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Back to antifungal brands cheap mentax 15 mg visa Top Date Sent: 3/24/2020 151 these criteria do not imply or guarantee approval anti fungal anti yeast diet discount mentax online. Prospective fungus killing frogs purchase mentax 15mg line, randomized fungal lung infection order cheap mentax online, blinded study of Prostatic Urethral Lift (pul): four-year results. Articles: PubMed search was conducted up to August 8, 2019 with the search terms prostate artery embolization. Of these, four were retained (two meta-analyses with comparative studies and two with noncomparative studies). The other meta-analyses are included in other references because their findings are similar to that of the two meta-analyses of noncomparative studies retained. Regarding nonrandomized studies, search yielded 18 studies, but none was included due to their inclusion in the meta-analyses of noncomparative studies. Back to Top Date Sent: 3/24/2020 152 these criteria do not imply or guarantee approval. Back to Top Date Sent: 3/24/2020 153 these criteria do not imply or guarantee approval. Local Coverage Article None For Non-Medicare Members 1) Breast Cancer Brachytherapy as an adjunct to whole breast radiation is covered when recommended by the treating practitioner. Standard brachytherapy is covered without medical necessity review for: Coronary Artery Brachytherapy, Intravascular Coronary Brachytherapy Endobronchial Brachytherapy Lung Cancer High-Dose or Low-Dose Brachytherapy for Cervical and Endometrial Cancer Prostate Cancer © 1998 Kaiser Foundation Health Plan of Washington. Back to Top Date Sent: 3/24/2020 154 these criteria do not imply or guarantee approval. Criteria | Codes | Revision History Procedure Criteria AccuBoost peripheral breast brachytherapy There is insufficient evidence in the published medical literature to show that this service/therapy is as safe as Radioactive Seeds for Treatment of Recurrent High standard services/therapies and/or provides better Grade Glioblastoma long-term outcomes than current standard services/therapies. Background Brachytherapy, also called internal radiation therapy, allows a physician to use a higher total dose of radiation to treat a smaller area and in a shorter time than is possible with external radiation treatment. Brachytherapy involves placing a radioactive material directly inside or next to the tumor. It has been proven to be very effective and safe, providing a good alternative to surgical removal of the prostate, breast, and cervix, while reducing the risk of certain long-term side effects. In temporary brachytherapy, the radioactive material is placed inside or near a tumor for a specific amount of time and then withdrawn. Permanent brachytherapy, also called seed implantation, involves placing radioactive seeds or pellets (about the size of a grain of rice) in or near the tumor and leaving them there permanently. After several weeks or months, the radioactivity level of the implants eventually diminishes to nothing. The inactive seeds then remain in the body, with no lasting effect on the patient. Evidence and Source Documents Breast Cancer Coronary Artery Brachytherapy, Intravascular Coronary Brachytherapy Endobronchial Brachytherapy Lung Cancer High-Dose vs. Researchers believe that whole breast irradiation after lumpectomy reduces local breast recurrence by eliminating residual cancer at the surgical site, as well as occult areas of in-situ or infiltrating cancer in remote areas in the breast. This may be a problem for working women, elderly patients, or those living at a considerable distance from a treatment center. Investigators also found that treating the entire volume of the breast may deliver small radiation doses to the adjacent tissues leading to acute and chronic toxicity to the skin, heart, lung, and contralateral breast (Fisher 1995, 2002, Baglan 2001, Veronesi 2002, Chen 2007, Cuttino 2007). This is based on the assumption that the microscopic tumor rarely extends 2 cm beyond the initial resection cavity when the margins are negative on final pathologic examination. Back to Top Date Sent: 3/24/2020 155 these criteria do not imply or guarantee approval. These techniques are widely different in terms of radiation delivery, degree of invasiveness, length of treatment, and acceptance by radiation oncologists (Chen 2007, Chao 2007). Breast brachytherapy involves the placement of radioactive sources inside the breast to deliver a relatively high dose of radiation to the tissue immediately surrounding the lumpectomy site, and very little dose to the surrounding normal structure. The interstitial multicatheter system, the most common method used, involves the placement of a number of catheters into the breast to guide the