ 16 ] The type of cystocele that can develop can be due to one, two or three vaginal wall attachment failures: the midline defect, the paravaginal defect, and the transverse defect. The midline defect is a cystocele caused by the overstretching of the vaginal wall; the paravaginal defect is the separation of the vaginal connective tissue at the arcus tendineus fascia pelvis ; the transverse defect is when the pubocervical fascia becomes detached from the top (apex) of the vagina. [ 2 ] There is some pelvic prolapse in 40–60% of women who have given birth. [ 17 ] [ 18 ] Muscle injuries have been identified in women with cystocele. These injuries are more likely to occur in women who have given birth than those who have not. These muscular injuries result in less support to the anterior vaginal wall. [ 19 ]
Some women with connective tissue disorders are predisposed to developing anterior vaginal wall collapse. Up to one third of women with Marfan syndrome have a history of vaginal wall collapse. Ehlers-Danlos syndrome in women is associated with a rate of 3 out of 4. [ 6 ]
Risk factors for developing a cystocele are:
Connective tissue disorders predispose women to developing cystocele and other pelvic organ prolapses. The tissues tensile strength of the vaginal wall decreases when the structure of the collagen fibers change and become weaker. [ 6 ]
There are two types of cystocele. The first is distension. This is thought to be due to the overstretching of the vaginal wall and is most often associated with aging, menopause and vaginal delivery. It can be observed when the rugae are less visible or absent. The second type is displacement. Displacement is the detachment or abnormal elongation of supportive tissue. [ 25 ]
The initial assessment of cystocele can include a pelvic exam to evaluate leakage of urine when the women is asked to bear down or give a strong cough ( Valsalva maneuver ), and the anterior vaginal wall measured and evaluated for the appearance of a cystocele. [ 26 ] [ 27 ] If a woman has difficulty emptying her bladder, the clinician may measure the amount of urine left in the woman's bladder after she urinates called the postvoid residual. This is measured by ultrasound . A voiding cystourethrogram involves taking X-rays of the bladder during urination. This X-ray shows the shape of the bladder and lets the doctor see any problems that might block the normal flow of urine. [ 1 ] A urine culture and sensitivity test will assess the presence of a urinary tract infection that may be related to urinary retention. [ 12 ] Other tests may be needed to find or rule out problems in other parts of the urinary system. [ 1 ] Differential diagnosis will be improved by identifying possible inflammation of the Skene's glands and Bartholin glands . [ 28 ]
Several scales exist to grade the severity of a cystocele. [ citation needed ]
The pelvic organ prolapse quantification (POP-Q) assessment, developed in 1996, quantifies the descent of the cystocele into the vagina. [ 6 ] [ 13 ] The POP-Q provides reliable description of the support of the anterior, posterior and apical vaginal wall. It uses objective and precise measurements to the reference point, the hymen . Cystocele and prolapse of the vagina from other causes is staged using POP-Q criteria can range from good support (no descent into the vagina) reported as a POP-Q stage 0 or I to a POP-Q score of IV which includes prolapse beyond the hymen. It also used to quantifies the movement of other structures into the vaginal lumen and their descent. [ 6 ] [ 13 ]
The Baden–Walker Halfway Scoring System is used as the second most used system and assigns the classifications as mild (grade 1) when the bladder droops only a short way into the vagina; (grade 2) cystocele, the bladder sinks far enough to reach the opening of the vagina; and (grade 3) when the bladder bulges out through the opening of the vagina. [ 1 ] [ 29 ]
Cystoceles can be further described as being apical, medial, or lateral. [ 30 ]
Apical cystocele is located upper third of the vagina. The structures involved are the endopelvic fascia and ligaments . The cardinal ligaments and the uterosacral ligaments suspend the upper vaginal-dome. The cystocele in this region of the vagina is thought to be due to a cardinal ligament defect. [ 16 ] [ 25 ]
Medial cystocele forms in the mid-vagina and is related to a defect in the suspension provided by a sagittal suspension system defect in the uterosacral ligaments and pubocervical fascia . The pubocervical fascia may thin or tear and create the cystocele. An aid in diagnosis is the creation of a 'shiny' spot on the epithelium of the vagina. This defect can be assessed by MRI . [ 16 ] [ 25 ]
Lateral cystocele forms when the pelviperineal muscle and its ligamentous–fascial develop a defect. The ligamentous– fascial creates a 'hammock-like' suspension and support for the lateral sides of the vagina. Defects in this lateral support system result in a lack of bladder support. Cystocele that develops laterally is associated with an anatomic imbalance between anterior vaginal wall and the arcus tendineus fasciae pelvis – the essential ligament structure. [ 16 ] [ 25 ]
Cystocele may be mild enough not to result in symptoms that are troubling to a woman. In this case, steps to prevent it from worsening include:
Treatment options range from no treatment for a mild cystocele to surgery for a more extensive cystocele. [ 1 ] If a cystocele is not bothersome, the clinician may only recommend avoiding heavy lifting or straining that could cause the cystocele to worsen. If symptoms are moderately bothersome, the doctor may recommend a pessary , a device placed in the vagina to hold the bladder in place and to block protrusion. [ 12 ] [ 23 ] Treatment can consist of a combination of non-surgical and surgical management. Treatment choice is also related to age, desire to have children, severity of impairment, desire to continue sexual intercourse, and other diseases that a woman may have. [ 6 ]
Cystocele is often treated by non-surgical means:
The surgery to repair the anterior vaginal wall may be combined with other procedures that will repair the other points of pelvic organ support such as anterior-posterior repair and anterior colporrhaphy. [ 12 ] Treatment of cystocele often accompanies the more invasive hysterectomy. [ 32 ] Since the failure rate in cystocele repair remains high, additional surgery may be needed. [ 13 ] Women who have surgery to repair a cystocele have a 17% chance of needing another operation within the next ten years. [ 33 ]
The surgical treatment of cystocele will depend on the cause of the defect and whether it occurs at the top (apex), middle, or lower part of the anterior vaginal wall. The type of surgery will also depend on the type of damage that exists between supporting structures and the vaginal wall. [ 2 ] One of the most common surgical repairs is colporrhaphy . [ 32 ] This surgical procedure consists of making a longitudinal folding of the vaginal tissue, suturing it into place and creating a stronger point of resistance to the intruding bladder wall. Surgical mesh is sometimes used to strengthen the anterior vaginal wall. [ 6 ] It has a 10–50% failure rate. [ 34 ] [ 32 ] In some cases a surgeon may choose to use surgical mesh to strengthen the repair. [ 32 ]
During surgery, the repair of the vaginal wall consists of folding over and then suturing the existing tissue between the vagina and bladder to strengthen it. [ 1 ] [ 11 ] This tightens the layers of tissue to promote the replacement of the pelvic organs into their normal place. The surgery also provides more support for the bladder. This surgery is done by a surgeon specializing in gynecology and is performed in a hospital. Anesthesia varies according to the needs of each woman. Recovery may take four to six weeks. [ 1 ] Other surgical treatments may be performed to treat cystoceles. Support for the vaginal wall is accomplished with the paravaginal defect repair. This is a surgery, usually laproscopic , that is done on the ligaments and fascia through the abdomen. The lateral ligaments and supportive structures are repaired, sometimes shortened to provide additional support to the vaginal wall. [ 32 ]
Sacrocolpopexy is a procedure that stabilizes the vaginal vault (the uppermost portion of the vagina) and is often chosen as the treatment for cystocele, especially if previous surgeries were not successful. The procedure consists of attaching the vaginal vault to the sacrum. It has a success rate of 90%. [ 32 ] Some women choose not to have surgery to close the vagina. This surgery, called colpocleisis , treats cystocele by closing the vaginal opening. This can be an option for women who no longer want to have vaginal intercourse. [ 22 ]
If an enterocele / sigmoidocele or prolapse of the rectum/colon is also present, the surgical treatment will take this concurrent condition into account while planning and performing the repairs. [ 2 ] Estrogen that is administered vaginally before surgical repair can strengthen the vaginal tissue providing a more successful outcome when mesh or sutures are used for the repair. Vaginal thickness increases after estrogen therapy. [ 33 ] Another review on the surgical management of cystocele describes a more successful treatment that more strongly attaches the ligaments and fascia to the vagina to lift and stabilize it. [ 35 ]
Post-surgical complications can develop. The complications following surgical treatment of cystocele are:
