Ravindu P. Gunatilake, MD
This book now comprises a signifcant amount of new material to be presented in two volumes blood pressure chart on age purchase cheap calan on-line, while maintaining the basic reasoning of the original manual heart attack demi lovato lyrics buy generic calan 120 mg. This frst volume is devoted to broad topics arteria 2013 generic calan 80mg without a prescription, with a number of entirely new chapters of a more general character whose contents are relevant not only to surgeons but also to those responsible for the organization and coordination of surgical programmes in times of armed confict and other situations of violence arrhythmia nursing care plans purchase calan 120mg overnight delivery. The surgical techniques presented herein share many fundamental ideas with more sophisticated medical services. However, they also derive from tried-and-tested improvisation and the use of very simple methods of treatment aiming to use technological means as appropriate as possible to the prevailing conditions of limited infrastructure, equipment, and human resources. The explanations of techniques are geared to the level of knowledge and practice of general surgeons in a rural hospital. These surgeons are often the frst to see patients wounded in confict and they know that, under the circumstances, referral to more sophisticated facilities – far away in an inaccessible capital city – is impractical or impossible. The disk also contains several downloadable fles – forms and checklists for example – that can be used in everyday practice and adapted by the reader. Unless stated otherwise masculine nouns and pronouns do not refer exclusively to men, for the manual is gender neutral. We hope that civilian and military surgeons, as well as Red Cross/Red Crescent surgeons, facing the challenge of treating the victims of armed confict and other situations of violence for the frst time under precarious and, at times dangerous, circumstances will fnd this book useful. The authors included: Bernard Betrancourt, Switzerland Daniel Dufour, Switzerland Ora Friberg, Finland Soeren Kromann Jensen, Denmark Antero Lounavaara, Finland Michael Owen-Smith, United Kingdom Jorma Salmela, Finland Erkki Silvonen, Finland G. Frank Stening, Australia Björn Zetterström, Sweden and was illustrated by Penelope L. The second edition (1990) was revised by Robin Gray (United Kingdom) and the third (1998) by Åsa Molde (Sweden). We owe a debt of gratitude to their pioneering work, and their clear and simple approach which has served as a model. Massey Beveridge (Canada) served as technical adviser on burns and skin grafting and made signifcant contributions to the relevant chapters. Holger Schmidt (Germany) and Eric Bernes (France) gave advice on frst aid and emergency room trauma care. Haide Beckmann (Germany) and Thomas Walker (Switzerland) made contributions to the chapter on anaesthesia and Dieter Jacobi (Germany) provided comments for the chapter on chronic infections. Christiane de Charmant handled the editing of the fnal text and was responsible for the production while Pierre Gudel provided the graphic design. Most surgeons today, the world over, derive their trauma training from road-trafc accidents and much that applies to the management of casualties in civilian settings will also apply to the situation of armed confict: war surgery follows classical surgical standards. However, the generation of surgeons who mostly had to deal with accidents among agricultural or industrial workers were well aware of the dangers of gas gangrene and tetanus and the necessity of good wound excision and delayed primary closure. It was relatively easy for the surgeon to shift from this “septic” civilian surgery to war wounds. This is no longer the case for many surgeons trained today; laparoscopy, radioscopic embolization, and unreamed intramedullary nails will not get you very far when facing a landmine injury of the abdomen or a machine-gun 1 wound to the thigh. Early specialist training of surgeons and sophisticated modern technology beneft many patients in a peacetime environment, but can be an obstacle to the practice of surgery during armed confict. The extent of tissue destruction and contamination seen in war injuries is nothing like what is seen in everyday trauma practice. Working conditions during war are radically diferent from those prevailing in peacetime. Resources are limited and surgeons are often obliged to improvise or make compromises in their management decisions. Their aim should be to bring the best care possible to their patients under the circumstances, not the best care as described in the academic literature. The logic of war triage has little to do with the routine emergency department triage of a major civilian trauma centre: war triage has a “leave to die in dignity” category unheard of in everyday civilian practice. War surgery involves the staged surgical management of the wounded, often at diferent echelons of care and provided by diferent surgeons, especially in a military context. In everyday civilian practice on the other hand, the same surgeon assumes responsibility for the entire surgical management of his or her patient. While modern civilian practice often involves a “multidisciplinary approach”, war surgery often demands a “multi-surgeon” approach. DeBakey1 these and other challenges mean that practitioners facing surgery for the victims of war for the frst time will have to change their mindset, i. DeBakey (1908 – 2008), an American surgeon of Lebanese origin, was a pioneer of modern cardio vascular surgery. Pirogov2 A number of special features characterize the practice of surgery in time of war. Outcome of hospital patient care is a function of the efciency of pre-hospital echelons. These include non-combatants, combatants who no longer participate in hostilities – “hors de combat” – either through sickness, injury, shipwreck, or by Figure 1. The latter two use the protective emblem