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Eduardo Castro, M.D.

  • Instructor in Medicine
  • Harvard Medical School
  • Massachusetts General Hospital
  • Boston, MA

Snipping this portion of the suture allows traction on the knot to pull the suture through the tissues for removal fungus on nails buy discount sporanox line. An anesthetic may be required based on exposure anti fungal cream in japanese order sporanox 100 mg on line, patient comfort, and provider or patient preference. Cervical cerclage is the placement of a suture or tape to support and partially occlude the uterine cervix to reduce the risk for preterm delivery in the face of cervical insufficiency. A number of procedures have been described, but the most common and simplest is the McDonald cerclage, which is described here. Cervical cerclage may also be accomplished by placing the suture via an abdominal route, although this is a much more invasive procedure and the suture is generally left in place permanently, precluding vaginal delivery. Cerclage may be placed based on history or cervical shortening documented through ultrasonography. Prophylactic cervical cerclage is generally delayed until after 14 weeks so that early pregnancy losses from other factors may be resolved. Any obvious vaginal or cervical infections should be treated, and cultures for gonorrhea, chlamydia, and group B streptococci should be obtained prior to proceeding. Sexual intercourse is generally proscribed for 1 week before and after the procedure. The anesthetized patient is placed in the dorsal lithotomy position, the vagina and cervix are disinfected, and the cervix is visualized using retractors. When the suture is placed vaginally, it is generally removed at 38 weeks of gestation. Because of scarring after cerclage, approximately 15% of patients require cesarean delivery. Cervical Incompetence Prevention Randomized Cerclage Trial: Emergency cerclage with bed rest versus bed rest alone. Cerclage for prevention of preterm birth in women with a short cervix found on transvaginal ultrasound examination: a randomized trial. Randomised trial of cervical cerclage, with and without occlusion, for the prevention of preterm birth in women suspected for cervical insufficiency. Multicenter randomized trial of cerclage for preterm birth prevention in high-risk women with shortened midtrimester cervical length. Cervical occlusion in women with cervical insufficiency: protocol for a randomised, controlled trial with cerclage, with and without cervical occlusion. Fetal Medicine Foundation Second Trimester Screening Group: Cervical cerclage for prevention of preterm delivery in women with short cervix: randomized controlled trial. Effectiveness of cerclage according to severity of cervical length shortening: a meta-analysis. Cervical cerclage for prevention of preterm delivery: meta-analysis of randomized trials. Abdominal versus vaginal cerclage after a failed transvaginal cerclage: a systematic review. Cold knife cone biopsy is generally used for special situations such as when the size or shape of the specimen must be customized to a greater degree than allowed by loop procedures. After providing appropriate informed consent, the anesthetized patient is placed in the dorsal lithotomy position, the vagina and cervix are disinfected, and the cervix is visualized using retractors. If necessary, a colposcopic examination, facilitated by acetic acid or Lugol solution, may be performed to further characterize any abnormalities present. These are generally tied and held to stabilize the cervix until the end of the procedure, although the role of these sutures in reducing blood loss has been debated and they may be omitted in certain cases. Dilute vasopressin (1 pressor unit/20 mL saline) or 1: 200,000 epinephrine solution may be injected into the cervical parenchyma to further reduce blood loss. If desired, a blunt uterine probe or small cervical dilator is placed into the endocervical canal to guide the dissection. A cone-shaped plug of cervical tissue is excised by sweeping the scalpel blade around the ectocervix