The test strip contains a chemical indicator called toluidine and the ‘immobilised’ enzyme glucose oxidase purchase genuine eldepryl on-line symptoms glaucoma. Glucose oxidase converts the glucose in urine to gluconic acid and hydrogen peroxide; hydrogen peroxide reacts with toluidine eldepryl 5mg fast delivery medicine allergies, causing the colour change buy eldepryl cheap online medicine 95a. A variety of metabolic diseases are caused by deﬁciencies or malfunctions of enzymes, due originally to gene mutation. Albinism, for example, may be caused by the absence of tyrosinase, an enzyme essential for the production of cel- lular pigments. One such example is Gaucher’s disease type I, caused by a deﬁciency in the enzyme glucocerebrosidase, causing lipids to accumulate, swelling the spleen and liver, and trigger- ing anaemia and low blood platelet counts. Such patients often suffer from fatigue, grossly distended abdomens, joint and bone pain, repeated bone fractures and increased bruising and bleeding. This can be treated using intravenous enzyme replacement therapy with a modiﬁed version of the enzyme, known generically as alglucerase. Type I (non-neuropathic type) is the most common; incidence is about 1 in 50 000 live births (particularly common among persons of Ashkenazi Jewish heritage). Ceredase is a citrate buffered solution of alglucerase manufactured from human placental tissue. Streptokinase is administered intravenously to patients as soon as possible after the onset of a heart attack, to dissolve clots in the arteries of the heart wall. Streptokinase belongs to a group of drugs known medically as ‘ﬁbrinolytics’, or colloquially as ‘clotbusters’. It works by stimulating production of a naturally produced protease, plasmin, which degrades ﬁbrin, the major constituent of blood clots. Asparaginase, extracted from bacteria, has proven to be par- ticularly useful for the treatment of acute lymphocytic leukaemia in children, in whom it is administered intravenously. Its action depends upon the fact that tumour cells are deﬁcient in an enzyme called aspartate-ammonia ligase, restricting their ability to synthesise the normally non-essential amino acid L-asparagine. The action of the asparaginase does not affect the functioning of normal cells, which are able to synthesise enough for their own requirements, but reduces the free circulating concentration, thus starving the leukaemic cells. A 60% inci- dence of complete remission has been reported in a study of almost 6000 cases of acute lymphocytic leukaemia. These can be used, for example to increase the efﬁcacy of the peni- cillin antibiotics. Bacteria can develop resistance to penicillins by producing enzymes called β-lactamases, which break down penicillins. It is possible to block the active sites of β-lactamase using the broad-spectrum inhibitor, Augmentin. Enzymes are particularly useful when it comes to small-molecule pharmaceutical chemicals. A racemic mixture of thalidomide had tragic conse- quences in the 1960s; taken by pregnant women as a sedative and to prevent morning sickness, it led in many cases to deformed children. Later research showed that the (+) isomer had the desired effect whilst the (−) isomer had a teratogenic effect. Laboratory tests are used to tailor individual treatment plans according to need, to monitor disease progression, to assess risk, to inform prognosis, and for population screening programs. Biomarkers may target a disease’s aetiology (risk factors for development of the illness), its pathophysiology (abnormalities associated with the illness) or its expression (manifestations of the illness). A biomarker is deﬁned as any characteristic that can be objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes or pharmaco- logical response to a therapeutic intervention. Any biomarker must generate robust assay performance consistent with the requirements for routine clinical laboratories in the form of analytic validation, and deﬁned disease management value in the form of clinical qualiﬁcation. Key milestones that must be met for any proposed clinical use of a biomarker would include: 1. That is, the accuracy and precision with which a particular biomarker is identiﬁed by the test. That is, the accuracy with which a test identiﬁes or predicts a patient’s clinical status. That is, assessment of the risks and beneﬁts, such as cost or patient outcome, resulting from using the test. Biomarkers have a key role, in both clinical practice and research, in the monitoring and evaluation of outcomes of interventions, both at individual and at population level. The fun- damental need for interdisciplinary collaboration, in order to develop, qualify and