of the red cross, red crescent or red crystal to mark the means and facilities that take care of the sick and wounded. According to the law, all these categories of protected individuals are immune from attack, as long as they do not take an active part in hostilities. International humanitarian law – the law of war – ofers particular rights to medical personnel, but also ascribes obligations to them. All health professionals are bound by medical ethics, in times of peace and of war. Compliance with these laws may create particular ethical dilemmas and security problems, and the military hierarchy does not always understand the demands of medical ethics. Chapter 2, Applicable international humanitarian law, explains the main principles and rules governing the rights and obligations of medical staf in times of armed confict. Founded modern feld surgery during the Crimean War (1854); devised the plaster cast Those who care for the sick and wounded. Representative of the Russian Red Cross sent to inspect the hospitals on both sides during the Franco-Prussian War in 1870. The nature of weapons, protective body armour, and any delay in transport will afect the anatomic distribution of injuries and their severity. The understanding of these epidemiological factors will have important consequences in terms of preparation and allocation of resources: i. Sophisticated techniques or reconstructive procedures have no place here, except well after combat and in a distant referral hospital (see Chapters 6 and 8). The limits of surgical work are 1 largely determined by the logistic difculties attending the supply of remote and dangerous areas and the lack of maintenance, repair and spare parts. There is seldom enough technical support staf to ensure that infrastructure functions correctly. Despite lavish outlays for feld hospitals by the armies of modern industrialized countries, equipment limitations in tactical situations are well recognized. The lack of sophisticated diagnostic equipment rather than the surgeon’s technical capabilities and expertise is often what determines what can be done. Security must be ensured for patients and staf, by selecting suitable sites for frst-aid posts and hospitals. Health facilities and ambulances should be clearly marked with the protective emblem of the red cross, red crescent or red crystal, according to the dictates of international humanitarian law. For anyone caught up in armed confict, there is an all too familiar syndrome seen amongst young fghting men who are under the infuence of a “toxic cocktail”: testosterone, adrenaline, alcohol and Figure 1. With few doctors and limited staf available, and wounded people pouring in, hospital facilities are easily overwhelmed. The physical and mental strain of working in new and strange circumstances and at times dangerous conditions means that they may not perform as well as usual. The logic followed must be to “do the best for the most” and not “everything for everyone”. This involves the most important change in the professional mindset of the surgeon. Triage decisions are amongst the most difcult in all medical practice, possibly creating ethical dilemmas. There may also be, at times, a confict between medical criteria and tactical ones of military necessity that require some form of compromise.
Venous angioma of the orbit may cause an intermittent proptosis associated with straining hypertension questions and answers cheap calan 240 mg with visa, bending blood pressure xl cuff order calan 120mg otc, coughing arteria thoracica lateralis calan 80 mg visa, or blowing the nose blood pressure medication for anxiety generic 120 mg calan. Middle cranial fossa tumours may cause pressure on the veins of the cavernous sinus with secondary intraorbital venous congestion causing a ‘false localizing’ proptosis. Familiar individuals may be recognized by their voices or clothing or hair; hence, the defect may be one of visually triggered episodic memory. It is impor tant to note that the defect is not limited solely to faces; it may encompass animals (‘zooagnosia’) or cars. Prosopagnosia is often found in association with a visual field defect, most often a left superior quadrantanopia or even hemianopia, although for the diag nosis of prosopagnosia to be made this should not be sufficient to produce a perceptual deficit. Alexia and achromatopsia may also be present, depending on the exact extent of the underlying lesion. Anatomically, prosopagnosia occurs most often in association with bilateral occipito-temporal lesions involving the inferior and mesial visual association cortices in the lingual and fusiform gyri, sometimes with subjacent white mat ter. Unilateral non-dominant (right) hemisphere lesions have occasionally been associated with prosopagnosia, and a syndrome of progressive prosopagnosia associated with selective focal atrophy of the right temporal lobe has been reported. Involvement of the periventricular region on the left side may explain accompanying alexia, and disconnection of the inferior visual association cortex (area V4) may explain achromatopsia. Progressive prosopagnosia associ ated with selective right temporal lobe atrophy. There is some experimental evidence that olfactory stimuli can cue autobiographical memories more effectively than cues from other sensory modal ities. The ‘petite madeleines phenomenon’ has been used to describe sudden triggering of memories in individuals with amnesia due to thalamic infarction. Odour-evoked autobiographical memories: psychological investigations of Proustian phenomena. The “Petites Madeleines” phenomenon in two amnesic patients: sudden recovery of forgotten memories. Cross Reference Amnesia Proximal Limb Weakness Weakness affecting predominantly the proximal musculature (shoulder abduc tors and hip flexors) is a pattern frequently observed in myopathic and dystrophic muscle disorders and neuromuscular junction transmission disorders, much more so than predominantly distal