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Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

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


Older patients with known heart disease should be evaluated for arrhythmic syncope order 40mg sotalol visa blood pressure bottom number 90. Older patients without known heart disease who present with unexplained syncope should undergo further cardiac assessment to purchase discount sotalol line blood pressure chart throughout the day include echocardiogram and stress testing buy generic sotalol 40 mg blood pressure quit smoking. Patients with a normal cardiac work-up may benefit from an upright tilt table test to look for signs of neurocardiogenic syncope. Because systolic blood pressure increases with age, what level of systolic hypertension should be treated in the elderly? According to randomized trials, patients older than 80 years with sustained systolic blood pressure > 160 mmHg benefit from treatment. Evidence is less clear for treating elderly patients with systolic pressure between 140 and 160 mmHg unless they have an additional indication such as chronic kidney disease or heart failure. Patients with coronary artery disease should maintain the diastolic blood pressure > 70 mmHg. Although metalazone is usually added to loop diuretic treatment in patients with refractory heart failure, other thiazide-type diuretics used in full dosage are also highly effective. Metalazone has an elimination half-life of 2 days, making dose titration difficult and leading to excessive diuresis in some patients. Autonomic dysfunction frequently leads to orthostatic hypotension, even in patients with chronic hypertension. Bed rest in frail elderly patients also contributes to orthostasis because of autonomic dysfunction and plasma volume loss. The English version is valid only in patients who are fluent in English and has not been well validated for patients who have completed less than 8 years of education. In assessing serial 7s, tell the patient to keep going but do not repeat your directions after each answer. Variable progression (either stepwise or gradual) of symptoms and cortical findings such as prominent aphasia or motor weakness can suggest vascular dementia. Subcortical vascular dementias often disrupt frontal lobe function and present with mild memory deficits but prominent personality changes such as passivity, abulia, and psychomotor retardation. Subcortical vascular dementia is often undiagnosed and misperceived as depression or apathy. Patients typically respond poorly to antipsychotic medications, with prominent extrapyramidal symptoms. At age 65, the prevalence is approximately 1?2% but increases each year thereafter, approaching 20?25% by age 85. When a demented patient has behavioral problems, what nonpharmacologic approaches are helpful? Cholinesterase inhibitors such as tacrine, donezepil, rivastagmine, and galantamine in general have minimal benefit in reversing dementia but are often given with the hope of slowing progression. Patients with mild-to-moderate dementia should be assessed for depression and treated appropriately. Severe agitation with delusions or hallucinations warrants a trial of an antipsychotic but adverse effects are common. Severe sleep disturbance that has not responded to nonpharmacologic measures warrants a trial of a nonbenzodiazepine hypnotic. Depression is commonly associated with cognitive difficulties (pseudodementia) and many patients in early stages of dementia become depressed. The differentiation of pseudodementia from true dementia can be a clinical challenge. Clues that depression is the cause of cognitive difficulties include decline over weeks to months rather than years and whether the patient has overt concern for their memory loss. Referral for complete neuropsychological testing can be helpful in elucidating the diagnosis in many cases. Treatment with antidepressants will significantly improve cognitive function in patients with pseudodementia, whereas truly demented patients may see improvements in overall function but will continue to have cognitive impairment. Current research, though, focuses on antihypertensive agents, omega-3 fatty acids, physical activity, and cognitive activities as possibly effective. There are no blood tests or imaging studies for confirming the diagnosis, and other medical conditions present with similar features. Presenting features leading to overdiagnosis include: & Tremor related to other causes. The most commonly used are nonselective beta blockers (such as propanolol) and primidone. Surgical procedures may be tried in patients who had an unsatisfactory response to drug therapy, and after carefully weighing the benefit-to-risk ratio. Available surgical procedures include thalamotomy or placement of electrodes for high-frequency stimulation of the thalamus. Many patients fail to mention restless legs, periodic limb movements, or nocturnal myoclonus unless specifically questioned, and only describe poor sleep. Evening treatment with a dopaminergic medication such as ropinirole is highly effective in many patients. What is the most effective treatment for patients who feel dizzy when they turn their head or roll over? This condition is attributed to the presence of free-floating calcium debris (dislodged from the utriculus) within the posterior semicircular canal. The diagnosis is confirmed by the Dix-Hallpike maneuver, which provokes similar symptoms and a typical nystagmus. The maneuvers encourage the migration of calcium debris from semicircular canals back to the utriculus.