properly utilise biomarkers, is widely recognised. For example, the prognosis for patients with lung cancer is strongly dependent on the stage of the disease at the time of diagnosis. Non-small-cell lung cancer, which accounts for 75–80% of cases, has a different clinical presentation, prognosis and response to therapy than small- cell lung cancer (which is less commonly met). Lung cancer is not a result of a sudden transforming event but the end of a multi-step process in which the accrual of genetic and cellular changes results in the formation of an invasive tumour. Patients with early clinical- stage non-small-cell lung cancer have a ﬁve-year survival of about 60%, while at later stages the ﬁve-year survival may be as low as 5%. In Alzheimer’s patients, cerebrospinal ﬂuid usually contains a reduced level of 42-aminoacid β-amyloid and an increase in Tau protein. Such biomarkers are however unreliable; they are not accurate for a diagnosis of Alzheimer’s, because the same pattern ﬁndings are also found in other conditions. At present the costs involved in mass or individual screening would be high; the procedures are also invasive, uncomfortable and not without additional risk. This enzyme exists in ﬁve closely related, but slightly different forms (isoenzymes). The characteristic isoenzyme in brain and in smooth muscle; 0% of the normal serum total. The ability to make albumin (and other proteins) is affected in some types of liver disorder. A raised level of ‘uncongugated’ bilirubin occurs when there is excessive breakdown of red blood cells, for example in haemolytic anaemia, or where the ability of the liver to conjugate bilirubin is compromised, for example in cirrhosis. A raised blood level of ‘congugated’ bilirubin occurs in various liver and bile duct conditions. It is particularly high if the ﬂow of bile is blocked, for example by a gallstone in the common bile duct or by a tumour in the pancreas. Other blood tests must be used to conﬁrm the diagnosis of a particular disorder and/or to monitor the activity of the disorder and response to treatment. Since the liver synthesises many of the blood-clotting proteins, blood- clotting tests may be used as a marker of the severity of certain liver disorders. A high level of this enzyme is particularly associated with heavy alcohol drinking. Blood tests can detect viruses and antibodies to viruses, for example hepatitis A/B virus, or auto-antibodies from autoimmune disorders of the liver, for example primary biliary cirrhosis (associated with anti-mitochondrial antibodies), autoimmune hepatitis (asso- ciated with smooth muscle antibodies) and primary sclerosing cholangitis (associated with antinuclear cytoplasmic antibodies).
As the load of sustained increased muscular normal consequence of any unrelieved tone affects the tendons and their periosteal chronic hypertonicity buy eldepryl 5mg visa symptoms 0f gallbladder problems. The inhibitory effect of hypertonic muscles on of dysfunction: their antagonists (Janda 1986) produces • Tenderness inappropriate ﬁring sequences (discussed in more detail later in this chapter) eldepryl 5 mg cheap medicine 0027 v, leading to a • Asymmetry range of functional changes cheap eldepryl 5mg without prescription inoar hair treatment, as demonstrated • Range of motion changes by crossed syndrome patterns. Chapter 6 • Assessment/Palpation Section: Skills 149 Whether a joint is being evaluated for its behavior, when your palpating ﬁngers are asking questions or a muscle is being tested for its length/strength or such as: presence of trigger points, or the periosteum is being 1. Simons (1993b, 1996) maintains that the high by using either pincer compression, using the tips of intensity of nerve impulses from an active trigger point the digits, or ﬂat palpation against underlying can, by reﬂex, produce vasoconstriction, a reduction of structures. Both methods entrap speciﬁc bands of the blood supply to speciﬁc areas of the brain, spinal tissue. Painfully stimulated tissues (such as the origins of tendons or Trigger points when active are a source of pain; joint capsules) can produce pain in associated muscles, however, symptoms may also involve functional tendons and overlying skin. For example, as far back as the early 1950s and increased sensitivity in the region of the sternum, there were reports that pelvic pain and bladder symp- clavicles and rib attachments to the sternum, through toms, such as cystitis, could be created by trigger occupational or postural patterns, may inﬂuence or points lying in the abdominal muscles (Kelsey 1951). More recent research conﬁrms this, and has shown that symptoms such as chronic pelvic pain and inter- stitial cystitis