weakness (the differential diagnosis of which encompasses myotonic dystrophy, distal myopathy of Miyoshi type, desmin myopathy, and, rarely, myasthenia gravis). Age of onset and other clinical features may help to narrow the differential diagnosis: painful muscles may suggest an inflammatory cause (polymyositis, dermatomyositis); fatiguability may suggest myasthenia gravis (although lesser degrees of fatigue may be seen in myopathic disorders); weakness elsewhere may suggest a specific diagnosis. Investigations (blood creatine kinase, neurophysiology, and muscle biopsy) may be required to determine exact diagnosis. Causes include any interruption to the anatomical pathway mediating proprioception, most often lesions in the dorsal cervical cord. Cross References Athetosis; Chorea, Choreoathetosis; Proprioception; Pseudochoreoathetosis Pseudo-Babinski Sign Pseudo-Babinski sign is the name given to dystonic extension of the great toe on stroking the sole of the foot, as when trying to elicit Babinski’s sign, with which this may be confused, although pseudo-Babinski responses persist for longer, and spontaneous extension of the toe, striatal toe, may also be present. Pseudo Babinski signs may normalize after dopaminergic treatment in dopa-responsive dystonia. There may be associated emotional lability, or pathological laughter and cry ing (‘pseudobulbar affect’), and a gait disorder with marche à petit pas. Thereare 292 Pseudodementia P otherwise few signs in the limbs, aside from brisk reflexes and upgoing plantar responses (Babinski’s sign). Bilateral internal capsule lacunar infarctions, widespread small vessel dis ease (Binswanger’s disease);. Congenital childhood suprabulbar palsy (Worster–Drought syndrome; peri sylvian syndrome). These may be observed with lesions anywhere along the proprioceptive pathways, including parietal cortex, thalamus (there may be associated ataxic hemiparesis and hemihypoaesthesia), spinal cord, dorsal root ganglia (neuronopathy), and mononeuropathy. Pseudochoreoathetosis in four patients with hypes thetic ataxic hemiparesis in a thalamic lesion. Cross References Ataxic hemiparesis; Chorea, Choreoathetosis; Dystonia; Proprioception; Pseudoathetosis; Useless hand of Oppenheim Pseudodementia Pseudodementia is a label given to cognitive impairments resulting from affective disorders, most commonly anxiety and depression; the terms ‘dementia syn drome of depression’ and ‘depression-related cognitive dysfunction’ have also been used. The pattern of cognitive deficits in individuals with depression most closely resembles that seen in so-called subcortical dementia, with bradyphre nia, attentional, and executive deficits. In addition there may be evident lack of effort and application, frequent ‘No’ or ‘don’t know’ answers, approximate answers (Ganser phenomenon, vorbereiden), and evidence of mood disturbance (tearfulness). Memory loss for recent and distant events may be equally severe -293 P Pseudodiplopia (cf. A 22-item checklist to help differentiate pseudodementia from Alzheimer’s disease has been described, based on clinical history, behaviour, and mental status. The recognition of pseudodementia is important since the deficits are often at least partially reversible with appropriate treatment with antidepressants. However, it should be borne in mind that depression is sometimes the pre senting symptom of an underlying neurodegenerative dementing disorder such as Alzheimer’s disease. Psychomotor retardation in dementia syndromes may also be mistaken for depression. Longitudinal assessment may be required to differentiate between these diagnostic possibilities. In the European psychopathological tradition, it may refer simply to vivid visual imagery, whereas in the American arena it may refer to hallucinations that are recognized for what they are, i. Some patients with dementia with Lewy bodies certainly realize that their percepts do not correspond to external reality and similar experiences may occur with dopamine agonist treatment. Pseudomyotonia is most commonly observed as the slow relaxing or ‘hung-up’ tendon reflexes (Woltman’s sign) of hypothyroidism, although other causes are described. Cross References Myotonia; Neuromyotonia; Woltman’s sign Pseudo-One-and-a-Half Syndrome Pseudo-one-and-a-half syndrome is the eye movement disorder of one-and-a half syndrome without a brainstem lesion. Cross Reference One-and-a-half syndrome Pseudopapilloedema Pseudopapilloedema is the name given to elevation of the optic disc that is not due to oedema. In distinction to oedematous disc swelling, the nerve fibre layer is not hazy and the underlying vessels are not obscured; however, spontaneous retinal venous pulsation is usually absent, and haemorrhages may be seen, so these are not reliable distinguishing features. Visual acuity is usually normal, but visual field defects (most commonly in the inferior nasal field) may be found. This may result simply from a redundant tarsal skin fold, especially in older patients, or be a functional condition. The term pseudoptosis has also been used in the context of hypotropia; when the non-hypotropic eye fixates, the upper lid follows the hypotropic eye and appears ptotic, disappearing when fixation is with the hypotropic eye. Cross Reference Ptosis Pseudoradicular Syndrome Thalamic lesions may sometimes cause contralateral sensory symptoms in an apparent radicular. If associated with perioral sensory symptoms this may be known as the cheiro-oral syndrome. Restricted acral sensory syndrome following minor stroke: further observations with special reference to differential severity of symptoms among individual digits. Pseudo-Von Graefe’s Sign Pseudo-Von Graefe’s sign is involuntary retraction or elevation of the upper eye lid (cf. Von Graefe’s sign), medial rotation of the eye, and pupillary constriction 296 Ptosis P seen on attempted downgaze or adduction of the eye. It may be confused with the akinesia of parkinsonism and with states of