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T. Pranck. Hampshire College.

Small Pituitary Fossa 25 – Fetal alcohol syn- drome – Maternal phenytoin use Miscellaneous – Chronic cardiopul- monary disease – Chronic renal disease – Xeroderma pigmen- tosa * TORCH: toxoplasmosis order prazosin 1 mg otc, other purchase 2mg prazosin with visa, rubella purchase 2 mg prazosin fast delivery, cytomegalovirus purchase prazosin 1mg with mastercard, and herpes simplex virus. Associated with benign intracranial hypertension Secondary The result of prior surgery or radiation therapy, usually for a pituitary tumor Raised intracranial pressure, chronic E. Suprasellar and Parasellar Lesions 27 Suprasellar and Parasellar Lesions The most frequent suprasellar masses are: suprasellar extension of pituitary adenoma, meningioma, craniopharyngioma, hypothalamic/ chiasmatic glioma, and aneurysm. These five entities account for more than three-quarters of all sellar and juxtasellar masses. Neoplastic Lesions The most common suprasellar tumor masses are suprasellar extension of pituitary adenoma and meningioma in adults, and craniopharyn- gioma and hypothalamic/chiasmatic glioma in children (Fig. Pituitary tumor – Pituitary adenoma Autopsy series indicate that asymptomatic microade- nomas account for 14–27% of cases, pars intermedia cysts 13–22%, and occult metastatic lesions 5% of patients with known malignancy. In descending order of frequency, the primary sources of pituitary metastases are:! In women: breast cancer is by far the most com- mon, accounting for over half of all secondary pituitary tumors; followed by lung, stomach, and uterus! In men: the most frequent primary tumors are neo- plasms of the lung, followed by prostate, bladder, stomach, and pancreas. On MRI, microadenomas are generally hypointense in comparison with the normal gland on T1-weighted images, and display a variable intensity on T2- weighted images. Macroadenomas have roughly the same signal charac- teristics as microadenomas, although they have a pro- pensity for hemorrhage and infarction due to their poor blood supply. Cystic areas produce low intensity signals on T1-weighted images and high intensity sig- Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. It can locate deformations of the optic tracks, chiasm, and optic nerves, and can demonstrate invasion of the cavernous sinuses or the surrounding structures by neoplasms. MRI is particularly helpful in outlining blood vessels and ruling out aneurysms – Pituitary carcinoma, or carcinosarcoma – Granular-cell tumor of the pituitary or choristoma Craniopharyngiomas These account for 20% of tumors in adults and 54% in children. Three neuroimaging hallmarks have been identified, which may be present in individual lesions: calcification, observed in 80% of cases; cyst formation, observed in 85% of cases; and solid or nodular en- hancement. MRI is relatively insensitive to calcifica- tion, shows varying intensities for cystic fluid, and is not as specific as CT for the diagnosis of calcification and the low-density appearance of cyst formation " Fig. Coronal T1WI with a pituitary macroadenoma in close relationship with the optic chiasm presenting a heterogeneous, post- contrast high intensity signal. Sagittal T1WI shows a pituitary tumor with a het- erogeneous postcontrast high intensity signal with cystic and/or necrotic features in its posterior section filling the suprasellar cisterns and exerting compression on the optic chiasm. A suprasellar space-occupying mass with no postcon- trast enhancement on coronal T1WI. Sagittal T1WI shows a suprasellar space-occupying neoplastic lesion with a postcontrast high intensity signal showing an unusual develop- ment alongside the pituitary stalk. Axial T2WI shows a right optic nerve glioma with widening of the optic foramen in a patient with neurofibromatosis type I. A highly enhanced mass, occupying part of the sella and the suprasellar cisterns and extending behind the optic chiasm, is seen on coronal and sagittal T1WI respectively. Axial T1WI demonstrates a multilobular space-occupying neo- plastic lesion, which is heterogeneously and highly enhanced, developing into the left parasellar region and ipsilateral temporal and posterior fossae along the ridge of the petrous bone. Coronal T1WI shows a postcontrast highly enhancing neo- plastic lesion of the right cavernous sinus. Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Rarely, meningiomas may arise from the parasellar lateral wall of the cavernous sinus, and they may extend posteriorly along the tentorial margin, with a dovetail appearance. The extra-axial mass is noncystic and heterogeneous in texture, and on CT imaging reveals hyperostosis, blistering of the tuberculum and erosion of the dorsum sellae; on T1- weighted images, the lesions are isointense and on T2-weighted images isointense to slightly hypertense to brain, enhancing dramatically Hypothalamic and optic These are the second most common form of pediatric nerve/chiasm gliomas suprasellar tumor, accounting for 25–30% of such cases. Bilateral optic nerve gliomas are associated with neurofibromatosis type I in 20–50% of these patients. On CT, the lesions are isodense to hypodense, and frequently enhance following contrast injection. On MRI, the lesions are hypointense on T1-weighted im- ages and hyperintense on T2-weighted images.