radioactive materials to the intended area. Pellets of iridium-192 are then inserted into the catheters over the course of the treatment. The catheters are briefly connected to a dose-rate brachytherapy machine for internal radiation treatment, which takes about ten minutes each. The procedure requires significant technical expertise, and can be difficult and challenging (Chen 2007, Bovi 2007, Haley 2008, Kacso 2008). Balloon-based brachytherapy Several balloon based brachytherapy devices were developed as an alternative to the interstitial multicatheter system to be more user-friendly to the clinician and more accessible and better tolerated by the patient. It consists of a small balloon connected to an inflation channel and a catheter for the passage of a high dose rate brachytherapy dose (Iridium-1 92 [192Ir]. The device is implanted in the lumpectomy cavity during or following breast surgery. The balloon is inflated with sterile saline containing a small amount of radiographic contrast to a size that completely fills the cavity and ensures conformance of the tissue to the balloon. A computed tomography scan is obtained to assess the balloon conformance to the lumpectomy cavity and determine its symmetry, diameter, distance from skin, planning target volume, and the dose distribution. After treatment is completed in several days, the balloon is deflated, and the catheter is removed. The treatment with the MammoSite device generally delivers 34 Gy in 10 fractions (3. Investigators recommend the system for patients with ductal carcinoma in situ, invasive ductal carcinoma, and primary tumors with a diameter less than 3cm. It may not be suitable for patients with small breast or for tumors located in the upper inner quadrant because of the requirement for skin-to-cavity distances (Bensaleh 2009, Njeh 2010). Similar to MammoSite, Xoft Axxent consists of a balloon catheter that is percutaneously inserted into the lumpectomy cavity. The x-ray source consists of a miniature x-ray tube that is inserted in the balloon catheter and delivers the radiation therapy to the patient. The system may be operated at variable currents and voltages to change the dose rate and penetration properties. The Xoft Axxent does not require a high-dose rate afterloader unit, or treatment in a shielded vault. Another potential advantage is the lower energy dose deposited in adjacent normal tissues, compared to other forms of balloon brachytherapy. It is unknown if these advantages would be outweighed by a potential harm of fat necrosis as a result of a significant dose inhomgeneity (Strauss 2009, Dickler 2009). The approach provides additional flexibility and has the potential of improving normal tissue sparing. The device includes a port which can be connected to suction to remove seroma fluid or air in an effort to improve conformity (Strauss 2009, Njeh 2010). The AccuBoost system consists of three main components: (1) A conventional mammography unit to immobilize the breast and localize the lumpectomy site. The patient’s breast is compressed to a thickness of 3-8 cm between two mammography paddles and imaged with a radiopaques cordinate grid. The radiation oncologist determines the isocenter coordinates and appropriate applicator size and shape based on the image. The process is repeated along an orthogonal axis to distribute the entrance dose (Rivard 2009, Yang 2009, AccuBoost website). Back to Top Date Sent: 3/24/2020 156 these criteria do not imply or guarantee approval. The authors set no equivalence boundary but took the lack of statistically significant difference between the two treatments as a proof of equivalence, which could lead to an erroneous judgment. The patients were not randomly assigned to the treatment group, and it is not discussed if they were consecutive, which may be a source of selection bias. The cohorts of women treated with brachytherapy were prospectively followed for a variable period of time (median 36 months in Vicini’s study, and 74 months in King’s study). The follow-up period was as short as a few months among some patients, and the dropout rate in the brachytherapy group was 82% after 5 years in Vicini’s study. In the two studies, data on the control group were obtained from retrospective chart reviews. Patients in the brachytherapy group received the treatment at either a low or high-dose rate but were analyzed as one group. There were some differences in the baseline characteristics that were not adjusted for in the analysis of the results. The overall control and cosmetic outcomes of the brachytherapy as a sole treatment after lumpectomy were similar to that achieved by the external beam radiation therapy.