with the blade angled inward to intersect the endocervical canal. The width and depth of the conization are determined by the anatomy of the cervix, the location of the transformation zone, and the lesion being treated; it must include the transformation zone and any specific lesion. Hemostasis may be obtained through electrosurgical energy or the application of styptics such as Monsel solution. Some advocate general cautery of the cut surface of the cervix, although the resultant slough of damaged tissue may delay final healing. If desired, the ectocervical edges may be sewn with a running suture to provide hemostasis at the edge and to roll the edges inward. As an alternative, Sturmdorf stitches may be placed to partially reconstruct the external cervical os, although some argue that this may increase the risk of cervical stenosis. At the close of the procedure, the held tails of the hemostatic sutures may be either clipped (leaving the suture in place) or tied across the cervix to apply pressure or to hold a hemostatic pledget (oxidized regenerated cellulose [Surgicel or similar]) in place. Cold-knife conization versus conization by the loop electrosurgical excision procedure: a randomized, prospective study. Obstetric outcomes after conservative treatment for intraepithelial or early invasive cervical lesions: systematic review and meta-analysis. The up-to-date evidence on colposcopy practice and treatment of cervical intraepithelial neoplasia: the Cochrane colposcopy and cervical cytopathology collaborative group (C5 group) approach. Interventions for preventing blood loss during the treatment of cervical intraepithelial neoplasia. Cervical conization as definitive therapy for early invasive squamous carcinoma of the cervix. Disinfection with a suitable solution may be performed, although most believe it is not required. The visible portion of the polyp is then grasped, and gentle traction, twisting through several revolutions, or excision accomplishes the removal of polyp. If the polyp is considered to arise from high in the endocervical canal, the base may be gently curetted with an endocervical curette. Curettage of the endocervical canal should also be considered to rule out a coexisting hyperplasia or cancer. Although malignancy is rare, all polyps should be submitted for histologic examination. The base of the polyp may be treated with chemical cautery (Monsel solution or silver nitrate), electrocautery, or cryocautery. Protruding giant cervical polyp in a young adolescent with a previous rhabdomyosarcoma. The rate of cesarean birth varies from 10% to 35% around the world, influenced by cultural factors and the availability of surgical care. In the United States, the rate of cesarean births increased by 5-fold for a 20-year period that ended in the early 1990s. The exact reasons for this are open to conjecture, but concerns about liability, almost universal use of electronic fetal monitoring, increasing birth weight, and an increased number of repeat cesarean deliveries have all been postulated. Despite this increase, only minor improvements in newborn outcomes have occurred as a result. Cesarean delivery may be accomplished through either a lower abdominal vertical midline or transverse (Pfannenstiel) incision. A transverse incision in the lower uterine segment is made (within the peritoneal flap, if one has been made), and this is carried down to the amniotic sac. The amniotic sac is entered, and the exact lie and position of the fetus are determined. Where possible, the fetal head is delivered through the uterine incision in the occiput-anterior position and extended to allow passage outside the abdomen by gentle upward traction. The delivery is completed, and the newborn is briefly dried, suctioned, and stimulated as needed. The umbilical cord is doubly clamped and cut, and the newborn is transferred from the sterile field to the pediatrician or other provider who will conduct the initial assessment and stabilization. If significant bleeding from the edge of the uterus is encountered, it is temporarily controlled using non-crushing clamps.