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Moreover buy prazosin 2 mg mastercard, visceral afferents are rones for long periods order 1mg prazosin amex, so that referred tenderness fewer than those from muscles and skin discount 1mg prazosin amex. Thus cheap 2 mg prazosin with visa, vis- in muscles continues long after the visceral patho- ceral nociception (i. Furthermore, a report of pain or tenderness in a mus- Thus, pathophysiology in one organ can either cle or skin may reflect current, or prior, pathophysiol- increase or decrease signs and symptoms associ- ogy in an internal organ (sometimes even in an organ ated with another organ, or result in referred mus- located in a segment remote from the tender area). Thus, the term ‘visceral pain’ has limited categorical • Diagnostically, visceral pathophysiology can be: validity. Treat- • A polytherapeutic approach is likely to be more ment for pathway mechanisms (Figure 21. Churchill Livingstone, Edinburgh; sensation of angina can be evoked by stimulation of the pp. Price The key points covered in this chapter include: Disuse Back pain Recovery Disability • The size and nature of the problem. Avoidance of Painful experiences Confrontation movement Catastrophising (planned movement) Epidemiology It is estimated that 60–80% of people will have low back pain (LBP) at some time in their life. The annual inci- Fear of movement No fear or reinjury dence of back pain in the UK is around 40%, with around 40% of sufferers visiting their general practi- Figure 22. These are dwarfed by the indirect costs of LBP, related to lack of productivity and informal care serv- ices, estimated to be 10. This makes the so-called ‘back pain epidemic’ one of the costliest mal- Aetiology adies in the Western world. However, it also The aetiology of LBP is at best multi-factorial, at has a major effect on industry through absenteeism and worst, unknown. Accurate diagnosis of the cause of avoidable costs (the Confederation of British Industries LBP is only possible in about 15% of cases. Long- estimate that back pain costs £208 for every employee term pain can be highly disabling and costly. The each year) and at any one time 430,000 people in UK are aetiology of the pain itself is often obscure, but the receiving various social security benefits primarily for mechanisms of disability are better understood. However, it is worth considering that The most powerful predictors of disability are the although back pain is probably a universal complaint, tendency to catastrophise regarding the ability to self- its impact on suffers level of disability seems to be manage the episode of LBP and the level of fear highest in the West, with sufferers in less developed engendered by that pain. Only a translates into the common clinical picture encoun- societal approach to the problem is, therefore, likely to tered in pain clinics. Increasing disability leads to have significant impact on the reduction of these costs. Pain clinics do not treat short-lived episodes Patient assessment of LBP, being generally referred patients who have developed chronic LBP and also suffer considerable Assessment of the patient should follow a bio- disruption to their lives. It begins with a full history, much on management rather than cure and should with particular attention paid to the patient’s description follow a chronic disease framework. This represents a of the pain in terms of the character and the chron- formidable challenge. The behavioural response to this pain should • Presentation under age 20 or over 55 be noted. This includes downtime (rest time), beliefs, • Constant, progressive, non-mechanical pain impact of pain on daily activities and goals of treat- • Past history of cancer, steroids, human immunodefi- ment. An examination with a focus on the musculo- ciency virus (HIV) skeletal and nervous systems is mandatory. A diag- nostic process that ‘flags’ areas for concern has been Nerve root pain is within the scope of a pain clinic. However, if there is major compression as evidenced by root signs or loss of bowel/bladder function this should be referred for surgical review. Red flags One or more of the following features suggests nerve A red flag, that is, serious systemic disease associated root pain: with spinal pathology, is outside the scope of the pain clinic. A brief assessment to exclude these conditions is • Unilateral leg pain that is worse than the back pain. The development of chronic pain and disability depends more on individual and work- Treatment options related psychosocial issues than on physical or clinical features. People with physically or psychologically A careful structured bio-psychosocial assessment as demanding jobs may have more difficulty working above will reveal the areas for treatment.

