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The urinary sensation scale is a five-point scale ranging from one (no urgency; can continue 195 activities until it is convenient to use the bathroom) to five (urge incontinence; extreme urgency discomfort generic 120mg starlix overnight delivery, cannot hold urine order starlix with a mastercard, and have a wetting accident before arriving at the bathroom)  buy cheap starlix 120 mg on-line. The content validity of this scale was established through a physician survey and patient interviews . The urgency rating scale, recommended by the European Medicines Evaluation Agency, consists of a five-point rating scale to be rated with every void, ranging from one (no urgency; I felt no need to empty my bladder but did so for other reasons) to five (urge incontinence; I leaked before arriving at the toilet). This scale was used in a tolterodine clinical trial, in which responses on this scale were used to calculate sum urgency, a measure that accounts for changes in both urgency and frequency [76,77]. A careful read of the chapter by Cotterill and Abrams will reveal that many of the questionnaires discussed in this and the chapter by Kopp have been adopted by the International Consultation as modules for the International Consultation on Incontinence Questionnaire. There are clearly many different questionnaires and types of questionnaires from which to choose. Plan a study carefully with respect to what you expect to measure and which populations you intend to survey, and read the content of a questionnaire carefully. The value of spending time to make an informed and careful decision will, however, always be worth the effort. Guidance for industry on patient-reported outcome measures use in medical product development to support labelling claims. Health-related quality of life measures for women with urinary incontinence: The Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Validation of an overactive bladder awareness tool for use in primary care settings. Estimation of a preference-based index from a condition-specific measure: The King’s Health Questionnaire. The Bristol Female Lower Urinary Tract Symptoms questionnaire: Development and psychometric testing. Urinary symptoms and incontinence in women: Relationships between occurrence, age, and perceived impact. Urinary incontinence in both sexes: Prevalence rates and impact on quality of life and sexual life. Lower urinary tract symptoms and falls risk among older women receiving home support: A prospective cohort study. A scored form of the Bristol Female Lower Urinary Tract Symptoms questionnaire: Data from a randomized controlled trial of surgery for women with stress incontinence. Validation of a computer version of the patient-administered Danish prostatic symptom score questionnaire. Effects of alfuzosin 10 mg once daily on sexual function in men treated for symptomatic benign prostatic hyperplasia. International Continence Society “Benign Prostatic Hyperplasia” Study: Background, aims, and methodology. Identifying cut-off scores with neural networks for interpretation of the incontinence impact questionnaire. Comparative efficacy and safety of transdermal oxybutynin and oral tolterodine versus placebo in previously treated patients with urge and mixed urinary incontinence. Responsiveness of quality of life measurements to change after reconstructive pelvic surgery. Quality of life of persons with urinary incontinence: Development of a new measure. Translation and linguistic validation of Korean version of the incontinence quality of life(I-QoL) instrument. The impact of urodynamic stress incontinence and detrusor overactivity on marital relationship and sexual function. Validation of the Portuguese version of the King’s Health Questionnaire for urinary incontinent women. Single-blind, randomized trial of pelvic floor muscle training, biofeedback-assisted pelvic floor muscle training, and electrical stimulation in the management of overactive bladder. A double-blind placebo-controlled trial on the effects of 25 mg estradiol implants on the urge syndrome in postmenopausal women. Surgical treatment for cancer of the oesophagus and gastric cardia in Hebei, China. Validity and reliability of a questionnaire to measure the impact of lower urinary tract symptoms on quality of life: The Leicester Impact Scale. Estimating a preference-based single index from the Overactive Bladder Questionnaire. Quality of life in patients with overactive bladder: Validation and psychometric properties of the Spanish Overactive Bladder Questionnaire-Short Form. Relationship between patient reports of urinary incontinence symptoms and quality of life measures. A randomised controlled trial comparing abdominal and vaginal prolapse surgery: Effects on urogenital function. Use of the Dowell Bryant Incontinence Cost Index as a post-treatment outcome measure after non-surgical therapy. The quality of life of older adults with urinary incontinence: Determining generic and condition-specific predictors. Short forms to assess life quality and symptom distress for urinary incontinence in women: The Incontinence Impact Questionnaire and the Urogenital Distress Inventory. The use of short-form quality of life questionnaires to measure the impact of imipramine on women with urge incontinence. Validation of the International Prostate Symptom Score in Chinese males