After surgery, a woman is instructed to restrict her activities and monitor herself for signs of infection such as an elevated temperature, discharge with a foul odor, and consistent pain. Clinicians may recommend that sneezing, coughing, and constipation be avoided. Splinting the abdomen while coughing supports an incised area and decreases pain with coughing. [ 12 ] This is accomplished by applying gentle pressure to the surgical site for bracing during a cough. [ 36 ] [ 37 ]
Recurrent surgery on the pelvic organs may not be due to a failure of the surgery to correct the cystocele. Subsequent surgeries can be directly or indirectly related to the primary surgery. [ 13 ] Prolapse can occur at a different site in the vagina. Further surgery after the initial repair can be to treat complications of mesh displacement, pain, or bleeding. Additional surgery may be needed to treat incontinence. [ 13 ]
One goal of surgical treatment is to restore the vagina and other pelvic organs to their anatomically normal positions. This may not be the most important outcome to the treated woman, who may only want symptom relief and to improve her quality of life. The International Urogynecological Association (IUGA) has recommended that the data collected regarding cystocele and pelvic organ repair success include the presence or absence of symptoms, satisfaction, and Quality of Life. Other measures of a successful outcome should include perioperative data, such as operative time and hospital stay. Standardized Healthcare Quality of Life should be part of the measure of a successful resolution of cystocele. Data regarding short- and long-term complications is included in the IUGA's recommendations to assess the procedure's risk–benefit ratio more effectively. [ 13 ] Current investigations into the superiority of using biological grafting versus native tissue or surgical mesh indicate that grafting provides better results. [ 38 ]
A large study found a rate of 29% over a woman's lifetime. Other studies indicate a recurrence rate as low as 3%. [ 13 ]
In the US, greater than 200,000 surgeries are performed each year for pelvic organ prolapse and 81% of these are to correct cystocele. [ 14 ] [ 11 ] Cystocele occurs most frequently compared to the prolapse of other pelvic organs and structure. [ 13 ] [ 14 ] Cystocele is found to be three times as common as vaginal vault prolapse and twice as often as posterior vaginal wall defects. The incidence of cystocele is around 9 per 100 women-years. The highest incidence of symptoms occurs between the ages of 70 and 79 years. Based on population growth statistics, the number of women with prolapse will increase by a minimum of 46% by the year 2050 in the US. Surgery to correct prolapse after hysterectomy is 3.6 per 1,000 women-years. [ 13 ]
Notable is the mention of cystoceles in many older cultures and locations. [ 39 ] In 1500 B.C. Egyptians wrote about the "falling of the womb". In 400 B.C., a Greek physician documented his observations and treatments:
"After the patient had been tied to a ladder-like frame, she was tipped upward so that her head was toward the bottom of the frame. The frame was then moved upward and downward more or less rapidly for approximately 3–5 min. As the patient was in an inverted position, it was thought that the prolapsing organs of the genital tract would be returned to their normal position by the force of gravity and the shaking motion." [ 39 ]
Hippocrates thought that recent childbirth, wet feet, 'sexual excesses', exertion, and fatigue may have contributed to prolapse. Polybus , Hippocrates's son-in-law, wrote: "a prolapsed uterus was treated by using local astringent lotions, a natural sponge packed into the vagina, or placement of half a pomegranate in the vagina." In 350 A.D., another practitioner named Soranus described his treatments, which stated that the pomegranate should be dipped into vinegar before insertion. Success could be enhanced if the woman were on bed rest and had reduced food and fluid intake. If the treatment was still not successful, the woman's legs were tied together for three days. [ 39 ]
In 1521, Berengario da Carpi performed the first surgical treatment for prolapse. This was to tie a rope around the prolapse, tighten it for two days until it was no longer viable, and cut it off. Wine, aloe, and honey were then applied to the stump. [ 39 ]
In the 1700s, a Swiss gynecologist, Peyer, published a description of a cystocele. He was able to describe and document both cystoceles and uterine prolapse. In 1730, Halder associated cystocele with childbirth. During this same time, efforts began to standardize the terminology that is still familiar today. In the 1800s, the surgical advancements of anesthesia, suturing, suturing materials, and acceptance of Joseph Lister's theories of antisepsis improved outcomes for women with cystocele. The first surgical techniques were practiced on female cadavers. In 1823, Geradin proposed that an incision and resection may provide treatment. In 1830, the first dissection of the vagina was performed by Dieffenbach on a living woman. In 1834, Mendé proposed that dissecting and repairing the edges of the tissues could be done. In 1859, Huguier proposed that the amputation of the cervix was going to solve the problem of elongation. [ 39 ]
In 1866, a method of correcting a cystocele was proposed that resembled current procedures. Sim subsequently developed another procedure that did not require the full-thickness dissection of the vaginal wall. In 1888, another method of treating anterior vaginal wall Manchester combined an anterior vaginal wall repair with an amputation of the cervix and a perineorrhaphy. In 1909, White noted the high rate of recurrence of cystocele repair. At this time it was proposed that reattaching the vagina to support structures was more successful and resulted in less recurrence. This same proposal was proposed again in 1976, but further studies indicated that the recurrence rate was not better. [ 39 ]
In 1888, treatments were tried that entered the abdomen to make reattachments. Some did not agree with this and suggested an approach through the inguinal canal . In 1898, further abdominal approaches were proposed. No further advances have been noted until 1961 when reattachment of the anterior vaginal wall to Cooper's ligament began to be used. Unfortunately, posterior vaginal wall prolapse occurred in some patients even though the anterior repair was successful. [ 39 ]
In 1955, using mesh to support pelvic structures became common. In 1970, tissue from pigs began to be used to strengthen the anterior vaginal wall in surgery. Beginning in 1976, improvement in suturing began along with the surgical removal of the vagina being used to treat prolapse of the bladder. In 1991, assumptions about the detailed anatomy of the pelvic support structures began to be questioned regarding the existence of some pelvic structures and the non-existence of others. More recently, stem cells and robot-assisted laparoscopic surgery have been used to treat cystoceles. [ 39 ]
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A cystoprostatectomy is a surgical procedure in which the urinary bladder and prostate gland are removed. The procedure combines a cystectomy and a prostatectomy . [ 1 ] [ 2 ]
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A cystourethrectomy or cysto-urethrectomy is a surgical procedure in which the urinary bladder and urethra are removed. [ 1 ] The procedure combines a cystectomy and a urethrectomy . [ citation needed ]
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Cyto-Stain , or CytoStain , is commercially available mix of staining dyes for polychromatic staining in histology. It provides results comparable to Papanicolaou staining , but in fewer operations and in shorter time. It is used in ultrafast Papanicolaou staining .
Cyto-Stain G is a modification of Cyto-Stain, producing greener cyanophilic hues in intermediate and basal cells. [1]
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CytoJournal is a peer-reviewed PubMed -indexed open access online scientific journal on cytology that publishes research articles and information related to all aspects of diagnostic cytopathology , including topics such as molecular cytopathology. It is owned and supported by a non-profit organization (Cytopathology Foundation Inc, USA).
Broad areas of cytopathology covered include fine needle aspiration biopsy , Pap test (including Anal Pap ), and serous fluids .
The journal was established in July 2004 and was published initially by BioMed Central and Medknow Publications . The Cytopathology Foundation moved it to a new platform in July 2020 and it is currently published by Scientific Scholar . The founding editors-in-chief were Vinod B. Shidham ( Medical College of Wisconsin ) and Barbara F. Atkinson ( University of Kansas Medical Center ). Atkinson has retired and continues as editor-emeritus. Other past editors-in-chief include Richard M. DeMay, MD (University of Chicago) and Martha B. Pitman, MD (Massachusetts General Hospital, USA). The current editors-in chief are Lester Layfield, MD (University of Missouri) and Vinod B. Shidham, MD, FIAC, FRCPath (Wayne State University School of Medicine) since 2020.
1. Shidham VB, Cafaro A, Atkinson BF. Editorial: CytoJournal joins 'open access' philosophy.
CytoJournal 2004, 1:1 doi:10.1186/1742-6413-1-1 Click here for FREE access in open access
2. Frisch NK, Nathan R, Ahmed YK, Shidham VB. Authors attain comparable or slightly higher rates of citation publishing in an open access journal (CytoJournal) compared to traditional cytopathology journals - A five-year (2007-2011) experience.
