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By: Ziad F. Gellad, MD

• Associate Professor of Medicine
• Core Faculty Member, Duke-Margolis Center for Health Policy
• Member in the Duke Clinical Research Institute

https://medicine.duke.edu/faculty/ziad-f-gellad-md

N Engl J angiopathy revisited: recent insights into pathophysiology and Med 2006;355:928-939 blood pressure medication first line benicar 10 mg mastercard. Clin Neuroradiol 2015; within six hours of onset of headache for diagnosis of sub25 Suppl 2:167-175 blood pressure medication ramipril generic benicar 20 mg overnight delivery. Acute ischaemic brain lesions in intracerebral rosurgery 2006;59:21-27; discussion 21-27 zopiclone arrhythmia purchase benicar without a prescription. Hemorrhagic transformation therapy for unruptured brain arteriovenous malformations after cerebral infarction: current concepts and challenges prehypertension causes buy cheap benicar online. Stroke 2011; of symptomatic arteriovenous malformations of the brain: a 42:2235-2239 prehypertension uk buy benicar 10 mg fast delivery. Hemorrhagic transformation of ischemic brain tissue: outcomes of arteriovenous malformation peripheral neuropathy generic benicar 10mg on line. Neurological manifestations of intracranial dural arteriovemation after acute ischemic stroke. Frequency and risk factors for spontaneous lar therapy, and pathophysiology of cerebral and spinal dural hemorrhagic transformation of cerebral infarction. Neuroradiology cerebral venous thrombosis: a statement for healthcare pro2015;57:775-782. Semin Neurol 2014;34:405evaluation of intracranial dural arteriovenous fistulas. Intracranial infectious aneurysm: presentation, Detection of cortical venous drainage and determination of management and outcome. Retrospective review of cerebral mycotic aneurysms graphic correlation with a revised classification of venous in 26 patients: focus on treatment in strongly immunocomdrainage. Synowitz Department of Neurosurgery, Helios Hospital Berlin, Berlin, Germany with a chemosis of the conjunctiva and loss of vision [Figure 1]. The authors the left parietal region with an intraventricular hemorrhage (Fisher discuss this case and review the relevant literature. The aneurysm was clipped via a right peritoneal approach and the intraorbital tumor on the left side was removed with orbital bony wall decompression via a left frontal approach on the same session. Includtic pathway gliomas, neurofibromas, astrocytomas, ing our case, we identified 28 cases of intracranial aneurysms meningeomas). Physical examination revealed that there were neurofibromas and café-au-lait spots distributed over the entire body. There was Grade 4 right hemiparesis, left-sided protrusio bulbi combined Figure 1: Orbital neurofibroma in neurofibromatosis Type 1 J. Baldauf Department of Neurosurgery, Ernst-Moritz-Arndt-University, Sauerbruchstrasse, 17487 Greifswald, Germany. In three cases, the aneurysms as a result of the radiation therapy of gliomas of the optic was in the vertebrobasilar circulation, and eight patients had chiasm. At least the intimal aneurysm form was typical for cerebral aneurysms and had marked, eccentric, fibrous intimal proliferation, a small number of sparsely distributed spindle cells in the intima and media, smooth muscle fibrosis, and elastica fragmentation. Other reports by Feylter et al added new or similar features of histological changes including irregular smooth muscle loss or nodular proliferation of epitheloid and spindle cells. Changes in the walls of vessels may depend on primary defects of myocytes inside these walls, and Figure 2: Lateral and anteroposterior views of the left internal carotid probably pericytes play an important role. Neurofibromatosis assoal demonstrated by immunochemical studies the expression ciated with intraand extracranial aneurysms and extracranial vertebral arteriovenous fistula. Cerebrovascular disorders associated with von Recklinghausen’s neurofibromatosis: a case report. Neurosurgery neurofibromin as a negative growth regulator (tumor suppres1988;22:544-9. Asymptomatic fusiform aneurysm of the petrous carotid artery in a patient with von Recklinghausen’s neurofibromatois possible that the loss (or reduction) of neurofibromin exsis. Multiple intracranial aneutistically and found no significant relation between the prevarysms and neurofibromatosis: A case report. Anéurysmes intracraniens topsy revealed an intracranial hemorrhage in four patients multiples en rapport avec une maladie de Recklinghausen. Cerebral aneurysms associated with von Recklinghausen neurofibromatosis: Report of two cases. Neurofibromatosis associated with multiple intracranial vascular lesions: Stenosis of the internal carotid artery conclusion, they suggested that there is an increased risk of and peripheral aneurysm of the Heubner’s artery; report of a case. Neurofibromatosis associated with moyamoya arteriopathy and fusiform aneurysm: case report. Arq understood and needs to be analyzed on a cellular level in the Neuropsiquiatr 1998;56:819-23. Two cases of subarachnoid hemorrhage associated with neurofibromatosis type I: a case of multiple cerebral aneurysms and arteriovenous malformation, and another case of References an anterior communicating artery aneurysm. Ann tiple intracranial aneurysms and vascular abnormalities associated with neuVasc Surg 1992;6:456-9. Insights into the pathogenesis of neurofibromaneurofibromatosis and aneurysm of circle of Willis. A cerebral