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And I’d like to think that you’ll have managed to hang on to some of the ideals which drew you to medicine in the first place prazosin 1 mg on-line. And finally 1 mg prazosin visa, to Dr Farhad Islam discount 2mg prazosin, who as a student contributed his impressions of his first delivery (p order prazosin 1 mg with visa. It was ten past nine in the morning and I wasn’t due to start work in the casualty department at St Mary’s Hospital until the afternoon. I weaved in and out of the traffic on my bicycle, and within two minutes I was at the police cordon. There were five commuters lying on the ground, each white with fear, shivering, although it was not cold. I felt as if I was on autopilot, driven by all the procedures that I had been taught and all the duty that had been ingrained in me. He was obviously in pain with a deformed broken lower *Taken from BMJ 1999;319:1079. It was soon emptied and we had to wait for the next fleet of ambulances for more bags. He was stabilised and put into an ambulance, all the while thanking those around him. The coordinator told me that it was unlikely that anyone else would be brought out alive from the wreckage. I grabbed my bike and sped down the main road still feeling as if some kind of compelling force was driving me. I had read the major incident plan two years before and remember being impressed by the precision and detail. What struck me was that there seemed to be order, there seemed to be a plan—and it was working. I was allotted a patient to look after and immediately recognised her as the woman I had attended at the scene. Now, like all the other patients, she had a number and I would be responsible for her. Never had I imagined a major incident running so efficiently, especially with the horrific severity of injuries. I glimpsed the sight of patients with major burns being whisked away for emergency surgery. My duty was to stay with my patient to continually assess her condition, anticipate potential problems, investigate and repair her wounds and be her friend. My main concern after establishing that her airway, breathing, and circulation were stable was to recognise that she might have a skull fracture and underlying serious head injury. It is funny how little things impress on your mind—hearing about members of the public ringing to donate blood, the catering department sending down sandwiches and drinks for exhausted staff, the gratitude of patients. Some were dreadfully burned, others had fractured limbs, ruptured spleens, or head injuries. Suddenly the department was quiet and then the debriefing—lots of emotion, satisfaction, and pride on all sides for the sheer professionalism shown not just by the medical and nursing staff but by the porters, receptionists, police, security, and caterers. FI 135 Appendices Appendix 1 The core outcomes of basic medical education The principles of professional practice The principles of professional practice set out in Good Medical Practice must form the basis of medical education. Doctors must practise good standards of clinical care, practise within the limits of their competence, and make sure that patients are not put at unnecessary risk. Doctors must keep up to date with developments in their field and maintain their skills. If doctors have teaching responsibilities, they must develop the skills, attitudes, and practices of a competent teacher. All curricula must include curricular outcomes that are consistent with those set out below. Maintaining good medical practice (a) Be able to gain, assess, apply, and integrate new knowledge and have the ability to adapt to changing circumstances throughout their professional life. Working with colleagues (a) Know about, understand and respect the roles and expertise of other health and social care professionals. Probity Graduates must demonstrate honesty in all areas of their professional work.

It is vital for people with Parkinson’s to have con- fidence that their caregivers will listen and understand when they explain that "on-off " periods are characteristic order 1 mg prazosin with visa, that there are bet- ter and worse days purchase prazosin 2mg visa, and that there are even times of the day when the medication works more effectively than at others cheap 1mg prazosin fast delivery. It is also vital for the person who has Parkinson’s to be able to communi- cate his or her feelings: "I feel demoralized when you berate me for something I can’t control or change cheap 1 mg prazosin fast delivery. The people with Parkinson’s all agreed that we worried more as the disease progressed, and the primary worry was centered on the dependency we felt on our spouses or 106 living well with parkinson’s principal caregivers. In this group, where spouses and caregivers are very devoted, one of the main questions was, "What would happen if my spouse/caregiver died first? Although we should not make generalizations (because we are all different), I expect that one of the concerns common to most patients and their spouses is the effect that Parkinson’s may have on the marriage. Of course, any change in circumstance will probably have some effect on one’s marriage, whether that change is due to a move to a new location, a new member of the family, a new job, a financial windfall or setback, or a chronic illness. But if the relationship was strong before the illness, it will withstand the additional stress. For example, the prospect of early retirement may be extremely difficult for men who feel responsible for earning the family’s liv- ing. Many men, especially older men, have been conditioned to feel that they must be strong. The arrival of Parkinson’s into their lives may result in feelings of weakness and loss of control. Such feelings can impact on a marriage if they are not confronted, dis- cussed openly, and resolved in some mutually acceptable way. I believe that in general, one’s marriage will be as good or as poor as it was before Parkinson’s. Nevertheless, in any marriage there are opportunities for growth and insight; often a major change in circumstance is just what creates these opportunities. The partners are shaken out of their routine existence and prompted to take a fresh view of their goals, activities, and lives. They reevaluate what is really impor- spouses—special and otherwise 107 tant to them. They dig a little more deeply within to see what they can contribute and how creative and innovative they can be. But couples embarking on this effort themselves, especially with the help of support groups, can accomplish much. In the process, both partners grow, discovering new potential within themselves and new resources that they never recognized before. Adopting a positive attitude and keeping communication open are essential to sustaining a good marriage; problems get solved that could otherwise beset the marriage. For example, many couples facing the spouse’s need for retire- ment and the resultant loss of income have examined their fears together, assessed their finances, opted for a less expensive home and lifestyle, and found that they enjoyed their leisure and many new activities together. One of the most pressing questions in the minds of people who were newly diagnosed with Parkinson’s and their spouses is, "How will Parkinson’s disease affect our sexual lives? The majority of doctors never introduce the subject, and most couples are too reticent to ask about it. Friends joke but don’t discuss it seriously (although women are more likely to talk about it with close female friends than men are with male friends). Unfortunately, if you can’t talk to your spouse, your chances of talking it over with anyone else are extremely limited. A lack of openness between the partners could lead to second-guessing and hurt feelings: "Am I unattractive to him now? The num- ber is so low that chance, rather than intimacy, is responsible for these few couples. That is, each of the partners would have devel- oped Parkinson’s no matter whom he or she married; one did not "catch it" from the other.

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