can often be relieved by manual deacti- Evaluation of muscle ﬁring sequences, vation of trigger points, as well as by injection of length, strength, tone (Janda 1983, 1996) these, or by acupuncture (Oyama et al 2004, Weiss Three ‘functional assessments’ will be outlined, 2001). The localized pain and • shortened (postural/predominantly Type 1 resulting palpable changes on the periosteum make ﬁbers/deep/inner unit/stabilizer/local them useful as diagnostic aids. This can sometimes be noted on spinous proc- esses where one side is tender, relating to sustained Janda (1988) has shown that postural muscles have heightened tension in the muscles on that side. Rota- a tendency to shorten, not only under pathological tional restrictions may be identiﬁed associated with conditions, but often under normal circumstances. Ligaments and fascia can therefore Chapter 6 • Assessment/Palpation Section: Skills 151 Table 6. Most problems of the musculoskeletal system If tone remains reduced then, and only then, should involve, as part of their etiology, dysfunction related exercise and/or isotonic muscle energy technique to aspects of muscle shortening (Janda 1978, procedures be brought in (Chaitow 2001). The following simple observation and/or palpation Where weakness (lack of tone) is apparently a major tests allow for a rapid gathering of information with feature of dysfunction, it will often be found that a minimum of effort. They are based on the work of antagonists are shortened and are reciprocally inhibit- Janda (1983) and Liebenson (1996b). In most instances it is thought that, before there is any effort to strengthen weakened muscles, hyper- tonic antagonists should be dealt with by appropriate Further assessment requirements means, after which spontaneous toning should be If any of the following tests is positive, this requires anticipated in the previously relatively weak muscles the additional assessments outlined, all of which are (Lewit 1999a). Reproduced with permission from Chaitow (2003a) Chapter 6 • Assessment/Palpation Section: Skills 153 Box 6. The slight resistance to the patient’s effort to abduct other hand palpates simultaneously gluteus medius the leg. If there is an immediate grabbing action by quadratus it indicates overactivity, and therefore stress, so shortness can be assumed. Reproduced with permission from Chaitow (2003a) Continued 154 Naturopathic Physical Medicine Box 6. It may be possible (depending on the practitioner’s hand size and patient anatomic size) to increase the number Box 6. Reproduced with permission from Chaitow (2003a) Chapter 6 • Assessment/Palpation Section: Skills 155 Box 6. Reproduced or spanning the lower back to palpate quadratus with permission from Chaitow (2007) ﬁring. This includes sitting slouched, sitting erect, standing slouched and standing erect. In dysfunctional states the most common substitutions If a response is demonstrated during any of these are said to involve: positions no increase in that direction of ﬂexion or extension is added – for example, if symptoms modify • shoulder elevation by levator scapulae and upper when lying supine, the knee-to-chest position would trapezius, as well as not be necessary. When overactivity involves the lower ﬁxators, weakness Translation and list and possible lengthening results (Norris 1999). Lisi (2007) points out that: In the McKenzie system, a patient who initially presents with an antalgic list is also assessed for the of positions and repetitive movements, the response response to side gliding, both standing and prone, in terms of changes in pain and other symptoms is active and passive. Dysfunction: Active ranges of motion are (whether pain or paresthesia) are eliminated or restricted in one or more directions with local substantially decreased during the positioning pain at end range. The problem local low back pain only, that pain is probably relates to chronic soft tissue eliminated. Treatment may element, and is often independent of proximal involve repetitive motions that increase pain in pain. For example, if a patient with low back order to break adhesions and increase pain and leg pain experiences relief of leg pain elasticity. This might include exercises and/or even though there is an increase of low back manual treatment, as well as application of pain, that patient has centralized. Derangement: Active ranges of motion are with relief of low back pain and an increase in restricted in one or more directions as well as leg pain has peripheralized. If the cause is discogenic pain with competent annulus, then • The reduction in symptoms must have some repetitive motion should reveal centralization. Treatment McKenzie has classiﬁed