aneurysm is a bulge or balloon like dilatation/swelling of the wall of a blood vessel Aneurysm in the brain. Aneurysms develop because of a weakness in the wall of the vessel, usually at branch points. In a small number of patients, aneurysms are inherited with multiple family members affected. We do not know why aneurysms develop in a majority of cases, however the following may play a role:. Sometimes aneurysms can causes pressure symptoms (like double vision, seizures, numbness). If you have two first-degree relatives with cerebral aneurysms, your risk of harboring an aneurysm is four times the general population. Most aneurysms present with hemorrhage which results in a sudden severe headache or unconsciousness. Carotid & Vertebral digital substraction angiography : is the definitive method to detect aneurysms. Using a groin artery, a catheter is placed in the blood vessels leading to the brain and a contrast agent or dye is injected to photograph the blood vessels. Endovascular treatment : through the artery in the groin, a platinium coil is introduced into the aneurysm to occlude it. Neurointerventional radiologist will make a small incision in the groin through which a tiny catheter is guided through the femoral artery into the brain vessels. When in through the microcatheter into position, the coil is released by an application of a the aneurysm. Most endovascular therapists are neuroradiologists or neurosurgeons who have completed training (ranging from one to two years) in endovascular techniques after their medical (five years) and speciality training (five to seven years). Before admission: Preadmission will be done one day or two prior to the embolization and routine blood tests may be done. Your doctor will instruct you to remain still, lying flat in bed for up to eight hours. If all goes well, you will be transferred to a neuroscience floor the next day and discharged home the following day. Possible complications include stroke like symptoms such as weakness in one arm or leg, numbness, tingling, speech disturbances and visual problems. A balloon occlusion of the parent artery may be required for an aneurysm at the base of the skull or a very large aneurysm. This will permanently close the artery, therefore no blood will reach the aneurysm. The patient Aneurysm is often tested in advance to assure he can tolerate the occlusion of the artery. Cerebral aneurysm: is a bulge or balloon like dilation/swelling of the wall of a blood vessel in the brain. Catheter: a thin, flexible tube that is injected with a contrast material so vessels can be visualized on an x-ray image. Contrast: water and iodine salts that can be injected into vessels and seen on x-ray. Embolization: treatment method using image guidance and a transvascular apporoach. Magnetic resonance angiography: is a method of producing highly detailed images of the body without the need for x-rays. It utilizes "pulse sequences" specifically designed to show the arteries and veins of the examined body part. Stroke: a blockage of a vessel which results in the death of brain cells that were fed by that blood vessel. Entrance Toronto Western Hospital (main floor) East Elevators Center Elevators North Elevators South Elevators Emergency Atrium Elevators Food Entrance Court? Neurosurgical Office: Take the Atrium elevator to the 4th floor, and down the left corridor. This booklet is to be viewed as supplementary to the information given by health care professionals. The Copyright Owner does not allow the republishing of any of its content on any form of media, except in the case of a specific licensing agreement for that purpose. You may not modify, copy, change, alter, reproduce, republish, in any manner, the material in this booklet. One in 5 patients report a less severe headache in the hours or days preceding the event. Grade 2: Moderate to severe headache, stiff neck, no neurologic deficit except cranial nerve palsy. Other patient factors include age and medical comorbidities, such as hypertension, atrial fibrillation, congestive heart failure, coronary heart disease, and renal disease. The classic location of hypertensive hemorrhages reflects the territories supplied by these small perforators, with 6065% in the putamen and internal capsule, 15-25% in the thalamus and 5-10% in the pons. Patients with Cerebellar hemorrhage >3cm who are deteriorating neurologically or who have brain stem compression should have surgical removal of the clot. Ventricular drainage should be considered in all stuporous or comatose patients with intraventricular hemorrhage and acute hydrocephalus. Volume 1 contains a list of three-character categories, the tabular list of inclusions and the four-character subcategories. The supplementary Z code appears in Volume 1 but is not used for classifying mortality data. Optional fifth characters are provided for certain categories and an optional independent four-character coding system is provided to classify histological varieties of neoplasms, prefixed by the letter M (for morphology) and followed by a fifth character indicating behavior. Volume 2 includes the international rules and notes for use in classifying and tabulating underlying cause-of-death data. Volume 3 is an alphabetical index containing a comprehensive list of terms for use in coding. The list of geographic codes (Appendix C), the list of abbreviations used in medical terminology (Appendix D), and the synonymous sites list (Appendix E) are included in this