abulia or catato nia. Psychomotor retardation may also be a feature of the ‘subcortical’ type of dementia or of impairments of arousal (obtundation). This may be due to mechanical causes such as aponeurosis dehiscence, or neurological disease, in which case it may be congenital or acquired, partial or complete, unilateral or bilateral, fixed or variable, isolated or accompanied by other signs. Enhanced ptosis, worsening of ptosis on one side when the other eyelid is held elevated in a fixed position, may be demonstrated in myasthenia gravis and Lambert–Eaton myasthenic syndrome. This is a stereo-illusion result ing from latency disparities in the visual pathways, most commonly seen as a 298 Pupillary Reflexes P consequence of conduction slowing in a demyelinated optic nerve following uni lateral optic neuritis. A tinted coloured lens in front of the good eye can alleviate the symptom (or induce it in the normally sighted). The symptomatic Pulfrich phenomenon can be successfully managed with a coloured lens in front of the good eye – a long-term follow-up study. Use of the Pulfrich pendulum for detecting abnormal delay in the visual pathways in multiple sclerosis. It is frequently related to previous occupation or hobbies but is seldom pleasurable. It is thought to be related to dopamin ergic stimulation and may be associated with impulse control disorder such as pathological gambling and hypersexuality.
Daycare Ophthalmic Operations tarsal strip operations) 2596 Blepharophimosis blood pressure of 160/100 generic 120 mg calan fast delivery, for pathology (not cosmetic) Daycare Ophthalmic Operations 2600 Repair of entropion; excision tarsal wedge/extensive arteria japan discount calan 120 mg free shipping. Side Room Repair of retinal detachment blood pressure cuff and stethoscope calan 80mg mastercard, retinopexy with scleral buckling heart attack 90 year old buy cheap calan on line, Codes 2665, 2675 and 2676 2675 cannot be combined for beneft Ophthalmic Operations scleral resection or scleral implant, etc. Ophthalmic Operations 2750 Canaliculus repair with or without tube Ophthalmic Operations 2755 Dacryocystorhinostomy with or without tubes Max 1 Night Hospital Stay Ophthalmic Operations 2756 Removal of D. In no circumstances may an additional professional fee be charged for such premium lens by a Consultant who elects to be fully participating with Aviva Discission of secondary membranous cataract (opacifed 2785 posterior lens capsule and/or anterior hyaloid); stab incision (I. Beneft is not payable for elective refractive lens replacement surgery, However the Aviva member may elect to have a premium lens inserted at time of surgery and an additional charge for the cost of the lens above an agreed Aviva contribution of 135 included in the hospital charge may be made by the hospital to the member. In no circumstances may an additional professional fee be charged for such premium lens by a Consultant who elects to be fully participating with Aviva In an approved Aviva Health facility. Buried tooth roots, (multiple) of teeth, removal of Dental/Oral/Periodontal 2935 See note below Daycare Surgery Pre-authorisation required For codes 2930 and 2935, the term “buried roots” refers to roots which are frmly invested in bone and require surgical removal of bone to effect their excision. Beneft does not apply to superfcial roots which can be removed with simple elevation. Please note that the beneft in respect of the removal of impacted or buried teeth and roots includes the removal of the follicle or associated pathological tissue such as abscess, granulomatous and/or cystic tissue. Cystic tissue removed in the process of tooth or root resection and extractions, surgical or Dental/Oral/Periodontal 2940 Dental cysts of maxilla or mandible otherwise, is considered to be Daycare Surgery an integral part of that surgical treatment and is not a seperate procedure. Extraction of teeth (more than six permanent teeth) with or Dental/Oral/Periodontal 2950 Daycare Surgery without alveolectomy Gingivectomy, one to four teeth Dental/Oral/Periodontal 2953 See note below Side Room Surgery Pre-authorisation required Gingivectomy is taken to include the removal of surface deposits from the roots. It is neccesary to provide the deepest pocket depth for each tooth involved in gingival/periodontal surgery on the pocket depth chart in order to have pre certifcation approval. Gingivectomy, twelve or more teeth Dental/Oral/Periodontal 2956 See note below Surgery Pre-authorisation required Gingivectomy is taken to include the removal of surface deposits from the roots. For codes 2953, 2954, and 2956 beneft is only approved incases of severe gingival hyperplasia and which, in the opinion of Aviva’s dental advisors, are not treatable by conservative methods. Prior notifcation including full clinical details, radiographs, or if more appropriate, photographs and pocket depths, should be sent to Aviva for this purpose. Periodontal mucoperiosteal fap surgery, fve to eleven teeth Dental/Oral/Periodontal 2997 See note below Surgery Pre-authorisation required For codes 2996, 2997 and 2998 the term periodontal mucoperiosteal fap surgery is used to denote the incisions and subsequent elevation of a mucogingival fap in order to gain access to tooth roots for the purpose of root planing, surettage, osseous surgery and placements of grafts. Beneft only applies when faps are raised in order to gain access to periodontal sites where pocket depths are 6mm or more. It is neccesary to provide the deepest pocket depth for each tooth involved in gingival/periodontal surgery on the pocket depths chart in order to have precertifcation approval. Periodontal mucoperiosteal fap surgery, twelve or more teeth Dental/Oral/Periodontal 2998 See note below Surgery Pre-authorisation required For codes 2996, 2997 and 2998 the term periodontal mucoperiosteal fap surgery is used to denote the incisions and subsequent elevation of a mucogingival fap in order to gain