Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
Fourth buy flibanserin 100mg amex menopause involves a decline in, a severity ratng has been added to order flibanserin now pregnancy calculator conception date the criteria to purchase generic flibanserin line menstruation chart refect research showing that the degree of pervasiveness of symptoms across setngs is an important indicator of severity. A descriptve features specifer has been added for individuals who meet full criteria for the disorder but also present with limited prosocial emotons. This specifer applies to those with conduct disorder who show a callous and unemotonal interpersonal style across multple setngs and relatonships. The specifer is based on research showing that individuals with conduct disorder who meet criteria for the specifer tend to have a relatvely more severe form of the disorder and a diferent treatment response. Furthermore, because of the paucity of research on this disorder in young children and the potental difculty of distnguishing these outbursts from normal temper tantrums in young children, a minimum age of 6 years (or equivalent developmental level) is now required. Finally, especially for youth, the relatonship of this disorder to other disorders. Substance-Related and Addictive Disorders Gambling Disorder An important departure from past diagnostc manuals is that the substance-related disorders chapter has been expanded to include gambling disorder. This change refects the increasing and consistent evidence that some behaviors, such as gambling, actvate the brain reward system with efects similar to those of drugs of abuse and that gambling disorder symptoms resemble substance use disorders to a certain extent. Rather, criteria are provided for substance use disorder, accompanied by criteria for intoxicaton, withdrawal, substance/medicaton-induced disorders, and unspecifed substance-induced disorders, where relevant. Neurocognitive Disorders Delirium the criteria for delirium have been updated and clarifed on the basis of currently available evidence. The term dementa is not precluded from use in the etological subtypes where that term is standard. With a single assessment of level of personality functoning, a clinician can determine whether a full assessment for personality disorder is necessary. Diagnostc thresholds for both Criterion A and Criterion B have been set empirically to minimize change in disorder prevalence and overlap with other personality disorders and to maximize relatons with psychosocial impairment. A greater emphasis on personality functoning and trait-based criteria increases the stability and empirical bases of the disorders. Personality functoning and personality traits also can be assessed whether or not an individual has a personality disorder, providing clinically useful informaton about all patents. These specifers are added to indicate important changes in an individual’s status. There is no expert consensus about whether a long-standing paraphilia can entrely remit, but there is less argument that consequent psychological distress, psychosocial impairment, or the propensity to do harm to others can be reduced to acceptable levels. Therefore, the “in remission” specifer has been added to indicate remission from a paraphilic disorder. The specifer is silent with regard to changes in the presence of the paraphilic interest per se. The other course specifer, “in a controlled environment,” is included because the propensity of an individual to act on paraphilic urges may be more difcult to assess objectvely when the individual has no opportunity to act on such urges. A paraphilic disorder is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satsfacton has entailed personal harm, or risk of harm, to others. A paraphilia is a necessary but not a sufcient conditon for having a paraphilic disorder, and a paraphilia by itself does not automatcally justfy or require clinical interventon. In the diagnostc criteria set for each of the listed paraphilic disorders, Criterion A specifes the qualitatve nature of the paraphilia. A diagnosis would not be given to individuals whose symptoms meet Criterion A but not Criterion B—that is, to those individuals who have a paraphilia but not a paraphilic disorder. This change in viewpoint is refected in the diagnostc criteria sets by the additon of the word disorder to all the paraphilias. While the term “anxiety” has been applied to diverse phenomena in the psychoanalytic, learning-based, and neurobiological literature, the term “anxiety” in the clinical psychopathological literature refers to the presence of fear or apprehension that is out of proportion to the context of the life situation. Hence, extreme fear