CytoJournal 2014,11:10. Click here for FREE access in open access
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A cytobrush is a plastic tool used to obtain cells from the cervix during the procedure of a Pap smear . [ 1 ] [ 2 ]
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Cytopathic effect (abbreviated CPE ) refers to structural changes in host cells that are caused by viral invasion. The infecting virus causes lysis of the host cell or when the cell dies without lysis due to an inability to replicate. [ 1 ] If a virus causes these morphological changes in the host cell, it is said to be cytopathogenic. [ 2 ] Common examples of CPE include rounding of the infected cell, fusion with adjacent cells to form syncytia , and the appearance of nuclear or cytoplasmic inclusion bodies . [ 3 ]
CPEs and other changes in cell morphology are only a few of the many effects by cytocidal viruses. When a cytocidal virus infects a permissive cell, the viruses kill the host cell through changes in cell morphology, in cell physiology, and the biosynthetic events that follow. These changes are necessary for efficient virus replication but at the expense of the host cell. [ 3 ]
CPEs are important aspects of a viral infection in diagnostics. Many CPEs can be seen in unfixed, unstained cells under the low power of an optical microscope , with the condenser down and the iris diaphragm partly closed. However, with some CPEs, namely inclusion bodies, the cells must be fixed and stained then viewed under light microscopy. [ 2 ] Some viruses' CPEs are characteristic and therefore can be an important tool for virologists in diagnosing an infected animal or human. [ 3 ] The rate of CPE appearance is also an important characteristic that virologists may use to identify virus type. If CPE appears after 4 to 5 days in vitro at low multiplicity of infection, then the virus is considered slow. If the CPE appears after 1 to 2 days in vitro at low multiplicity of infection, then the virus is thought to be rapid. Inoculations always occur at low multiplicity of infection because at high multiplicity of infection, all CPEs occur rapidly. [ 2 ]
Typically, the first sign of viral infections is the rounding of cells. Inclusion bodies often then appear in the cell nucleus and/or cytoplasm of the host cell. The inclusion bodies can first be identified by light microscopy in patient blood smears or stained sections of infected tissues. However, to fully characterize their composition, electron microscopy must be performed. Inclusion bodies may either be accumulation of virus replication byproducts or altered host cell organelles or structures. [ 3 ]
Some viral infections cause a strange CPE, the formation of syncytia . Syncytia are large cytoplasmic masses that contain many nuclei. They are typically produced by fusion of infected cells. This mechanism is useful to the virus as it allows the virus to spread from infected to uninfected cells. [ 3 ]
Viral infections may have clinically relevant phenotypical CPEs. For example, with the hepatitis C virus (HCV), liver steatosis is characteristic enough of the virus that it may be used to help identify the genotype , the genetic composition of the virus. HCV genotype 3 patients are significantly more likely to develop liver steatosis than those with genotype 1. [ 4 ] Also, CPEs may be used during research to determine the efficacy of a new drug. An assay has been developed that screens the dengue virus's CPEs in order to assess cell viability. [ 5 ]
Due to the host cell specificity of CPEs, researchers can also use them to test any discrepancies in an experiment. For many viral infections, different host cell strains may have a characteristic response. Currently, there are many concerns within the research community about the validity and purity of cell strains. Contamination has risen within and among laboratories. CPEs can be used to test the purity of a certain cell line. For example, HeLa CCL-2 is a common cell line used in a wide variety of research areas. To test the purity of the HeLa cells, CPEs were observed that occurred after inoculation with Coxsackievirus B3 . These CPEs included morphology changes and cell morbidity rates. Carson et al. determined that the discrepancy is due to the heterogeneous nature of the commercial HeLa cells as compared to the homogeneous nature of HeLa cells that have been propagated for generations in a lab. [ 6 ]
Total destruction of the host cell monolayer is the most severe type of CPE. To observe this process, cells are seeded on a glass surface and a confluent monolayer of host cell is formed. Then, the viral infection is introduced. All cells in the monolayer shrink rapidly, become dense in a process known as pyknosis , and detach from the glass within three days. This form of CPE is typically seen with enteroviruses . [ 2 ]
Subtotal destruction of the host cell monolayer is less severe than total destruction. Similarly to total destruction, this CPE is observed by seeding a confluent monolayer of host cell on a glass surface then introducing a viral infection. Subtotal destruction characteristically shows detachment of some but not all the cells in the monolayer. It is commonly observed with some togaviruses , some picornaviruses , and some types of paramyxoviruses . [ 2 ]
Focal degeneration causes a localized attack of the host cell monolayer. Although this type of CPE may eventually affect the entire tissue, the initial stages and spreading occur at localized viral centers known as foci. Focal degeneration is due to direct cell-to-cell transfer of the virus rather than diffusion through the extracellular medium. This different mode of transfer differentiates it from total and subtotal destruction and causes the characteristic localized effects. Initially, host cells become enlarged, rounded, and refractile. Eventually, the host cells detach from the surface. The spreading of the virus occurs concentrically, so that the cells lifting off are surrounded by enlarged, rounded cells that are surrounded by healthy tissue. This type of CPE is characteristic of herpesviruses and poxviruses . [ 2 ]
Swelling and clumping is a CPE where host cells swell significantly. Once enlarged, the cells clump together in clusters. Eventually, the cells become so large that they detach. This type of CPE is characteristic of adenoviruses . [ 2 ]
Foamy degeneration is also known as vacuolization. It is due to the formation of large and/or numerous cytoplasmic vacuoles. This type of CPE can only be observed with fixation and staining of the host cells involved. Foamy degeneration is characteristic of certain retroviruses , paramyxoviruses , and flaviviruses . [ 2 ]
Syncytium is also known as cell fusion and polykaryon formation. With this CPE, the plasma membranes of four or more host cells fuse and produce an enlarged cell with at least four nuclei. Although large cell fusions are sometimes visible without staining, this type of CPE is typically detected after host cell fixation and staining. Herpesviruses characteristically produce cell fusion as well as other forms of CPE. Some paramyxoviruses may be identified through the formation of cell fusion as they exclusively produce this CPE. [ 2 ]
Inclusion bodies – insoluble abnormal structures within cell nuclei or cytoplasm – may only be seen with staining as they indicate areas of altered staining in the host cells. Typically, they indicate the areas of the host cell where viral protein or nucleic acid is being synthesized or where virions are being assembled. Also, in some cases, inclusion bodies are present without an active virus and indicate areas of viral scarring. Inclusion bodies vary with viral strain. They may be single or multiple, small or large, and round or irregularly shaped. They may also be intranuclear or intracytoplasmic and eosinophilic or basophilic . [ 2 ]
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Cytoreductive surgery ( CRS ) is a surgical procedure that aims to reduce the amount of cancer cells in the abdominal cavity for patients with tumors that have spread intraabdominally ( peritoneal carcinomatosis ). It is often used to treat ovarian cancer but can also be used for other abdominal malignancies.
CRS is often used in combination with hyperthermic intraperitoneal chemotherapy (HIPEC); for some cancer diagnoses it considerably increases life expectancy and reduces the rate of cancer recurrence.
Its main developer was Paul Sugarbaker , who is known for the development of cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy, [ 1 ] or HIPEC , a treatment alternately referred to as the Sugarbaker Procedure. [ 2 ] [ 3 ]
Among patients with stage III epithelial ovarian cancer , the addition of HIPEC to interval cytoreductive surgery resulted in longer recurrence-free survival and overall survival than surgery alone and did not result in higher rates of side effects . [ 4 ]
Among colorectal cancer patients with peritoneal carcinomatosis cytoreductive surgery, with the addition of HIPEC can be used to prolong overall survival in patients. [ 5 ] In a typical case an incision is made from the sternum down to the pelvis, and cancerous cells are removed. Then heated chemotherapy liquid is poured in to destroy remaining cells. The procedure, which may take 15 hours, is risky, and followed by prolonged recovery. [ 6 ]
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Cœur en sabot (French for "clog-shaped heart" or "boot-shaped heart" [ 1 ] ) is a radiological sign seen most commonly in patients with tetralogy of Fallot , [ 2 ] a cyanotic congenital heart disease. It is a radiological term to describe the following findings in the x-ray: [ citation needed ]
Echocardiography has been used for confirmation and differentiation of congenital heart diseases. [ citation needed ]
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DISCERN is an instrument designed to provide users with a reliable way to measure the quality of written health information . It was originally developed by Deborah Charnock, Sasha Shepperd, Gill Needham, and Robert Gann, who reported on its development and validation in a February 1999 paper. [ 1 ]
DISCERN is designed for use by individual consumers , health information providers, and health professionals . The instrument contains 15 questions that may be rated on a scale of 1–5. Questions are intended to draw user attention to issues of potential bias , content currency, relevance , clarity, evidence, and balance. [ 2 ]
The DISCERN website was launched in May 1999. Despite originally being developed using printed materials, the tool has been shown to be effective at evaluating the quality of health information on the internet , as well as for printed information. [ 3 ] [ 4 ]
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DT-PACE refers to a chemotherapy regimen for multiple myeloma consisting of Dexamethasone , Thalidomide , Cisplatin or Platinol , Adriamycin or doxorubicin , Cyclophosphamide , and Etoposide . [ 1 ]
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The da Vinci Surgical System is a robotic surgical system that uses a minimally invasive surgical approach. The system is manufactured by the company Intuitive Surgical . The system is used for prostatectomies , increasingly for cardiac valve repair and for renal [ 1 ] and gynecologic surgical procedures. [ 2 ] [ 3 ]
It was used in an estimated 200,000 surgeries in 2012, most commonly for hysterectomies and prostate removals. [ 4 ] The system is called "da Vinci" in part because Leonardo da Vinci 's study of human anatomy eventually led to the design of the first known robot in history. [ 5 ]
The system has been used in the following procedures:
The da Vinci System consists of a surgeon's console that is typically in the same room as the patient, and a patient-side cart with three to four interactive robotic arms (depending on the model) controlled from the console. The arms hold objects, and can act as scalpels , scissors , bovies , or graspers. The final arm controls the 3D cameras. [ 7 ] The surgeon uses the controls of the console to manoeuvre the patient-side cart's robotic arms. The system always requires a human operator.
The Food and Drug Administration (FDA) cleared the da Vinci Surgical System in 2000 for adult and pediatric use in urologic surgical procedures , general laparoscopic surgical procedures, gynecologic laparoscopic surgical procedures, general non-cardiovascular thoracoscopic surgical procedures, and thoracoscopically assisted cardiotomy procedures.
