Should both teacher and visitor be involved in either writing to or briefing 25mg pamelor overnight delivery, parents beforehand  how you will evaluate the input Although some visitors may prefer that the teacher is not present buy pamelor 25mg with amex, it is recommended that the class teacher stay with the class for the duration of the input discount 25 mg pamelor with mastercard. This safeguards the students, the teacher and the visitor in both child protection and insurance matters. It ensures that the teacher is aware of exactly what was covered should any issue arise at a later stage and that the visitor has understood the school ethos. All of these feelings are valid because most adults find it difficult to understand the arena of youth culture and this coupled with a low level of factual information on substances and substance use often increases the sense of apprehension. It must be remembered that within the school setting it is not just students who may be involved in substance use but also any individual who is part of the school community whether principal, teacher, support staff or parent. These may include finding a substance, seeing something suspicious being passed from one person to another, observing a ‘stoned’ parent arriving to collect a young child from school, noticing a teacher who comes to school smelling strongly of alcohol or finding a child inhaling solvents. How a school responds to these incidents may be crucial not only to the individuals directly involved but also to the whole school community. Rather than putting forward a list of scenarios and possible responses each school needs, within the context of its ethos, to decide on its own course of action, guided in the first instance by the Children First National Guidelines for the Protection and Welfare of Children along with school policy on substance use. In attempting to deal effectively with such instances, the following questions may be of use and should at least stimulate discussion on the issue. Will the school’s response be identical in every case or will there be flexibility depending on the specific circumstances? Within the Eastern Region these services can all be contacted at one of the ten Community Services offices or your local health center East Coast Area Health Board y Community Services Area 1. Tel: 0404 68400 South Western Area Health Board y Dublin South City Carnegie Building, 1-25 Lord Edward St, Dublin 2. Tel: 01 626 8101, 01 626 7914 y Dublin South West Health Centre, Old County Road, Dublin 12. Tel: 01 454 2511 83 Contacts, Further Reading and Websites y Kildare /West Wicklow Poplar House, Poplar Square, Naas, Co. Tel: 045 876 001 Northern Area Health Board y Community Services Area 6, Rathdown Road, Dublin 7. Tel: 01 857 5400 y Community Services Area 8, Coolock Health Centre, Cromcastle Road, Coolock, Dublin 5. Tel: 01 847 6122, 01 847 6033 Drug Treatment Services A number of treatment options are available for both adults and young people who may be experiencing problems related to alcohol or drug use. For further information about these services contact: Drug Advisory and Treatment Centre Trinity Court, 30/31 Pearse Street, Dublin 2. Tel: 01 882 0300 Alcohol Services y East Coast Area Health Board: Baggot Street Community Alcohol Treatment Unit. Tel: 01 660 7838 y South Western Area Health Board: Community Alcohol Services Tel: 01 451 6589/754 y Northern Area Health Board: Stanhope Treatment Centre. Tel: 01 677 9447 Medical Support and Information In the event of a suspected drug overdose/poisoning by alcohol or drugs, early medical intervention saves lives. Vincent’s Hospital Tel: 01 209 4358 y Poisons Information Services Beaumont Hospital, Dublin 9. Tel: 01 837 996601, 01 837 9964 Garda Síochána Garda Juvenile Diversion Programme: Contact your local Garda Station to get the name of the local Juvenile Liaison Officer and/or Community Garda who are available for advice and educational support. Local Drug Task Forces The local Drug Task Forces were set up in 1997 to implement local action plans and implement community based initiatives, which were designed to compliment and add value to the drug programmes and services already being provided or planned by the State Agencies. Some of the types of measures funded include: y “Stay at School” projects and after-school activities, aimed at children involved or at risk of becoming involved in drugs y The development of activities aimed at “at risk” children and young people outside the school setting (in youth clubs, etc. It includes components aimed at developing young peoples’ life-skills and emotional well being. Walk Tall was initially a National Pilot Programme run by the Department of Education and Science and was offered to all designated disadvantaged schools. Following the success of the Pilot phase the programme was offered to all schools nationwide. For further information, contact: The Walk Tall Programme Dublin West Education Centre Old Blessington Road, Tallaght, Dublin 24. This is an educational package for use with all post primary students aimed at the development of personal and social skills for the prevention of substance misuse. Support Service (Post-Primary) Marino Institute of Education, Griffith Avenue, D9. Other Resources The Health Promotion Departments within your local health board also distributes a wide range of leaflets and posters on smoking, alcohol and illegal drugs. This service is available free of charge and there are qualified professional staff on site to assist users. Address: National Documentation Centre on Drug Use Drug Misuse Research Division Health Research Board Holbrook House, Holles Street Dublin 2, Ireland Tel: 01 676 1176 Fax: 01 661 8567 Blanchardstown Drug Education Resource Centre Blanchardstown Drug Education Resource Centre, is dedicated to information on all aspects of drugs, including prevention, education, treatment and rehabilitation. The collection of books, journals, reports and supporting programmes covers a wide range of subjects. It also provides a platform for lobbying to improve the resources available to the drug education sector.