and females with lower urinary tract symptoms. Effects of oxybutynin transdermal system on health- related quality of life and safety in men with overactive bladder and prostate conditions. Darifenacin treatment of patients >or= 65 years with overactive bladder: Results of a randomized, controlled, 12-week trial. Predictability of urodynamic findings based on the Urogenital Distress Inventory-6 questionnaire. The standardisation of terminology of lower urinary tract function: Report from the Standardisation Sub-committee of the International Continence Society. The role of urinary urgency and its measurement in the overactive bladder symptom syndrome: Current concepts and future prospects. A Comparison of three approaches to analyze urinary urgency as a treatment outcome. Note for guidance on the clinical investigation of medicinal products for the treatment of urinary incontinence. Symptom and condition screeners help identify health conditions to identify patients who may benefit from treatment. Patient expectation, goal assessment, and satisfaction questionnaires help clinicians understand the patients’ point of view regarding their treatment goals and expectations so that the clinician can enhance the probability of a satisfactory outcome. The development process steps from conceptual design through cognitive debriefings, psychometric, and linguistic validation are described in detail earlier in this section.
When used starlix 120 mg, frozen section has a role in the assessment of the complete- ness of surgical resection margins and clearance of nerve margins in cases with nerve invasion purchase 120mg starlix visa. Frozen section can be helpful in clarifying what may have been an equivocal cytological diagnosis by defning the histologic classifca- tion buy 120mg starlix amex, tumor grade, and extent of invasion. Clinicians are cautioned that frozen sections have their own sets of artifacts and limitations to consider. The impact on decision making on neck management is addressed in the prior section. Non-Neoplastic The majority of “Non-Neoplastic” lesions are managed non-surgically. Any change in either the clinical exam or imaging could war- rant repeat sampling to confrm no change in cytological status. Examples would be a painful mass that lacks signs of infammation, a concurrent facial nerve weak- ness or paralysis, or a prior history of cutaneous malignancy. Intraoperative frozen section can be used for more defnitive histologic classifcation and to help inform any decisions pertaining to possible neck dissection. However, a nerve dissecting parotidectomy with nerve preservation is the most oncologically safe option. Frozen section can be performed to determine malignancy and to assist in the decision to 9 Clinical Management 163 perform a selective neck dissection for intermediate and high-grade malignancies. Lesions in the superfcial or lateral lobe would undergo superfcial parotidectomy; those in the deep lobe would require resection of the deep lobe lesion often with preservation of the superfcial portion of the gland. Sparing the superfcial portion of the gland helps to minimize the postoperative contour defect. The surgeon may choose to use intra- operative frozen section to confrm malignancy before sacrifcing the facial nerve. If the frozen section is positive for malignancy and path- ological nodes are identifed, then concurrent comprehensive neck dissec- tion is performed, sparing nonlymphatic structures (internal jugular vein, 9 Clinical Management 165 sternocleidomastoid muscle, spinal accessory nerve) if possible. For tumors >4 cm in greatest dimension, high-grade features on frozen section of the primary site, extraglandular extension on imaging or noted intraoperatively, or preoperative facial weakness, perform elective selective neck dissection for the clinically and radiographically N0 neck. In cases of malignancy, the decision to offer radiation therapy or further surgery (i. If fndings are consistent with an intermediate or high-grade malignancy, selective neck dissection may be performed. Malignant In the clinical management of clearly “Malignant” salivary gland lesions, a defni- tive classifcation of a specifc malignant histologic tumor type, including grade (low- versus high-grade), provides important information for clinical decision mak- ing. When a defnitive classifcation is not possible, information about tumor grade is still useful. Low- versus intermediate- versus high-grade classifcation may be useful to the clinician in determining the extent of surgery required at the primary site and the likelihood that a neck dissection would be needed. For high-grade malignancies involving the deep lobe, a total parotidectomy is necessary. For lateral lesions, controversy exists regarding the extent of surgery with some surgeons elect- ing to perform a total parotidectomy to optimize surgical clearance and others per- forming a superfcial parotidectomy with the knowledge that the patient will be receiving postoperative radiotherapy. In addition, a subcategory of “metastatic” would also be informative for the managing clinician. Parotid gland lymph nodes are a common site for metastases from cutaneous primaries, and these patients often require a concurrent neck dissection. The surgeon may choose to use intra- operative frozen section to confrm malignancy before sacrifcing the facial nerve. If identifed, management