or apprehension can be considered “clinical anxiety” if it is developmentally inappropriate. The last 30 years of clinical research has led to progressive refinement of the nosology for clinical anxiety disorders. Consensus has emerged on the view of anxiety disorders as a family of related but distinct mental disorders. There is some disagreement, however, on whether all of these syndromes are most properly considered anxiety disorders. This includes the primary symptomatology, history, epidemiology, differential diagnosis, and course of each disorder, along with a clinical vignette designed to capture the essential features of each disorder as it typically presents in the clinic. The panic attack is defined as an episode of abrupt intense fear that is accompanied by at least four autonomic or cognitive symptoms listed in Table 15. For example, a healthy person might experience a panic attack when confronted with sudden extreme danger, and an individual with a phobia of heights might experience a panic attack when confronted with the feared situation. The unexpected or spontaneous panic attack occurs without cue or warning; the situationally bound panic attack occurs upon exposure to, or in anticipation of, exposure to a feared stimulus; and the situationally predisposed panic attack is more likely to occur, but does not necessarily have to occur, on exposure to a situational trigger. In panic disorder, panic attacks occur spontaneously, arising without any trigger or environmental cue. There has in fact been some debate about whether agoraphobia is best conceptualized as a complication of panic disorder or as a separate condition. This controversy centers on the frequency with which patients develop agoraphobia in the absence of panic disorder or panic attacks (Table 15. However, even in agoraphobia without history of panic disorder, agoraphobia is considered related to the fear of developing paniclike symptoms.
Surgery • Used for short distance claudication purchase flibanserin with paypal women's health clinic johnson county, severe lifestyle limitation discount 100 mg flibanserin with visa birth control for women's health, and failure/unsuitability of endovascular treatment in the aorto-iliac segments buy discount flibanserin 100mg on-line womens health institute taos. Used for isolated common femoral disease; good results and a low complication rate. Clinical features • European consensus statement deflnes critical ischaemia if there is: • Rest pain for >2 weeks not relieved by simple analgesia; or • Doppler ankle pressure <50mmHg (toe pressures <30mmHg if diabetic). Interventional, carries risk of arterial injury and renal toxicity of contrast, good for popliteal and distal vessel assessment. Treatment • All efforts should be made to revascularize if possible (providing the general condition of the patient allows it). Endovascular treatments Angioplasty 9 stent proximal disease (aorto-iliac, common femoral, superflcial femoral). Underlying cause is usually atherosclerosis-related, but may be associated with infective causes (‘mycotic aneurysm’), Marfan’s and Ehlers–Danlos syndromes (collagen and elastin abnormalities). Do not contain all three layers of vessel wall and often only lined by surrounding connective tissue or adventitia. Sites Thoracic, abdominal, and peripheral (iliac, femoral, popliteal, visceral, carotid or subclavian), cerebral ‘berry’ aneurysms. Abdominal aortic • Ninety-flve per cent start below the origin of the renal arteries (‘infrarenal’). May be ‘straight’ if aneurysm conflned to aorta or ‘bifurcated/trouser’ if there are common iliac aneurysms as well; 3–7% operative mortality. Percutaneous insertion of covered stent to exclude the aneurysmal segment from arterial pressure. High early re-intervention rate, requires lifelong surveillance, no long-term survival beneflts over open repair shown to date. Signs • Cardinal signs are unexplained rapid onset hypotension, pain, and sweating. Emergency management Resuscitation • If the diagnosis is seriously considered, call for senior surgical assistance immediately. The decision is based on age, physiological status, comorbidities, expressed patient preference, family wishes. May be stable after initial presentation, but likely to progress to free or complicated rupture unless urgently surgically treated. Principles of surgery for rupture • Go straight to the operating table, not anaesthetic room. High flow • these are largely asymptomatic, but there may be a detectable venous hum or bruit. Interventional radiology • Percutaneous or intravascular embolization using wire coils or sclerosant under radiological guidance. Neurological features Depend on the territory supplied by the vessel affected by