While the use of robotic surgery has become an item in the advertisement of medical services, there is a lack of studies that indicate long-term results are superior to results following laparoscopic surgery . [ 8 ] Critics of robotic surgery assert that it is difficult for users to learn. [ 3 ] The da Vinci system uses proprietary software , which cannot be modified by physicians, thereby limiting the freedom to modify the operating system. [ 4 ] The system has a cost of $2 million which places it beyond the reach of many institutions. [ 9 ]
The manufacturer of the system, Intuitive Surgical, has been criticized [ 10 ] for short-cutting FDA approval by a process known as 510(k) premarket notification instead of entering the market through a more stringent premarket approval process. The company has also been accused of providing inadequate training and encouraging healthcare providers to reduce the number of supervised procedures required before a doctor is allowed to use the system without supervision. [ 11 ]
There have also been claims of patient injuries caused by stray electrical currents released from inappropriate parts of the surgical tips used by the system. Intuitive Surgical counter this argument by saying the same type of stray currents can occur in non-robotic laparoscopic procedures. [ 12 ] A study published in the Journal of the American Medical Association found that side effects and blood loss in robotically-performed hysterectomies are no better than those performed by traditional surgery, despite the significantly greater cost of the system. [ 13 ] [ 14 ] As of 2013 [update] , the FDA was investigating problems with the da Vinci robot, including deaths during surgeries that used the device; a number of related lawsuits were also underway. [ 15 ]
Doctors in Japan were considering promoting the procedure for cardiac surgery. A way to show this, both its good and bad sides is through visual media. 2018 Japanese drama Black Pean takes on this challenge, showing both sides' point of view. Two University Hospitals are competing to be the best in the Cardiac Surgery Department. One, Tojo, has the best traditional surgeons, while the other, Teika, is all about researching and implementing the most recent technology. With this, Teika sends its technical specialist to Tojo to try to convince them to update their techniques, including the use of the Da Vinci robot (named in the drama as Darwin). Newhart Watanabe International Hospital, a pioneer in Da Vinci surgery for the heart in Japan, was used as background for the drama, with Dr. Gou Watanabe providing technical support. [ 16 ] [ 17 ]
In Grey's Anatomy season 5 episode 23, Chief of Surgery Dr. Richard Webber (played by James Pickens Jr. ) reveals to Chief Resident Dr. Miranda Bailey (played by Chandra Wilson ) that he has purchased a Da Vinci surgical robot to entice her to choose general surgery over the paediatrics fellowship she is considering under the supervision of Dr. Arizona Robbins (played by Jessica Capshaw ).
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Dabur Ltd is an Indian multinational consumer goods company, founded by S. K. Burman and headquartered in Ghaziabad . [ 4 ] It manufactures Ayurvedic products [ 5 ] and fast-moving consumer goods . [ 6 ] Dabur derives around 60% of its revenue from the consumer care business, 11% from the food business and remaining from the international business unit. [ 7 ]
Dabur was founded in Kolkata by Ayurvedic practitioner S. K. Burman in 1884. In the mid-1880s, he formulated Ayurvedic medicines for diseases like cholera, constipation and malaria. [ 8 ] As a qualified physician, he went on to sell his medicines in Bengal on a bicycle. His patients started referring him and his medicines as "Dabur", a portmanteau of the words daktar (doctor) and Burman. [ 9 ] He later went on to mass-produce his Ayurvedic formulations.
C.L. Burman, set up Dabur's first R&D unit. Later, his grandson, G.C Burman was gherao-ed by his own workers during a labor unrest in Kolkata. Due to the unpleasant situation, G.C Burman decided to move the factory to Delhi , where his brothers later relocated. In Delhi, the business thrived and the company soon became headquartered there. In the words of business historian Sonu Bhasin "Calcutta's loss was Delhi's gain." [ 9 ]
In 1997, Dabur set up a wholly-owned consumer goods subsidiary called Dabur Foods under which it launched its fruit juice brand called Real. [ 10 ] [ 11 ]
In 1998, Dabur separated ownership from management, when they handed over the management of the company to professionals. [ 8 ]
Dabur demerged its pharma business in 2003 and hived it off into a separate company, Dabur Pharma. [ 12 ] German company Fresenius bought a 73% stake in Dabur Pharma for ₹ 872 crore (US$200.44 million) in 2008. [ 13 ]
In 2005, Dabur acquired three Balsara group companies, gaining control of brands such as Babool , Promise , Meswak , Odonil, Odomos, Odopic, and Sani Fresh. [ 14 ]
In 2009, Dabur completed the acquisition of a majority stake in female skincare products company Fem Care Pharma for ₹ 270 crore (US$55.78 million) and later merged the company into itself. [ 15 ]
In 2022, Dabur acquired a 51% stake in the Indian spices company Badshah Masala for ₹ 588 crore. [ 16 ]
In November 2024, Dabur acquired a 51% stake in Sesa Care, an Indian haircare company for an enterprise value of ₹ 315-325 crore. [ 17 ]
Dabur's Sustainable Development Society (Sundesh) is a non-profit organisation started by Burman that aims to carry out welfare activities in the spheres of health care, education and other socio-economic activities. Dabur drives its corporate social responsibility (CSR) initiatives through Sundesh. [ 18 ] [ 19 ]
The 2015 Brand Trust Report puts Dabur at 19th place. [ 20 ]
Former executive director Pradip Burman was on the list of black money account holders on 27 October 2014 when the government published the list. Dabur rejected the black money charge. [ 21 ]
In December 2020, a report by the Centre for Science and Environment showed that Dabur Honey, along with other major brands' products, was adulterated with sugar syrup. [ 22 ]
Hajmola or Hazmola ( transl. Digestion, from hazma/hajma ) is an ayurvedic digestive tablet sold as a treatment for dyspepsia by Dabur under that name since the 1950s. A counterfeit of the product was trademarked by "Hilal Foods (Pvt.) Limited" (estb. 1986), [ 23 ] a Karachi based company in Pakistan, which had been selling it since at least the 1980s. When Dabur began operating in Pakistan, Hilal filed an intellectual property infringement suit against Dabur which was ultimately settled by the Sindh High Court allowing both Hilal and Dabur to use the Hajmola trademark. [ 24 ]
In May 2025, the FSSAI informed the Delhi High Court that Dabur's '100% fruit juice' claim on its product is misleading, as the juices contain water and fruit concentrates. [ 25 ] [ 26 ]
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Daflon is an oral micronized purified phlebotonic flavonoid fraction containing 90% diosmin and 10% hesperidin . It is manufactured by Laboratoires Servier and often used to treat or manage disorders of the blood vessels. [ 1 ] [ 2 ] Flavonoids are a type of phytochemical that have been associated with various effects on human health and are a component of many different pharmaceutical , nutraceutical , and cosmetic preparations. [ 3 ] Diosmin is a flavone glycoside that is derived from hesperidin. Hesperidin is a flavone that is extracted from citrus fruits. [ 4 ]
Daflon is not an FDA-approved medication, and therefore it cannot be advertised for treatment of diseases in the United States. Daflon is under preliminary research for its potential use in treating vein diseases, [ 5 ] or hemorrhoids . [ 6 ] It is sold as a drug in France , [ 7 ] [ 8 ] Spain, [ 9 ] Malaysia [ 10 ] [ 11 ] , Portugal and Belgium.
There is moderate certainty evidence for the effectiveness of daflon for slightly reducing oedema compared to placebo in the treatment of chronic venous insufficiency . [ 12 ] Little to no differences in quality of life after treatment with Daflon were found and there is low certainty evidence that this class of drugs do not influence ulcer healing. [ 12 ] Diosmiplex, a micronized purified flavonoid fraction of daflon, with similar venous insufficiency indication, is sold as a prescription medical food in the US. [ 13 ]
Daflon plays a crucial role in the prevention of perivascular edema formation and treatment of venous stasis . This activity can be explained by its antagonist activity against prostaglandin E2 (PgE2) and thromboxane (TxA2) biosynthesis leading to inhibition of inflammatory process. Moreover, it also has a contraction activity on the lymphatic vessels which cause the lymphatic flow maximal. [ 14 ]
For venous insufficiency, the dosage is 2 tablets of 500mg daily. For acute hemorrhoidal attack, the dosage is 6 tablets daily for 4 days, followed by 4 tablets daily over the next 3 days. [ 15 ] For chronic venous disease, the dosage is 2 tablets a day for at least 2 months. [ 16 ]
Possible side effects include routine gastric disorders and neurovegetative disorders, however, toxicology studies indicate that diosmin is quite safe. [ 2 ] Diosmin interacts in an inhibitory manner with some metabolic enzymes so drug-interactions are probable. [ 2 ]
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The Dahl effect or Dahl concept is used in dentistry where a localized appliance or localized restoration is used to increase the available interocclusal space for restorations.
A steep incisal guidance angle (the angle formed between the sagittal plane when the incisors are in centric occlusion and the horizontal plane) must be reduced in order to decrease excessive horizontal forces on anterior teeth, which would lead to failure. [ 1 ] The two methods used to reduce this are; to decrease the edge of the incisors and to increase the OVD (occlusal vertical dimension). The Dahl effect focuses on the latter of the two. Without increasing the OVD, needless restorative work of otherwise healthy teeth, would be required. Therefore, the Dahl concept is a more conservative technique to increase OVD.
The Dahl concept is the relative axial tooth movement that is observed when a localised appliance or localised restorations are placed in supra-occlusion and the occlusion re-establishes full arch contacts over a period of time. [ 2 ] It involves the vertical tooth movement that occurs when anterior localised appliances/restorations are placed in supra occlusion causing the posterior teeth to disclude. Rather than restoring occlusion by means of restoration, it is allowed to re-establish over time through a combination of intrusion and over-eruption. This, in turn, will increase the OVD.
