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Health Counseling/ Health Links: Health education materials developed specifcally to treatment for shingles pain and itching cheap trihexyphenidyl 2 mg line accompany these guidelines pain treatment and wellness center greensburg order trihexyphenidyl in india. Title(s) of Health Link(s) relevant to pain medication for shingles order trihexyphenidyl in united states online each Further Considerations guideline section are referenced in this column pain treatment after knee replacement generic trihexyphenidyl 2 mg with amex. Counseling: Suggested patient counseling regarding measures to prevent/reduce risk or promote early detection of the potential treatment complication. Resources: Books and websites that may provide the clinician with additional relevant information. Considerations for Further Testing and Intervention: Recommendations for further diagnostic evaluations beyond minimum screening for individuals with positive screening tests, recommendations for consultation and/or referral, and recommendations for management of exacerbating or predisposing conditions. Score assigned by expert panel representing the strength of data from the literature linking a specifc late effect with a therapeutic exposure coupled with an assessment of the appropriateness of the screening recommendation based on collective clinical experience. Cancer Screening Sections 157–166 contain preventive screening recommendations for common adult-onset cancers, organized by column as follows: Recommendations Organ: the organ at risk for developing malignancy. Population Risk Factors: Risk factors such as age, gender, genetic susceptibility, personal or family history, health-related behaviors or co morbidities generally associated with increased risk for the specifed malignancy in general populations. Highest Risk Factors: Populations considered by the panel of experts or other evaluating bodies (such as the American Cancer Society) as being at signifcantly increased risk for the specifed malignancy. Risk factors may include therapeutic exposures resulting from cancer treatment, as well as other factors listed above. Periodic Evaluations: Standard Risk: Guidelines provided under the “Standard Risk” category are per the American Cancer Society recommendations for standard-risk populations and are included here for reference. In addition, clinicians are encouraged to consult recommendations from other organizations, such as the U. Highest Risk: Recommendations for high-risk populations, when applicable, are specifed and may differ from recommendations for the standard risk groups due to the signifcantly increased risk of the specifed malignancy within the high-risk group References References are listed immediately following each guideline section. Included are medical citations that provide evidence for the association of the therapeutic intervention with the specifc treatment complication and/or evaluation of predisposing risk factors. In addition, some general review articles have been included in the Reference section for clinician convenience. The following documents are also included to further assist with application of these guidelines: Explanation of Scoring Elucidation of the process used by the panel of experts to assign scores to each guideline section. Patient-Specifc Due to signifcant overlap of toxicities between therapeutic agents, and in order to avoid an enormously lengthy document, duplicate entries have Guideline Identifcation been avoided as much as possible. Therefore, use of the Patient-Specifc Guideline Identifcation Tool is imperative in order to determine Tool each potential late effect associated with each therapeutic agent within this document (see Appendix I). Obtain the survivor’s Cancer Treatment Summary (see templates for comprehensive and abbreviated summaries in Appendix 1). For list of chemotherapeutic agents addressed by these guidelines (Sections 10–43), see the “Chemotherapy” portion of the Patient-Specifc Guideline Identifcation Tool in Appendix I. For list of generic and brand names of chemotherapy agents, see Chemotherapy Agents in Appendix I. For list of radiation felds addressed by these guidelines (Sections 44–102), see “Radiation” portion of the Patient-Specifc Guideline Identifcation Tool in Appendix I. For clarifcation of anatomical areas included in common radiation felds, see Radiation Fields by Anatomic Region and Radiation Fields Defned in Appendix I. For clarifcation regarding radiation dose calculations for deter mining screening recommendations for individual patients, see Determining Applicability of Radiation Sections for Specifc Patients Based on Exposure on page 56 of guidelines and in Appendix 1. For list of surgical procedures addressed by these guidelines (Sections 120–152), see “Surgery” portion of the Patient-Specifc Guideline Identifcation Tool in Appendix I. For list of other therapeutic modalities addressed by these guidelines (Sections 153–156), see “Other Therapeutic Modali ties” portion of the Patient-Specifc