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Complications Prognosis Local spread especially into the renal vein buy 25mg pamelor with mastercard, and may grow If confined to renal capsule 10-year survival is 70% buy pamelor 25mg without prescription. Tumour poor if metastases present pamelor 25 mg without a prescription, 25% of patients present with may also spread into neighbouring tissues, such as the metastases and they have a 45% 5-year survival. Bladder cancer Definition Investigations Bladder cancer is the most common urological malig- Urinalysis shows haematuria in ∼40%. A solid tumour >3cmisdiagnostic, but sometimes a cyst is seen which needs to be differentiated Incidence/prevalence between a simple benign cyst, a complex cyst or solid Common malignancy; 1 in 5000 in United Kinddom. Management Surgical removal is the treatment of choice for those Aetiology without metastases (if there is a single metastasis this There are several risk factors for the development of can be resected along with the primary tumour). In the past, radical nephrectomy with removal of r Exposure to certain carcinogens and industries cause the kidney, perinephric fact, together with the ipsilateral as many as 20% of cases. Aromatic amines, or deriva- adrenal gland and hilar and para-aortic lymph nodes tives, which are strongly carcinogenic are commonly was routinely performed. Some now perform either total found in the printing, rubber, textile and petrochemi- nephrectomy (without removal of the adrenal or lymph cal industries. Genetic: Macroscopy r Through polymorphisms of various cytochrome P450 Low-grade tumours have a papillary structure and look enzymes, some individuals appear to oxidise ary- like seaweed. Higher grade tumours lamines more rapidly, which makes them more prone appear more solid, ulcerating lesions. T3 Deep muscle involved, through bladder wall Radiotherapy, for example for pelvic tumours, pre- (mobile mass). It is thought that in most cases, the bladder and ureters G2 Moderately well differentiated. This may ex- plain why, in many cases, there is a ‘field change’ to the Complications whole of the urothelium from renal pelvis to urethra, so Tumours of stage >T3 metastasise, but this is uncom- that multiple and recurrent tumours occur. Adenocarcinoma arises from the urachal rem- Investigations nants in the dome of the bladder. Whilst all these symptoms are most commonly be performed from the bladder upwards. Pain may be felt in the loin when there is ob- Depends on stage: struction, or suprapubically if there is invasion through i TisorTa, and T1 are initially treated by cysto- the bladder wall. Follow-up 3 months later has a 50% re- Prostate cancer currence rate and regular follow-up is needed, usu- Definition ally for 5–10 years. Age ii Localised,muscle-invasivedisease(T2,butalsohigh- >50 years (40% > 70 years, 60% > 80 years) grade T1) is optimally treated by a radical cystec- tomy – malesaretreatedbycystectomywithproximal Sex urethral and prostate removal, females require cys- Male tectomy with the whole urethra removed and an ileal conduit with urinary diversion (ureters to ileum). In Geography males it is possible to use a