Diseases

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  • Teratocarcinosarcoma
  • Robin sequence and oligodactyly
  • Placenta disorder
  • Intrinsic factor, congenital deficiency of
  • Epidermolysis bullosa, generalized atrophic benign
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A rectangle template for hemiglossectomy defects incorporates the principles of the biolobed flap into a simple design without any concern for partial flap necrosis from devascularization antifungal zone of inhibition discount sporanox 100 mg on-line. However fungus eating fish purchase sporanox amex, a majority of these patients had T1 or T2 lesions, and there was no assessment of swallowing function. However, a retrospective review of 50 patients that had submental flaps for oral cavity reconstruction demonstrated a 10% occult metastatic node rate in level 1 with no local recurrences. Although not found in this study, it should be noted that peripheral and complete necrosis of the supraclavicular artery island flap has been reported. There is evidence that reinnervation of sensory nerves from the flap to the lingual nerve improves sensation. Speech and swallowing function postreconstruction is likely predominately mediated by the amount of native tongue sacrificed and the final volume of the reconstruction rather than a return to baseline sensation. It is difficult to extrapolate meaningful conclusions with such small sample sizes and lack of a control group. Our protocol for freeflap reconstruction is for flap checks every hour for the first 24 hours, every 2 hours for the second 24 hours, and every 4 hours thereafter. Pedicled regional flaps require no monitoring, and have been shown to have decreased hospital stay compared to free-flap reconstruction. Patients with free-flap reconstruction typically are hospitalized for 5 to 10 days depending on the type of reconstruction and their ability to safely ingest an oral diet. Subsequent posthospital care involves local wound care to free flap and local flap donor sites and continued work with speech-language pathology for speech and swallow rehabilitation. This is predominately due to the split-thickness skin graft used to cover the forearm defect with dehiscence of the graft overlying the flexor carpi radialis tendon. The appropriate reconstructive option should consider functional outcome, patient comorbidities in relation to operative time, and potential donor site morbidity. The principles of oral tongue reconstruction, including restoration of sufficient volume for premaxilla, palatal, and pharyngeal contact of the reconstructed tissue, should be followed. Perform laryngeal suspension in patients who have had lingual release for tumor resection to help prevent postoperative aspiration. Reinnervation of flaps improves sensation; however, the functional implications are yet to be known. Microvascular reconstruction of the tongue using a free anterolateral thigh flap: three-dimensional evaluation of volume loss after radiotherapy. A systematic approach to functional reconstruction of the oral cavity following partial and total glossectomy. Analysis of the relations between the shape of the reconstructed tongue and postoperative functions after subtotal or total glossectomy. Individual design of the anterolateral thigh flap for functional reconstruction after hemiglossectomy: experience with 238 patients. Functional reconstruction of swallowing and articulation after total glossectomy without laryngectomy: money pouch-like reconstruction method using rectus abdominis myocutaneous flap. Modification of flap design for total mobile tongue reconstruction using a sensitive antero-lateral thigh flap. A new flap design for tongue reconstruction after total or subtotal glossectomy in thin patients. Quality of life in patients after resection of pT3 lateral tongue carcinoma: microvascular reconstruction versus primary closure. Swallowing function in patients who underwent hemiglossectomy: comparison of primary closure and free radial forearm flap reconstruction with videofluoroscopy. Submental island pedicled flap vs radial forearm free flap for oral reconstruction: comparison of outcomes. Oncologic safety of the submental flap for reconstruction in oral cavity malignancies. Functional comparison after reconstruction with a radial forearm free flap or a pectoralis major flap for cancer of the tongue. Pedicled supraclavicular artery island flap versus free radial forearm flap for tongue reconstruction following hemiglossectomy. Usefulness of supraclavicular flap in reconstruction following resection of oral cancer. Microvascular free tissue transfer for tongue reconstruction after hemiglossectomy: a functional assessment of radial forearm versus anterolateral thigh flap. Radial forearm versus anterolateral thigh flap reconstruction after hemiglossectomy: functional assessment of swallowing and speech. Comparison of morbidity after reconstruction of tongue defects with an anterolateral thigh cutaneous flap compared with a radial forearm free-flap: a meta-analysis. Motor and sensory morbidity associated with the anterolateral thigh perforator free flap. True functional reconstruction of total or subtotal glossectomy defects