Guideline Identifcation Tool in Appendix I. Develop a list of guideline sections relevant to the survivor: • Sections 1–6 (“Any Cancer Experience”) and 157 (“General Health Screening”) are relevant to all survivors. Review all guideline sections generated in the list above, and develop a plan for screening the individual survivor, taking into consideration the survivor’s relevant risk factors, current health, co-morbidities, health-related behaviors and preferences. Therefore, we strongly advise that a comprehensive treatment summary be prepared for each childhood cancer survivor, including a record of all therapeutic exposures with applicable dates, details of administration, and cumulative doses of all agents, including those not currently addressed by these guidelines. We are hopeful that this revised version of the Children’s Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers will enhance the follow-up care provided to this unique group of cancer survivors. Refer as indicated to school liaison in community or cancer center (psychologist, social worker, school counselor) to facilitate acquisition of educational resources. A long-term follow-up study of psychosocial functioning after autologous bone marrow transplantation in childhood. Educational and social late effects of childhood cancer and related clinical, personal and familial characteristics. Long-term outcomes of childhood cancer survivors in Sweden: a population-based study of education, employment, and income. Hearing loss, quality of life, and academic problems in long-term neuroblastoma survivors. Predictors of marriage and divorce in adult survivors of childhood cancers: a report from the Childhood Cancer Survivor Study. Unemployment among adult survivors of childhood cancer: a report from the childhood cancer survivor study. Occupational outcomes of adult childhood cancer survivors: A report from the Childhood Cancer Survivor Study. Predictors of independent living status in adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. Educational attainment among adult survivors of childhood cancer in Great Britain: a population-based cohort study. Utilization of special education services and educational attainment among long-term survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. Physical impairment and social life goals among adult long-term survivors of childhood cancer: a population based study from the childhood cancer registry of Piedmont, Italy. Psychological outcomes in long-term survivors of childhood leukemia, Hodgkin’s disease, and non-Hodgkin’s lymphoma: a report from the Childhood Cancer Survivor Study. Comparison of psychologic outcome in adult survivors of childhood acute lymphoblastic leukemia versus sibling controls: a Cooperative Children’s Cancer Group and National Institutes of Health study. Psychological outcomes and health beliefs in adolescent and young adult survivors of childhood cancer and controls. Psychological distress in adult survivors of childhood cancer: the Swiss Childhood Cancer Survivor study. Suicide ideation in adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. Psychiatric hospitalizations among survivors of cancer in childhood or adolescence. Prevalence and predictors of posttraumatic stress disorder in adult survivors of childhood cancer. Self-esteem, depression, and anxiety among Swedish children and adolescents on and off cancer treatment. Psychological status in childhood cancer survivors: a report from the Childhood Cancer Survivor Study. Behaviors associated with ultraviolet radiation exposure in a cohort of adult survivors of childhood and adolescent cancer: a report from the Childhood Cancer Survivor Study. Predictors of smoking initiation and cessation among childhood cancer survivors: a report from the Childhood Cancer Survivor Study. Extent of alcohol consumption among adult survivors of childhood cancer: the British Childhood Cancer Survivor Study. Attentional and executive dysfunction as predictors of smoking within the Childhood Cancer Survivor Study cohort. Establishing the predictive validity of intentions to smoke among preadolescents and adolescents surviving cancer. Alcohol consumption patterns and risk factors among childhood cancer survivors compared to siblings and general population peers. Review of health behaviors and their correlates among young adult cancer survivors. Health and risk behaviors in survivors of childhood acute myeloid leukemia: a report from the Children’s Oncology Group. Survivors of childhood cancer and comparison peers: the infuence of peer factors on later externalizing behavior in emerging adulthood. Neural correlates of interindividual differences in the subjective experience of pain. Pain intensity processing within the human brain: a bilateral, distributed mechanism.