would be based upon specifc aspects of the primary cancer. If no primary site is identifed and the salivary gland lesion is isolated, it can be managed as a high-grade primary lesion in order to avoid issues related to uncontrolled head and neck malignancy. Unequivocal diagnosis of benign cytology of a lesion with very low risk of malignant transformation in an asymptomatic patient 2. When there is clinical or radiographic evidence of nodal disease, comprehensive dissection should be performed, sparing any non-lymphatic structures that can be spared (internal jugular vein, spinal accessory nerve, or sternocleidomastoid muscle) 2. Clinically and radiographically N0 necks with high risk primary site cytology (tumor >4 cm, high-grade features on frozen section of the primary site, extraglandular extension on imaging or noted intraoperatively, or preoperative facial weakness) should undergo selective neck dissection Table 9. Benign neoplasm cytology: Nerve-preserving tumor resection with small cuff of normal parotid tissue, may be less than complete lateral lobectomy or superfcial parotidectomy 2. If fndings consistent with low-grade malignancy, consider completion superfcial parotidectomy to encompass intraparotid lymph nodes. If found to be high-grade by frozen section, consider nerve-preserving subtotal parotidectomy 3. Malignant cytology: Superfcial parotidectomy for low-grade lesions, total or subtotal parotidectomy for higher grade lesions, both with facial nerve preservation whenever possible Table 9. Never sacrifce a major nerve branch when removing benign disease unless the nerve branch is completely encased, and even in that circumstance consider debulking 2. Do not sacrifce a functioning nerve without frst establishing a diagnosis of malignancy (unequivocal cytology or frozen section) and determining that the nerve cannot be separated from tumor with microscopic residual disease 3. A non-functional nerve in the setting of proven malignancy should be resected and rehabilitated with the appropriate method based on available donor and recipient nerve for grafts and transfers and by static techniques 168 M. The indications for elective treatment of the neck in cancer of the major salivary glands. Feasibility of a novel classifcation for parotid gland cytology: a retrospective review of 512 cytology reports taken from 4 United Kingdom general hospitals. Salivary gland tumor fne-needle aspiration cytology: a proposal for a risk stratifcation classifcation. Extracapsular dissection for clinically benign parotid lumps: reduced morbidity without oncological compromise. Chapter 10 Histologic Considerations and Salivary Gland Tumor Classifcation in Surgical Pathology Bruce M. Wenig The classifcation of salivary gland neoplasms is dynamic and continues to evolve (Table 10. This includes recently identi- fed and defned tumor types such as intraductal carcinoma, cribriform adenocarci- noma of minor salivary glands, and new nomenclature for well-established tumors. Newly identifed and growing numbers of specifc molecular alterations in salivary gland tumors support the morphologic-based classifcation (Table 10. The oncocytic cells in the latter two lesions often are bland, lacking malignant cytomorphologic fndings that would differentiate them from benign oncocytic lesions. It should be noted 10 Histologic Considerations and Salivary Gland Tumor Classifcation in Surgical… 173 Table 10. These tumors have overtly malignant cytomorphologic features, including marked nuclear pleomorphism, necrosis, and increased mitotic activity.
It is located on the vertical line that The abdominal region is delimited superiorly by the rib runs from the sternal xiphoid process to the symphysis pubis cheap 120 mg starlix overnight delivery. Equally edge of the pubic region buy starlix cheap online, and by two oblique lines buy starlix 120 mg without prescription, which important is the palpation of the umbilical and periumbilical starting from the lateral side reach the anterior superior iliac (superior and inferior) area in order to detect the presence of spines. This surface must be carefully inspected sue of the abdominal region consists, especially in abdominal Aesthetic Abdominoplasty 327 Fig. This division becomes less clear heading toward caudal-cranial, to disappear entirely in quadrants located above the umbilical scar, in which adipose tissue is present in a single layer (Fig. They are Arterial vascularization of the abdominal region is provided joined together, in the midline, by a tendon raphe called the by the deep epigastric arteries, internal thoracic arteries, cir- linea alba, of about 2–3 mm thickness and a variable width, cumﬂex iliac arteries, and the intercostal and lumbar arteries. This area represents the “locus minoris resistetiae” of great importance for surgery because it prevents postop- of the entire region to stresses arising from ﬂuctuations in erative ischemic complications. In particular, in female subjects, lation of the abdomen is ensured by a network of subcutaneous physiological events, such as pregnancy, will induce a strain abdominal arteries, formed by the branches arising from the with a consequent increase in width with widening of the circumﬂex iliac arteries and a series of perforating arteries medial edges of the rectus muscles (diastasis), and will facil- which, coming from the arterial deep circulation, cross the