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Adipose mass is increased due to order genuine sotalol on line blood pressure effects enlargement of adipose cells due to purchase cheap sotalol line pulse pressure young adults excess of intracellular lipid deposition as well as 2 buy discount sotalol 40 mg online blood pressure chart usa. Obesity often important environmental factor of excess consumption of exacerbates the diabetic state and in many cases weight nutrients can lead to obesity. A strong association between hyperten observations that obesity is familial and is seen in identical sion and obesity is observed which is perhaps due to twins. Weight reduction leads to and its protein product leptin, and db gene and its protein significant reduction in systolic blood pressure. Total blood and pathological changes described below and illustrated in cholesterol levels are also elevated in obesity. As a result of atherosclerosis and increased adipose stores in the subcutaneous tissues, hypertension, there is increased risk of myocardial infarction skeletal muscles, internal organs such as the kidneys, and stroke in obese individuals. Many obese individuals exhibit hyper this is characterised by hypersomnolence, both at night and glycaemia or frank diabetes despite hyperinsulinaemia. This during day in obese individuals along with carbon dioxide is due to a state of insulin-resistance consequent to tissue retention, hypoxia, polycythaemia and eventually right-sided insensitivity. The term pickwickian 245 syndrome was first used by Sir William Osler for the sleep apnoea syndrome). These individuals are more prone to develop degenerative joint disease due to wear and tear following trauma to joints as a result of large body weight. Diet rich in fats, particularly derived from animal fats and meats, is associated with higher incidence of cancers of colon, breast, endometrium and prostate. Its causes may be the following: i) deliberate fasting?religious or political; ii) famine conditions in a country or community; or iii) secondary undernutrition such as due to chronic wasting Figure 9. After about one week of starvation, protein A starved individual has lax, dry skin, wasted muscles breakdown is decreased while triglycerides of adipose tissue and atrophy of internal organs. The following metabolic changes by most organs including brain in place of glucose. Starvation take place in starvation: can then continue till all the body fat stores are exhausted 1. This results in of primary dietary deficiency or conditioned deficiency may release of glycogen stores of the liver to maintain normal cause loss of body mass and adipose tissue, resulting in blood glucose level. Protein stores and the triglycerides of adipose socioeconomic factors limiting the quantity and quality of tissue have enough energy for about 3 months in an dietary intake, particularly prevalent in the developing individual. Proteins breakdown to release amino acids which countries of Africa, Asia and South America. The impact of are used as fuel for hepatic gluconeogenesis so as to maintain deficiency is marked in infants and children. Feature Kwashiorkor Marasmus Definition Protein deficiency with sufficient calorie intake Starvation in infants with overall lack of calories Clinical features Occurs in children between 6 months and 3 years Common in infants under 1 year of age (Fig. Marasmus is starvation in infants occurring due to overall nutrients are common due to generalised malnutrition of lack of calories. In the developed countries, individual vitamin the salient features of the two conditions are contrasted deficiencies are noted more often, particularly in children, in Table 9. However, it must be remembered that mixed adolescent, pregnant and lactating women, and in some due forms of kwashiorkor-marasmus syndrome may also occur. General secondary causes of conditioned nutritional deficiencies listed already above. Chronic alcoholism is a within the body and are essential for maintenance of normal common denominator in many of vitamin deficiencies. Thus, these substances must be other noteworthy features about vitamins are as under: provided in the human diet. While both vitamin deficiency and excess may occur from or animal origin so that they normally enter the body as another disease, the states of excess