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Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

  • Professor of Medicine
  • Joint Appointment in Radiology and Radiological Science


A difference of 8 mm Hg between the initial reading and the peak rise following pupillary dilatation suggests the possibility of angle-closure glaucoma order zebeta with visa pulse pressure 57. A: Horizontal radial remain under observation until the pupil attains fibers purchase zebeta now pulse pressure transducer, B and D: Oblique fibers generic zebeta 5mg pulse pressure 60 mmhg, C: Vertical fibers its normal size. Glaucoma 241 Predictive values of the provocative tests have Incisional surgery is generally avoided during not been demonstrated in the recent studies. Suspected cases of narrow To quell an acute attack both topical and systemic angle glaucoma should be advised to report for hypotensive agents should be used. The examination tration of topical corticosteroids 3-4 times a day of the other eye may provide important clues to reduces the accompanying inflammation in the eye. The mild attacks of acute angle-closure glaucoma may be broken by 1-2 % pilocarpine eye drop 4-6 Treatment times a day, which induces miosis and pulls the iris Primary angle-closure glaucoma carries an away from the trabeculum. It is often managed surgically and the and may not respond to pilocarpine therapy. A medical treatment is usually limited to the combination of topical timolol maleate and preoperative reduction of intraocular pressure. When necessary a hyperosmotic agent like Pilocarpine: During the prodromal stage and stage oral glycerol (1. It is advisable, Besides medication, globe compression and comtherefore, to instill pilocarpine 0. Hyperosmotic agents are of great value in Laser iridectomy: the laser iridectomy is the controlling the acute phase of primary angletreatment of choice for the management of early closure glaucoma. The operation is simple and Glycerol is practically without any risk or complication. The medical treatment of acute congestive anglethe maximal hypotensive effect of glycerol starts closure glaucoma is aimed at preparing the patient within one hour and lasts for nearly 3 hours. Therefore, prophylactic iridectomy should be performed in the eye unless the angle is clearly Mannitol is administered intravenously as 20% nonoccludable. It Treatment of Chronic Congestive penetrates the eye poorly, therefore, reduces the Glaucoma intraocular pressure effectively within 30 minutes and its effect lasts for about 4 hours. The drug is As the diagnosis of chronic congestive glaucoma contraindicated in patients with renal disease and is established, an operation is warranted. The should be used with caution in congestive heart development of peripheral anterior synechiae in failure. In these cases a Urea is used intravenously as a 30% solution in filtration operation should be performed. Its use is contraindicated in patients with Treatment of Absolute Glaucoma impaired renal function. In such eyes the pain Isosorbide is administered orally in the dose of 1 may be relieved temporarily by retrobulbar to 2 gm/kg body weight. It has a minty flavor and injection of 1 ml of 2% xylocaine followed seven is free of nausea. A peribulbar injection of 1 ml of 2% xylocaine with adrenaline 1 in 10000 common, may be caused by anteriorly positioned gives great relief owing to its hypotensive and ciliary processes which push the peripheral iris anesthetic effects. The glaucoma can Surgery be managed by miotics or laser iridoplasty Once the acute attack is broken and cornea regains (gonioplasty). In the absence of peripheral anterior synechia, a laser iridotomy Classification is the most preferred surgery. But if goniosynechiae the secondary glaucoma can be divided into are extensive, a filtration operation is indicated. Secondary glaucoma with angle closure: the untreated fellow eye has a 40-80% chance of a. In Secondary glaucoma is also found in Fuchs contrast to the primary, the etiology of the heterochromic cyclitis and glaucomatocyclitic secondary glaucoma is fairly known. They are described in the chapter on Diseases factors such as inflammation, neoplasia, trauma, of the uveal tract. Generally, the disease process obstructs the lens may cause secondary glaucoma in a the trabecular meshwork or the pupil and lead to number of ways. Phacomorphic Glaucoma Glaucoma due to Uveitis the lens may cause both open-angle and anglethe intraocular pressure may rise both in the acute closure secondary glaucomas. The process of development inflammation of the trabecular meshwork of phacomorphic glaucoma is much more rapid (trabeculitis) which results in reduction of and is precipitated by swelling of the lens during intertrabecular spaces, (iii) trabecular meshwork intumescent stage