After the application of cricoid pressure we gave additional 1mg/ stage kidney disease; and use of preoperative renal replacement therapy antifungal nail paste effective mentax 15 mg. Endotracheal intubation was quickly done with defned according to fungus gnats get rid order mentax online now the Kidney Disease: Improving Global Outcomes guidelines 7 fungus cancer mentax 15mg amex. Endoscopy lasted 2 and a half hours but the toothbrush after liver transplantation antifungal whole foods purchase mentax 15 mg on line. Statistical analyses were performed by using Fisher’s couldn’t be removed endoscopically. We added 10mg rocuronium and then the exact test, Mann-Whitney Utest and multivariate logistic regression analysis. Then she started breathing spontaneously and was analysis revealed that Child-Pugh score B or C (odds ratio, 2. High Child-Pugh score, a large amount of intraoperative blood loss and a gastrointestinal tract: a retrospective study of 1294 cases. Scandinavian journal of large postoperative positive fuid balance were independently associated with the gastroenterology, 2017. Learning points: It is important to prevent aspiration in the foreign body ingestion procedures. We therefore describe our single-centre experience with this simple Background and Goal of Study: the use of centrally inserted central venous technique for major neonatal surgery and the perioperative period. Data were extracted from the electronic anaesthesia and intensive care Materials and Methods: this retrospective study was performed using data unit records. Relationship between demographic, clinical and hematologic variables was time of surgery of which 84,8% had laparotomy and 15,2% thoracotomy were investigated. Identifcation of patients who may require revision intervention and increased Conclusion: Continuous caudal anaesthesia with intermittend peridural morphine awareness on catheter infection may improve success rate and decrease the is a feasible anaesthetic technique for major neonatal surgery with the potential likelihood of complications and hazards. Retrospective analysis of 166 central line placements Acknowledgements: the author would like to acknowledge the assistance of in children Tanja Rappel with data extraction. Materials and Methods: the entries from 2016, 2017 interventions Pediatric Kamal M. Background: Epidural analgesia is the standard and reliable technique of 68% of time the right internal jugular vein was used followed by the subclavian and perioperative pain relief in patients undergoing abdominal and thoracic surgeries. In 63% the vein was It’s use in paediatric age group is not being widely practiced because of concerns cannulated from the frst attempt. In one patient 10 attempts for higher chances of dura puncture and neurological complications as they have were made at different sites. In 22% a straight wire was used instead of a J informed parental consent were taken. Analysis showed that cannulation attempts and diffculties were more frequent surgery, neurological disorder, coagulopathy, local infection or sepsis and allergy with decreasing weight, especially below 5 kg. Under general anaesthesia, in left lateral patients were non-advancement of the J wire and malposition of the needle after position, congruent epidurals were inserted using linear/hockey probe (8 to13 disconnection from the syringe. Also when a cathlon was used instead of a needle no optimum ligamentum favum and anterior dura complex views by para median syringe was necessary. Further confrmation of epidural space was done by loss of resistance to saline and Conclusions: As expected the most challenging patients proved to be the youngest. Procedure time, number of bone contacts or needle redirections, number of 5 kg it is better to use a straight wire. A cathlon catheter instead of a needle can attempts and procedure related complications like dura puncture, bloody tap were reduce malpositioning due to syringe disconnection. Results: Real time ultrasound guided epidural placement was performed in 9 infants in lower thoracic and upper lumber interspaces. Seven out of 9 required single needle insertion attempts, while 2 and 3 attempts were needed in one patient each. Two patients had no bone contact, while 4 had single bone contact and 3 had it twice. No needle redirections were required in 2 patients, single redirections in 2 patients and 2 redirections in 4 patients. Discussion and Conclusion: Ultrasound helps in identifcation of interlaminar space, ligamentum favum, dural complexes and needle tip. Jayme Santos Neves Serra (Brazil), 2Disciplina high risk of perioperative complications. We reviewed patients with congenital heart diseases who had undergone general anesthesia at Kitasato University Hospital between Background: Sugammadex can be used for immediate reversal of neuromuscular January 2016 and August 2018 and ranged in age from 0 to 12 