The idea of creating interocclusal space was first proposed by D.J. Andersen in 1962. He introduced the concept of experimental malocclusion by inducing the over-eruption of teeth, placing restorations in the dentition in supra-occlusion. [ 3 ] Anderson carried out a study on five human adult subjects aged 19–49 years; by placing a 0.5mm metal bite-raising cap on the occlusal surface of the subjects’ lower right first permanent molars, he found that each of the subjects were able to occlude their teeth after an experimental period of 23–41 days. He observed the changes in the distances of teeth in opposing arches using reference points on the capped tooth and its opponent, where he identified the introduction of an inter-occlusal space. It was not possible, however, to determine whether the creation of this space was due to the intrusion of the teeth in contact with the bite-raising cap or the eruption of the separated teeth due to the lack of fixed reference points. [ 3 ]
In 1975, Bjørn L. Dahl from the Faculty of Dentistry of the University of Oslo became the first author through a series of papers to report the successful use of this technique for the management of the worn dentition. [ 4 ] Along with Olaf Krogstad and Kjell Karlsen, Dahl described the use of a bite-raising appliance to increase the available interocclusal space available for future restorations. [ 4 ] The removable appliance was originally cast in cobalt chromium and placed on the palatal aspects of an 18-year-old’s upper incisors which had been subject to localised attrition. Over a period of eight months, the appliance was worn 24 hours a day and over time enough space was created to allow the application of palatal gold inlays to the worn upper incisors. [ 2 ] Dahl found that it was a combination of intrusion of the anterior teeth in contact with the appliance (40%) and passive eruption of the unopposed posterior teeth (60%) that permitted the reestablishment of posterior occlusion whilst maintaining the interocclusal space. [ 5 ]
Adhesive dentistry can be used to achieve the same results today, as well as the use of provisional restorations in the treatment of anterior tooth surface loss. [ 6 ]
The Dahl concept is commonly used when an increase in the interocclusal space is required together with an increase in occlusal vertical dimension; for example when restoring a case of severe anterior tooth surface loss. Therefore, the main applications are for localised anterior wear caused by factors such as bulimia, GERD leading to severe dental erosion, resulting in insufficient interocclusal space for adequate restorations.
The apparent lack of inter-occlusal space presents a dilemma for the restorative dentist. Without the dahl concept, one main approach would be to further reduce the occlusal height of the already worn teeth. However, this would lead to a lack of axial height and thus insufficient retention and resistance for conventional extra-coronal restorations. Tooth preparation and the associated loss of coronal tissue can risk further insult to the pulp and limit the options for future restoration replacement. [ 2 ] An alternative approach is to create the necessary space by reorganising the occlusion by means of an arbitrary increase of the vertical dimension of occlusion, i.e. the use of a dahl appliance. The creation of this interocclusal space will significantly reduce the amount of tooth preparation required, especially on the already compromised palatal surfaces of the maxillary anterior teeth.
Adaptation occurs over a period of some months: compensatory eruption of the posterior teeth will occur, together with some intrusion of the anterior teeth and potential growth of the alveolar bone . This will allow the posterior occlusion to reestablish at the new increased OVD, stabilizing the increased interocclusal space.
The Dahl appliance is used to generate space between the upper and lower jaws. Traditionally this has been used in order to aid the placement of fillings on worn front teeth. Alterations to the teeth, from tooth wear or tooth loss, can lead to a decreased facial height due to physiological compensation that allows for maintenance of upper and lower teeth contact. [ 6 ] The Dahl appliance can increase the height of a patient's face and correct for this loss of facial height.
The original Dahl appliance was a removable metal bite platform made with cobalt chromium. However, today many different materials can be used.
Placing Dahl composite resin appliance on worn down front teeth can separate and stimulate eruption of the back teeth. Once the back teeth contact, restorations can be placed on the front teeth without needing to remove excessive tooth structure to accommodate the restorations.
A Dahl appliance should fulfill the following aims:
The advantages of this approach are:
[ 8 ]
The limitations of this approach are:
Planned occlusal changes can be tested using a removable appliance prior to permanent treatment. Dental composite based approaches to tooth surface loss allow for easy adjustment or removal if required. One study published in the British Dental Journal, 2011 found that patient satisfaction was high when composite restorations were used in the Dahl approach and that the median survival time was between 4.75 and 5.8 years. [ 11 ]
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Damage control surgery is surgical intervention to keep the patient alive rather than correct the anatomy . [ 1 ] [ 2 ] It addresses the "lethal triad" for critically ill patients with severe hemorrhage affecting homeostasis leading to metabolic acidosis , hypothermia , and increased coagulopathy . [ 3 ]
This lifesaving method has significantly decreased the morbidity and mortality of critically ill patients, though complications can result.
It stabilizes patients for clinicians to subsequently reverse the physiologic insult prior to completing a definitive repair. While the temptation to perform a definitive operation exists, surgeons should avoid this practice because the deleterious effects on patients can result in them succumbing to the physiologic effects of the injury, despite the anatomical correction.
The leading cause of death among trauma patients remains uncontrolled hemorrhage and accounts for approximately 30–40% of trauma-related deaths. [ 4 ]
While typically trauma surgeons are heavily involved in treating such patients, the concept has evolved to other sub-specialty services.
A multi-disciplinary group of individuals is required: nurses, respiratory therapist, surgical-medicine intensivists, blood bank personnel and others.
Damage control surgery can be divided into the following three phases: Initial laparotomy, Intensive Care Unit (ICU) resuscitation, and definitive reconstruction. Each of these phases has defined timing and objectives to ensure best outcomes. The following goes through the different phases to illustrate, step by step, how one might approach this. There are clearly different approaches throughout the country, and no one way is necessarily correct. However, the ability to evaluate objectively the differences and then choose the one that fits your team is important. [ citation needed ]
This is the first part of the damage control process whereby there are some clear-cut goals surgeons should achieve. The first is controlling hemorrhage followed by contamination control, abdominal packing, and placement of a temporary closure device. [ 5 ] Minimizing the length of time spent in this phase is essential.
For groups (i.e., trauma centers) to be effective in damage control surgery, a multi-disciplinary team is critical. The approach to caring for such critically ill patients is dependent on nurses, surgeons, critical care physicians, operating room staff, blood bank personnel, and administrative support. In addition to having the right team in place is having a prepared team. The more facile the team is enhances the ability for centers to effectively implement damage control surgery. This is referred to by some as damage control ground zero (DC0). [ 6 ] The ability to mobilize personnel, equipment, and other resources is bolstered by preparation; however, standardized protocols ensure that team members from various entities within the health care system are all speaking the same language. This has been seen during implementation of complex processes such as the massive transfusion protocol (MTP).
Controlling of hemorrhage as discussed above is the most important step in this phase. Eviscerating the intra-abdominal small bowel and packing all four abdominal quadrants usually helps surgeons establish initial hemorrhagic control. Depending up on the source of hemorrhage a number of different maneuvers might need to be performed allowing for control of aortic inflow. Solid organ injury (i.e., spleen, kidney) should be dealt with by resection. When dealing with hepatic hemorrhage a number of different options exist such as performing a Pringle maneuver that would allow for control of hepatic inflow. [ 7 ] Surgeons can also apply manual pressure, perform hepatic packing , or even plugging penetrating wounds. Certain situations might require leaving the liver packed and taking the patient for angio-embolization or if operating in a hybrid operating room having perform an on table angio-embolization . Vessels that are able to be ligated should, and one should consider shunting other vessels that do not fall into this category. This has been described by Reilly and colleagues when they shunted the superior mesenteric artery to decrease the length of time in the operating room. [ 8 ]
Once hemorrhage control is achieved one should quickly proceed to controlling intra-abdominal contamination from hollow-viscus organs. The perception might be that one could quickly perform an anastomosis . This should not be attempted in the damage control setting. The key is to simply prevent continued intra-abdominal contamination, and to leave patients in discontinuity. A number of different techniques can be employed such as using staplers to come across the bowel, or primary suture closure in small perforations. Once this is complete the abdomen should be packed. Many of these patients become coagulopathic and can develop diffuse oozing. It is important to not only pack areas of injury but also pack areas of surgical dissection. There are various methods that can be used to pack the abdomen. Packing with radiopaque laparotomy pads allow for the benefit of being able to detect them via x-ray prior to definitive closure. As a rule abdomens should not be definitively closed until there has been radiologic confirmation that no retained objects are present in the abdomen.
The final step of this phase is applying a temporary closure device. Numerous methods of temporary closure exist, with the most common technique being a negative-vacuum type device. Regardless of which method one decides to use it is important that the abdominal fascia is not reapproximated. The ability to develop abdominal compartment syndrome is a real concern and described by Schwab. [ 9 ]
On completion of the initial phase of damage control, the key is to reverse the physiologic insult that took place. This specifically relates to factors such as acidosis, coagulopathy, and hypothermia ( lethal triad ) that many of these critically ill patients develop. When developing a strategy to best care for these patients, the same principles of having a multi-disciplinary team that work together in parallel for the same result apply. The intensivist is critical in working with the staff to ensure that the physiologic abnormalities are treated. This typically requires close monitoring in the intensive care unit, ventilator support, laboratory monitoring of resuscitation parameters (i.e., lactate).