the embolism, the degree of collateral circulation to that territory, and the size/resolution of the embolism. Transient monocular visual loss (described as a curtain coming down across the eye), lasting for a few seconds or minutes—central retinal artery (occlusion can lead to permanent blindness). Dense hemiplegia, usually including the face—striate branches of the middle cerebral artery. Diabetics are 15 times more likely to undergo major lower limb amputation than non-diabetics. Diagnosis and investigation Pure neuropathic ulceration • Warm foot with palpable pulses. Level • the level is chosen according to: • Lowest level where tissue is viable for healing. Bone transected at junction of upper two-thirds and lower third of femur (12–15cm above knee joint), common in end-stage vascular disease. Increasingly popular for bilateral amputees as creates a long stump; especially good for wheelchairdependent patients. Weight bearing on patellar tendon with good prosthetic flt; good knee function essential. Few indications for this in vascular patients and best avoided other than in trauma or diabetics. Used when digital gangrene extends to forefoot, especially useful for diabetics when infection tracks up tendon sheath. Treatment Preoperative care • Restore Hb levels and correct fluid and electrolyte balance. Due to hypersensitivity in divided nerves, can be helped with gabapentin, amitryptyline, or carbamazepine. Diagnosis and investigations • Stop all vasoactive treatment 24h prior to assessment. Reserved for patients with failure to respond to medical therapy or secondary complications. Mostly now thoracoscopic technique; effects are poor response rate and high relapse rate. Pain, aching, itching, heaviness, swelling, oedema, worse at end of day/hot weather/premenstruation, cosmetic concerns. Oedema, eczema, ulcers (usually medial calf), lipodermatosclerosis, atrophie blanche, healed ulceration. Most accurate outpatient method of diagnosis and localization of primary venous reflux disease. Treatment options Medical • Microsclerotherapy, laser sclerotherapy for thread and reticular veins. Diagnosis and investigations Aim to conflrm presence and extent of thrombosis (to decide on necessity and type of treatment, risk of embolization). Investigation of choice; visualizes anatomy, gives extent of thrombosis, and relies on flow of blood and compressibility of vein.
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Frequency and nature of treatment many distinct genetic forms cheap generic flibanserin canada menopause panic attacks, each with a different set of Relative to order discount flibanserin on line menstruation 6 days late patients with other psychiatric disorders cheap flibanserin 100mg line women's health liposlim, pagenes, or in one form with an underlying set of genes that tients with panic disorder seek help relatively frequently confer broad vulnerability to panic and anxiety (556). Some studies have shown that reducIn the following sections available data on the efflcacy of tions in other dimensions. Short-term effunctional impairment) are more important to overall imflcacy has usually been evaluated over the course of 6to provement than reduction in panic frequency (74). Thus, 12-week clinical trials by observing changes in the presthe fleld has moved toward a broader deflnition of remisence and severity of patientand physician-rated panic and sion that includes substantial reductions in panic attacks, agoraphobic symptoms. Earlier studies have focused on anticipatory anxiety, and agoraphobic avoidance, as well as Copyright 2010, American Psychiatric Association. It is also important to use of additional treatment have been considered indicaconsider the nature of the components that are used. Many studies report only shortseveral related, but not identical, approaches (133, 136, term outcome. It is also important to note whether a speciflc treatup periods of several years are needed in order to assess ment protocol has been used and whether efforts have been the potential of different treatments to produce sustained made to ensure that all study clinicians have demonstrated remission. Issues in study design and interpretation treatments have employed waiting-list control groups, When evaluating clinical trials of medications for panic which only control for the passage of time and not for the disorder, it is important to consider the design of the study “nonspeciflc” effects of treatment. In addition, Placebo response rates (often in the range of 40%–50%) patients in medication studies may be taking additional could explain much of the observed treatment effect in doses of the tested medications or other antipanic mediuncontrolled trials or make signiflcant