Eggs in the brain present as space occupying lesions with focal neurological defcits back pain treatment guidelines order 2mg trihexyphenidyl otc, seizures and encephalopathy interventional spine and pain treatment center nj trihexyphenidyl 2mg with mastercard. Hydatid disease occurs nerve pain treatment uk purchase trihexyphenidyl online, when humans come into contact with dog’s faeces and the ingested ova develop into the cystic stage treatment pain post shingles proven 2 mg trihexyphenidyl. It is endemic in large parts of Africa, mainly afecting the traditional cattle and sheep grazing communities. Life cycle The dog excretes the tapeworm eggs in its stool and these are accidentally ingested by grazing herbivores which then become intermediate hosts. Humans become accidentally infected by ingesting food or drink which has been contaminated by faeces containing ova from infected dogs. It is a chronic disorder mainly of children and young persons but adults are also afected. They may be asymptomatic or present acutely with hydrocephalus, focal neurological defcits and seizures. The main diferential diagnosis is between cystic brain tumours, an arachnoid cyst and abscesses. The recommended dosage of albendazole is 400 mg twice daily over a three or six month period. Tere is limited data on praziquantel but 40 mg/kg/week in combination with albendazole has been suggested and is the currently recommended treatment of choice. The advantage of two drugs is that while albendazole acts on the germinal membrane, praziquantel kills the proto-scolices or daughter cysts. Outcome with medical treatment is variable but clinical improvement and radiological resolution of cysts has been shown. Cotrimoxazole for treatment of cerebral toxoplasmosis: an observational cohort study during 1994-2006. Clinical characterization of neuroschistosomiasis due to Schistosoma mansoni and its treatment. Changing trends in incidence and 184 Part ii – Neurological Disorders hydatid disease aetiology of childhood acute non-traumatic coma over a period of changing malaria transmission in rural coastal Kenya: a retrospective analysis. After reading the chapter the student should aim to understand the main mechanisms, clinical presentations, diagnosis and management of these illnesses. Laboratory investigations can help to distinguish the diferent types of meningitis. The clinical diagnosis of stroke is suggested by its acute onset, non progressive course and better clinical outcome. Investigations and management are the same as for any stroke patient and should include a serology test for syphilis. Management is directed at investigating and treating the suspected cause and suppressing the seizures (Table 8. The clinical presentation is one of a devastatingly severe progressive neurological disorder occurring over weeks and months. It is characterized by motor dysfunction (hemiparesis, quadriparesis), ataxia, seizures and cognitive changes (60-70%) and aphasia, visual problems and cranial nerve palsies (30-40%). It also has a higher rate of complications including varicella dissemination (Fig. The local application of a 1% gentian violet solution at the vesicular stage helps to prevent secondary infection and the application of a 1% phenol solution with calamine helps with local pain and itching. Analgesics may be required in addition to carbamazepine 200-400 mg/po/bid for post herpetic neuralgia. Primary infection is mostly acquired during early childhood, when it is either asymptomatic or associated with a mild febrile illness with a rash. Trombocytopenia is a side efect of treatment and blood counts should be checked regularly. The dementia ranges from early features such as mild apathy, disinterest and loss of attention with a general slowing of both mental and motor functions. However, many patients in Africa die of opportunistic processes, mostly infections before reaching these later stages. Histopathology includes characteristic multi-nucleated giant cells and the presence of P-24 antigen on special staining. William Howlett Neurology in Africa 201 Chapter 8 neurologiCal illness in hiv disease the palmomental refex Figure 8. In positive cases it causes a brief contraction of the ipsilateral chin muscles and occasionally the corner of the mouth. Spinal cord disease presents clinically as paraparesis occurring typically in an otherwise asymptomatic person. Frequently, these upper motor neurone signs overlap with distal sensory neuropathy and then the ankle refexes are absent. Investigations of spinal cord disease are directed at diagnosing and treating the underlying cause. Sensation involving light touch is mostly intact but is perceived as painful or dysaesthetic or hyperaesthetic particularly on the soles of the feet and palms. The use of carbamazepine or gabapentin either alone or in combination with low dose tricyclics is helpful in some patients. In particular this occurs with the use of the nucleoside reverse transcriptase inhibitors, stavudine (d4T). Care should be taken to ensure that pyridoxine 20 mg/po/daily has been prescribed in those patients taking isoniazid, and thiamine 100 mg/po/daily should be given in suspected cases of B-1 vitamin defciency. In states of coma the patient remains in a sleep like state with no purposeful movements or response to any external stimuli. Coma can