mechanical low back pain demands that motions which centralize are into three syndromes, each of which is deﬁned by a performed and that motions which theoretical model of the underlying pathology, plus peripheralize are not. This might include patient history, postural assessment and mechanical appropriate exercises (that centralize) and/or examination ﬁndings (Razmjou et al 2000): manual treatment, as well as application of appropriate ergonomics Patients whose 1. Postural: Examination ﬁndings include full and symptoms peripheralize during assessment pain-free active ranges of motion, with using positions and movements have a poor repetitive motions also pain-free. Sustained prognosis, and usually respond poorly to posture at normal end of range causes pain. Testing muscles for length Treatment involves primarily avoiding painful positions and maintaining correct posture. Janda (1983) suggests that to Dommerholt (2000), discussing enhancement of obtain a reliable evaluation of muscle shortness, the posture and function in musicians, has summarized following criteria be observed during passive an important concept: testing: In general, assessment and treatment of individual • The starting position, method of ﬁxation and muscles must precede restoration of normal posture direction of movement must be observed and normal patterns of movement. Instead, muscle • If possible, the force exerted on the tested imbalances must be corrected through very speciﬁc muscle must not work over two joints. Once the musculoskeletal conditions of ‘good posture’ have been met, postural • The examiner should keep the stretch and the retraining can proceed. The functional tests described above offer evidence • Pressure or pull must always act in the of overactivity. Understanding ‘ease’ and ‘bind’ It is in shortened muscle ﬁbers, as a rule, that reﬂex The concept and reality of tissues providing the pal- activity is noted. This takes the form of local dysfunc- pating hands or ﬁngers with a sense of their relative tion variously called trigger points (Simons et al 1999), ‘bind’, as opposed to their state of ‘ease’, is one which hyperalgesic skin zones (Lewit 1999a), tender points needs to be literally felt to be appreciated. The examples of assessment of shortness in muscles, given here as exercises, are meant to encourage Why do we need to identify muscle acquisition and/or reﬁnement of the skills required shortness? Greenman (1996) offers a summary of his clinical approach that demands knowledge of shortness: Hamstring notes: Should obviously tight After short tight muscles are stretched, muscles that hamstrings always be treated? The patient lies with the non-tested leg abducted • A sense of bind should be noted by the palpating slightly, heel over the end of the examination table. The leg to be tested should be close to the edge of • An observation sign can conﬁrm this barrier. After the table, and you should ensure that it is in its it has been passed there will be movement of the anatomically correct position: knee in full extension, pelvis as a whole, laterally towards the tested and with no external rotation of the hip, which would side.
Findings include tense compartments associated with pain out of pro- portion with passive stretching of the muscles involved purchase eldepryl amex medicine wheel teachings. Paresthesias generic eldepryl 5mg with mastercard medical treatment 80ddb, diminished pulses discount 5 mg eldepryl medicine wheel native american, pallor, and poikiothermia may also be manifested. Measurement of the compartments is necessary (>0 mm Hg is abnormal, and microcirculation is compromised when pressures reach 30 mm Hg). Clincial findings are fever, tachycardia, respiratory distress, altered mental status and, al- though a late finding, a petechial rash over the chest. Signs of vascular injury include pulsa- tile hematoma, hemorrhage, absent distal pulses, palpable thrill or audible bruit. More often than not, patients with penetrating trauma do not illicit these “hard” findings and have more subtle findings such a small nonexpanding hematoma, diminished pulses etc. Modrall, Weaver, and Yellin’s algorithm for penetrating trauma 8 is shown on Figure 8. If a patient has signs of vascular injury, then arteriogram and surgical repair is necessary. Re- printed from Emed Clin North Am 2000; 18(1):61, ©2000 Elsevier, with per- mission. Management Prehospital • Prehospital care entails immobilization to prevent further neurovascular injury, eleva- tion and ice. Physical Exam • Neurovascular exam is crucial especially if knee dislocation is suspected. Always remember to identify other injuries by examining the femur, tibia, and patella. Radiography • Plain Films • The Ottawa Knee Rules were described in order to delineate which patients require plain films. A knee X-ray series is only required for knee injury patients with any of these findings: 1. Implementation of the Ottawa Knee Rule for the use of radiography in acute knee injuries. Emergent orthopedic Dislocation Posterior, Exclusion of vascular consultation Lateral, Medial, injury usually requires Rotatory angiography. Evaluation for com- partment syndrome Patellar Medial and Reduction by knee exten- Referral to orthopedics Dislocation lateral sion simultaneous move- ment of patella. Compartments, lower leg Fascial Compartment Structures Contained Clinical Findings Anterior Extensor muscles Great toe extension, ankle dorsiflexion Anterior tibial artery and veins Dorsalis pedis pulse Deep peroneal nerve Sensation of great toe web space Lateral Peroneus longus muscle Foot eversion Peroneus brevis muscle Superficial peroneal nerve Sensation to dorsum of foot Deep Posterior Deep flexor muscles Great toe flexion Posterior tibial artery and veins Posterior tibial pulse Tibial nerve Sensation to plantar surface Peroneal artery and veins of foot Superficial Posterior Superficial flexor muscles Ankle plantar flexion Sural nerve Sensation to lateral side of foot and distal calf Tibia and Fibula Anatomy and Function • The tibia and fibula are joined together at the superior and inferior tibiofibular joint 8 at each end and via the interosseous membrane along the length of the two bones. The artery di- vides inferiorly to the knee joint into three branches: the anterior tibial, the posterior tibial, and the peroneal artery. Management Prehospital Care • Immobilization, ice, and elevation are important prior to transport to the hospital. History and Physical Exam • Knowing the mechanism and nature of the injury is always important in any fracture. Classification, Treatment, and Disposition • Tibial fractures can be divided into extra-articular proximal fractures and shaft frac- tures, and intra-articular proximal and distal fractures (see knee and ankle joint sec- tions respectively). Extra-Articular Proximal Tibial Fractures • Subcondylar tibial fractures are usually associated with tibial plateau fractures but can occur in isolation. Isolated, stable, nondisplaced transverse fractures are treated with analgesia, ice, long-leg posterior splint and referral to an orthopedic surgeon. Comminuted fractures or those involving the joint require admission for open re- duction and internal fixation. Fracture of the tubercle is rare, occurring most commonly in younger indi- viduals. The patients may present with swelling and pain at the site that is exacerbated with extension of the knee. Incomplete avulsions require cast immobilization with the knee in extension and orthopedic follow-up. The patient should use crutches and remain nonweight-bearing until orthopedic evaluation. Extra-articular complete avulsions require closed reduction, and if adequate, cast immobilization with the knee in extension, and orthopedic follow-up. Tibia Shaft Fractures • There are multiple classification systems used to identify tibial shaft fractures and their treatment. Johner and Wruhs report a system by Muller based on the mechanism of injury, comminution, soft-tissue injury and displacement of the fracture. Proximal Fibula Fractures • Isolated uncomplicated fibula fractures can be treated with ice, elevation and analgesia. Complications • Tibia fractures, as mentioned previously, have a higher incidence of malunion, de- layed union and nonumion. Management Prehospital Care • Ankle injuries are commonly isolated injuries, but can be assosciated with multisys- 8 tem trauma. History • Understanding the mechanism and position of the ankle at the time of injury can help understand the fracture or sprain pattern. Physical Exam • Examination of the ankle must include the foot and proximal tibia and fibula. Orthopedic Emergencies 195 An ankle radiographic series is only required if there is any pain in malleolar zone and any of these findings: 1. A foot radiographic series is only required if there is any pain in midfoot zone and any of these findings: 1. Ottawa ankle rules for foot and ankle radiographic series in acute ankle in- jury patients (adapted from Stiell et al). Classification and Treatment Ankle Fracture • There are several classification systems for ankle fractures, however the Danis-Weber and the Lauge-Hansen are the most commonly used (Table 8. The two most commonly used classification systems for ankle fractures Lauge-Hansen Danis Weber Treatment Supination-adduction Type A: Fibula fracture below tibotalar joint Stage I: Transverse fracture A1: isolated Cast for 6-8 wk, of the lateral malleolus at level 3 wk nonweight- below joint or lateral collateral bearing, close ortho ligament tear. Pronation-abduction Stage I: Transverse fracture of medial malleolus or deltoid ligament rupture. Stage I: Transverse fracture of medial C1: Diaphyseal fracture malleolus or deltoid ligament rupture. Orthopedic Emergencies 197 • If there is associated tenderness over the deltoid ligament orthopedic consult is recom- mended. Ankle Sprains • As discussed previously, the ankle is supported by the syndesmotic, lateral, and medial ligaments. Tendon Rupture • Achilles tendon ruptures are commonly occur in middle-aged men during physical activity. If the movement is decreased when compared to the opposite or ankle, or absent, then an Achilles tendon rupture is present. Foot Anatomy and Function • The foot is comprised of the hindpart (seven tarsal bones including the calcaneus and the talus), the midfoot (navicular, cuboid, and three cuneiform bones), and the forepart (five metatarsals, two phalanges of the great toe, and three phalanges of each of the lateral four toes). Management Prehospital Care • Foot injuries are commonly isolated injuries, but can be associated with multisystem trauma.
Whereas the ideal management of endometrial cancer at any age is total hyster- bilateral salpingo-oophorectomy should be Several studies have shown that complex 3 buy discount eldepryl 5mg online symptoms for bronchitis. Familial (hereditary non-polyposis high as 58% following treatment with proges- of progression to frankly invasive carcinoma with or without pelvic/para-aortic lymph node colorectal cancer syndrome or the Lynch togens eldepryl 5mg without prescription treatment qt prolongation. The risk of concurrent syndrome); get pregnant immediately order generic eldepryl line medicine 319 pill, long-term mainte- management of very early stage endometrial endometrial cancer at the time of diagnosis 5. It is axiomatic that such women contraceptive pill or the levonorgestrel intra- Thus, the recommended treatment standard In hereditary non-polyposis coli, a mismatch desiring to retain their uterus and ovaries uterine system (Mirena) may be appropriate. Epithelial ovarian tumors – derived from stages, with spread into the peritoneum or mone treatment, as discussed above, may be are usually highly non-specifc, about 75% of the surface epithelium of the ovary; omentum, they usually produce characteris- a good compromise treatment in this group of patients present with advanced stage disease tic ‘non-invasive’ implants. It is impor- and 21,650 cases in 2008; the condition was operative imaging should be carried out with 22 tant for every woman to know her body very responsible for 15,520 deaths in 2008. The ideal treatment, even if bor- Unilateral salpingo-oophorectomy or even ignore the so-called ‘non-specifc’ symptoms, derline ovarian tumor is suspected, is total ovarian cystectomy is all that is required. Such especially when they appear in women who abdominal hysterectomy, bilateral salpingo- procedures can be undertaken with minimally have presented without symptoms for years oophorectomy and omentectomy. However, in young women markers should lead to a high index of suspi- desiring to preserve their fertility, and when the onset, nature and extent of the symptoms, cion. Therefore, conservative management can the tumor is unilateral, it may be feasible to especially in those who have not been known be offered to women desiring to preserve their carry out conservative surgery such as uni- to complain of anything in the past. Salpingo- and approximately 90% of cases occur in oophorectomy is preferred to cystectomy even women older than 40 years, with the major- Epithelial ovarian tumors of low malignant if the disease is confned to one ovary, as this ity usually above the age of 55 years. Women potential (borderline ovarian tumors) is less likely to be associated with risk of recur- are only more likely to have ovarian cancer at 23 rence. Cystectomy is more likely to be asso- an earlier age if they are at a high risk, such These types of epithelial ovarian tumors dif- ciated with intraoperative surgical rupture, as having a family history of ovarian or breast fer from the typical cancerous ovarian tumors thus increasing the risk of recurrence. The com- because they appear not to invade the ovarian contralateral ovary looks normal, there may bined oral contraceptive pill appears to offer stroma. On the other hand, if Figure 5 Ovarian tumor and ascites causing mark- some degree of protection against the develop- epithelial ovarian tumors and are usually very it looks cystic and/or abnormal, a frozen sec- edly distended