treatment effects cations (either explicitly, as doses taken as needed, or surmore difflcult to detect in controlled trials. Studies that monitor such occurrences have portant to consider the potential use of additional treatshown rates of surreptitious benzodiazepine use to be as ments that are not prescribed as part of the study protocol high as 33% (278). Alcacy of the treatment as an adjunct to the speciflc prior type though these studies are useful for comparing the efflcaof treatment. It is also important to consider the dose of medacteristics of the study participants. Practice Guideline for the Treatment of Patients With Panic Disorder 51 features of the sample and the inclusion/exclusion criteria parator treatment. No clinical trial adequately important to realize that this is not a measure of absolute represents all patients with panic disorder, and some studdifference. Thus, the odds may be represented as the proies have speciflcally excluded patients with features. The odds ratio for treatment B versus A would then the p value, which is typically set at no higher than p<0. It is imporneed to be treated with the new intervention to achieve tant to note that as sample sizes become large, smaller the desired outcome for one additional patient. For examabsolute differences between the effects of agents on outple, if 20% of the study population achieved remission come measures are more likely to be statistically signiflcant with one intervention and 40% with the alternate inter(i. Thus, from a larly, small studies that fail to flnd a difference between two public health point of view, to have one additional patient agents may not have had sufflcient statistical power to deachieve remission with the novel intervention than would tect such a difference. Under such circumstances, small with the standard intervention, flve patients would need randomized controlled trials with negative results cannot to be treated. Further, flndings from small beneflt of a novel intervention clinically, the risks associstudies are less reliable. Effect sizes can provide a common metric for comparing the magnitude of effects 1. Did they all improve signiflcantly more with in their emphasis on different treatment components. The imipramine treatment was slowly titrated up to tients achieving remission with two different interventions a maximum of 300 mg/day. Remission of symptoms panic disorder who also have substantial agoraphobia (149, therefore may not be completely attributable to the expo184, 218, 565–568). However, use of benzodiazepines during exexposure treatment in reducing panic and agoraphobic posure treatment predicted worse outcome in this sample, symptoms. Given the efflcacy of exposure treatment, some making it unlikely that medication effects explain the susinvestigators have questioned whether more elaborate protained remission in the majority of patients who retocols that include cognitive restructuring are necessary for sponded well to exposure therapy. Both groups received individual sessions twice (deflned as attainment of normal functioning on measures weekly for 12 weeks. Only 9% of the therapy showed signiflcantly superior reduction in panic control group met the remission criteria at posttreatment. It has been studied as a possible treatment for panic mended to patients with panic disorder. In conwaiting-list control group were crossed over to an active trast, partner-assisted exposure therapy for panic disorder form of treatment, no comparison with a waiting-list conhas been shown to reduce symptoms of panic disorder in trol condition was possible. Thus, some evidence exists that couples-based come measures and was equivalent to the attention-placebo interventions can enhance response to exposure treatment control. Combined treatments of panic disorder have consisted primarily of cognitive-beInvestigators have examined use of the combination of havioral approaches. Some older studies that evaluated compared to those who received exposure plus placebo short-term efflcacy showed that the combination of the (149). At 12-month follow-up, 68% of in the treatment of panic disorder with severe agoraphothe patients in the collaborative-care group and 38% in the bia (68). This study suggested a relatively modest beneflt tients with panic disorder (with and without agoraphobia) of combination treatment, which was apparent at the aswere randomly assigned to receive clomipramine alone or sessment point conducted after 6 months of maintenance clomipramine plus 15 sessions of psychodynamic psychotreatment. Most studAnother randomized controlled trial, which included ies have focused on their ability to stop or reduce the 154 patients, compared alprazolam plus