be caused by disorders that afect either a part of the brain focally or the whole brain difusely (Figs. The causes of coma are generally classifed as intracranial or extracranial and are outlined in Table 9. Tese arise either from the disorders of the cardiovascular system with an acute reduction of blood fow to the brain (syncope) or a disruption in brain electrical activity (seizure). The chapter outlines the main mechanisms, causes, investigations and management of coma and syncope. Disorders that physically afect these areas can lead to disordered arousal, awareness and to altered states of consciousness. All comatose patients should have their blood glucose checked on arrival and treated immediately if hypoglycaemic (blood sugar <2. The history The history is the most important part of the assessment as it frequently points to the underlying cause of coma. If the cause is not obvious then it is necessary to obtain a history from the patient’s family members, friends or colleagues. The history should include information and details concerning the immediate circumstances and the possible cause of the coma. Key points · loss of consciousness is a medical emergency · cause may be obvious & reversible causes · assessment needs to be brief and focused need to be considered · history is the most important part of the initial · main causes are head injuries, assessment encephalopathies, infections & strokes Table 9. Signs pointing to an underlying illness include paresis, hypertension, tongue biting, ketoacidosis, jaundice and evidence of infection including fever, meningitis, and pneumonia or discharging ear. Confusion can be tested at the bedside by checking if the patient is fully orientated in time, person and place with a score of 10/10 being fully orientated (Table 9. If the patient is not responding to voice then test eye opening and limb movement response to deep pain by applying pressure to sternum or supra orbital ridge or nail beds. The neurological assessment in coma is necessarily shortened concentrating on the possible neurological causes of coma. Note the level of consciousness and any obvious neurological abnormalities such as seizures, the pattern of breathing and the position of the eyes and posture of the trunk and limbs. Abnormalities include fxed dilated pupil (s), >7 mm in size and non reactive to light. In states of coma the most common cause of a unilateral fxed pupil is herniation (Table 9. The presence or absence of the corneal refexes should be noted and fundi checked for papilloedema. If there William Howlett Neurology in Africa 217 Chapter 9 Coma and transient loss of ConsCiousness is no contra indication to moving the neck such as spinal or head injury neck stifness should be tested although its absence is unreliable in coma.
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The World Health Organization recommends that essential fatty acids be added to pain treatment elderly discount 2 mg trihexyphenidyl otc infant formulas neuropathic pain treatment guidelines australia order 2 mg trihexyphenidyl fast delivery. It goes without saying that lactating mothers should also consider taking omega-3 essential fatty acid supplements as long as they are breast-feeding pain stomach treatment trihexyphenidyl 2 mg line. Omega-3 essential fatty acids are crucial in the development of the fetal and neonatal brain and nervous system pain management for dying dog order trihexyphenidyl toronto. One study showed that intellectual 28 development may also suffer in infants deprived of these fatty acids. Although it is used in infant formulas, there are no data supporting that use either. It is likely that both processes are important for the development of a pathological state. In an uncontrolled study, dietary supplementation with concentrated fish oil led to significant improvement in negative (alogia, flat affect, anhedonia, apathy, motor retardation) but not positive symptoms (hallucinations, disorganized thought) as rated by the Positive and Negative Syndrome Scale. Improvement in clinical symptoms was related to increased levels of omega-3 essential fatty acids in the 30 blood. Thus, it is conceivable that dietary supplementation with antioxidants and omega-3 essential fatty acids at the initial stages of illness may prevent further oxidative injury and thereby ameliorate and prevent further possible deterioration of associated neurological and behavioral deficits in schizophrenia. Hibbeln and Mischoulon have suggested that omega-3 fatty acids are less effective in schizophrenia and dementia than in depression and bipolar disorder. The 2012 Oregon Brain Study results confirmed the coincidence of higher 36 omega-3 levels and higher cognitive function. A 2011 review and meta-analysis of ten studies by Bloch et al, cited in Brown et al. In fact, on almost every measure, including attention, hyperactivity, and cognition, the children taking fish oil showed substantial improvement, whereas those 42 taking placebo had minimal or no improvement. In addition, omega-3 essential fatty acids may