using a chimeric anterolateral thigh flap with both sensorial and motor innervation. Oral sensation and function: a comparison of patients with innervated radial forearm free flap reconstruction to healthy matched controls. Its lack of a physical barrier permits early invasion to lymphatics and adjacent neurovascular structures. The limited surgical access, coupled with the small space increase the likelihood of positive margins, and the propensity for cervical metastases make this area challenging for surgeons. Keywords: floor of the mouth cancer, oral cavity cancer, squamous cell carcinoma, approach to floor of the mouth, mandibulotomy, mandibulectomy, mandibular invasion 17. This can be readily achieved under local anesthetic, followed by a punch biopsy of the edge of the tumor and normal tissue. A thorough history and examination should be performed in all these patients, beginning with an inquiry about the presenting symptoms including pain, paresthesia, ear pain, dysphagia, odynophagia, voice change, dysarthria, trismus, bleeding, weight loss, lower lip/chin numbness, loose dentition, and preexisting dentures. This should be followed by specific questions about their past medical history and surgical history, allergies, social network and support, tobacco use, and alcohol consumption. These factors all influence the preoperative counseling and optimization of patients. It is our practice to routinely refer patients with 10% weight loss to a dietitian for optimization of nutrition prior to surgery. These factors also significantly influence the postoperative management of the patient in terms of rehabilitation and progression through to adjuvant therapies including radiotherapy and chemotherapy. A thorough examination, in particular, with bimanual palpation of the lesion should be attempted to ascertain the size. Laterally, fixation of the tumor through involvement of the periosteum may indicate underlying involvement of the mandible. The medial extent of the tumor edge should also be evaluated, focusing on the extent of involvement of the oral tongue. Loose dentition, particularly, adjacent to the tumor should be noted for potential invasion of the mandible. Trismus should also be noted as this will influence the choice of surgical access, which will be discussed later. The neck should then be systematically examined for the clinical determination of regional spread. Flexible laryngoscopy should be routinely performed to evaluate for potential posterior extension of the tumor, synchronous primaries, and the status of the airway. Following this if reconstruction with a pedicled or free flap is being considered, the appropriate donor sites should be assessed, as discussed in Chapter 18. In addition, patients may initially present with a neck mass from regional lymph node metastases or even direct extension of tumors into the submental or submandibular region. If there is mandibular invasion noted preoperatively or intraoperatively, a segmental mandibulectomy is needed. Routinely sacrificing the sublingual gland not only puts the lingual nerve, hypoglossal nerve, and submandibular duct at risk, but also increases the risk of fistula formation and neck wound complications to 25% compared to 14% of patients who did not undergo sublingual gland excision. It is bounded anteriorly and laterally by the lingual surface of the mandible and its overlying mucoperiosteum, medially by the lateral surface of the tongue. On each side of the frenulum (from superior to inferior) are the deep lingual vein, the sublingual ridge, and the sublingual caruncles. Medial to the mylohyoid muscle are the sublingual gland, submandibular duct, hypoglossal nerve, and lingual nerve. The submandibular gland lies at the posterior free edge of the mylohyoid with the deep lobe situating deep to the mylohyoid muscle.

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Risk of oral cancer associated with tobacco smoking fungus like protists definition sporanox 100mg free shipping, alcohol consumption and oral hygiene: a casecontrol study in Madrid jessica antifungal treatment discount sporanox 100mg mastercard, Spain. Epidemiologic characteristics of oral cancer: single-center analysis of 4097 patients from the Sun Yat-sen University Cancer Center. The prevalence of oral leukoplakia in 138 patients with oral squamous cell carcinoma. Screening for oral potentially malignant epithelial lesions and squamous cell carcinoma: a discussion of benefit and risk. Toward a multimodal cell analysis of brush biopsies for the early detection of oral cancer. Oral health-related quality of life of patients with oral lichen planus, oral leukoplakia, or oral squamous cell carcinoma. Comparison of orofacial pain of patients with different stages of precancer and oral cancer. Predicting cancer development in oral leukoplakia: ten years of translational research. Genetic aberrations in oral or head and neck squamous cell carcinoma 2: chromosomal aberrations. Screening for and diagnosis of oral premalignant lesions and oropharyngeal squamous cell carcinoma: role of primary care physicians. The limitations of the clinical oral examination in detecting dysplastic oral lesions and oral squamous cell carcinoma. Squamous