publication. Thus, there are two codes for those diagnostic statements subject to dual classification. Corrections have been made to clarify instructions, spelling and format throughout the manual. Throughout the manual, plural forms of a number of diseases have been changed to singular to reflect preferred usage among medical professionals. Standard Certificate of Death provides spaces for the certifying physician, coroner, or medical examiner to record pertinent information concerning the diseases, morbid conditions, and injuries which either resulted in or contributed to death as well as the circumstances of the accident or violence which produced any such injuries. The medical certification portion of the death certificate is designed to obtain the opinion of the certifier as to the relationship and relative significance of the causes which he reports. A cause of death is the morbid condition or disease process, abnormality, injury, or poisoning leading directly or indirectly to death. The underlying cause of death is the disease or injury which initiated the train of morbid events leading directly or indirectly to death or the circumstances of the accident or violence which produced the fatal injury. These conditions may be completely unrelated, arising independently of each other or they may be causally related to each other, that is, one cause may lead to another which in turn leads to a third cause, etc. The order in which the certifier is requested to arrange the causes of death upon the certification form facilitates the selection of the underlying cause when two or more causes are reported. He is requested to report in Part I on line (a) the immediate cause of death and the antecedent conditions on lines (b), (c) and (d) which gave rise to the cause reported on line (a), the underlying cause being stated lowest in the sequence of events. However, no entry is necessary on I(b), I(c) or I(d) if the immediate cause of death stated on I(a) describes completely the sequence of events. A reported sequence two or more conditions on successive lines in Part I, each condition being an acceptable cause of the one on the line immediately above it. Accident in medical care a misadventure or poisoning occurring during surgery or other medical care. Causation table (Table D) contains address codes and subaddress codes that indicate an acceptable causal relationship (reported sequence). Combination code a third code which is the result of the merging of two or more codes. Conflict in linkage when the selected underlying cause links con-currently with or in due to position with two or more conditions. Contributory cause any cause of death that is neither the direct, intervening, originating antecedent nor underlying is a contributory cause of death. Direct cause of death also known as terminal cause of death, is the condition entered on line I(a) in Part I.

Where appropriate sheer heart attack buy discount benicar online, the health professional should consider direct referral rather than simply providing sources for further information hypertension diagnosis jnc 7 cheap benicar 40mg free shipping, for example: wellbutrin xl arrhythmia buy discount benicar 10 mg line. Vocational assessors will assess a person’s ability to arteria tibialis posterior discount benicar 20 mg rehabilitate blood pressure guidelines 2013 buy genuine benicar online, retrain and reskill for another industry arrhythmia electrolyte imbalance purchase 40mg benicar otc, or a new sector within the industry. For older drivers, early advice will help them plan for the inevitable changes in their independence. There are also specifc information resources available for drivers with dementia and their carers (refer to resources below). Roles and responsibilities Roles and responsibilities of those involved in ftness to drive assessment and decision making are summarised in Table 2 and discussed in this section. Legislation relating to driver and health professional responsibilities is also summarised in Appendix 3: Legislation relating to reporting. Figure 2 summarises the relationships and interactions between the driver licensing authority, health professional and vehicle driver. The responsibility for issuing, renewing, suspending, refusing or cancelling, or reinstating a person’s driver licence (including a conditional licence) lies ultimately with the driver licensing authority. Licensing decisions are based on a full consideration of relevant factors relating to the driver’s health and driving performance record. Table 2: Key roles and responsibilities with respect to ftness to drive Driver Health professional Driver licensing authority. To make all decisions regarding the authority any long-term or permanent drive based on relevant clinical and licensing of drivers. The driver licensing injury or illness that may affect their functional information and on the authority will consider reports provided ability to drive safely. To adhere to prescribed medical restrictions, ongoing monitoring, driver licensing authority will consider treatment. Note: Medical practitioners or other clinicians do not have the legal authority to restrict or reinstate a patient’s driver licence; this can only be done by the relevant driver licensing authority. Brochures describing the responsibilities of patients, examining professionals and licensing authorities may be available from state and territory driver licensing authorities. The above relationships are generalised and may