and deficiency constituents of ingested plant food or animal food. Vitamins are conven rod cells, and iodopsins sensitive in bright light and formed tionally divided into 2 groups: fat-soluble and water-soluble. Maintenance of structure and function of specialised epithe presence of bile salts and intact pancreatic function. Retinol plays an important role in the synthesis of deficiencies occur more readily due to conditioning factors glycoproteins of the cell membrane of specialised epithelium (secondary deficiency). Beside the deficiency syndromes of such as mucus-secreting columnar epithelium in glands and these vitamins, a state of hypervitaminosis due to excess of mucosal surfaces, respiratory epithelium and urothelium. Water-soluble vitamins are more readily absor skin diseases, premalignant conditions and certain cancers. Being water soluble, ciency of vitamin A is common in countries of South-East these vitamins are more easily lost due to cooking or Asia, Africa, Central and South America whereas mal processing of food. Night blindness is usually the first sign of vitamin A It is available in diet in 2 forms: deficiency. As a result of replacement metaplasia of mucus-secreting cells by squamous cells, there is dry and As preformed retinol, the dietary sources of which are scaly scleral conjunctiva (xerophthalmia). The lacrimal duct animal-derived foods such as yolk of eggs, butter, whole also shows hyperkeratosis. The skin develops papular lesions Retinol is stored in the liver cells and released for trans giving toad-like appearance (xeroderma). This is due to port to peripheral tissues after binding to retinol-binding follicular hyperkeratosis and keratin plugging in the protein found in blood. This invol i) Squamous metaplasia of respiratory epithelium of bronchus ves formation of 2 pigments by oxidation of retinol: rhodopsin, and trachea may predispose to respiratory infections. Very large doses of vitamin A can produce toxic manifestations in children as well as in adults. The clinical manifestations of chronic the liver and kidney for being functionally active (Fig.

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There was no history of prior abdominal surgery cheap sotalol 40mg on line blood pressure 50 0, making adhesive bowel obstruction a less likely etiology generic sotalol 40mg fast delivery blood pressure medication knee pain. Wen Z et al: the lymphoscintigraphic manifestation of (99m)Tc-dextran lymphatic imaging in primary intestinal lymphangiectasia generic 40 mg sotalol blood pressure chart athlete. Ersoy O et al: Evaluation of primary intestinal lymphangiectasia by capsule endoscopy. Urganci N et al: Evaluation of paediatric patients with protein losing 0 Secondary form enteropathy a single centre experience. A rare diagnosis chylomicrons and fat-soluble vitamins, excessive leakage of protein-losing enteropathy. Milone M et al: Computed tomography findings of pneumatosis and portomesenteric venous gas in acute bowel ischemia. Zorgdrager M et al: Pneumatosis intestinalis associated with enteral tube cough (depending on etiology) feeding. The patient remained relatively asymptomatic, confirming this as "benign" (nonischemic) pneumatosis, likely due to medications. This combination of findings is essentially diagnostic of transmural bowel infarction. Despite the interpretation of benign pneumatosis coli, this patient was taken to surgery. Lianos G et al: Adult bowel intussusception: presentation, location, etiology, 0 Intussuscipiens: Sheath or outer tube diagnosis and treatment. El Fortia M et al: Tetra-layered sign of adult intussusception (new ultrasound Microscopic Features approach). Long-segment, obstructing intussusceptions such as this often have a lead mass when seen in adults. The track is outside the internal sphincter, but does not cross the external sphincter, compatible with an intersphincteric perianal fistula. Enhancement along fistulous tracts suggests that the fistula is active, rather than chronic and healed. Seton catheters, often utilized to keep fistulous tracts open and facilitate drainage, appear low signal on all pulse sequences. Notice that the fistula is contiguous with a large T2 hyperintense "horseshoe" type abscess? Crohn disease is a common cause of spontaneous enteric fistulas, as it is a chronic, transmural inflammatory