In using a number of different resuscitation parameters, the critical care team can have a better idea as to which direction is progressing. The first 24 hours often require a significant amount of resources (i.e., blood products) and investment of time from personnel within the critical care team. In many circumstances, especially trauma patients, require that other specialties address a variety of injuries. Moving the patient early on, unless absolutely necessary, can be detrimental. Certain circumstances might require this, and the patients should continue to receive care from the critical care team during the entire transport period. As the literature begins to grow within the field of damage control surgery, the medical community is continuously learning how to improve the process. Certain pitfalls have also become evident, one of which is the potential to develop abdominal compartment syndrome.
In some cases, temporary abdominal closure itself or underlying conditions may contribute to abdominal compartment syndrome, causing increased intraabdominal pressure and compromising organ perfusion. [ 10 ] Temporary abdominal dressings with high negative pressures can be a cause of recurrent abdominal compartment syndrome and one should not hesitate to turn off the dressing's suction when evaluating a patient with signs of recurrent abdominal compartment syndrome. [ 11 ]
While it might sound counterintuitive since the fascia is left open during the placement of these temporary closure devices, they can create a similar type process that leads to abdominal compartment syndrome. If this occurs the temporary closure device should be taken down immediately. [ citation needed ]
The third step in damage control surgery is addressing closure of the abdomen. Definitive reconstruction occurs only when the patient is improving. At this point in process the critical care team has been able to correct the physiologic derangements. The optimization typically takes 24 to 48 hours, depending on how severe the initial insult is. Prior to being taken back to the operating room it is paramount that the resolution of acidosis, hypothermia, and coagulopathy has occurred. [ citation needed ]
The first step after removing the temporary closure device is to ensure that all abdominal packs are removed. Typically the number of packs has been documented in the initial laparotomy; however, an abdominal radiograph should be taken prior to definitive closure of the fascia to ensure that no retained sponges are left in the abdomen. Once the abdominal packs are removed the next step is to re-explore the abdomen allowing for the identification of potentially missed injuries during the initial laparotomy and re-evaluating the prior injuries. Attention is then turned to performing the necessary bowel anastomosis or other definitive repairs (i.e., vascular injuries). [ citation needed ]
An attempt should be made to close the abdominal fascia at the first take back, to prevent complications that can result from having an open abdomen. The concern for early closure of the abdomen with development of compartment syndrome is a real one. A method to pre-emptively evaluate whether fascial closure is appropriate would be to determine the difference in peak airway pressure (PAP) prior to closure and the right after closure. An increase of over 10 would suggest that the abdomen be left open. [ 9 ] As mentioned above, it is important to obtain an abdominal radiograph to ensure that no retained sponges are left intra-operatively.
Considering that not all patients can undergo definitive reconstruction at first return, there are other options that surgeons can consider. Data would suggest that the longer the abdomen is left open from initial laparotomy the higher the rate of complications. [ 12 ] After about one week, if surgeons can't close the abdomen, they should consider placing a Vicryl mesh to cover the abdominal contents. This lets granulation occur over a few weeks, with the subsequent ability to place a split-thickness skin graft (STSG) on top for coverage. These patients clearly have a hernia that must be fixed 9 to 12 months later.
Damage control resuscitation has had a dramatic impact on how care for critically ill patients is administered. [ citation needed ] . The core principles of resuscitation involve permissive hypotension, transfusion ratios, and massive transfusion protocol. The resuscitation period lets any physiologic derangements be reversed to give the best outcome for patient care.
Typical resuscitation strategies have used an approach where aggressive crystalloid and/or blood product resuscitation is performed to restore blood volume. The term permissive hypotension refers to maintaining a low blood pressure to mitigate hemorrhage; however, continue providing adequate end-organ perfusion [Duchesene, 2010]. The key is to prevent exacerbation of hemorrhaging until definitive vascular control can be achieved, the theory being that if clots have formed within a vessel then increasing the patient's blood pressure might dislodge those established clots resulting in more significant bleeding. Permissive hypotension is not a new concept, and had been described in penetrating thoracic trauma patients during World War I by Bickell and colleagues demonstrating an improvement in both survival and complications. [ 13 ]
Subsequent animal studies have shown equivalent outcomes with no real benefit in mortality [ 4 ] Recently there has been further data in trauma patients that has demonstrated increased survival rates [Morrison, 2011]. Cotton and colleagues found that the use of a permissive hypotension resuscitation strategy resulted in better outcomes (increased 30-day survival) in those undergoing damage control laparotomy. This would not be used in situations where patients might have injuries such as a traumatic brain injury considering that such patients are excluded from the studies.
For over a century the casualties of war have provided valuable lessons that can be applied within the civilian sector. Specifically the past decade has seen a paradigm shift in early resuscitation of critically injured patients. Instead of replacing blood volume with high volumes of crystalloid and packed red blood cells with the sporadic use of fresh frozen plasma and platelets, we have now learned that maintaining a transfusion ratio of 1:1:1 of plasma to red blood cells to platelets in patients requiring massive transfusion results in improved outcomes [Borgman 2007] [ 4 ] While this was initially demonstrated in the military setting, Holcomb and colleagues extrapolated this to the civilian trauma center showing improved results as well [ 14 ] [ 15 ] Broad implementation across both the military and civilian sector has demonstrated a decreased mortality in critically injured patients. [ 4 ] Debate has gone back and forth as to the correct ratio that should be used; however, recently Holcomb and colleagues published the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) Study. [ 15 ] [ 16 ] They compared administration a higher ratio of plasma and platelets (1:1:1) compared to a lower ratio (1:1:2). The patients that received a higher ratio had an associated three to four-fold decrease in mortality. To help mitigate confounding variables a randomized control trial called the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) has been performed to evaluate the transfusion requirement. There was no difference in 24 hour or 30 day mortality between the 1:1:1 group and the 1:1:2 group - https://jamanetwork.com/journals/jama/fullarticle/2107789 . [ 14 ]
Initial resuscitation of trauma patients continues to evolve. Massive transfusion (defined as receiving greater than or equal to 10 units of packed red blood cells with a 24-hour period) is required in up to 5% of civilian trauma patients that arrive severely injured. [ 17 ] Patients who are arriving severely injured to trauma centers can be coagulopathic. Data suggests that around 25% of patients arrive with coagulopathy. [ 18 ] New ways of measuring coagulopathy such at thromboelastography and rotational thromboelastometry have allowed for a more robust assessment of the coagulation cascade compared to traditional methods of measuring international normalized ratio allowing clinicians to better target areas of deficiency. [ 4 ] For trauma teams to systematically and efficiently deliver blood products institutions have created protocols that allow for this. The protocols allow for clear communication between the trauma center, blood bank, nurses, and other ancillary staff. They also allow for the quick delivery of certain set of blood products depending upon the institution. One example might be that a “cooler” would contain 10 units of packed red blood cells, 10 units of plasma, and 2 packs of platelets. The idea is that the coolers would continue to be delivered to the location where the patient is being treated until the trauma team leader (typically the trauma surgeon) would discontinue the order. [ 17 ] Systolic blood pressure <90 mmHg, hemoglobin <11 g/dL, temperature <35.5 o C, international normalized ratio > 1.5, base deficit ≥6 mEq/L, heart rate ≥120 bpm, presence of penetrating trauma, and Focused Abdominal Sonography Trauma exam have been evaluated to determine their predictive ability in patients arriving at trauma centers. All were be predictive of the need of massive transfusion protocol except for temperature. [ 16 ]
Surgeons have used the concept of damage control surgery for years, and controlling hemorrhage with packing is over a century old. Pringle described this technique in patients with substantial hepatic trauma in the early twentieth century. [ 7 ] The U.S. military did not encourage this technique during World War II and the Vietnam War. Lucas and Ledgerwood described the principle in a series of patients. [ 19 ] Subsequent studies were repeated by Feliciano and colleagues, [ 20 ] and they found that hepatic packing increased survival by 90%. This technique was then specifically linked to patients who were hemorrhaging, hypothermic, and coagulopathic. [ 21 ] This extrapolation allowed for the first article in 1993 by Rotondo and Schwab specifically adapting the term “damage control”. [ 22 ] This term was taken from the United States Navy who initially used the term as “the capacity of a ship to absorb damage and maintain mission integrity” (DOD 1996). This was the first article that brought together the concept of limiting operative time in these critically ill patients to allow for reversal of physiologic insults to improve survival. In addition, the description illustrated how the three phases of damage control surgery can be implemented. Since this description the development of this concept has grown both within the trauma community and beyond.