access to tooth roots for the purpose of root planing, surettage, osseous surgery and placements of grafts. We have been advised that periodontal surgical procedures have been replaced by more conservative (closed) methods of treatment, such as root planing or scaling. However, in exceptional cases, where serious periodontal disease is present which, in the opinion of Aviva’s dental advisors, is not treatable by conservative methods and where pocket depths are 6mm or more, Aviva will consider such cases for payment. Prior notifcation, including full clinical details, relevant radiographs and pocket depths, should be sent to Aviva for this purpose. Two osseointegrated mandibular implants including second 3017 stage abutment installation See note below Dental/Oral Surgery Pre-authorisation required Osseointegrated mandibular implants; professional fee beneft as detailed in this schedule is payable for non-cosmetic osseointegrated mandibular implants. Three osseointegrated mandibular implants including second 3018 stage abutment installation See note below Dental/Oral Surgery Pre-authorisation required Osseointegrated mandibular implants; professional fee beneft as detailed in this schedule is payable for non-cosmetic osseointegrated mandibular implants. Four osseointegrated mandibular implants including second 3019 stage abutment installation See note below Dental/Oral Surgery Pre-authorisation required Osseointegrated mandibular implants; professional fee beneft as detailed in this schedule is payable for non-cosmetic osseointegrated mandibular implants. This beneft is restricted to those who otherwise would be unable to wear a conventional full denture on the lower arch. Six or more osseointegrated mandibular implants including 3022 second stage abutment installation See note below Dental/Oral Surgery Pre-authorisation required Osseointegrated mandibular implants; professional fee beneft as detailed in this schedule is payable for non-cosmetic osseointegrated mandibular implants. Beneft is not payable for implants where (a) a patient is partially dentate in the lower arch or (b)where a patient has no remaining natural teeth in the mandible opposing a natural dentition in the upper jaw or maxilla, unless there are exeptional circumstances. Operations Wrist Orthopaedic 3163 Arthroscopy, wrist, surgical; synovectomy, complete (I. Operations Wrist Orthopaedic 3164 Arthroscopy, wrist, surgical; excision and /or repair of triangular I. Orthopaedic Operations 3409 Shoulder replacement, total shoulder (includes reverse total I. Operations Humerus & Shoulder 3415 Amputation through arm Orthopaedic Operations 3420 Arthrodesis, humerus/shoulder Orthopaedic Operations 3430 Biopsy, synovial, humerus/shoulder Diagnostic Orthopaedic Operations 3435 Capsulotomy (acute capsulitis) Orthopaedic Operations 3440 Disarticulation, humerus/shoulder Orthopaedic Operations 3445 Dislocation, open reduction of, humerus/shoulder Orthopaedic Operations 3450 Dislocation, acute, manipulation under general anaesthetic, Daycare Orthopaedic Operations humerus/shoulder 3455 Dislocation, Open recurrent, operation for, humerus/shoulder Orthopaedic Operations 3464 Forequarter amputation Orthopaedic Operations 3465 Fractured clavicle, closed reduction of Orthopaedic Operations 3470 Fractured clavicle, open reduction of Orthopaedic Operations 3471 Open reduction internal fxation and bone grafting non union of Orthopaedic Operations a fracture of the clavicle 3475 Fractured humerus, open reduction with internal fxation Orthopaedic Operations 3480 Fractured humerus, open reduction and bone graft Orthopaedic Operations 3485 Fractured humerus, closed reduction of Orthopaedic Operations (I. Operations 3592 External fxature of the spine Orthopaedic Operations 3595 Spinal fusion Orthopaedic Operations 3596 Spinal fusion, in scoliosis spine, anterior and posterior Orthopaedic Operations 3597 Spinal fusion involving two or more levels Orthopaedic Operations Spinal fusion, multiple level, with internal fxation (insertion of rods, plates and/or screws and/or the insertion of an artifcial Note Code 3598, 35981 and Neurosurgical 3598 35982 cannot be charged together Operations disc, and not simply the insertion of a stand-alone spacer) – up to 3 levels in any one specifc case Spinal fusion, multiple level, with internal fxation (insertion of rods, plates and/or screws and/or the insertion of an artifcial Note Code 3598, 35981 and Neurosurgical 35981 35982 cannot be charged together Operations disc, and not simply the insertion of a stand-alone spacer) – 4 to 8 levels in any one specifc case Spinal fusion, multiple level, with internal fxation (insertion of rods, plates and/or screws and/or the insertion of an artifcial Note Code 3598, 35981 and Neurosurgical 35982 35982 cannot be charged together Operations disc, and not simply the insertion of a stand-alone spacer) – over 8 levels in any one specifc case Neurosurgical 3599 Cervical spine laminoplasty with segmental plate fxation (I. Operations 3615 Biopsy of sacro iliac joint region Diagnostic Orthopaedic Operations (I. Orthopaedic Operations 1 night hospital stay 4140 Hammertoe, bilateral, correction of Orthopaedic Operations 4145 Grice’s operation, subtalar bone block Orthopaedic Operations (I. Extremity, pelvis) Application of multiplane external fxation system, for the 4307 treatment of complex peri-articular and intra-articular fractures, Orthopaedic Operations or non unions and correcting deformity following malunited fractures, unilateral. Extremity, pelvis) 4308 Adjustment or revision of (uniplane or multiplane) external Orthopaedic Operations fxation system requiring general anaesthetic 4309 External fxation system (uniplane or multiplane as in procedure Orthopaedic Operations codes 4306 and 4307) removal under general anaesthetic 4310 Osteomyelitis, drilling of bones Orthopaedic Operations 4315 Osteomyelitis, marsupialisation and bone grafting Daycare Orthopaedic Operations Removal of