years. Although its use is extensively procedures, anesthesia methods, airways management, intraoperative elapsed described in adults for elective and emergency purposes, sugammadex is still time, perioperative complications such as cardiovascular events, and outcomes an off-label alternative in the neonatal and pediatric populations. Perioperative complications were observed in 16 Case Report: A 30 weeks 2/7 premature female neonate with 1060g was scheduled cases (17. Focusing of department, pediatric surgery and anesthesia was induced and maintained with dexmedetomidine, S-ketamine otolaryngology have a larger number of noncardiac surgery cases, and the frequency and fentanyl. Despite appropriated anesthetic doses for providing hypnosis and of perioperative complications in pediatric surgery was the highest (68. Then, it was of perioperative complications in noncardiac surgeries for pediatrics with congenital decided to administer rocuronium. However, after apnea, she became impossible heart diseases indicated that the frequency of perioperative complications are same to be ventilated or oxygenated, presenting with increased abdominal volume, or slightly higher when compared with previous reports. While the surgeon was preparing for an emergency diseases group had a higher frequency of perioperative complications, such as gastric decompression, it was given a high dose of sugammadex with atropine. In spite of all the expected and inherent challenges of the procedure, the consideration of treated or untreated cardiovascular disease. In addition, clinicians fstula was ligated and the esophagus was successfully reconstructed. Enteral should consider both circulation and airway management as important factors. However, there are no data available about the effcacy and safety of Niigata (Japan) the drug in this age group. In addition, for example, in patients with pulmonary artery stenosis (such as in Tetralogy of Fallot) with no venous blood Anesthetic management in pediatric patients with access or in whom a venous catheter is not available due to an extravascular leak congenital long qt syndrome undergoing left cardiac suffering an anoxic spell, swift intravenous catheterization for fuid and medication administration is needed. However, it is often not only diffcult to perform peripheral sympathetic denervation intravenous catheterization, but also to fnd a peripheral vein using ultrasound in patients in shock. Barcelona Children’s Hospital brachiocephalic vein is to be an alternative approach in cases of diffcult peripheral 2 veins. Arrythmias Discussion: Access to the internal jugular vein, the most popular approach among and Sudden Death Unit. Barcelona Children’s Hospital Sant Joan de anesthesiologists, is sometimes diffcult, especially in babies or small pediatric Deu, Barcelona (Spain) patients because their large head, short neck, and the ultrasound probe interfere with each other. In the real-time ultrasound-guided left disorder resulting from malfunction of cardiac ion channels. It predisposes to malignant supraclavicular approach, the target vein (left brachiocephalic vein) is shown in a ventricular arrhythmias, such as “torsade de pointes”, which may lead to syncope, long-axis view and the puncture needle is inserted from the left side of the patient cardiac arrest and sudden death. It has been reported that the real-time ultrasound therapeutic option for patients who cannot tolerate pharmacotherapy, patients who guided left supraclavicular approach is easier and its success rate higher than that continue to have cardiac events despite pharmacotherapy or those who received of the right approach(3). Therefore, this technique is helpful as one of solution frequent shocks from the implantable cardiac defbrillators. The aim of this study is to describe our experience in the anesthetic 1 Yamamoto T, Schindler E. Materials and Methods: We have performed a retrospective observational study of 3 Breschan C, et al. External defbrillator pads were placed in all patients and emergency induction for heart surgery in a case of small pediatric patient with diffcult peripheral drugs were prepared. Secondary outcomes included early and late patients after the induction as a prophylaxis of nausea and vomiting. Statistics: Relative Risks with corresponding 95% confdence intervals achieved with a double lumen tube in 60% of patients, and with a standard tube in (Mantel-Haenszel, Random Effects Modeling), p<0. At the end of surgery 30% of patients received local anesthesia in the trocar Results and Discussion: Out of 1,455 search results, 22 studies comprising 2,200 insertions (levobupivacaine). However, there was insuffcient evidence for droperidol in combination with other antiemetic drugs. Age based formula for nasotracheal tube size in References: developmental disability patients. Inadequate tube size might lead to insuffcient ventilation or give damage to the trial vocal code. We previously reported height is the most important factor to select tube size in healthy children.