The data that have been published regarding definitive laparotomy versus damage control surgery demonstrate a decrease in mortality when performed in the critically ill patient. [ 21 ] [ 6 ] Subsequent studies by Rotondo and colleagues in a group of 961 patients that had undergone damage control surgery demonstrate an overall mortality of 50% and a 40% morbidity rate. [ 23 ]
There are four main complications. The first is development of an intra-abdominal abscess. This has been reported as high as 83%. [ 20 ] [ 21 ] Next is the development of an entero-atmospheric fistula, which ranges from 2 to 25%. [ 5 ] [ 24 ] The third is abdominal compartment syndrome that has been reported anywhere from 10 to 40% of the time. [ 25 ] [ 26 ] Finally fascial dehiscence has been shown to result in 9–25% of patients that have undergone damage control surgery. [ 27 ] [ 28 ]
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In neurosurgery, Dandy's point is a common entry point for occipital burr hole . Originally described by Walter Dandy in 1918 as a way to perform ventriculography via occipital approach. [ 1 ] [ 2 ] It is located 2 centimetres (0.79 in) lateral to the midline and 3 centimetres (1.2 in) above the inion . The catheter tip is directed toward a point 2 cm above the glabella and passed to a distance of 4 to 5 cm or until CSF is encountered. [ 2 ] [ 3 ]
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Dao Yin Yang Sheng Gong ( Chinese : 导引养生功 ) is a form of Qigong system originated in China by Zhang Guangde , a Chinese martial artist and a former professor at the Beijing Sport University . [ 1 ] [ 2 ] It integrates physical movement with mental cultivation and controlled breathing. [ 3 ]
The system was recognized and integrated into China's education curriculum in sports and medical schools by the Ministry of Health of the People's Republic of China in 1990. The system has been adopted by hospitals for the treatment of diseases, and it's been practiced in other countries such as France and Portugal. [ 1 ] [ 2 ]
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Darapladib is an inhibitor of lipoprotein-associated phospholipase A2 (Lp-PLA 2 ) that is in development as a drug for treatment of atherosclerosis . [ 1 ]
It was discovered by Human Genome Sciences in collaboration with GlaxoSmithKline (GSK). [ 2 ]
In November 2013, GSK announced that the drug had failed to meet Phase III endpoints in a trial of 16,000 patients with acute coronary syndrome (ACS). [ 3 ] An additional trial of 13,000 patients (SOLID-TIMI 52) finished in May 2014. The study failed to reduce the risk of coronary heart disease death, myocardial infarction , and urgent coronary revascularization compared with placebo in acute coronary syndrome patients treated with standard medical care. [ 4 ]
In 2022, Darapladib has been found to inhibit intraerythrocytic growth of the malaria parasite Plasmodium falciparum by inhibition of the human host enzyme peroxiredoxin 6 . [ 5 ] The authors present data that the original target of Darapladib, Lp-PLA 2 , is absent in the host red blood cell .
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Das Reizleitungssystem des Säugetierherzens (English: " The Conduction System of the Mammalian Heart ") is a scientific monograph published in 1906 by Sunao Tawara . It has been recognized by cardiologists as a monumental discovery, [ 1 ] and a milestone in cardiac electrophysiology ". [ 2 ]
The monograph revealed the existence of the atrioventricular node and the function of Purkinje cells . It was used by Arthur Keith and Martin Flack as a detailed guide in their attempts to verify the existence of the Bundle of His , which subsequently led to their discovery of the sinoatrial node . Throughout the beginning of the 20th century, Tawara's monograph influenced the work of many cardiologists and it was later cited by Willem Einthoven in his anatomical interpretation of the electrocardiogram . [ 3 ]
Prior to Tawara's discoveries, it was assumed that electrical conduction through the Bundle of His was slow, because of the long interval between atrial and ventricular contractions. The Swiss cardiologist Wilhelm His, Jr. assumed that the heart bundle was connected directly to the base of the ventricle, and physiologists incorrectly taught that the base of the ventricle contracted first, followed by the apex. [ 1 ]
However, Tawara postulated that ventricular contraction occurs in the opposite manner, with the apex contracting earlier than the base. He also believed that the heart's electrical conduction was not slow but rapid. Working under the guidance of his mentor, Ludwig Aschoff , Tawara performed a histological examination of 150 hearts with myocarditis (which led to the discovery of Aschoff bodies ), and he began examining the atrioventricular bundle before embarking on a comprehensive study of the anatomy and histology of the heart's conduction system. [ 1 ]
The implications of his work were immediately recognized by Aschoff, who arranged for it to be published in the form of a monograph . [ 1 ]
Tawara's monograph, titled " Das Reizleitungssystem des Säugetierherzens " (English: " The Conduction System of the Mammalian Heart ") was published in 1906. The most important discoveries are listed below:
Tawara commented that the system represents a transporting or conducting pathway, and "because the pathway is not a ductal, but a continuously related protoplasmic cord, conduction of excitation impulses surely must take place there." [ 1 ]
On 26 September 1905, shortly before the monograph was due to be published, Ludwig Aschoff wrote an article about Tawara's work. It was subsequently read by the Scottish cardiologist James Mackenzie and forwarded to anatomist Arthur Keith , who was attempting to confirm the existence of the Bundle of His . Despite putting in his best efforts, he failed to locate the structure. On 15 January 1906, Keith wrote a letter to Mackenzie and acknowledged his skepticism about its existence: " I have given up the search for His' bundle—having come to the conclusion that there is not and never was any such thing. ” [ 4 ]
In response to Arthur Keith's skepticism, Mackenzie forwarded Aschoff's article about Tawara's findings, which stimulated Keith's renewal of his studies on the cardiac conduction system. [ 5 ] Despite having written a letter to The Lancet about his failure to locate the Bundle of His and his increasing doubts about its existence, Keith (with his student Martin Flack ) later reported that they had succeeded in locating the structure by following the detailed descriptions and figures in Tawara's monograph. [ 6 ] In a paper published in The Lancet on 11 August 1906, they acknowledged the monograph's high degree of accuracy:
Encouraged by their initial success and inspired by Tawara's discovery of the atrioventricular node , Keith and Flack extended their studies and eventually discovered the sinoatrial node in 1907. [ 4 ] They wrote that they were examining other regions of the heart for "peculiar musculature" similar to the one discovered by Tawara. [ 8 ]
In 1908, the Dutch physiologist Willem Einthoven referred to Tawara’s monograph as the anatomical basis for interpreting the electrocardiogram. [ 3 ] In his monograph, Tawara theorized about the velocity of the excitatory process in the conduction system and the mode of ventricular contraction. Together with his anatomic findings and physiological assumptions, it contributed to the rapid popularization of electrocardiography . [ 9 ]
In 1909, the American pathologist Lydia DeWitt created the first 3D wax model of the conduction system, using Tawara’s description as a guide. [ 10 ] In 1911, the British cardiologist Thomas Lewis reviewed the auriculo-ventricular connection system and described Tawara's discoveries in Das Reizleitungssystem des Saugetierherzens as the "main advance" in knowledge about the system:
In his autobiography published in 1950, Arthur Keith explained how he had systematically searched for Tawara's system to verify its components:
Acknowledging the significance and implications of these discoveries, Keith commented: "With the discovery of the conducting system of Tawara, heart research entered a new epoch." [ 12 ]
Shortly before his death, Wilhelm His, Jr. published a personal account about the discovery of the Bundle of His . He noted that it took ten years before anatomists began to pay attention to the bundle, starting with the studies of Retzer and Brauning in 1903, followed by the "important work of Tawara" in 1906, and the subsequent discovery of the sinus node which completed the system. He credited Tawara for connecting the bundle with the Purkinje fibers and for declaring it the heart's conduction system. [ 13 ]
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Sir David Ferrier FRS (13 January 1843 – 19 March 1928) was a pioneering Scottish neurologist and psychologist . Ferrier conducted experiments on the brains of animals such as monkeys and in 1881 became the first scientist to be prosecuted under the Cruelty to Animals Act, 1876 which had been enacted following a major public debate over vivisection . [ 1 ]
Ferrier was born in Woodside, Aberdeen , the sixth child of David and Hannah; he was educated at Aberdeen Grammar School before studying for an MA at Aberdeen University (graduating in Classics in 1863), before studying psychophysiology in Germany and medicine at Edinburgh. [ 2 ] As a medical student, he began to work as a scientific assistant to the influential free-thinking philosopher and psychologist Alexander Bain (1818–1903), one of the founders of associative psychology .
Around 1860, psychology was finding its scientific foundation mainly in Germany , with the rigorous research of Hermann von Helmholtz (1821–1894), who had trained as a physicist, and of Wilhelm Wundt (1832–1920). They focused their work mainly in the area of sensory psychophysics . Both worked at the University of Heidelberg . In 1864, Bain prompted Ferrier to spend some time in their laboratories.
On returning to Scotland, Ferrier graduated in medicine in 1868 at the University of Edinburgh . A few years later, in 1870, he moved into London and started work as a neuropathologist at the King's College Hospital and at the National Hospital for Paralysis and Epilepsy , Queen Square . The latter - now the National Hospital for Neurology and Neurosurgery - was the first hospital in England to be dedicated to the treatment of neurological diseases and has a David Ferrier ward named in his memory.
At that period, the great neurologist John Hughlings Jackson (1835–1911) worked in the same hospital as Ferrier. Jackson was refining his concepts of the sensorimotor functions of the nervous system , derived from clinical experience. Jackson proposed that there was an anatomical and physiological substrate for the localization of brain functions, which was hierarchically organized.
Influenced by Jackson who became a close friend and mentor, Ferrier decided to embark on an experimental program. It aimed to extend the results of two German physiologists, Eduard Hitzig (1838–1907) and Gustav Fritsch (1837–1927).
In 1870, they had published results on localized electrical stimulation of the motor cortex in dogs. Ferrier wanted also to test Jackson's idea that epilepsy had a cortical origin, as it was suggested by his clinical observations.