itate the onset of release of the abdominal viscera (hernia). Based on studies conducted on the vascular- overlap of more muscular structures, in particular the trans- ization of the superﬁcial layers of the abdomen in relation to versus abdominis muscle, the internal oblique muscle, and surgical dissection (Huger ), the abdominal region can, the external oblique muscle. These play a key role in the con- schematically, be divided into three zones (Fig. Of particular interest for • Zone 1: The blood supply derived from branches of the abdominoplasty is the role of deﬁning the minimum abdomi- superﬁcial epigastric artery and the continuation of the nal circumference performed mainly by the oblique muscles, branches of Zone 3. The area’s upper limit is the sternal which must be carefully evaluated both preoperatively and xiphoid process and the costal arch, the lower limit is a during surgery. Nisi transverse line passing through the anterior superior iliac spines, the lower limit is on the top of the pubic region, and the inferior limit is represented by the lateral inguinal fold. The latter has as its upper limit the costal arch, as lower limit a transverse line passing through the anterior superior iliac spine, and as medial limit the lateral margin of the rectus abdominis muscle. The venous blood ﬂow is ensured by superﬁcial epigastric veins, tributaries of the femoral vein, the thoracic and axil- lary veins, and superﬁcial venous branches of the last inter- costal veins, the lumbar veins, and the external pudendal vein. The large network of anastomoses between the superﬁ- cial and deep circulation, the knowledge of abdominal vas- Fig. Huger cular areas, and their appreciation during surgery allows one to perform large detachments in relative safety. The abdominoplasty determines an alteration in the lymphatic system, especially at the groin and subumbilical level, which can cause the onset of a postoperative seroma; however, tar- geted maneuvers of the technique can decrease the occur- rence of this complication [17, 18, 20 ]. For this reason it is essential for the • Zone 2: The blood supply derived from the branches of the success of the surgical procedure to search for any imperfec- superﬁcial and deep circumﬂex iliac arteries and branches tions during the preoperative evaluation of the various units of the pudendal external artery. The superior limit is a of the abdominal region, in order to implement a modulated Aesthetic Abdominoplasty 329 represented by the umbilical scar, and for this reason the skin and subcutaneous tissue in this area are characterized by an almost entirely absent mobility on deep layers. In young and slim women, the umbilicus resembles an oval-shaped depression with a vertical major axis. It is located on the median xipho-pubic line at a variable distance, between 10 and 15 cm, from the top edge of the pubic region. This distance must be carefully measured and recorded, together with the marking of xipho-pubis line, preoperatively and intraoperatively, to perform a correct repositioning. It should be noted that, as the navel is the only point of reference of the entire abdominal region, any imperfection (congenital, acquired, iatrogenic) will lead, inevitably, to a signiﬁcant alteration of the harmony not only of the aesthetic unit itself but also the entire abdominal region. From the aesthetic point of view, one can identify the ponent, which is quite mobile on the deep structures and following areas or units in the abdomen. This area is limited superiorly by the sternal xiphoid process Consequently, major aesthetic alterations of the entire and the costal arch, laterally by the lateral margin of the rec- abdominal region are concentrated in this area. The superior the deep planes, and is organized to form a single layer and limit is the costal arch, the medial limit is the lateral margin the presence, in normal-weight subjects, of a slight depres- of rectus abdominis muscles, and the lower limit an oblique sion on the skin surface relative to the surrounding planes, on line which, starting from the anterior-superior iliac spine, the median line corresponding with the linea alba. The fatty components are charac- terized by a discrete mobility on deep planes and are orga- 4. It is bilical region medially, while laterally it closely adheres to limited superiorly by the line passing through the lower edge the iliac crest. This area plays a key role, especially in of the last ribs, laterally by the lateral margin of the rectus women, in the deﬁnition of an “ideal” body proﬁle. In abdominis muscles, and inferiorly by a transverse line women, in fact, the margin of the side draws a concavity passing through the anterior superior iliac spines. This line below the rib cage that suddenly changes in convexity at the represents the maximum circumference of the abdominal iliac crest, while medially it presents in the pararectal region region. Nisi 5 Selection and Evaluation of the Patient The main indication for abdominoplasty is represented by the correction of excess skin and fat of the abdominal region with or without skin and/or muscle wall laxity. In fact, there are many variables that, individually or synchronously, form the basis of changes in the aesthetic “ideal” of the abdominal region: • Age • Pregnancies • Changes in weight • Changes in posture • Past surgeries These changes can affect the skin-fat component, the