It is highly For the consumer test definition of fungus medical cheap mentax american express, a group of 30 participants Scientific Affairs for SeroVital fungus amongus order 15 mg mentax with amex. Photos were taken at day 1 and then Subject 1: ‘Over the past few years fungus gnats garlic cheap mentax 15 mg with visa, gobs and Hollywood’s top names since launching again at 30 fungus speed run order cheap mentax on-line, 60, 90, 120, and 150 days to show hair gobs of my hair fell out every day. None of the photos were edited or were receding to the point of my friends saying, highest pharmaceutical grade retouched in any way. Many in the group saw Subject 2: ‘I feel like I’m turning professional outlets and highly effective regrowth of their natural, back the clock. This pigmentation as well as offering before and after has reversed it; I barely see exceptional results within the anti programme received it anymore. M y tem ples were receding to the point of m y friends saying, ‘Your clinically proven wavelengths of light, all hair is really thinning. W e anticipate having over 1000 the w orld w ork together to foster Tprim ed to take place in the delegates from m ore than 40 countries derm atologic surgery in their ow n great city of Buenos Aires, Argentina, and from all over the w orld. The organizational set-up of everyone is invited to attend and that you don’t w ant to m iss. Law rence Rosenthal, form erly international derm atologic surgical surgical society. W e are proud to be this incredible and open society that has garnered an excellent reputation in such a short period of tim. So now w e head to Buenos Aires, Argentina w here w e w ill hold our 7th W orld Congress. The Congress President, There will be an extensive Cutaneous Oncology program e, as well as discussions on photodynam ic therapy, chem ical peels, vitiligo and new concepts with it. Attendees w ill be able to participate in program s on Liposuction and Liposculpture, Hair Transplantation, Injectables for the Skin, Energy-Based Devices, Basic and Advanced Derm atologic Surgery, Scars and Scar Prevention, Needling, Fem inine Rejuvenation, and an Advanced Reconstruction course. Then, for the next 3 days, attendees w ill have four tracks available for them to follow or to m ove from one to the other. W e w ill delve deeper into the literature and science from the w orkshops m entioned above. Also up in learning m ore about the city, its people, w ith global colleagues and have the tim e for discussion w ill be acne, acne scars, and its culture. See you devices to treat acne and w hat is new in m any m ay opt for one of the exciting post all in Buenos Aires. Patients this study was conducted according to the principles of the Declaration of Helsinki, Good Clinical Practice Guidelines and General Principles of Portuguese Law (46/2004). All m astectom y w ith lym ph node rem oval, a unilateral continuous data com parisons w ere subm itted to the m astectom y w ith lym ph node rem oval w ithin the Student-T test or the W ilcoxon rank sign test. A 5% level of last year, or a bilateral axillary lym ph node rem oval significance w as used. The subjective data of efficacy Individuals w ith a history of im m une w as subm itted to binom ial testing, p<0. No skin reactions w ere assessed by several biom etric noted after each procedure. The Optical experienced any discom fort during the study, or during In-Vivo Prim os 3D Skin Device the follow -up period. Quality surface im aging and percentage changes in all subjects after 169 days revealed dense 3D geom etry m esh in a single a relative transform ation in relation to D0 of -37. A significant percentage fine w rinkle im provem ents in skin increase in skin firm ness param eters in the m alar area, surface structures. Also, changes evaluations to m easure the elasticity of in the nasolabial area dem onstrated a significant the upper skin layers using negative im provem ent after 56, 84, and 169 days (p=0. The R2 param eter m easures overall Figure 5 Change in skin firm ness in the m alar area elasticity, representing the ability of the skin to return to its basal state. All biom etric instrum ental protocol evaluations w ere -25 perform ed in a fully controlled room and after an initial -35 acclim atization process of at least 30 m inutes. The biom etric instrum ental Figure 6 Ultrasonography images assessing the sub-epidermal low echogenic band of the malar area of subject number 6. After injection into the derm is and chem otaxis, biochem ical processes are involved