Coincidentally, Ferrier had received a proposal to direct the laboratory of experimental neurology at the Stanley Royd Hospital , a psychiatric hospital located in Yorkshire. The hospital's director was the psychiatrist James Crichton-Browne (1840–1938). Working under good material conditions and having an abundance of animals for experimentation (mainly rabbits, guinea pigs and dogs), Ferrier started his experiments in 1873, examining experimental lesions and electrical stimulation of the cerebral cortex. Upon his return to London, the Royal Society sponsored the extension of his stimulation experiments to macaque monkeys, work he undertook at the Brown Institution in Lambeth. By the end of the year, he had reported his first results to local and national meetings and had published an account in the enormously influential West Riding Lunatic Asylum Medical Reports .
Ferrier had succeeded in demonstrating, in a spectacular manner, that the low intensity faradic stimulation of the cortex in both animal species indicated a rather precise and specific map for motor functions. The same areas, upon being lesioned, caused the loss of the functions which were elicited by stimulation. Ferrier was also able to demonstrate that the high-intensity stimulation of motor cortical areas caused repetitive movements in the neck, face and members which were highly evocative of epileptic fits seen by neurologists in human beings and animals, which probably were due to a spread of the focus of stimulation, an interpretation very much in line with Jacksonanian thought.
These - and other investigations in the same line - resulted in international fame for Ferrier and assured his permanent place as one of the greatest experimental neurologists.
In June 1876, he was elected a Fellow of the Royal Society at the age of 33 [ 3 ] and Fellow of the Royal College of Physicians the following year. [ 4 ] He was also the first physiologist to make an audacious (if scientifically incorrect) transposition of cortical maps obtained in monkeys to the human brain. This proposal soon led to practical consequences in neurology and neurosurgery.
A Scottish surgeon, Sir William Macewen (1848–1924), and two English physicians (clinical neurologist Hughes Bennett, and Rickman J. Godlee ) demonstrated in 1884, that it was possible to use a precise clinical examination to determine the possible site of a tumor or lesion in the brain, by observing its effects on the side and extension of alterations in motor and sensory functions. This method of functional neurological mapping is still used today. Jackson and Ferrier were present at the first operation performed by Godlee on 25 November 1884. Godlee was a nephew of the eminent physician Sir Joseph Lister (1827–1912), the discoverer of surgical antisepsis .
Practical results of animal research were used to justify Ferrier before a noisy public persecution carried out by antivivisectionist societies against him and other scientists, who were accused of inhumane use of animals for experimental medicine. [ 5 ]
In 1892, Ferrier was one of the founding members of the National Society for the Employment of Epileptics (now the National Society for Epilepsy ), [ 2 ] along with Sir William Gowers and John Hughlings Jackson.
He received a knighthood in 1911. [ 4 ]
He died of pneumonia on 19 March 1928 in London . He left a widow, Constance (née Waterlow, sister of painter Ernest Albert Waterlow ), they had a son and daughter; [ 6 ] several of his scientific papers were illustrated by Waterlow. [ 2 ] . His son Claude was a well-known architect .
The Royal Society created the Ferrier Medal and lectureship in his honour; it is still running in 2025. [ 7 ]
Of Ferrier's publications, two books are particularly notable. The first one, published in 1876, The Functions of the Brain , [ 2 ] [ 4 ] describes his experimental results and became very influential in the succeeding years, in such a way that today it is considered one of the classics of neuroscience. In 1886, he published a new edition, considerably expanded and reviewed.
His second book was published two years later, The Localization of Brain Disease [ 8 ] It had as its subject the clinical applications of cortical localization.
Some of his speeches were also published. [ 9 ] [ 10 ]
Ferrier was one of the founders of the journal Brain , [ 2 ] , together with his friends Hughlings Jackson and Crichton-Browne. The journal was dedicated to the interaction between experimental and clinical neurology and is still published today. In 1878 Ferrier delivered the Goulstonian Lecture [ 6 ] to the Royal College of Physicians on "The localisation of cerebral diseases".
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The David Rall Medal is an award given annually by the National Academy of Medicine of the United States to one of its members who "...has demonstrated distinguished leadership as chair of a study committee or other such activity, showing commitment above and beyond the usual responsibilities of the position." [ 1 ] It is named in honor of the late David Rall , the former director of the National Institute of Environmental Health Sciences . [ 2 ] The first award was given in 2000. [ 3 ]
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David Nesaraja Ratnavale (1928 – November 29, 2023) was a Sri Lankan-born psychiatrist who specialized in disaster relief on which he advised the Sri Lankan president. [ 1 ] [ 2 ]
Ratnavale graduated from the University of Ceylon and in 1973 was the first Western-trained psychiatrist invited to China. [ 1 ] [ 3 ] He was the chairman of Human Disaster Management council of Sri Lanka. Dr Ratnavale had his primary and secondary education in Trinity College, Kandy where he won The Ryde Gold Medal for the best all round boy in 1947. [ citation needed ]
As of 2015, he was still privately practicing in Bethesda, Maryland . [ 1 ] He died on November 29, 2023, at the age of 95. [ 4 ]
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The Davis Phinney Foundation is a non-profit to help people with Parkinson's live well with the disease. It was founded in 2004 by Davis Phinney , a former professional road bicycle racer and Olympic medal winner. [ 1 ] Today, Davis is a figure in the cycling community and people living with Parkinson's (estimated 60,000 Americans and estimated 10 million worldwide). [ 2 ]
The Foundation is a 501(c)(3) public charity that functions without an endowment and depends on donations from individuals, foundations and corporations. It reaches an international audience through its programs and online programming. [ 3 ]
As an Olympic Bronze medalist and Tour de France stage winner, Phinney has the most victories of any cyclist in American history. From the late 1970s until his retirement from professional cycling in 1993, Phinney achieved 328 victories. Phinney is one of only three Americans who have won multiple stages of the Tour de France. [ 4 ] Greg LeMond and Lance Armstrong are the others. [ 5 ]
In 2000, Phinney was 40 when he was diagnosed with young-onset Parkinson's disease after years of feeling "off". [ 6 ] [ 1 ] Shortly after his Parkinson's diagnosis, Davis and his family moved to Italy. [ 7 ] While living there, Phinney was contacted by Kathleen Krumme, a cyclist who asked Phinney to let her use his name in conjunction with her ride (the Sunflower Revolution ) to benefit Parkinson's. From this connection, the Davis Phinney Foundation was born. [ 8 ]
Phinney realized there were many ways he could improve the quality of his daily life with Parkinson's, including through exercise. He started the Davis Phinney Foundation as a way to fund and advance research that demonstrates the benefits of exercise , speech therapy , and other behavioral elements that are critical to quality of life with Parkinson's. It has since expanded to include a variety of programming that helps people with Parkinson's take a more active role in their own care. [ 9 ]
The Davis Phinney Foundation funds research that explores a range of factors that affect quality of life. Its primary interest is in funding research related to exercise; however, it has also funded research in depression, telemedicine, deep brain stimulation and speech. [ 9 ] The tendency is to fund smaller, innovative studies that lead to proof of concept and greater funding from larger institutions, such as the National Institute of Health and the Michael J. Fox Foundation. [ 10 ]
The Foundation's grassroots fundraising initiative raises funds and awareness for Parkinson's disease. Team DPF members turn all types of events and activities, from bike rides and runs, to mountain climbs, to sales of original works of art into fundraisers benefiting the Foundation. The Davis Phinney Foundation also has a Pay It Forward initiative tied to The Victory Summit symposia, wherein attendees of the free events are asked to donate in order to fund future events. Fully 81% of the Foundation's revenue is devoted to funding program services. [ 11 ]
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https://en.wikipedia.org/wiki/Davis_Phinney_Foundation
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The day–evening–night noise level or L den is a 2002 European standard to express noise level over an entire day. It imposes a penalty on sound levels during evening and night [ 1 ] and it is primarily used for noise assessments of airports , busy main roads, main railway lines and in cities over 100,000 residents. [ 2 ] [ 3 ] [ 4 ] The penalty for sound production during evenings and nights is due to higher nuisance perception during quieter hours and to prevent sleep deprivation for nearby residents.
L den is calculated as: [ 5 ]
L d e n = 10 ⋅ log 10 ( 1 24 ( 12 ⋅ 10 L d a y 10 + 4 ⋅ 10 L e v e n i n g + 5 10 + 8 ⋅ 10 L n i g h t + 10 10 ) ) {\displaystyle L_{\mathrm {den} }=10\cdot \log _{10}\left({\frac {1}{24}}\left(12\cdot 10^{\frac {L_{\mathrm {day} }}{10}}+4\cdot 10^{\frac {L_{\mathrm {evening} }+5}{10}}+8\cdot 10^{\frac {L_{\mathrm {night} }+10}{10}}\right)\right)}
Where the long-term average noise levels are defined as:
The exact hours of the three periods may be chosen differently by individual EU member states.
The formula for L den can be considered a weighted average of the yearly individual noise level during day, evening and night.
This article relating to European Union law is a stub . You can help Wikipedia by expanding it .
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https://en.wikipedia.org/wiki/Day–evening–night_noise_level
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Dazzle reflex is a type of reflex blink where the eyelids involuntarily blink in response to a sudden bright light ( glare ).
Neurological pathways for the dazzle reflex involve subcortical pathways, such as the supraoptic nucleus and superior colliculus . [ 1 ]
This medical article is a stub . You can help Wikipedia by expanding it .
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https://en.wikipedia.org/wiki/Dazzle_reflex
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