of cataract and development of endothelial cells dysfunction, and (iv) breakdown pupillary block. The secondary glaucoma in Phacolytic Glaucoma chronic anterior uveitis occurs either due to Phacolytic glaucoma is usually associated with seclusio pupillae (total ring synechia), occlusio mature or hypermature cataract and it occurs due pupillae or extensive peripheral anterior to the leakage of lens proteins through an opening synechiae. The leaked denatured lens proteins Secondary angle-closure can also occur due to uveal effusion, exudative retinal detachment are engulfed by macrophages which subsequently and choroidal effusion followed by forward block the trabecular pores. The medical treatment of the condition is not the extraction of lens is the only possible effective. The pupillary block should be relieved treatment, but it should be done after reducing the by a peripheral iridectomy and the presence of intraocular pressure by hyperosmotic agents. In More than 50% cases of pseudoexfoliation the event of penetrating ocular trauma or followsyndrome may develop open-angle glaucoma. A ing extracapsular cataract extraction, a severe combination of pseudoexfoliation and glaucoma phacoanaphylactic reaction to the lens matter is known as glaucoma capsulare. The rise in intraocular pressure is due to the the dandruff-like material is deposited on the obstruction of trabecular meshwork by particulate pupillary border of the iris and on the anterior matter. The condition must be treated by mydrialens capsule (except the central zone) (Fig. The In most cases the angle of the anterior chamber lens matter should be aspirated or removed. The pigments are seen arranged Glaucoma Associated with in a linear fashion anterior to Schwalbe’s line Dislocated Lens (Sampaolesi’s line).

Objectives 2 Through efficient buy 10mg zebeta fast delivery blood pressure medication how it works, focused purchase zebeta 5mg otc blood pressure questions, data gathering: ­ Elicit a history including menstrual generic zebeta 10mg arteria gastrica sinistra, fertility, and obstetrical history, sexual activity, and associated symptoms. Once the diagnosis is established, specific and usually successful treatment may be instituted. Gynecological conditions in pregnancy (ovarian cyst rupture, degenerating fibroids) 2. Substance abuse Key Objectives 2 Determine whether the pain is acute or chronic, pregnancy is likely, and stabilize the patient whose pain is acute and life threatening. Given the intense time commitment required, the clinician should proactively schedule accordingly. Child 3 12 years (visual/hearing deficit, accidents, development, abuse/neglect) 3. Objectives 2 Through efficient, focused, data gathering: ­ In an infant, toddler, or child elicit information about risk factors at conception, pregnancy, and birth, familial factors, and existing signs of illness or environmental risk factors (missed immunization, diet, passive smoke inhalation, skin protection). Subjecting such a person to the risk of diagnostic tests when there is no known problem requires that the procedure should be especially safe. For example, although colonoscopy is not a dangerous procedure for a patient with a specific gastrointestinal complaint, the bowel perforation rate of 0. There is growing anxiety for a more lucid definition of the criteria that tests should meet before they are incorporated into the periodic health examination. Most importantly, the patient should be involved in the decision about preventive activities. For another example, there are several genes known to be associated with colorectal and breast cancer. People who have been told they have one of the genes will be living with the possibility of an ominous event for a long time. Such labelling is especially troublesome ethically if the test is a false-positive one. In such circumstances, screening might promote a sense of helplessness instead of wellbeing, and might do more harm than good. This same selective approach is needed for testing so that the percentage of false-positive results can be diminished. In most cases, parents require direction and reassurance regarding the health status of their newborn infant. Well-newborn care Key Objectives 2 Determine development through ongoing monitoring because new circumstances may interfere. Objectives 2 Through efficient, focused, data gathering: ­ Examine newborn within 24 hours of birth and before discharge from hospital; review maternal history. Recommended immunization schedules are constantly updated as new vaccines become available. Pneumococcal pneumonia (selected provinces 12 18 months + selected populations) c. Meningococcal meningitis (selected provinces) Key Objectives 2 Discuss the population health benefits of immunization programs. Objectives 2 Through efficient, focused, data