exposure, alprafrequency of panic attacks, but many have also addressed zolam plus relaxation (psychosocial placebo), placebo the effect of medication on anticipatory anxiety, agoraplus exposure, and placebo plus relaxation (double plaphobic avoidance, limited symptom attacks, associated cebo) (149). When interpretfour groups improved signiflcantly on panic measures ing results from trials of pharmacological interventions, it and were not statistically different. After treatment withis important to consider the study design and methods for drawal, participants who received exposure plus almeasuring treatment outcome (see Section V. A) and the prazolam were less likely to maintain their response, funding source of the study.
Trigeminal neuralgia following referral by a consultant neurologist recognised by Aviva Health and when the condition has persisted for at least six months despite conservative treatment with pharmacotherapies (carbamazepine effective flibanserin 100mg menopause 34, phenytoin and baclofen) or the member is unable to flibanserin 100 mg line pregnancy 9 or 10 months tolerate the side effects of the medications 3) buy flibanserin 100 mg otc breast cancer prevention. Meningioma’s, excluding the initial treatment of those with a cortical or spinal location 4). Neurosurgical 5610 Sensory nerve, neurectomy Operations Injection, anaesthetic agent and/or steroid or other substance (I. Neurodestructive thermal rhizotomy (temperature >69°C), under Neurosurgical 5617 image guidance, with sensory and motor testing, one or more See note below I. Repeat of procedure 5616 to the same anatomical site, one or Neurosurgical 5618 See note below I. L4/5 or L5/S1 and whether this was carried out on the left or right side of the spine and confrm the temperature used to perform the procedure. Repeat of procedure 5617 to the same anatomicla site, one or Neurosurgical 5619 See note below I. Thalmus, globus pallidus, subthalamic, Operations nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording Twist drill, burr hole, craniotomy or craniectomy with sterotactic implantation of nuerostimulator electrode array in Neurosurgical 5707 subcortical site. Thalmus, globus pallidus, subthalamic, Operations nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording Neurosurgical 5708 Revision or removal of intracranial nuerostimular electodes Operations 5709 Required course of radiotherapy for patients with symptoms of Radiotherapy rejection of a transplanted organ(s). In that foraminotomy to expose and decompress the nerve roots and circumstance the code 3601 or spinal cord. Intracardiac catheter ablation of arrhythmogenic focus for treatment of supraventricular or ventricular tachycardia by 5961 ablation of fast or slow atrioventricular pathways, accessory See note below Cardiological Procedures atrioventricular connections or other atrial foci, (including foci pulmonary vein) singly or in combination. Gleeson score < 8 Detailed prostate volume study under anaesthesia includes tumour and prostate volume estimation; modelling and planning for second stage radioactive seeds implantation, 5997 patient consultation, with or without digital rectal examination. Brachytherapy Clinical indications for the prostate brachytherapy procedures are as follows: 1. Beneft will be provided for fve days for members who proceed immediately following the trial to implantation during a single hospital admission. Beneft is payable to the consultant who interprets the results and reports on them and only payable to one consultant. Beneft is not payable for routine screening purposes, and is subject to the conditions of payment outlined below. The Radiologist who performs the procedure must have specialist embolisation experience or undergone appropriate training and be registered with Aviva All cases of uterine artery embolisation must be performed in a hospital listed in the Aviva Directory of Hospitals, by a Consultant Radiologist who participates in a primary research program All cases must be registered on the national register Benefts are not paid where: a) There is evidence of recent or current genital tract infection b) the patient is unwilling to proceed to a hysterectomy if the embolisation procedure is complicated; c) if the above criteria are not satisfed in full 6686 Biopsy of focal lesion in the liver, kidney, pancreas or spleen Side Room Anaesthesia including embolisation. PreMaxillofacial / Dental / 12930 authorisation Oral Surgery pre-authorisation required required Performed under Local Anaesthesia or by sedation Buried tooth Side Room roots, (multiple) of teeth, removal of. Service 1517 Destruction by cryosurgery of actinic keratoses or warts other than plantar warts with or without surgical