plates, pins, screws; superfcial (includes removal of (I. Beneft shown is payable in full with code for the primary procedure) 4477 Breast reconstruction with free fap, post-mastectomy Plastic Surgery Breast reconstruction with free fap, post-mastectomy Diep 44771 (deep inferior epigastric perforators) Upper end Paid at 100% in conjunction with Plastic Surgery code 44772 pre-authorisation required Breast reconstruction with free fap, post-mastectomy Diep 44772 (deep inferior epigastric perforators) Lowe end Paid at 100% in conjunction with Plastic Surgery code 44771 pre-authorisation required Free Fat injection, post mastectomy For correction of breast defect post breast reconstruction surgery Independent Plastic Surgery 44773 Procedure pre-authorisation required (non cosmetic). Symptoms: (a) Back pain, either thoracic or cervical, that has persisted for at least a continuous three month period and has been severe enough to require daily use of prescription analgesia for at least four weeks. Restoration of symmetry following mastectomy 4489 Facial trauma, suturing of facial nerve Plastic Surgery 4491 Facial trauma, suturing of facial nerve branch Plastic Surgery 4492 Facial trauma, grafting of facial nerve, sural nerve, greater Plastic Surgery auricular nerve 4493 Excision of facial nerve and graft, sural nerve, greater auricular Plastic Surgery nerve 4494 Wedge excision of lower lip to restore oral continence in the Side Room Plastic Surgery presence of facial palsy 4496 Nasolabial skin/dermal hitch Plastic Surgery 4497 Temporalis fascial sling, oral, nasolabial, ocular Plastic Surgery 4498 Orbicularis oris hitch Plastic Surgery 4499 Masseter to oral angle, digastric to lower lip or temporalis to Plastic Surgery fascial slings 4500 Facial nerve graft (in face), (see E. Ear, Nose & Throat 4538 Treatment of superfcial wound dehiscence; simple closure with Service Plastic Surgery or without packing (single layer closure) Secondary closure of surgical wound or dehiscence, (post 4539 infectious breakdown) includes excision of granulation and scar (I. The Clinical Indicators in respect of this 3rd line therapy is following at least 3 years of erectile disfunction following failure of medication prescribed by a Consultant Urologist and / or Consultant Psychiatrist and following failure (where appropriate) of the use of inter-cavernous injections and use of vacuum pump devices and where the patient will have undergone a prolonged course of Psychiatric evaluation and advice and/or including medication. The life expectancy of the above prosthesis will be expected to be a minimum of 15 years (subject to any clinical reasons. This is applicable to a constant with relevant specialist training in this area and registered as such with Aviva Excision of benign or malignant lesion(s), any area; adjacent Sideroom Plastic Surgery Local 4938 See note below Only Flaps & Grafts tissue transfer or rearrangement, 4. This is applicable to a constant with relevant specialist training in this area and registered as such with Aviva Excision of benign or malignant lesion(s), any area; adjacent Plastic Surgery Local 4939 See note below Day Care Flaps & Grafts tissue transfers or rearrangement, 10. This is applicable to a constant with relevant specialist training in this area and registered as such with Aviva Skin graft (pinch, split thickness, epidermal, dermal or tissue culture or free fap excised from a distant site and harvested as a graft from non adjacent skin) for repair when direct wound Plastic Surgery Local 4942 closure or adjacent tissue transfer is not possible; with codes See note below Flaps & Grafts 4937 or 4938. Beneft shown is payable in full with code for the primary procedure) the donor site for the grafting material must be specifed. This is applicable to a constant with relevant specialist training in this area and registered as such with Aviva Skin graft (pinch, split thickness, epidermal, dermal or tissue culture or free fap excised from a distant site and harvested as a graft from non adjacent skin) for repair when direct wound Plastic Surgery Local 4943 closure or adjacent tissue transfer is not possible; with code See note below Flaps & Grafts 4939. This is applicable to a constant with relevant specialist training in this area and registered as such with Aviva 4944 Excision of pressure sore and myocutaneous fap Plastic Surgery 4945 Reconstruction with imported faps, partial Plastic Surgery Skin graft (pinch, split thickness, epidermal, dermal or tissue culture or free fap excised from a distant site and harvested as a graft from non adjacent skin) for repair when direct wound Plastic Surgery Local 4946 closure or adjacent tissue transfer is not possible; with code See note below Flaps & Grafts 4941. Beneft shown is payable in full with code for the primary procedure) (see note after procedure 4946) the donor site for the grafting material must be specifed. If more than one is performed on a patient (whether one or more consultants are involved), during a hospital stay, beneft will be payable as follows: 100% of the highest valued procedure, 50% of the second highest valued procedure, and 25% of the third highest valued procedure. Consultant consultation and evaluation including monitoring of cardiovascular status for six hours for a patient commencing a course of oral Gilenya (fngolimod) to treat relapsing forms 5023 of multiple sclerosis. Beneft will be provided for Thoracoscopic Epicardical radiofrequency Ablation for patients with atrial fbrillation who have failed to respond to trans catheter endocardial ablation provided the decision is the consensus of a multidisciplinary team that includes both a cardiologist and a cardiothoracic surgeon, both with training and experience in the use of intra -operative electrophysiology 2). Also for adults with congenital heart disease assessed by a Consultant Paediatric Cardiologist. Syncope is defned as a sudden but transient total loss of consciousness with spontaneous