gathering: ­ Obtain an immunization history on all children and determine whether child (or family member) is immuno-suppressed or is receiving immuno-suppressive drugs. The objectives of such an evaluation include the detection of unrecognized disease that may increase the risk of surgery and how to minimize such risk. Other Key Objectives 2 Identify factors likely to influence peri-/post-operative morbidity and mortality, and measures required to reduce the risk. Objectives 2 Through efficient, focused, data gathering: ­ Elicit evidence of feeling unwell, serious past illnesses and any medications in previous 3 months. Laboratory tests, as part of the pre-operative medical evaluation, should be used selectively. Normal test values are usually defined as occurring within 2 standard deviations from the mean. If 20 tests are ordered in a healthy patient, 64% of the time there will be at least one abnormal test reported. The consequence of such an abnormal test might include not only alarming the patient, but also unnecessary costs and potential delay of surgery. For example, screening panels of tests ordered pre-operatively are frequently not acted upon prior to surgery, thereby creating an additional medico-legal risk. Most physicians, as well as hospitals with such policies, now support a selective approach to pre-operative testing, so that random test ordering may actually represent a deviation from the local standard of care. Equally important, physicians can not only play an important role in preventing occupational illness but also in promoting environmental health. Clinical preventive services Key Objectives 2 Determine whether the work place or environmental conditions are potentially hazardous, the impact on the health of the workers, and recommend preventive strategies. Objectives 2 Through efficient, focused, data gathering: ­ Ask whether symptoms better/worse at home or work, during week, or weekend. They represent important risk factors for a variety of medical, interpersonal, and psychiatric difficulties. For example, patients with personality difficulties may attempt suicide, or may be substance abusers. As a group, they may alienate health care providers with angry outbursts, high-risk behaviours, signing out against medical advice, etc. Obsessive-compulsive Key Objectives 2 Differentiate between patients with long enduring patterns of behaviour from repetitive but short-lived episodes of disturbed behaviour. Objectives 2 Through efficient, focused, data gathering: ­ Determine whether the patient is excessively suspicious or jealous, distant or emotionally cool with little need for personal relationships, or has disturbances in thinking and communication. Personality disorders are usually chronic, difficult to manage, and require extensive resources.

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These data lend support to generic zebeta 5mg overnight delivery blood pressure 9050 arguments for the use of adjuvant therapies despite the potential risk of systemic sepsis associated with the use of prosthetic graft material purchase discount zebeta line pulse pressure in septic shock, and again relate to buy zebeta 5 mg without prescription blood pressure youth the late stage at presentation. Prospects for transplantation There is much experience in transplantation for hepatoma. There is no doubt that it is a suitable therapy for patients with small hepatomas in cirrhotic livers, where the cirrhosis is the primary indication for the transplant. Unfortunately, however, where the hepatoma is the primary indication for liver transplantation because of the enormity of the lesion, the results of transplantation have been almost universally poor. This is probably related to the necessary immunosuppression used following organ transplantation, and the development of more specific immunosuppressive agents may enable transplantation to be used in the future for these tumours. Our group has been investigating the use of cluster resection and multivisceral grafting 34 as an alternative for neuroendocrine tumours. These are most often tumours of midgut origin with foregut metastases and adequate lymphadenectomy involves both the coeliac and superior mesenteric arterial distributions, so surgery involves excision of all organs supplied by these arteries: stomach, duodenum, liver, pancreas, spleen, jejunum, ileum and large bowel as far as the descending/sigmoid colon. This approach provides superb access to the para-aortic lymph nodes for adequate lymphadenectomy. This is followed by implantation of a multiorgan block of liver, pancreas, duodenum, jejunum and ileum. We have used a Roux loop (created from the transplanted jejunum) to the oesophagus, as gastric stasis can be a problem for several weeks following stomach transplantation. An