I. Two-cyanocrylate) either singly or in combination with sutures or staples or in combination, Side Room with adhesive strips. Wound closures utilising adhesive strips as the sole repair material may only be claimed uner our out-patient products. Two-cyanocrylate) either singly or in combination with sutures or staples or Side Room in combination with adhesive strips. The beneft payable covers: • Performance or personal supervision of the investigation/s • Evaluation of the results of the investigation/s • Written report and/or discussion with the referring doctor 2. The inclusion of a schedule of largely automated analyses in the category is a non-volume related indicator of the above activities carried out by Consultant Pathologist and is not intended to specifcally refect the input of individual sub-specialities in which most of these investigations are carried out. Aviva will recognise only one such charge for code 8900 for a patients’ episode of care which requires the use of consultant pathologist services but will not pay this fee where any charges for this service beneft (code 8900) are raised by any other Consultant Pathologist or Consultant Pathologist group during the same episode of care. Where a Specialist Clinical Pathologist admits a patient and provides continuing care, the inPatient Attendance beneft is payable. The benefts towards pathology investigations are payable in respect of Consultant Pathologists’ services only. The code of the precise investigations(s) carried out must be reported to Aviva health in order that beneft may be paid. Pathology investigations performed on an out-patient basis, may only be included in an outpatient claim. Pathology investigations performed as part of a Day Care case may be included in the Day Care claim. Beneft is not payable for samples sent to an external laboratory, because the external laboratory results are inclusive of Consultant Pathologist interpretation of the test(s). Pathology investigations not specifcally listed in the pathology section of the schedule of benefts will be deemed to be listed under code 8900. An in-patient consultation is payable to a Consultant Pathologist where the patient is transferred from one hospital to another for tertiary level care arising from complicated illness. Code 9359 will not include examinations emanating from the national newborn Screening Programme for inherited metabolic and Genetic Disorders 9360 Small (1-2 blocks) include cytology and neuropathology When 2 or more tissue sources from separate sites require examination they must be assigned one code only refective of the number of clocks it is necessary to examine the separate sites must be identifed on the claim form. Skin lesion(s) are payable based on the total; number of blocks it is necessary to examine and only one of code, 9360, 9530 or 9650 is payable Surgical Pathology, gross microscopic examination, medium. Skin lesion(s) are payable based on the total; number of blocks it is necessary to examine and only one of code, 9360, 9530 or 9650 is payable 9650 Large (5 + blocks and all major dissections) A total of only 5+ blocks from a specifc site is payable under this code. Radiology gelfoam) 6688 Radiofrequency ablation of liver tumour(s) including embolisation. Radiology 6735 Venogram, peripheral, single limb Radiology 6740 Venography (selective, catheter, single vessel study and/or venous sampling, I. The fee is payable for: • the performance or personal supervision of the radiological examination. The surgical beneft shown is inclusive of services such as ultrasound and/or ultrasound or radiological guidance. Some of the procedures, by defnition, embrace lesser procedures which may be listed in their own right in the Schedule of Benefts. The benefts towards Diagnostic Radiology procedures are payable in respect of Consultant Radiologists’ services only, and, Radiological procedures are only payable when the radiological procedure(s) has been requested by the admitting consultant or another consultant requested to see the patient at the request of the admitting Consultant in a complex case (and where we agree to pay a Consultant consultation beneft to the second Consultant).