abdomen with prominent veins, evi- ment of ovarian cancer. The management of epi- Stage 1c disease (stage 1a or 1b plus one or tumor resection following surgery or response Even if there is the need to remove the con- thelial ovarian cancer in women who wish to more of the following – tumor on the surface of to chemotherapy. They are also very useful for tralateral tube and ovary, the uterus does not preserve their fertility depends on the stage of the ovary, positive peritoneal cytology or surgi- subsequent follow-up after a successful treat- necessarily need to be removed. Hormone ian cancer should undergo complete surgical above but with the addition of adjuvant che- of disease extent (involvement of the omen- replacement is recommended following bilat- staging which includes total abdominal hys- motherapy (single agent platinum or platinum tum or the para-aortic lymph nodes). Once again, in younger Over the past two decades, treatment of terectomy, bilateral salpingo-oophorectomy the endometrium and prevent menopausal women, hormone replacement is usually rec- ovarian germ cell tumors has improved sig- and omentectomy with pelvic and para-aortic symptoms and osteoporosis due to estrogen ommended for the reasons given above. In young relates positively with absence of residual dis- Following conservative surgery for border- women desiring fertility preservation and with ease following surgery (optimal cytoreductive line ovarian tumors, the patient should be Germ cell ovarian tumors stage 1 and 2 disease, unilateral salpingo- surgery), younger age of the patient, favorable closely followed up at 3-monthly intervals in oophorectomy should be considered at lapa- histological type (apart from serous or clear the frst 2 years with 6-monthly pelvic ultra- These are rare of gynecological tumors. Other sites where germ stage 2 and above, apart from ovarian dysger- scans for a total follow-up period of 10 years, be considered in younger women with stage cell tumors can be found include the testicle minoma where radiotherapy might be consid- except if she opts for a full hysterectomy and 1 disease and favorable histological type as (12%), sacrococcygeal region (40%), brain ered, combination chemotherapy consisting of removal of the remaining ovary and tube hav- detailed below. Other combina- this in women who have previously had ele- Stage 1a disease (confned to one ovary without cyst which is usually benign, the immature tion chemotherapy has also been used. Very stromal) tumors survival for women with stage 1 and 2 dis- lymph node dissection is also performed to rarely, they may also be found in children ease is greater than 90%. The symptoms are a feel- These are tumors derived from the connective used chemotherapy for advanced stage disease with invasive implants and have reported var- ing of pelvic-abdominal fullness or bloating, tissue elements of the ovary. They are rare and Stage 1b disease (involvement of both ovaries, abdominal pain, occasional irregular bleed- account for about 5–10% of all types of ovar- ied results. It is therefore important girls and women of reproductive age, and only non-invasive implants in either the perito- is again by laparotomy, peritoneal washings to have a high index of suspicion as some of about 10% occur in women above the age of neum or the omentum. Tumors derived from the ovarian omentectomy and para-aortic lymphadenec- nal and pelvic examination may reveal a pel- stroma may be associated with abnormal pro- Invasive epithelial ovarian tumors tomy. A pelvic ultrasound would show a duction of the sex steroid hormones (proges- give the woman the option of egg donation complex ovarian mass which is usually unilat- terone, estrogen, testosterone, androstenedi- Epithelial ovarian cancer is relatively uncom- for in vitro fertilization. Most integrity as well as to prevent menopausal sensitive tumor markers which are usually cause abnormal uterine bleeding or precocious women have completed their family before symptoms and osteoporosis. They are a rare Adjuvant radiotherapy is only indicated in Whilst it is important to discuss these options cause virilization, hirsutism, greasy skin and cause of precocious puberty in children and women with very close tumor excision mar- and their relative degrees of success, it is also infertility. In those with important for the clinician to consider the The most common types are granulosa cell disease when conservative surgery and fertility very close tumor resection margins, the option overall disease survival and life expectancy tumor and Sertoli-Leydig tumors. It may not be ethically justif- of ovarian stromal tumors include theca cell considered before resorting