ileostomy is used to provide access for regular endoscopic biopsies for careful monitoring for rejection and cytomegalovirus infection during the first few months, but it is our practice to reverse this at about 6 months if graft function is stable. We have found that the donor innominate artery forms an ideal conduit for anastomosis of the donor coeliac and superior mesenteric arteries to the recipient aorta. Our early results with neuroendocrine disease are more encouraging than with other tumours, but long-term analysis is necessary. This may be related to the more extensive resection or, more probably, to the tumour type. The human colonic cancer cell line LoVo was incubated for 4 days in a 5% concentration of the patient’s serum in a medium. The immunosuppressed and non-immunosuppressed control groups showed no significant differences from normal. An alternative growth factor may be active in the resection group both before and after resectional surgery. Our results supported the hypothesis that rapid tumour recurrence following liver transplantation is the result of the necessary immunosuppression. The development of more specific immunosuppressive agents may enable transplantation to be used in the future for more hepatic tumours, but for the moment the role of transplantation remains very limited. Summary Techniques for hepatic resection continue to advance and the involvement of liver transplant teams has aided the development of new types of resection and anaesthetic techniques. Short-term warm hepatic ischaemia is practised widely but there is often a necessity to hurry during this demanding surgery as prolonged warm ischaemia can result in irreversible liver failure. Transplant experience, particularly relating to cut-down and split liver techniques, has demonstrated that bench dissection and reimplantation after long periods of cold ischaemia can be successful in the majority of cases. Summary panel the short-term survival of untreated patients with both primary and secondary liver tumours, the unpredictability of chemotherapy response on an individual patient basis and the disappointing results of transplantation for cancer provide adequate impetus for attempts to extend the boundaries of liver resection as far as possible. Major improvements in hepatic surgery have occurred during the past few years and improvements in anaesthesia have been integral to this success. Pringle’s manoeuvre and total vascular isolation (hepatic vascular exclusion) are used widely, and this short-term warm ischaemia appears to be well tolerated. Portal triad clamping or hepatic vascular exclusion for major liver resection: a controlled study. Vascular occlusions for liver resections— operative management and tolerance to hepatic ischemia: 142 cases. Partial hepatic resection under intermittent hepatic inflow occlusion in patients with chronic liver disease. Mortality, endotoxaemia and cytokine expression after intermittent and continuous hepatic ischaemia. Normothermic complete hepatic vascular exclusion for extensive resection of the liver. Liver ischemia for hepatic resection: where is the Surgical management of hepatobiliary and pancreatic disorders 86 limit Resection of benign hepatic lesions with selective use of total vascular isolation. Effects and limitations of prolonged intermittent ischaemia for hepatic resection of the cirrhotic liver. Total vascular exclusion for hepatic resection in cirrhotic patients: application of venovenous bypass. In situ and ex situ in vivo procedure for complex major liver resections requiring prolonged hepatic vascular exclusion in normal and diseased livers. Technique and preliminary results of extracorporeal liver surgery (bench procedure) and of surgery on the in situ perfused liver. Reconstruction of the hepatic vein to the prosthetic inferior vena cava in right extended hemihepatectomy with ex situ procedure. Four new hepatectomy procedures for resection of the right hepatic vein and preservation of the inferior right hepatic vein. Extended left hepatic trisegmentectomy with resection of main right hepatic vein and preservation of middle and inferior right hepatic veins.