piece of ileum to form Varies by population (90x). Most common in Afro abladder substitute ‘substitution urethroplasty’ be- Caribbeans, common in Europe, rare in Orientals. Predisposing factors include age, ethnicity, family his- iii Locally advanced disease (T3 and T4) is life threaten- tory,genetic factors and diet, with a diet high in ani- ing and requires radical cystectomy in combination mal fat, low in vegetables showing an increased risk, but with radiotherapy or chemotherapy. Morbidity results from radiation cystitis and proctitis leading to a small Pathophysiology fibrosed rectum. In females radiation vaginitis and/or The cancer is commonly androgen-dependent, but anasensatevagina,andinmalesimpotenceoccursdue there is no evidence that its growth is driven by a to nerve damage. However, popu- r Chemotherapy is increasingly used with surgery, or lation studies have shown that men with higher testos- may be used alone as a palliative measure. Neoad- terone levels appear to be at greater risk of prostate juvant chemotherapy (i. Depends on stage and grade at presentation and the age r In most cases it is diagnosed either on rectal exam- of the patient. Recurrence is common and may be of ination as the finding of an asymmetric prostate, a a higher grade (25%). Some patients appear to have a nodule or a hard, irregular craggy mass, often alter- few,minorrecurrences,whereasothershavewidespread, ing the median groove. T1 has an 80% 5-year survival and diagnosed because of the finding of a raised prostate T4 has 10% 5-year survival (but very age dependent). Macroscopy Management The tumours usually are in the peripheral zone of the This depends on the tumour staging, grade and also on prostate and appear as hard yellow-white gritty tissue the patient’s age and co-morbidity, as many of the treat- (see Table 6. Organ-confined, low-grade disease: r These tumours tend to grow slowly, in older patients Microscopy (>70 years) and those likely to die of co-morbidity be- Most are well differentiated and consist of small acini fore the cancer causes significant symptoms or metas- in a glandular pattern. However, rad- Gleason score: The biopsy material is examined under ical surgery is a major operation, with a 60% incidence a microscope and a Gleason grade 1–5 (grade 1 being of impotence (compared to 16% preoperatively) and most differentiated, grade 5 the least) is assigned to the anincreaseinurinaryincontinence. These also cause complications such as acute and chronic ra- two grades are then added together to give the Gleason diation proctitis (diarrhoea, urgency, bleeding), and score (2–10). Complications Metastatic or high grade local disease: Urinary tract infection and renal tract obstruction may r Treatment is for symptoms only (palliative). Chapter 6: Genitourinary oncology 281 iv Chemotherapy is not as effective and is used mainly Aetiology for non-responsive disease. Ten per r Throughout treatment a multidisciplinary approach cent of all testicular tumours develop in testes which is needed with regard to palliation of symptoms. A family phosphonates are used for bone pain and to prevent history is also a known risk factor as is infertility.