increase the risk of bleeding when taken with herbs and supplements that are believed to increase the risk of bleeding such as ginkgo, garlic and salt palmetto. However, Fugh-Berman and Gerbarg state categorically that fish and fish oil do not increase bleeding risk. An interaction with anti-clotting medication (such as warfarin) is theoretically possible, but recent research has found no evidence of significant risk, even at high doses. Similarly, [one] need not worry about interactions with aspirin, which also has an anti-clotting effect. Indeed the American Heart Association advises low-dose aspirin and omega-3s for people with heart disease. Specifically, he states that: “No cases of bleeding have been reported in the greater than 17,000 subjects that have participated in omega-3 51 clinical trials. Thus, caution is warranted if the consumer has low blood pressure or is taking blood-pressure-lowering medications. The Natural Standard concludes that the risk of blood pressure changes at lower dosages is low. Still, people contemplating surgery or dental procedures should discuss significant omega-3 supplementation with their surgeon or dentist and consider tapering off for the procedure. However, the Natural Standard states that significant blood sugar effects are “unlikely. Berkeley Wellness cites a 2006 review by researchers at Tufts, which, "found that the doses used in most studies have little or no effect on blood sugar control. The Norwegian researchers suggested that taking one g of omega-3s a day would have a negligible effect on blood sugar. And the effect of fish and fish oil on the heart and circulatory system is sufficiently demonstrated that we all need to eat more. As a result, regular use may lead to elevated levels of these fat soluble vitamins. Since fat soluble vitamins can build up in the body and cause toxicity, consumers should be aware of any vitamins added to fish oil products in order to assure appropriate total vitamin dosages. Hypervitaminosis A occurs when the maximum limit for liver stores of retinoids is exceeded. Given the side effects and the likely benefits, the use of omega-3s by pregnant and breastfeeding mothers as well as young children seem reasonable. Moreover, the mercury in fish is water soluble and thus tends to accumulate in fish meat, not in the fat or oil. Small, short-lived fish such as anchovies, sardines, menhaden, carp, catfish, herring, lake trout, and mackerel, and small predators like bluefish, pompano, salmon, striped sea bass, tuna (albacore), and the like are preferred, since large, predatory, long-lived fish tend to concentrate pollutants at the top of the food chain. Commercial fish oils are generally derived from appropriate uncontaminated fish stocks, but attention to the label is important to assure this. They may also suffer from contamination, especially if animal byproducts are used for food. Thus, despite the increased risk of contamination, “wild” fish are preferable until fish farm inspection reports are included on fish labels. Regular canned salmon, with skin and bones, has about 10 to 14 grams of total fat per four ounces (about cup), which provides about 2,000 milligrams of omega-3s. Skinless, boneless, “premium” canned salmon has much less total fat (about three to four g per four ounces), and thus only about 650 milligrams of omega-3s. Greater dosages have been associated with nosebleeds or blood in the urine and call for closer monitoring to avoid serious complications such as stroke or high blood sugar. Gastrointestinal upset is common with the use of fish oil supplements, as is diarrhea, with potentially severe diarrhea at very high doses. The Natural Standard also documents reports of fishy aftertaste, increased burping, acid reflux/heartburn/indigestion, abdominal bloating, and abdominal pain. The Natural Standard recommends that gastrointestinal side effects be minimized by taking fish oil with meals and starting with low dosages. The World Health Organization and governmental health agencies in “several countries” recommend consuming 0. Claims about “molecular distillation” and other special purification processes are unverified. Still, recent tests of dozens of brands found that nearly all supplements contained the amount of omega-3 fats listed on the labels—with no significant contamination. The oil usually contains very high levels of A, which may weaken bones and cause birth defects. Since it is made from livers, which filter out toxins, there is also greater concern about contaminants, even though the oil is supposed to be purified. But fish also contains vitamins, minerals, other fats, and other substances that may work with the omega-3s to protect the heart and overall health. Moreover, fish, which is rich in protein and low in saturated fat, can replace less-healthful foods such as red meat. As emphasized by Berkeley Wellness, the benefits of fish far outweigh the potential risks from contaminants, especially if you eat it in moderation (two servings a week, about 8 to 12 ounces total) and vary the types of fish. A