in w ound form ation subcutaneous layers, endogenous platelet w hich are sim ilar to the required changes to reverse the form ation of the activation occurs by the subject’s ow n effects of intrinsic and extrinsic skin ageing13. The increase in density is attributed to an increase in collagen production, creating a ‘filler effect. In the thickness and increase in authors’ study, the w rinkle count started to decrease density is attributed to an Tables 1-2 ©Peter A. Scale: a clinical validated measurement tool for plasma be used for skin rejuvenation? Separation Systems Designed for Preparation of Platelet-Rich Plasma Gels in Gynecologic, Cardiac, and 19. Fitzpatrick J, Bulsara M, McCrory P, Richardson M, Platelet-Rich Plasma Yield Differences in Cellular General, Reconstructive Surgery Beneficial? Dermal Injections for Facial Skin Rejuvenation: Variations in Platelet and Blood Components Between 9. The Effect of Clinical, Instrumental, and Flow Cytometry 4 Common Commercial Kits. Aging skin: histology, physiology, Sports Med 2014;42:1204-1208 Evaluation of effects of platelet-rich plasma on human in platelet growth factor release and leucocyte and pathology. This energy is dissipated as heat in the targeted cells in order to tighten the eyelid skin while respecting the surrounding tissue. This is Objective: To evaluate the efficacy, safety, the reason why the area around the eyes is the first to show and local tolerance of medical blepharoplasty without surgery using Jett Plasma Lift Medical signs of fatigue and ageing. Patients underwent one treatment session Over tim e, the very thin skin around the eye contours develop w rinkles carried out by the same dermatologist. The principal efficacy criterion was the assessment and lose their elasticity and firm ness. Eyelids becom e heavy, progressively of reduction of droopy eyelids at three months, droopy, fat pockets appear in the low er eyelids, and expression lines patient satisfaction was the second criteria. The aim of blepharoplasty is to elim inate or reduce these palpebral an aesthetic practitioner, Paris, Results: A total of 38 patients, 34 women im perfections to m ake the eyes look m ore relaxed and younger. Palpebral M any practitioners still use the conventional scalpel or laser scalpel to emailcentremedicalniel@gmail. The developm ent of soft, non of all cases, associated to the patient’s invasive — such as non-surgical techniques including m edical satisfaction. Transitory adverse effects, commonly observed for cosmetic procedures blepharoplasty — open the possibility for new cosm etic procedures. Plasm a is a gas that has been ionized by post-procedure hyperpigmentation requiring a topical depigmenting treatment. This energy is dissipated as heat in the targeted cells in patient has presented with areas of erythema order to tighten the eyelid skin w hile respecting the surrounding tissue. No serious adverse effects such as burning or Both doctors and patients searching for a less invasive m eans to scars were reported. Further confirmatory investigations w ith topical anaesthesia and w ith a short recovery tim e (5 days on average). Patients w ith an ongoing anticoagulant treatm ent, w earing pacem akers or m etallic objects in the treatm ent Distance of the tip of the active 1-2mm area such as piercings, suffering from epilepsy, pregnant electrode from the skin or breastfeeding w om en, or w ith an infectious skin Number of treatment sessions 1 disease on the treatm ent zones, or patients w ho w ere exposed to tanning beds, natural sunlight or w ho had Duration of treatment 5-7 min high skin phototypes (to avoid any hyperpigm entation Intensity chosen 8 problem s) w ere not suitable for the procedure. The rem aining four patients received tw o treatment sensation treatm ent courses, perform ed by the sam e physician. During this consultation, doctor’s hand, is placed near to the skin but is not in a derm atological exam ination to m easure the skin contact w ith the tissue in order to obtain a folds w as carried out by the doctor and photos therm al effect. A follow -up Plasm a locally increases the electrical consultation w as planned one w eek tension of the cellular m em brane later, and a final control visit took place w hich then tightens. The treatm ent 3 m onths after the procedure to zone tightens through successive assess the treatm ent outcom. Suitable recovery is usually sim ple, w ith patients had to be adult w ith m ild to erythem a observed for about tw o m oderate sagging eyelids, not days, sm all scabs three days follow ing associated w ith fat pockets in the low er the erythem a on the treated zones, eyelid or w ith periorbital w rinkles. M oreover, w hich could be covered using m ake-up, and patients suffering from xanthelasm a, a palpebral oedem a. Patients w ere procedure or w ho presented strongly advised to avoid any who presented contraindications to surgery exposure to the sun and to protect contraindications to surgery w ere suitable for the procedure. Results Demographics this retrospective study included 38 patients: 34 w om en and four m en, w ith an average age of 48. Com m on skin of approxim ately 2 m m w as observed by the adverse events observed for all cosm etic procedures practitioner.