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Fundus examination: Invasive meningioma dermoid or prolapsed lacrimal gland or may lead to order zebeta 10mg with amex blood pressure medication how it works papilledema or optic atrophy buy zebeta 10 mg on line arrhythmia 2014 ascoms. Exophthalmometry: Hertels exophthalmosoft tissues by a series of spikes of varying meter is generally used to cheap zebeta 10mg visa blood pressure 1 measure the heights depending on the echogenic characprotrusion of the apex of cornea from the teristics of each tissue. B-scan ultrasonography lateral orbital rim in both the eyes simultapresents two-dimensional images and helps neously. Exophthalmometric readings in identifying the size, shape and position of between 10 and 21 mm are considered an orbital lesion. Examination of paranasal sinuses: Paranasal venography was used in the diagnosis of orbital sinuses should be examined to exclude a varices but now it is rarely performed. Arteriomass or a mucocele encroaching on the graphy is indicated in the diagnosis of aneurysm orbital cavity. Systemic examination: It should be conducted carries a risk of neurological and vascular to exclude the developmental anomalies of complications. Magnetic resonance angiothe orbit, neuroblastoma and leukemia graphy is a recent noninvasive technique which especially in children, and thyroid disorder allows the visualization of large and medium (Graves disease) and malignancies of breast, sized vessels. These tests are abnormal in nearly the inflammatory diseases of the orbit and 90% of patients. Estimation of serum angiocavernous sinus, and Wegener’s granulotensin-converting enzyme may be helpful in matosis and neoplasm. Biopsy: the accurate diagnosis of an orbital Investigations mass lesion requires a histopathological examination. Frozen-section analysis ensures a because it provides a good view of bony orbit, complete tumor removal. Cell-marker studies extraocular muscles and retained metallic foreign are required for the orbital lymphoid lesions. Blow-out fracture of the orbit unassociated provides unidimensional images of the orbital with orbital hematoma (most common). Atrophy of the orbital tissue due to senility, dehydration, after repeated periocular injections of corticosteroids and following irradiation of the orbit. Neurogenic causes include Horner’s syndrome and paralysis of superior and inferior oblique muscles. A simple classification Lipodermoid of common orbital tumors is given in Table 26. Lipodermoid is a solid tumor which often occurs Benign Orbital Tumors beneath the conjunctiva near the superotemporal Dermoid quadrant of orbit. Dermoid is the most common congenital orbital tumor frequently found adjacent to the frontoHemangioma zygomatic suture (Fig. Hair, Hemangiomas are benign tumors of the orbit cartilage, teeth, bone and other tissues may be which manifest in two forms—capillary and found in the dermoid. The tumor involves the skin Primary Orbital Tumors producing an elevated strawberry discoloration. Congenital Dermoid, Dermolipoma, Teratoma Vascular Hemangioma Deep seated orbital hemangioma causes bluish Neural Optic nerve glioma, Neurofibroma, discoloration. The capillary hemangioma usually Nerofibromatosis, Meningioma involves the superonasal quadrant of the orbit and Mesenchymal Rhabdomyosarcoma Lymphoid Lymphoma the medial part of upper eyelid. The tumor causes Lacrimal Pleomorphic adenoma, Malignant cosmetic deformities of the eyelid and leads to mixed tumor anisometropia, strabismus and deprivation Secondary Orbital Tumors amblyopia. Eye Retinoblastoma, Malignant Treatment includes local corticosteroids melanoma Eyelids Adenocarcinoma, Squamous cell injection of an equal mixture of betamethasone, carcinoma 6 mg/ml and triamcinolone, 40 mg/ml. Repeat Sinuses Squamous cell carcinoma of injection may be needed in some patients. Small maxillary sinus and nasopharynx Brain Meningioma lesions can be excised surgically. It may Cutaneous malignant melanoma cause slowly progressive proptosis, hyperDiseases of the Orbit 433 Fig. Meningioma Meningioma arises from the arachnoid villi and Neurofibroma is usually attached to the dura mater. The Neurofibromas are mainly composed of prolifesphenoidal ridge meningioma usually originates rating Schwann cells within the nerve sheath. The disease is characterized by localized bone thickening associated with 434 Textbook of Ophthalmology Fig. Lymphoma of the orbit can occur either in Malignant Orbital Tumors isolation or as a part of systemic disease. Rhabdomyosarcoma Lymphoid tumors can be divided into two Rhabdomyosarcoma is the most common primary groups—benign reactive lymphoid hyperplasia malignant orbital tumor of childhood (approxiand malignant lymphomas (90%). It is more common in orbital soft tissue and not from extraocular elderly females (50-70 years of age). The tumor typically chemical studies help in establishing the diaginvolves the superonasal quadrant, but it may nosis. Orbital lymphoma shows monoclonality to define the site and extension of the neoplasm. Malignant An excisional biopsy should be performed lymphoma have multiclonal infiltrates. Eye should be protected by metallic contact lens and a dose of 2000-2500 cGys is recommended. More aggressive lymphomas need chemotherapy or a combination of radiotherapy and chemotherapy. Secondary Orbital Tumors Tumors from contiguous structures such as the eyeball, eyelids, sinuses and brain may invade the orbit.