resolution. Removal of implantable, patient-activated cardiac event loop 5054 recorder (where the original implantation met the conditions Cardiological Procedures of payment) 5055 Aortic endarterectomy Thoracic Operations Insertion of neurostimulator pulse generator and electrodes: 5056 sacral nerve for bladder muscle control: trial stage See note below Day Care Urology Procedures Pre-authorisation required Treatment of urge urinary incontinence or symptoms or urge-frequency when all of the following criteria are met (a) the member has experienced urge urinary incontinence or symptoms of urge frequency for at least 12 months and the condition has resulted in signifcant disability (this frequency limits the members ability to participate in activities of daily living) and (b) Pharmacotherapies. Treatment of urge incontinence or symptoms of urge frequency insertion of neurostimulator pulse generator and electrodes: provided test stimulation of sacral nerve for bladder muscle control: permanent implantation the patient satisfes the criteria Thoracic Operations 5057 (Hospital stay applies for a maximum of 1 night only. Treatment of non-obstructive urinary retention provided test stimulation of the patient satisfes the criteria indicating at least 50% decrease in residual urinary volume.
In addition to these factors blood pressure chart age nhs buy 240 mg calan visa, the risk also exists that crewmembers will develop various illnesses during flight blood pressure 120 0 order calan 120mg on-line. The risk of illness is no less during space flight than on Earth blood pressure medication best time to take purchase calan online, and may actually be greater for some classes of diseases arteriovenous fistula order calan uk. The overall goals of the medical flight support system are to minimize the physiological effects of destabilizing factors, to maintain crew health and performance, and to solve problems regarding medical flight safety. Although the forms in which medical support programs are organized may differ between Russia and the United States, both countries involve groups of medical specialists working toward the common goals of medical support before, during, and after space flights. This set of medical support measures was designed to maintain human health and performance capacity, and thereby contribute to flight safety and success. The goals of this system can be attained only through the systematic use of such measures. Chapter 1 discusses the medical selection process through which applicants are selected to become astronauts and cosmonauts. For example, while the American process selects to exclude those with significant health risks during space flight, the Russian selection approach identifies those who will perform best in and adapt quickly to space flight conditions. Although differing approaches also exist between Russian and American approaches to crew-training systems, they share many fundamental concepts and practices. Because of their basic similarities, Chapter 2 discusses mainly the Russian experiences with crew training. Because of the high level of physical fitness in the astronaut and cosmonaut population (through the selection process), physiological adaptations that develop in the course of flight may mask any negative conditions in medical evaluations made without consideration of individual baselines. Therefore, both Russian and American systems have adopted the principle of continuous monitoring rather than periodic health checks. Chapter 3 discusses monitoring before flight to establish the baseline health status of each crewmember; these data are used for monitoring during and after flight. Chapter 4 discusses the continuous monitoring which takes place during flight to track any negative trends in each individual’s health. In order to preserve the health and performance of the crew in space, scientists seek to understand the etiology of diseases or injuries that occur. Chapter 5 presents a brief overview of which kinds of factors could be expected to contribute to functional disorders in flight and in other analogous situations, goes on to describe actual episodes of in-flight diseases and injuries, and finally underscores the importance of a comprehensive set of countermeasures to prevent—or at least minimize the complications of—in-flight medical problems. Chapter 6 is devoted to explaining the principles and diagnosis of medical treatment in space flight. To prevent and minimize negative impacts to the mission, the programs must consider the infrastructure and facilities to keep crewmembers in optimal health, as well as have well-defined and -characterized risks of medical events occurring in flight. Past, present, and future capabilities for in-flight diagnosis and treatment are also discussed. Chapter 7 outlines the importance of providing rehabilitation after flight is completed. Combined measures— medical, educational, social, and vocational—are used to train and reestablish a crewmember’s full health and functionality, thus ensuring the long-term condition and longevity of the individual. Chapter 8 discusses the physiological adaptations experienced in space flight in the context of countermeasures to them. Both Russian and American countermeasures aim to protect and condition crews for the unfamiliar environment of space flight and for optimal readaptation to Earth conditions upon return. The discussion also presents the different countermeasure protocols according to the length of the mission, as the degree of adaptation varies with this factor. Described are the dynamics of psychological adaptation during the phases of the mission, as well as current measures to ensure the psychological well-being of the crew. The authors also share their experiences in providing support for Mir, as these long missions in space allowed the testing of various types and schedules of psychological support. Chapter 10 covers general, yet critical, issues concerning the ergonomic