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In more developed countries antifungal yeast cream 15 mg mentax mastercard, victims’ needs and available services increased mortality rates due to antifungal treatment for grass generic mentax 15mg free shipping trauma and chronic disease dominate fungus under breast 15mg mentax amex. The lack of Essential services access to antifungal treatment for scalp mentax 15mg care, either because of poverty, the disorganization of the medical system, or for reasons of security, aggravates the problems. Victims’ To pre-confict poverty and fragile health services are added the problems of the needs collapse of medical supply and distribution, the targeting of hospitals and clinics in violation of medical neutrality, and the neglect or abandonment of preventive health programmes. In addition, health professionals are often amongst the frst people to Increase in needs Deterioration fee a confict zone. Having to provide for war trauma also means a greater investment associated in eectiveness with: of services: in curative services to the disadvantage of the preventive. The of war wounds extraction of diamonds and other precious stones, oil, timber, and various minerals, Figure 5. In addition to death and disability, there are the long-term socio-economic efects of disrupted economic activity through the loss of farmland, livestock, water resources, and industrial capacity because of the presence of landmines. Demobilized combatants with guns are not often successfully reintegrated into social and economic life: criminal violence replaces political violence; peace combined with high criminality ofers little respite from war. In addition, one must count the social costs of deliberate physical, psychological, and sexual abuse as methods of warfare. Serious disease continues to afect modern armies, still accounting for high rates of non-availability of personnel for military duty. Of course, certain natural environments (jungle, high mountains) increase the incidence of non-battle pathology. In some conficts, the burden of war trauma is greater than the public health consequences. This was the case in the wars in the former Yugoslavia (1991 – 99) in 5 Lebanon (1975 – 90), and Rwanda (1994), among others. One must also take into consideration the relatively small population of certain countries; a limited number of deaths may represent a proportionately high death toll. In some conficts, the burden of the war-wounded is greater than the consequences on public health. The type of combat may place civilians at greater risk and war casualties may overwhelm civilian medical services, even in situations where the public health efects are greater than the direct efects of trauma (Biafra 1967 – 70, Uganda 1987, Democratic Republic of the Congo since 1997 to the time of writing). Morbidity and disability rates due to injuries are testimony to the long-term socio economic burdens. Demographics of the victims Historical military casualty statistics concern young, ft and healthy men. In the past, women were not close to combat in most classical armies; more recently, however, various revolutionary guerrilla groups have had female combatants. This has clinical consequences for the trauma may at times far exceed the efects on treatment of endemic diseases and chronic pathologies among the wounded. Missing and displaced persons, constraints of time, lack of access to populations, and dangerous security situations, all create formidable problems for a limited number of qualifed personnel to conduct proper studies. Furthermore, the distinction between civilian and military during a civil war is not always obvious. The ratio of military to civilian wounded and sick may be very sensitive political and military information, easily exploited for propaganda purposes by the various antagonists. Many authors have recently written about the public health efects of armed confict and complex emergencies. What information will help the individual surgeon managing war wounds for the frst time? What needs to be taken into consideration to set up an efcient system for the care of the war wounded? Is it possible to determine the “normal” levels of morbidity and mortality during armed confict? To respond adequately to the challenge requires preparation, on