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Ito T discount zebeta uk heart attack 40 year old female, et al: Unique association of p53 mutations with undifferentiated but not with differentiated carcinomas of the thyroid gland purchase cheap zebeta online heart attack under 30. Ruter A order zebeta 5 mg line hypertension 12080, Nishiyama R, Lennquist S: Tall-cell variant of papillary thyroid cancer: disregarded entity Perry A, Molberg K, Albores-Saavedra J: Physiologic versus neoplastic C-cell hyperplasia of the thyroid: separation of distinct histologic and biologic entities. Machens A, et al: Early malignant progression of hereditary medullary thyroid cancer. Yip L, et al: Multiple endocrine neoplasia type 2: evaluation of the genotype-phenotype relationship. Li Y, et al: Autoantibodies to the extracellular domain of the calcium sensing receptor in patients with acquired hypoparathyroidism. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Benoist C, Mathis D: Autoimmunity provoked by infection: how good is the case for T cell epitope mimicry Kadowaki T: Insights into insulin resistance and type 2 diabetes from knockout mouse models. Yamauchi T, et al: the fat-derived hormone adiponectin reverses insulin resistance associated with both lipoatrophy and obesity. Shimomura I, et al: Leptin reverses insulin resistance and diabetes mellitus in mice with congenital lipodystrophy. Ellard S, et al: A high prevalence of glucokinase mutations in gestational diabetic subjects selected by clinical criteria. The Diabetes Control and Complications Trial Research Group: the effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. Astrup A, Finer N: Redefining type 2 diabetes: "diabesity" or "obesity dependent diabetes mellitus" Rindi G, Capella C, Solcia E: Cell biology, clinicopathological profile, and classification of gastro-enteropancreatic endocrine tumors. Goossens A, Heitz P, Kloppel G: Pancreatic endocrine cells and their non-neoplastic proliferations. Future directions in the study and management of congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Pitkanen J, Peterson P: Autoimmune regulator: from loss of function to autoimmunity. Vaidya B, Pearce S, Kendall-Taylor P: Recent advances in the molecular genetics of congenital and acquired primary adrenocortical failure. Mignon M, Cadiot G: Diagnostic and therapeutic criteria in patients with Zollinger-Ellison syndrome and multiple endocrine neoplasia type 1. Poisson A, Zablewska B, Gaudray P: Menin interacting proteins as clues toward the understanding of multiple endocrine neoplasia type 1. Salvatore D, et al: Increased in vivo phosphorylation of ret tyrosine 1062 is a potential pathogenetic mechanism of multiple endocrine neoplasia type 2B. Then, and for the century that followed, the skin was considered primarily a passive barrier to fluid loss and mechanical injury. During the past three decades, however, enormously productive avenues of scientific inquiry have demonstrated the skin to be a complex organ in which precisely Figure 25-1 A, the skin is composed of an epidermal layer (e) from which specialized adnexa (hair follicles, h; sweat glands, g; and sebaceous glands, s) descend into the underlying dermis (d). B, this projection of the epidermal layer (e) and underlying superficial dermis demonstrates the progressive upward maturation of basal cells (b) into cornified squamous epithelial cells of the stratum corneum (sc). Melanin-containing dendritic melanocytes (m) (and rare Merkel cells containing neurosecretory granules) and midepidermal dendritic Langerhans cells (lc) are also present. The underlying dermis contains small vessels (v), fibroblasts (f), perivascular mast cells (mc), and dendrocytes (dc), potentially important in dermal immunity and repair. Figure 25-2 Schematic representation of dynamic interaction between the epidermal layer and the dermal layer. Keratinocytes at the edge of an ulcer (A) produce cytokines and factors that influence both keratinization and the function of underlying dermal cells (B). In turn, dermal cells (B), such as mast cells, also release cytokines (green granules) and proteases (red granules), which may regulate both endothelial cells and overlying keratinocytes. Perturbations in these interactions between epidermal cells and dermal cells may contribute to pathologic processes, such as psoriasis (C), in which both compartments become morphologically abnormal. Lichenification Thickened and rough skin characterized by prominent skin markings; usually the result of repeated rubbing in susceptible persons. Excoriation Traumatic lesion characterized by breakage of the epidermis, causing a raw linear area. Parakeratosis Modes of keratinization characterized by the retention of the nuclei in the stratum corneum. Hypergranulosis Hyperplasia of the stratum granulosum, often due to intense rubbing. Papillomatosis Surface elevation caused by hyperplasia and enlargement of contiguous dermal papillae. Dyskeratosis Abnormal keratinization occurring prematurely within individual cells or groups of cells below the stratum granulosum. Acantholysis Loss of intercellular connections resulting in loss of cohesion between keratinocytes. Hydropic swelling (ballooning) Intracellular edema of keratinocytes, often seen in viral infections.


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