Complicated malaria • Should always be managed in a hospital with experience and appropriate facilities purchase flibanserin without prescription women's health issues on thrombosis, if possible purchase discount flibanserin on line 4 menstrual cycle stages. Prognosis Untreated vivax malaria subsides in 10–30 days purchase flibanserin 100mg mastercard breast cancer 85, but may recur intermittently. The intermediate host is a snail (bullinus contortus) that inhabits slow running water. After shedding their tails, they are swept by the bloodstream to all parts of the body. The worms mate and the ova pass into the urine and faeces where they pass out and infect new water (especially stagnant). Clinical features and complications • Intestinal worms cause: • Intestinal ulcers with bleeding, leading to abdominal pain and distension (due to ascites). Diagnosis and investigations • Microscopic examination of an early morning urine or faecal specimen can demonstrate the presence of living eggs. Surgical Surgical intervention is necessary when complications such as portal hypertension, urethral stricture, or peritonitis after perforation develop. Clinicopathological features • Transmitted to humans by the bite of many genera of mosquitoes. Abnormal subcutaneous tissue can be excised and the affected part covered with a split skin graft. One variation is to excise the skin of the leg in long strips and then excise the subcutaneous tissue and apply skin to the denuded tissue. Clinicopathological features Pathological features • Caused by the larval forms of the cestode worms, Echinococcus granulosus and Echinococcus multinodularis. Humans are an incidental ‘dead end’ host, but the ova penetrate the small intestine and enter the portal circulation. Clinical features/complications • Infection is usually contracted in childhood, but produces symptoms and signs in adult life. Cyst fluid also causes a severe allergic reaction with urticaria and eosinophilia if it enters the circulation (either by spontaneous rupture or surgical intervention). Diagnosis • Casoni’s test (serum antigen) is positive in 80%, but gives many false positives. Black packs soaked in hypochlorite are placed around the liver to show up any daughter cysts or scolices. Prevention Community hygiene projects to reduce the risk of humans being exposed to infected dog faeces in areas of endemic disease. Treatment Medical • Piperazine, one dual dose sachet repeated after 14 days (adults), onethird sachet (age 3–12 months), two-thirds sachet (age 1–6y), 1 sachet (age >6y). Causes flaccid paralysis of roundworms and threadworms and permits their expulsion by peristalsis. Clinicopathological features • the common route of infection is by bites from infected sand flies. Cutaneous leishmaniasis • May be a simple sore at the site of fly bite with primary healing. Visceral leishmaniasis (kala-azar) • An infection of the reticuloendothelial system with enlargement of the liver, spleen, and lymph nodes. Mucocutaneous leishmaniasis • Affects the skin and subsequently the mucous membranes of the mouth and nose, causing nodules and ulceration. Clinicopathological features Infection routes include: • Infection from food contaminated with the bacilli. Deep, transversely placed ulcers in the direction of the lymphatics that may cause perforation and peritonitis. Fibroplastic reaction, resulting in thickening of the bowel wall along the mesentery and affecting the lymph nodes and the omentum, which may lead to malabsorption. Associated with strictures in the small intestine, leading to intestinal obstruction. Surgical Laparotomy for peritonitis due to perforation, obstruction, or unresolving inflammatory masses. Clinicopathological features • Caused by the acid-alcohol fast bacillus, Mycobacterium leprae. Highly infectious; open ulcerating lesions contain macrophages loaded with bacilli. Pronounced lymphocytic inflltration of lesions causing scarring; nerve damage is prominent feature. Clinical features Consider the diagnosis of leprosy in any patient who presents with a combination of neural and dermatological disorders. Typically widespread hypopigmented and erythematous rash affecting the face, limbs, and trunk. Often widespread neuritis followed by nerve thickening and progressive neuropathic tissue injury and ulceration due to anaesthesia. Typically focal destruction of melanocytes (hypopigmentation), hair follicles, sweat and sebaceous glands (dry, hairless, anaesthetic plaques of tissue). In practical terms, infected tissue is usually obtained by taking a smear with a scalpel blade inserted into the pinched skin of an affected eyebrow or earlobe. Surgical Surgical treatment is indicated to correct deformities which may be: • Primary. Education of the patient in avoidance of injury and self-care is vital to prevent progressive injury since damaged nerves may be permanently anaesthetic. Clinicopathological features • Contracted from drinking fresh water contaminated by the arthropod, Cyclops, which contains the larva of the guinea worm (Dracunculus mediensis). When the blister bursts, the worm physically extrudes to allow the cycle of water re-infection to complete. Clinical features Usually present as blistering rash on the legs with visible worm in the base.