disease. Romano S et al: Small bowel vascular disorders from arterial etiology and 0 60-70% of acute ischemia due to arterial occlusion, 5 impaired venous drainage. Complications: Stricture, infarction, necrosis, perforation spectrum of imaging findings. The wall is thickened and ascites is present, findings worrisome for transmural ischemic injury. This patient was subsequently diagnosed with a hypercoagulable state and responded to anticoagulation. The mesenteric injury was surgically repaired and a segment of small intestine was resected. Honaker D et al: Blunt traumatic abdominal wall hernias: Associated injuries and optimal timing and method of repair. The active mesenteric bleeding alone would have warranted surgical intervention in this case. At surgery, serosal avulsion and transmural laceration of the small bowel were confirmed. This and the seat belt contusion are highly associated with bowel and mesenteric injuries. The elevated intraluminal pressure within the duodenum contributed to the biliary obstruction. Farinella E et al: Modified H-pouch as an alternative to the J-pouch for anorectal reconstruction. Ileoanal pouch "failure" (need for permanent end intermittent small bowel obstruction after biliopancreatic diversion with duodenal switch. The biopsy had shown adenocarcinoma of the cecum, and this and the perforation were confirmed at surgery. Anastomotic leaks often result in infection and further breakdown of the anastomosis; abscesses and fistulas commonly result. The patient was treated with steroids and symptoms resolved over a 2 week period. Spot film from a barium enema reveals a persistent and high-grade stricture of the rectum? Qin Q et al: Clinical risk factors for late intestinal toxicity after radiotherapy: a Microscopic Features systematic review protocol. Birgisson H et al: Late gastrointestinal disorders after rectal cancer surgery perforation with and without preoperative radiation therapy. Beasley M et al: Complications of radiotherapy: improving the therapeutic watery diarrhea index. There is similar thickening of the bladder wall and hyperenhancement of the bladder mucosa, consistent with radiation cystitis. Ischemic or infectious colitis could have a similar appearance, but colonoscopic biopsy confirmed radiation colitis.

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Obstruction to cheap sotalol 40 mg amex blood pressure top number the venous drainage and arterial supply may result in infarction or Transmural Infarction gangrene of the affected loop of intestine sotalol 40mg fast delivery heart attack zine archive. The gross and Ischaemic necrosis of the full-thickness of the bowel wall is microscopic appearance of strangulated intestine is the same more common in the small intestine than the large intestine order sotalol 40 mg amex heart attack white sea acapella remix. The common causes of transmural Intussusception infarction of small bowel are as under: i) Mesenteric arterial thrombosis such as due to the following: Intussusception is the telescoping of a segment of intestine Atherosclerosis (most common) into the segment below due to peristalsis. The telescoped Aortic aneurysm segment is called the intussusceptum and lower receiving segment is called the intussuscipiens. The condition occurs Vasospasm more commonly in infants and young children, more often Fibromuscular hyperplasia in the ileocaecal region when the portion of ileum invaginates Invasion by the tumour into the ascending colon without affecting the position of Use of oral contraceptives the ileocaecal valve (Fig. Less common forms are ileo Arteritis of various types ileal and colo-colic intussusception. In the case of adults, the usual Endocarditis (infective and nonbacterial thrombotic) causes are foreign bodies and tumours. Atherosclerotic plaques the main complications of intussusception are intestinal Atrial myxoma obstruction, infarction, gangrene, perforation and peritonitis. The causes are as under: Volvulus is the twisting of loop of intestine upon itself through 180 or more. This leads to obstruction of the intestine as well as cutting off of the blood supply to the affected loop. The usual causes are bands and adhesions (congenital or acquired) and long mesenteric attachment. The condition is also referred to as haemorrhagic gastroenteropathy, and in the case of