large study in the journal Circulation: Heart Failure found that eating fried fish at least once a week was associated with a 48 percent 58 higher risk of heart failure, so other cooking methods are preferred. Atlantic salmon is almost 2%, but most fish are under 1%, meaning 100grams of fish for each gram of omega-3s. At that rate, a therapeutic dose of 6-9 grams would take a lot of fish: up to two pounds a day, so supplementation is essential. Psychiatry 72(8):1054–1062 (2010) 24 Natural Standard Herb and Supplement Guide: An Evidence-based Reference, op. However, a 2013 update from Berkeley Wellness examines the recent evidence: “In 2012, two large analyses pooled data from well-designed clinical trials involving people with pre-existing heart disease or multiple risk factors. One was published in the Archives of Internal Medicine, the other in the Journal of the American Medical Association. They concluded that overall the evidence does not support claims that omega-3 supplements help prevent cardiovascular events. It found that the 26 observational studies suggested that higher fish intake was associated with moderately reduced stroke risk, but that the 12 clinical trials (considered the gold standard in medical research) concluded that the supplements offered no benefit. In a large trial in the New England Journal of Medicine in 2012, people with diabetes or prediabetes, who are at elevated risk for cardiovascular disease, took 1,000 milligrams of omega-3 supplements a day or a placebo.
The etiology of epithelial tissue in an unusual location is the subject of debate pain management for dogs with kidney disease purchase 2mg trihexyphenidyl with mastercard. The 2002 text by Order and Donaldson supplies several references pain treatment center west hartford ct 2mg trihexyphenidyl free shipping, each with few cases to pain medication for a uti trihexyphenidyl 2 mg amex report pain treatment for bursitis purchase 2 mg trihexyphenidyl fast delivery, and mainly of mandible or maxillary origin. Amyloidosis There is only an occasional case report of the use of ionizing radiation therapy in the treatment of amyloidosis. Because of the availability of alternative therapy and the typically young age of patients, the use of ionizing radiation is a last resort. Radiation therapy is medically necessary only if accompanied by documentation that its use is considered essential by a multi-disciplinary team. Angiofibroma of nasopharynx (juvenile nasopharyngeal angiofibroma) While optimum management is controversial, there is general agreement that surgery is preferred if considered safe, as in cases when there is no extension into the orbital apex or base of skull. When radiation is used, the radiation dose is lower than in malignant tumors of the same location. Angiomatosis retinae (von Hippel Lindau syndrome) Capillary hemangiomas associated with von Hippel Lindau syndrome may be single or multiple, and can severely affect vision. Ankylosing spondylitis the use of radiation therapy in the treatment of ankylosing spondylitis is of historical interest. Resolution is slow and may take years, during which the risk of hemorrhage is not eliminated. Arthritis (see total lymphoid irradiation for radioimmunosuppression) (see rheumatoid arthritis) (see osteoarthritis) N. Basalioma this synonym for basal cell carcinoma of the skin is sometimes included in lists of "benign" disorders of skin suitable for treatment with radiation therapy. It can be mistaken for other disorders because of the features it shares with psoriasis and eczema. The presentation and behavior ranges from truly benign to aggressive with metastatic potential. Bursitis, synovitis, and tendinitis Randomized studies in 1952, 1970, and 1975 cited in the Order and Donaldson review claimed "no benefit" to the use of radiation therapy for any of these, and the authors of the review recommend against its use. Department of Health, Education, and Welfare survey report of 1977 reporting the results of a survey of American radiation oncologists included these diagnoses as acceptable for treatment, as did the German survey of 2008. There is support in modern era texts, concluding that the use of radiation "may provide an alternative to conventional conservative treatment for patients who are not surgical candidates" (Perez Brady). Typical treatment is with photon beam therapy using, at most, complex treatment planning in five or fewer fractions. For secreting tumors, radiation therapy is limited to those causing symptoms that are not controllable by medical means. The relationship to subsequent malignant lymphoma is unclear, with malignant lymphoma reported in as many as 30% of cases. Synonyms include giant follicular lymph node hyperplasia, follicular lymphoreticuloma, angiomatous lymphoid hamartoma, and giant benign lymphoma. Castration There is evidence that with sufficient dose radiation can effectively and permanently cease gamete production and hormone production in the testes and ovaries. Department of Health, Education, and Welfare survey report of 1977 