the part of the individual surgeon as well as the institution’s, and a system for monitoring the results of patient management. Yet, epidemiological studies clearly show that combat injuries difer from those in civilian practice: diferent aetiology and pathology; multiple-cause injuries; delayed access to care and austere working conditions requiring diferent philosophies of treatment. Epidemiological studies show that the management of the war-wounded is diferent from civilian trauma. Various indices have been devised to defne injury patterns, which difer according to the type of confict and the nature of the weapons used: the lethality of wounding agents; the anatomic distribution of wounds; delay to treatment; and pre-hospital and post-operative mortality are among the most important. Knowledge of these helps determine the high-risk factors afecting the outcome of surgical treatment and what set of specialist skills are needed: orthopaedic surgery, vascular, visceral, etc. The reader is directed to the publications in the Selected bibliography for further study. The standardization of protocols and knowledge of the workload permits the establishment of ready-made kits of equipment, medicines and supplies that are easily deployed in an emergency situation as a rapid response to well-known needs. This facilitates the setting up of a surgical hospital to treat the victims of war. Knowing what kind of patient comes through the hospital door helps in planning a response: allocation of medical resources and personnel and the training of surgeons. Many surgeons will be seeing war pathology for the frst time, under conditions that do not resemble their routine work circumstances. At times, a strict and rigid application of protocols is required; on other occasions, there will be a need for improvisation and adaptation. Surgeons, civilian or military, may be involved in training or helping set up pre-hospital programmes so that the injured reach them in better condition and in a timely fashion, which makes their surgery easier and ensures a better outcome for the patient. Health professionals were instrumental in gathering the epidemiological data from clinical studies to make the humanitarian argument for the banning of blinding laser weapons and anti-personnel landmines. For example, mortality statistics can help elucidate the occurrence of executions of prisoners of war being passed of as killed in combat. Other actors may do likewise, in compliance with their humanitarian responsibilities. It is therefore important for the surgeon reading the vast literature on war surgery to understand what is being said, what the shortcomings are, and what some of the traps and pitfalls are. Most of the war surgery literature consists of large retrospective studies written by military surgeons of industrialized countries; some of the exceptions are included in the Selected bibliography at the end of this volume. Most surgeons are not well trained in epidemiology or statistical methods, and civilian surgeons are usually not knowledgeable about military terminology. Thus, the surgeon facing the new experience of dealing with the war-wounded who wishes to read up on the topic will often fnd a bewildering vocabulary and methodology. Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey. Comparisons of data between a single battle and longer wars may not be valid; a small cohort may not be representative. On the other hard, the individual surgeon will face individual casualties from particular battles. Thus, the experience with small cohorts may help prepare the surgeon to face a novel situation or specifc injuries. Fatigue and lack of time, a shortage of trained staf, and the personal danger that medical staf must often confront complicate the keeping of statistics. The administrative personnel and time and efort required to keep up full documentation and archives can appear to be a luxury when faced with the stress of caring for battle casualties. In an article on American casualties during the war in Viet Nam, based on data obtained from a statistical record flled out by physicians in Viet Nam at the time of discharge or transfer, the author made the following telling comment. Foremost is the very important problem of diferent defnitions of epidemiological categories. Some military defnitions have changed over the last century or been replaced by other terms. Civilian authors have often invented their own epidemiological categories and defnitions in articles on the subject. Who exactly composes the target population under study is diferent from one article to the next, although all deal with the “wounded” and during the same war. There are important frst questions the reader must ask of all war surgery studies: who is counting whom and where?