colon as Torsion membranous colitis. Grossly, irrespective of results from conditions causing non-occlusive hypoperfusion the underlying etiology, infarction of the bowel is (compared from transmural infarction which occurs from haemorrhagic (red) type (page 126). In the case of colonic Shock infarction, the distribution area of superior and inferior Cardiac failure mesenteric arteries. The affected areas become dark purple and Intake of drugs causing vasoconstriction. The affected segment of the of demarcation between the infarcted bowel and the bowel is red or purple but without haemorrhage and normal intestine, whereas in venous occlusion the exudation on the serosal surface. The mucosa is infarcted area merges imperceptibly into the normal bowel oedematous at places, sloughed and ulcerated at other (Fig. Microscopically, there is coagulative necrosis and ulcera Microscopically, there is patchy ischaemic necrosis of tion of the mucosa and there are extensive submucosal mucosa, vascular congestion, haemorrhages and haemorrhages. Subsequently, inflammatory cell infiltration superficial muscularis but deeper layer of muscularis and and secondary infection occur, leading to gangrene of the serosa are spared. The condition is clinically characterised by abdominal angina in which the patient has acute abdominal pain, Clinically, as in transmural infarction, the features of nausea, vomiting, and sometimes diarrhoea. The disease is abdominal pain, nausea, vomiting and diarrhoea are present, rapidly fatal, with 50-70% mortality rate. With adequate therapy, normal morphology is completely restored in In healed cases, stricture formation, malabsorption and 565 superficial lesions, while deeper lesions may heal by fibrosis short bowel syndrome are the usual complications. Ischaemic having many similarities but the conditions usually have colitis is characterised by chronic segmental colonic distinctive morphological appearance. Ischaemic colitis passes through 3 commonly the segment of terminal ileum and/or colon, stages: infarct, transient ischaemia and ischaemic stricture. External surface of the affected chronic ulcero-inflammatory colitis affecting chiefly the area is fusiform or saccular. On cut section, there are mucosa and submucosa of the rectum and descending colon, patchy, segmental and longitudinal mucosal ulcers. Thus, though sometimes it may involve the entire length of the the gross appearance can be confused with either of the large bowel. Both these disorders primarily affect the bowel but may Microscopically, the ulcerated areas of the mucosa show have systemic involvement in the form of polyarthritis, granulation tissue. The submucosa is characteristically uveitis, ankylosing spondylitis, skin lesions and hepatic thickened due to inflammation and fibrosis. Both diseases can occur at any age but are more muscularis may also show inflammatory changes and frequent in 2nd and 3rd decades of life. The condition has been considered as a variant causing diminished epithelial barrier function. Establishment of feeding disease-predisposing loci are present in chromosomes 16q, 5. Grossly, the affected mocosa which in mutated form results in loss of its function segment of the bowel is dilated, necrotic, haemorrhagic and renders an individual about 50-times higher risk to and friable. In addition to role of genetic factors and deranged T-cell mediated immunity, a role for several c) Interference with normal epithelial barrier function in the exogenous and environmental factors has been assigned: intestine. Location Commonly terminal ileum and/or Commonly rectum, sigmoid colon and ascending colon extending upwards 3. Extent Usually involves the entire thickness Usually superficial, confined to mucosal of the affected segment of bowel wall layers 4. Ulcers Serpiginous ulcers, may develop Superficial mucosal ulcers without fissures into deep fissures 5. Type of inflammation Non-caseating granulomas and infiltrate Crypt abscess and non-specific acute and of mononuclear cells (lymphocytes, chronic inflammatory cells (lymphocytes, plasma cells and macrophages) plasma cells, neutrophils, eosinophils, mast cells) 3. Submucosa Widened due to oedema and lymphoid Normal or reduced in width aggregates 5. Muscularis Infiltrated by inflammatory cells Usually spared except in cases of toxic megacolon 6.