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Modern era Nineteenth century to today The nineteenth century saw the development of Claude Bernard’s modern phys- iology purchase pamelor 25 mg amex, William Morton’s anesthesia purchase 25mg pamelor fast delivery, Joseph Lister and Ignatz Semmelweis’ anti- sepsis buy 25mg pamelor amex, Wilhelm Roentgen’s x-rays, Louis Pasteur and Robert Koch’s germ the- ory, and Sigmund Freud’s psychiatric theory. Changes in medical practice were illustrated by the empirical analysis done in 1838 by Pierre Charles Alexandre Louis. He showed that blood-letting therapy for typhoid fever was associated with increased mortality and changed this practice as a result. The growth of san- itary engineering and public health preceded this in the seventeenth and eigh- teenth centuries. This improvement had the greatest impact on human health through improved water supplies, waste removal, and living and working con- ditions. John Snow performed the first recorded modern epidemiological study in 1854 during a cholera epidemic in London. He found that a particular water pump located on Broad Street was the source of the epidemic and was being con- taminated by sewage dumped into the River Thames. At the same time, Florence Nightingale was using statistical graphs to show the need to improve sanitation and hygiene in general for the British troops during the Crimean War. Specifics include the discovery of modern medicines by Paul Erlich, antibiotics (specif- ically sulfanilamide by Domagk and penicillin by Fleming), and modern A brief history of medicine and statistics 7 chemotherapeutic agents to treat ancient scourges such as diabetes (specifically the discovery of insulin by Banting, Best, and McLeod), cancer, and hyperten- sion. The modern era of surgery has led to open-heart surgery, joint replacement, and organ transplantation. Before the middle of the twentieth century, advances in medicine and conclusions about human illness occurred mainly through the study of anatomy and physiology. The case study or case series was a common way to prove that a treatment was beneficial or that a certain etiology was the cause of an illness. There were intense battles between those physicians who wanted to use statistical sampling and those who believed in the power of inductive reasoning from physiological experiments. This argument between inductive reasoning and statistical sampling contin- ued into the nineteenth century. Pierre Simon Laplace (1814) put forward the idea that essentially all knowledge was uncertain and, therefore, probabilistic in nature. The work of Pierre Charles Alexandre Louis on typhoid and diphtheria (1838) debunking the theory of bleeding used probabilistic principles. On the other side was Francois Double, who felt that treatment of the individual was more important than knowing what happens to groups of patients. The art of medicine was defined as deductions from experience and induction from phys- iologic mechanisms. The rise of modern biomedical research Most research done before the twentieth century was more anecdotal than sys- tematic, consisting of descriptions of patients or pathological findings. James Lind, a Royal Navy surgeon, carried out the first recorded clinical trial in 1747. In looking for a cure for scurvy, he fed sailors afflicted with scurvy six different treatments and determined that a factor in limes and oranges cured the disease while other foods did not. His study was not blinded, but as a result, 40 years later limes were stocked on all ships of the Royal Navy, and scurvy among sailors became a problem of the past. Research studies of physiology and other basic science research topics began to appear in large numbers in the nineteenth century. By the start of the twenti- eth century, medicine had moved from the empirical observation of cases to the scientific application of basic sciences to determine the best therapies and cat- alog diagnoses. Although there were some epidemiological studies that looked at populations, it was uncommon to have any kind of longitudinal study of large 8 Essential Evidence-Based Medicine groups of patients. There was a 200-year gap from Lind’s studies before the con- trolled clinical trial became the standard study for new medical innovations. It was only in the 1950s that the randomized clinical trial became the standard for excellent research. Beginning in the early 1900s, he developed the basis for most the- ories of modern statistical testing. Austin Bradford Hill was another statistician, who, in 1937, published a series of articles in the Lancet on the use of statisti- cal methodology in medical research. In 1947, he published a simple commen- tary in the British Medical Journal calling for the introduction of statistics in the medical curriculum. He showed that streptomycin therapy was superior to standard therapy for the treatment of pulmonary tuberculosis. Finally, Archie Cochrane was particularly important in the development of the current movement to perform systematic reviews of medical topics. He was a British general practitioner who did a lot of epidemiological work on respira- tory diseases.