cell carcinoma and precursor lesions: diagnosis and screening in a technical era. Oral leukoplakia: clinical, histopathologic, and molecular features and therapeutic approach. Nomenclature and classification of potentially malignant disorders of the oral mucosa. Potentially malignant disorders of the oral and oropharyngeal mucosa; present concepts of management. Carcinoma and dysplasia in oral leukoplakias in Taiwan: prevalence and risk factors. Pathophysiology, etiologic factors, and clinical management of oral lichen planus, part I: facts and controversies. Oral lichen planus and oral lichenoid lesions: diagnostic and therapeutic considerations. Squamous cell carcinoma development in previously diagnosed oral lichen planus: de novo or transformation Prevalence of bilateral "mirror-image" lesions in patients with oral potentially malignant epithelial lesions. A retrospective study of oral lichen planus patients with concurrent or subsequent development of malignancy. The possible premalignant character of oral lichen planus and oral lichenoid lesions: a prospective study. Oral potentially malignant disorders: is malignant transformation predictable and preventable Oral potentially malignant disorders among dental patients: a pilot study in Jordan. Oral squamous cell carcinoma associated with oral submucous fibrosis have better oncologic outcome than those without. Concomitant association of oral submucous fibrosis and oral squamous cell carcinoma and incidence of malignant transformation of oral submucous fibrosis in a population of Central India: a retrospective study. Early stage oral submucous fibrosis is characterized by increased vascularity as opposed to advanced stages. Oral submucous fibrosis: an update on pathophysiology of malignant transformation. An update on studies on etiological factors, disease progression, and malignant transformation in oral submucous fibrosis. Major advances in the knowledge and understanding of the epidemiology, aetiopathogenesis, diagnosis, management and prognosis of oral cancer. A survey of the current approaches to diagnosis and management of oral premalignant lesions. The usefulness of toluidine staining as a diagnostic tool for precancerous and cancerous oropharyngeal and oral cavity lesions. A cross-sectional study evaluating chemiluminescence and autofluorescence in the detection of clinically innocuous precancerous and cancerous oral lesions. Non-invasive visual tools for diagnosis of oral cancer and dysplasia: a systematic review. Influence of fluorescence on screening decisions for oral mucosal lesions in community dental practices. The utility of toluidine blue staining and brush cytology as adjuncts in clinical examination of suspicious oral mucosal lesions. American Dental Association Council on Scientific Affairs Expert Panel on Screening for Oral Squamous Cell Carcinomas. Evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas. Utility of toluidine blue staining and brush biopsy in precancerous and cancerous oral lesions. Reliability of toluidine blue application in the detection of oral epithelial dysplasia and in situ and invasive squamous cell carcinomas. Chemiluminescence as a diagnostic aid in the detection of oral cancer and potentially malignant epithelial lesions. Toluidine blue uptake in potentially malignant oral lesions in vivo: clinical and histological assessment. Development of a facile fluorescent assay for the detection of 80 mutations within the p53 gene. The efficacy of oral brush biopsy with computer-assisted analysis in identifying precancerous and cancerous lesions. The clinical features, malignant potential, and systemic associations of oral lichen planus: a study of 723 patients. Adjunctive techniques for oral cancer examination and lesion diagnosis: a systematic review of the literature. The use of toluidine blue in the detection of premalignant and malignant oral lesions. The utility of tolonium chloride rinse in the diagnosis of recurrent or second primary cancers in patients with prior upper aerodigestive tract cancer. Toluidine blue staining identifies highrisk primary oral premalignant lesions with poor outcome. The role of vital tissue staining in the marginal control of oral squamous cell carcinoma. A reason for the use of toluidine blue staining in the presurgical management of patients with oral squamous cell carcinomas. Final evaluation of tolonium chloride rinse for screening of high-risk patients with asymptomatic squamous carcinoma. Toluidine blue staining in the detection of oral precancerous and malignant lesions. Sensitivity and specificity of OraScan (R) toluidine blue mouthrinse in the detection of oral cancer and precancer. The utility of toluidine blue application as a diagnostic aid in patients previously treated for upper oropharyngeal carcinoma. Detection of minimal residual cancer to investigate why oral tumors recur despite seemingly adequate treatment. The need to reassess studies on detection of potentially premalignant and malignant oral lesions. Understanding the biological basis of autofluorescence imaging for oral cancer detection: high-resolution fluorescence microscopy in viable tissue.

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