design of workstations and crew performance technology—such as the controls, displays, and signals that present information to the crew—in addition to methods of evaluating the ergonomics of crew-spacecraft systems. Chapter 11 discusses the analysis of crew performance in the unique conditions of space. The authors provide a review of results from psychological performance analyses of space crews conducted during the support of long missions on Skylab, Salyut, and Mir. Chapter 12 details the safety requirements for environmental control systems on crewed spacecraft, as well as methods of analyzing flight safety, and criteria and techniques for safety assessments. Chapter 13 summarizes the historical development of emergency systems in space flight and the mishaps that have occurred in crewed flight, outlines the rationale for escape systems and discusses the types of hazards and events that might prompt escape procedures, and discusses escape and rescue from low Earth orbit, emphasizing the Space Shuttle Program and the International Space Station. The author also reviews the international considerations of space rescue and briefly considers lunar and planetary escape-and-rescue scenarios. Finally, Chapter 14 reviews how the principles used in designing equipment for the spacecraft environment can be beneficial for Earth-based settings, for example the many benefits accrued in the development of imaging, communications, and robotics technologies; materials science; and biotechnology. The authors also consider the potential commonalities between aging and space flight exposure in terms of bone loss and postural control. The experience accrued in organizing and implementing medical support of space flights already has been put to good use in solving humanitarian problems involving effective international collaboration. Cosmonaut Training Stanislav Alexeyevich Bugrov, Yuri Alexandrovich Senkevich, Leonid Ivanovich Voronin, Viktor Stepanovich Bednenko, and Marks Mikhaylovich Korotayev (R. Incidence of Disease and Injury in Space Igor Borisovich Goncharov, Irina Vasilyevna Kovachevich, and Anatoliy Fedorovich Zhernavkov (R. Postflight Rehabilitation of Space Crews Valeriy Vasilyevich Bogomolov and Tatyana Dmitriyevna Vasilyeva (R. Countermeasures to Short-Term and Long-Term Space Flight Anatoliy Ivanovich Grigoriev, Inessa Benediktovna Kozlovskaya (R. Ergonomic Support of Crewmember Performance Albert Petrovich Nechayev, Aleksandr Vasilyevich Astakhov, Vladimir Nikolayevich Trofimov, and Gennadiy Fedorovich Isayev (R. Psychological Analysis and Monitoring of Crew Performance Vyacheslav Ivanovich Myasnikov, Sergey Vasilyevich Bronnikov, and Oleg Igorovich Zhdanov (R. Human space flight is one of the most outstanding scientific accomplishments of the 20th century. Since the early days of space exploration in the 1950s, milestones such as the development of crewed spacecraft and orbital stations, the implementation of longer flights, moon landings, extravehicular activities, and locomotion in open space have significantly affected the medical requirements for astronauts and cosmonauts. The United States and the former Soviet Union have independently developed medical procedures and standards for selecting astronauts and cosmonauts. Both countries began selecting their first candidates in 1959, and both have relied heavily on the tenets of aviation medicine, a discipline that already had an established, validated process for 1,2 3 selecting flight crews. In fact, the first candidates for the astronaut and cosmonaut corps were military jet pilots. In the 1950s and early 1960s, little information was available as to how humans would respond physiologically to space flight, although the U. Given the largely unknown nature of the space flight environment at that time, both countries recognized the importance of ensuring that crews had some medical “margin of safety. The time and expense associated with space flight, as well as the risk of having to abort missions because of illnesses or defects 4–7 overlooked in the screening process, heightened the importance of this process. Although the first sets of astronaut and cosmonaut candidates were ranked with regard to other candidates before the final selections, neither country had a specific set of “pass/fail” medical standards for space flight duty. The applicants were considered to be exceptionally well screened by virtue of their selection as military pilots and had maintained their physical qualifications for duty as high-performance jet pilots. The first set of 8 Soviet/Russian medical selection procedures and standards were adopted in 1982 and revised in 1989. The Russian approach involves in-depth clinical examinations that include a battery of stress tests, which together are thought to provide the most complete picture of the health and functional and reserve capacities of the individuals being tested. In contrast, one of the main goals of the Russian medical selection process is to identify those individuals who can best tolerate space flight, adapt quickly to the physical factors associated with the spacecraft environment, and perform acceptably during flight. Russian standards for cosmonaut selection thus consider an individual’s personality, psychophysiological traits, health status, functional capacities, and the rates at 9–13 which adaptive skills and responses are learned and retained. This difference between American and Russian selection philosophies has engendered spirited debate that continues to the present. Russian space scientists maintain that their test battery allows them to predict who will perform well in space; U. This chapter describes the similarities and differences in the evaluation processes used to select astronauts and cosmonauts, and the processes involved in certifying those that have been accepted for specific missions. Generic calan 240mg on line. Laparoscopic Gastric Sleeve Surgery PreOp® Patient Education and Engagement. |