to adjuvant radio- able to offer these options to patients with tumor, fbroma, thecoma, lipid cell tumor and therapy. Of the above three options, ian stromal tumors (approximately 75%) will ating the pelvis as well as with the potential embryo freezing appears to carry most success present with stage 1 disease. Their earlier Vulvar cancer is very rare in women in the of ovarian tissue damage which can lead to and should be the preferred option in women presentation, unlike their epithelial counter- reproductive age group with only a handful premature menopause. Until recently, parts, is probably because of the associated of cases reported in women below the age have implications for fertility in women of egg preservation or freezing was still experi- symptoms secondary to abnormal hormone of 40 years. If it is a early stage cervical cancer and conservative technique of transplantation of previously be associated with abnormal uterine bleed- lateralized disease, then unilateral groin node management in some women with either early stored ovarian tissue to the same woman has ing or endometrial hyperplasia. Because Nowadays, women with small volume disease in young women within the reproductive age any other organ transplantation, the risks of these tumors tend to present early, unilateral can be offered the lesser surgical option of sen- range, ovarian function is a major issue that immunosuppression and rejection should be salpingo-oophorectomy and omentectomy tinel lymph node dissection of the groin. The opinion of the author with preservation of the contralateral ovary is a far less morbid surgical option without the nifcant other or family, as appropriate. Other fertility options bilateral salpingo-oophorectomy, omentec- tumor would in most cases preserve the apy treatment, especially external beam irra- are available and should also be considered, tomy and surgical debulking of all macroscopic anatomy of the external vulva. In young women still desiring fertility, subsequent deliveries should be by cesarean decades make it possible to offer women desir- ing to conceive after cancer treatment options 1. Cancer Statistics Sertoli-Leydig tumors section as the vulva, although adequate for Registrations: Registrations of Cancer Diagnosed sexual intercourse, may be too tight for vagi- such as: in England. Without doubt, obesity is a complex the general health of the public, the number of chronic disease to which adding a pregnancy bariatric procedures performed increased from further complicates management and perina- less than 20,000 in 1995 to more than 200,000 tal outcomes. In general, operative complications including infections, pregnancies occurring after bariatric surgery hemorrhage and increased operating times are have favorable outcomes17,18, and studies sug- common9–11. Nevertheless, the keys to improving than 35kg/m2 with co-morbidities such as car- perinatal outcomes after bariatric surgery are appro- diovascular disease, diabetes, or sleep apnea. This chapter restrictive, malabsorptive and mixed proce- addresses issues that occur in reproductive age dures – are named by the mechanism by which women either planning a pregnancy or preg- weight loss occurs. Bone loss can occur after bariatric surgery 21 pregnancies within 1 year of surgery and new body image as well as diffculty in distin- gonadotropin secretion, elevated leptin levels because of vitamin defciencies, especially in 13 pregnancies after the frst year of surgery, guishing postsurgical symptoms from changes and diminished ovarian reserve24. All things being considered, consensus tory dysfunction, including syndromes such gery, this also needs to be considered in plan- pounds) in the pregnancies occurring early suggests that conception should be delayed as polycystic ovarian syndrome. Unfortunately, limited after surgery group, to excessive weight gains 12–18 months after bariatric surgery to mini- ric surgery, menstrual cycle irregularities and evidence is available regarding the use, effec- (13–75 pounds, mean 34 pounds) in the preg- mize complications from nutritional defcien- hyperandrogenism improve25–28. Weight gain during cies and promote optimal and stable maternal eral reports have observed improved fertility iatric surgery, but it is unlikely that there is a pregnancy may predict long-term weight sta- weight loss39. In the event that an early preg- and/or unanticipated pregnancies after bariat- signifcant decrease in effcacy for oral contra- tus; however, studies on the impact of early vs. Long-acting reversible methods late pregnancy and long-term maternal out- that overall the outcomes are reassuring, based Despite this, future fertility may not be (i.