There is increasing inflammation and There is a high risk of hepatocellular carcinoma if cir- fibrosis and untreated order 25mg pamelor visa, it progresses to cirrhosis generic 25mg pamelor free shipping. Clinical features Investigations Heterozygous individuals are asymptomatic and usually Diagnosed on liver biopsy purchase pamelor 25 mg otc. Kayser–Fleischer rings (green/brown rings around the edge of the cornea) are a late diagnostic sign, but are Management variably present. Regular venesection reduces the iron load and the risk Microscopy of cirrhosis and hepatocellular carcinoma. Other man- Excess copper can be seen in the liver using special stain- ifestations are treated symptomatically, e. Itis∼2–20 × normal, but this also occurs in chronic diabetes, testosterone for gonadal failure. Investigations Reduced serum copper and ceruloplasmin levels (not Prognosis specific and 25% of patients will have normal levels). The earlier the diagnosis and treatment, the better the Urinary copper is high and increases markedly following prognosis. If diagnosed Poor prognostic factors are co-existent biliary tract dis- and treated sufficiently early, there is some improvement ease, old age and multiple abscesses. Amoebic liver abscess Pyogenic liver abscess Definition Definition Infection of the liver by Entamoeba histolytica. The development of liver abscesses is thought to follow Aetiology/pathophysiology bacterial infection elsewhere in the body. The infection water is food borne and is most common Aetiology/pathophysiology in parts of the world with poor sanitation, e. Infectionmay reach the liver by the portal of trophozoites in the intestine, which are thought to vein from a focus of infection drained by the portal vein, invade through the mucosa gaining entry to the portal e. Infection may also result from a generalised septicaemia or direct spread from the biliary tree. Clinical features Symptoms include right upper quadrant pain, anorexia, Symptoms and signs range from mild to severe, often nausea, weight loss and night sweats. Tender hepatic en- the symptoms are less marked in elderly patients, with largement without jaundice is usual. Macroscopy/microscopy Maybesingle or multiple lesions ranging from a few Investigations millimetres to several centimetres in size. Investigations Guided aspiration and stool ova, cyst and parasite exam- Ultrasound scan is useful for screening, and pus may be ination may demonstrate the organism. Blood cultures, Management liver function tests and inflammatory markers should Treated with metronidazole. Hydatid disease Management Repeated ultrasound guided aspirations may be re- Definition quired. Extensive, difficult to approach abscesses are A tapeworm infection of the liver common in sheep rear- drained by open surgery, with soft pliable drains. Chapter 5: Disorders of the liver 213 Aetiology/pathophysiology r Hepatic adenomas are oestrogen dependent tumours In man hydatid disease is caused by one of two tape- generally only seen in women. They are strongly asso- worms Echinococcus granulosus and Echinococcus mul- ciated with the oral contraceptive pill. Clinical features The disease may be symptomless but chronic right up- Primary hepatocellular carcinoma perquadrant pain with enlargement of the liver is the common presentation. The cyst may rupture into the Definition biliary tree or peritoneal cavity and may cause an acute Also called hepatoma, this is a tumour of the liver anaphylactic reaction. Investigations Incidence/prevalence Eosinophilia is common and serological tests are avail- Relatively uncommon in the Western world (2–3%), but able. Small, calcified cysts may be seen on plain abdom- by far the most common primary tumour of the liver inal X-ray. Percutaneous ultrasound guided fine nee- Sex dle aspiration with injection of scolicidal agents and re- M > F (3–4:1) aspiration may be used. Large symptomatic cysts may be surgically excised intact taking great care to avoid con- Geography tamination of the peritoneal cavity. High incidence (40% of all cancers) in countries where predisposing factors such as hepatitis B are common, e. Tumours of the liver Aetiology Benign tumours of the liver Tumours arise in a chronically damaged liver especially Benign tumours of the liver must be differentiated from in cirrhosis independent of the cause. Hepatitis B virus malignant tumours such as metastases or primary hepa- carrier states and chronic active hepatitis predisposes to tocellular tumour and cysts or abscesses. There are four primary hepatocellular carcinoma, especially when hep- main types: atitisBinfectionoccursinearlylife. Hepatotoxinssuchas r Cavernous haemangiomas are the most common be- mycotoxinspresentinfood,increasetheincidenceofpri- nign tumours of the liver. Aflatoxin, produced by Aspergillus flavus, rarely become large and produce pain, enlarged liver is frequently found in stored nuts and grains in tropical or haemorrhage. Sometimes rare syn- mour,whichusuallypresentslateinpatientswhoalready dromes occur such as hypercalcaemia, hypoglycaemia haveaseriousunderlyingpathology,cirrhosis.

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