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Various management options are available buy 40 mg sotalol fast delivery blood pressure medication effects on kidneys, including photodynamic therapy and the types of evidence and the grading of photocoagulation buy sotalol without a prescription blood pressure table. Recurrence and retinal detachment recommendations used within this review are can complicate management of the condition generic sotalol 40mg without a prescription pulse blood pressure normal. Low-dose proton beam therapy for patients with Sturge-Weber Syndrome treated for circumscribed choroidal hemangiomas. Arch choroidal haemangioma with 20 Gray (Gy) external Ophthalmol 2004; 122(10): 471?475. To summarise briefly, the risk is small for adults but may be more important for young children. Cataract development is a potential medium to long-term dose-dependent consequence of radiation exposure of the eye, although its development can be managed with lens replacement. Central nervous system Meningiomas Management of Grade 1 meningiomas Background Watch and wait Meningiomas account for about 20?30% of all primary In some circumstances, it can be appropriate to adopt brain and central nervous system tumours. Many are1 a watch and wait approach after the diagnosis of a asymptomatic and found in the elderly, making it meningioma. Observations of tumour growth rates in challenging to determine the population prevalence untreated patients have suggested that calcification accurately. Overall, they are more common in women, rates, making radiological surveillance important if with a female to male ratio of about two or three to treatment is a potential option. For spinal meningiomas, which comprise about co-morbidities that threaten to limit their lives, active 10% of all meningiomas, the female to male ratio is treatment or surveillance may be unnecessary. Various case series have been published which more common in women than men (particularly are heterogeneous in terms of dose and technique. This circumscribed, slow-growing tumours that are thought has been shown consistently in a large number of to arise from mesodermal arachnoid cells. They show studies (even if randomised studies have not been performed) see Table 8. Some show barely perceptible growth, Recommended doses are usually in the range of while more anaplastic forms can be locally invasive 50?55 Gray (Gy) (1. Table 9 (page this suggested better control with doses >52 Gy vs 63) lists some of these, including a range of older lower doses (ten-year local control 93% vs 65%), studies and two much larger series published although this difference disappeared on multivariate recently. A recent paper by However, the multiple series quoted in Tables 8 and Qi et al carefully evaluated the pathology of resected 9 would suggest similar levels of tumour control meningiomas in the region of dural tails. Therefore a pragmatic view has to be taken >3 cm diameter; to higher doses: >15?18 Gy; and to when outlining dural tails, striking a balance between a tumours in a non-basal location). Close proximity to desire for complete tumour coverage and, at the same sensory cranial nerves also carries a risk of temporary time, a minimisation of toxicity. It does, however, immobilisation and position verification strategies in achieve high rates of local control with the convenience individual departments. Tumours are often achieve excellent results and has the advantage of relatively small with clearly defined margins. Older series produced structures is also attractive in a patient group that may higher rates of toxicity, presumably due to poorer live for many years, and where the effects of dose to planning techniques. Localised, small volume recurrence after previous surgery can be another suitable target. In one large study of >5,000 patients meningiomas) (1,200 with >10 years follow-up), there was no measurable increase in brain tumours. As such, they fall outside the scope knife radiosurgery for vestibular schwannoma, found of these guidelines. Other tumours that might arise are radiation-induced meningioma increased with dose, sarcomas and leukaemias; again the risks are small in volume and, not unexpectedly, was also age adults but increased in younger patients. This is where the treated volume is likely to be large (for particularly the case in patients with pressure example, treating a large postoperative tumour symptoms (such as headache, nausea) from the bed) (Grade C). It the types of evidence and the grading of also lends itself to the treatment of small, clearly recommendations used within this review are based defined foci of residual or recurrent disease after on those proposed by the Scottish Intercollegiate previous surgery (Grade C). Radiation therapy in the J Neurooncol 1996; 29(3): 197?205 treatment of partially resected meningiomas. Growth pattern changes the role of radiotherapy in the treatment of of meningiomas: long-term analysis. The natural history of incidental Intracranial meningiomas: analysis of meningiomas. Postoperative irradiation for subtotally J Neurol Neurosurg Psychiatry 2000; resected meningiomas. J Neurol Neurosurg Psychiatry 1957; the role of postoperative irradiation in the 20(1): 22?39. Benign meningiomas: primary treatment the recurrence of intracranial meningiomas selection affects survival. Meningioma: analysis of recurrence and factors in 581 Mayo Clinic patients, 1978 through progression following neurosurgical resection. Stereotactic meningiomas: 15 years experience at the radiotherapy for treatment of cavernous sinus Bordeaux University Hospital Center. Milker-Zabel S, Zabel A, Schulz-Ertner D, Schlegel Fractionated external-beam radiation therapy for W, Wannenmacher M, Debus J. Int J Radiat stereotactic radiotherapy in patients with benign Oncol Biol Phys 1999; 44(1): 75?79. Int J radiotherapy of meningiomas: symptomatology, Radiat Oncol Biol Phys 2000; 48(5): 1363?1370.


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