included castration as an acceptable indication. The availability of drugs which achieve the same result has largely rendered this as obsolete. These are chromaffin-negative, benign tumors that can arise in the chemoreceptor system, such as the aortic body; carotid body; glomus jugulare; and tympanic body. It is generally accepted that radiation therapy, with or without surgical resection, is medically necessary, with a significant probability of control. Postoperative radiation therapy, and radiation therapy for inoperable lesions, is considered medically necessary. Adjuvant radiation is not indicated unless there is progression that cannot be dealt with surgically. Typically, radiation therapy is given using complex or three dimensional conformal external photon beam technique, or using low dose rate brachytherapy plaque. Corneal Vascularization Radiation therapy is not indicated in the treatment of corneal neovascularization. Reports in old literature of the treatment by contact radiation or photons do not establish any definite benefit. First line therapy, when observation is not selected, is steroid therapy or surgery. Craniophayngioma Radiation therapy most oftenly is used as an adjuvant after maximal safe resection. Dermatitis Skin inflammation from a variety of etiologies (both known and unknown) has been treated in the past by using low dose, very superficial radiation or Grenz rays. Most common sites are trunk, extremity, abdominal wall, and intra-abdominal sites, including bowel and mesentery. Radiation therapy is indicated for inoperable cases, and may be used in conjunction with surgery and chemotherapy. Fractionated radiation therapy in excess of 50 Page 164 of 258 Gy is needed for control, which may preclude its use in those of intra-abdominal location. Dupuytren’s Contracture (fibromatosis) this may develop in the hand (Morbus Dupuytren) or foot (Morbus Ledderhose) and is a connective tissue disorder of the palmar or plantar fascia. Radiation therapy is useful, especially in the earlier stages of development, and has been demonstrated in prospective clinical trials. Policy: Cases will require medical review, including documentation that medical management has been exhausted and unsatisfactory. Extramammary Paget’s disease (adenocarcinoma of the skin) When it occurs, adenocarcinoma of the skin usually arises in areas of abundant apocrine glands. Sites reported include retroperitoneum, mediastinum, bile ducts, thyroid, meninges, orbits and others. While anecdotal reports of improvement have been reported, radiation therapy is generally regarded as ineffective and should not be used. Gas gangrene Before the discovery of antibiotics, radiation therapy was used to treat open wounds to prevent infections, and reports exist that this was of benefit. Surgery is the initial treatment of choice, but many osteoclastomas arise in bones (spine and pelvis) in which surgical resection would be unnecessarily debilitating. Graves’ Ophthalmopathy this is an autoimmune disorder associated with hyperthyroidism that affects the eye musculature and retrobulbar tissues causing proptosis and visual impairment. Gynecomastia In the older era of orchiectomy or the use of diethylstilbestrol for the treatment of metastatic or locally advanced prostate cancer, it was commonplace to irradiate the breasts on a prophylactic basis to prevent uncomfortable gynecomastia. In the modern era of chemical androgen deprivation for the treatment of prostate cancer, the use of modest doses of radiation to the breasts may arrest or prevent the resultant gynecomastia and is medically appropriate. Typically the radiation is given with electron beam therapy in five or fewer fractions. Depending on circumstances, the technique employed may range from simple to intensity modulated, and is usually delivered in thirty or fewer sessions. Herpes Zoster Presented here only for historical perspective, the use of radiation to treat the nerve roots associated with cutaneous eruption of zoster was once employed, and even said to be sometimes acceptable in the 1977 survey of the U. Heterotopic Ossification (before or after surgery) Radiation is known to prevent the heterotopic bone formation often seen in association with trauma or joint replacement in high risk patients. The radiation is most effective if given shortly (within four hours) prior to surgery, or within three or four days after surgery. Hypersalivation (of amyotrophic lateral sclerosis) It is well known that radiation will decrease saliva production as a consequence of treating head and neck cancer. Hyperthyroidism the use of systemic 131-I is an accepted alternative to surgery and/or medical management. Immunosuppression Total lymphatic irradiation as an immunosuppressive agent has been used to suppress the immune system for a variety of conditions. Its use to treat autoimmune or immune-mediated diseases (lupus, rheumatoid arthritis, multiple sclerosis) is considered investigational. Similarly, its use for immunosuppression in conjunction with organ transplants is also investigational.