Fig. In our clinical practice we prefer to distinguish various degrees of abdominal alteration in relation to the location and extension, with or without associated musculofascial laxity (Figs. In addition to a careful physical examination of the abdominal region, the clinician must perform a detailed clinical history of the patient and appropriate laboratory investigations (complete blood count, evaluation of liver and kidney function, lipids, coagulation, and electrolytes). Furthermore, it is important to submit the patient to X-ray control of the lung parenchyma to exclude the presence of pathology. In the case of signiﬁcant diastasis of the abdomi- nal musculature and/or the presence of hernia or incisional hernia, it is very important to consider a preoperative study of lung function, which can be greatly affected by the increase in intra-abdominal pressure in the postoperative period plication result of a possible hernioplasty, or of a simple plication of the rectus abdominis muscles. Furthermore, blood values are to be taken into consideration in cases of patients with particularly low hemoglobin values and/or to be subjected to important dermoadipose removals, for which it is mandatory before surgery to organize a series of blood samples for use in the postoperative period if a blood transfusion is necessary. It is signiﬁcant musculofascial laxity also very important to detect the anthropometric data of the • Grade V: The panniculus extends to the knee with patient, paying particular attention to body mass index which important musculofascial laxity can be, as reported in the literature, a reliable predictor of surgical risk . In our clinical experience the importance Of course, as regards the abdominoplasty with only of assessments has been underlined by the use of a special aesthetic purposes, the indication for surgery is reserved for checklist that allows all health practitioners involved to ver- patients with distinct obesity of ﬁrst and second degree. As with all surgical procedures, before planning an abdominoplasty it is necessary to make a careful analysis of 6 Photographic Acquisition the patient’s general condition, in addition to cessation of smoking at least for 2–3 weeks before surgery and stopping The iconographic acquisition also plays a fundamental role any pharmacological treatment (nonsteroidal anti- because with it, the surgical team can investigate and inﬂammatory drugs, oral contraceptives) from 10–14 days re-evaluate the clinical situation and the operative strategy, before surgery. In addition, it plays an important role in medico- fying and marking the landmarks useful for planning the legal terms. Particular attention should be paid to reporting any are acquired with a standardized method to obtain compara- scarring of the pelvic or abdominal area and the presence of ble iconography before and after surgery, and to promptly palpable swellings. In the orthostatic position, asymmetric place and precisely highlight the anatomical region of the distribution of abdominal adipose tissue and changes in surgical object, limiting to a minimum discrepancies and the level of the umbilical scar are also evaluated. Speciﬁcally for the abdominal patient in the supine position, the examiner palpates the region, the patient should be placed, completely naked and abdominal region with the abdomen relaxed (palpation barefoot, in the center and near the wall area chosen as static) or by running sequential contractions of the abdomi- background (preferably dark colored so as to highlight the nal muscles through coughing (dynamic palpation), which proﬁle body and minimize any glare light), and the surgeon allows better evaluation of the “possible” presence of mus- must be positioned at a distance of 1. The patient’s positioning is fundamental to obtaining a com- prehensive and accurate acquisition of the abdominal region and, in particular: 7 Informed Consent • Frontal position: The patient is placed in front of the lens Proper administration of an informed consent to the patient with arms crossed behind the back (Fig. It must be precise, complete, and comprehen- should be folded behind the back and the patient laterally sive, and has to be administered to the patient within an ade- rotated by 90° from the front (Fig. It is necessary that it • Semi-lateral left and right position: In this position the contains the master data of the patient, the diagnosis, the arms should be folded behind the back and the patient type of surgery proposed with its description, the type of laterally rotated by 45° from the front (Fig. It is essential that the agreement has to be drawn up with common terms, supported by the equiva- lent strictly medical terminology in brackets, so as to be readily understandable by the patient. It must also not be merely delivered, but has to be read and discussed with the patient, well in advance of surgery, to settle any doubt or misunderstanding and to allow the patient to peacefully decide whether or not to undergo the surgery procedure. It must be signed by the patient or legal guardian, where required, and countersigned by the doctor who administers and (this is not strictly necessary but desirable) by at least one witness. In particular, the patient should stop taking oral contraceptives and drugs contain- ing acetylsalicylic acid, and smoking at least 2 weeks before the scheduled date of surgery.