vary between states/territories in terms of legislative requirements. Licensing decisions are individualised and are based on a full consideration of relevant factors relating to:. In making a licensing decision, the authority will seek input either directly from the driver and/or from a health professional. The authority will also act on unsolicited reports from health professionals, the police or members of the public regarding a person’s ftness to drive. Under national driving licensing arrangements current at the time of publication, the driver licensing authority issuing the driver licence and the driver’s residential address should be in the same jurisdiction. Payment for health examinations or assessments related to ftness to drive is generally not the responsibility of the driver licensing authority. Each state and territory has an appeal system for situations where drivers do not agree with a decision made about their driver licences. The driver licensing authority will inform drivers of the appeal process when informing them of the licensing decision. For general advice regarding legal or ethical issues, health professionals should contact their professional defence organisation. Appendix 9 contains the contact details for driver licensing authorities around Australia. At licence application and renewal, drivers can be asked to complete a declaration regarding their health, including whether they have any long-term conditions such as diabetes, epilepsy or cardiovascular disease. Based on this information, the driver licensing authority may request a medical examination to confrm a driver’s ftness to hold a driver licence. In the case of medical examinations requested by the driver licensing authority, drivers have a duty to declare their health status to the examining health professional. Drivers are also required to report to the driver licensing authority when they become aware of a health condition that may affect their ability to drive safely. There is some variability in these laws between the states and territories, thus drivers and health professionals should be aware of the specifc reporting requirements in their jurisdiction and should contact their driver licensing authority for details of local requirements. These laws may impose penalties for failure to report (refer to Appendix 3: Legislation relating to reporting). Drivers may be liable at common law if they continue to drive knowing that they have a condition that is likely to adversely affect safe driving. Drivers should be aware that there may be long-term fnancial, insurance and legal consequences where there is failure to report an impairment to their driver licensing authority. The health professional has an ethical obligation, and potentially a legal one, to give clear advice to the patient in cases where an illness or injury may affect safe driving ability. Health professionals are advised to note in the patient’s medical record the nature of the advice given. The ethical duty is generally expressed through codes issued by professional bodies. The legal duty is expressed through legislative and administrative means and includes measures to protect personal information about a specifc individual. Patients disclose highly personal and sensitive information to health professionals because they trust that the information will remain confdential. If such trust is broken, many patients could either forgo examination/treatment and/or modify the information they give to their health professional, thus placing their health at risk. Although confdentiality is an essential component of the patient–professional relationship, there are, on rare occasions, ethically and/ or legally justifable reasons for breaching confdentiality. With respect to assessing and reporting ftness to drive, the duty to maintain confdentiality is legally qualifed in certain circumstances in order to protect public safety. The health professional should consider reporting directly to the driver licensing authority in situations where the patient is either:. In the Australian Capital Territory, New South Wales, Queensland, Tasmania, Victoria and Western Australia, statute provides that health professionals who make such reports to driver licensing authorities without the patient‘s consent but in good faith that a patient is unft to drive are protected from civil and criminal liability. The Northern Territory does not currently provide indemnity cover (refer to Appendix 3: Legislation relating to reporting). In South Australia and the Northern Territory current legislation imposes mandatory reporting. A positive duty is imposed on health professionals to notify the relevant authority in writing of a belief that a driver is physically or mentally unft to drive (refer to Appendix 3: Legislation relating to reporting). Assessing Fitness to Drive 2016 17 Roles and responsibilities It is preferable that any action taken in the interests of public safety should be taken with the consent of the patient wherever possible and should certainly be undertaken with the patient’s knowledge of the intended action. The patient should be fully informed as to why the information needs to be disclosed to the driver licensing authority and be given the opportunity to consider this information. Failure to inform the patient will only exacerbate the patient’s (and others’) mistrust in the patient– professional relationship. It is recognised that there might be an occasion where the health professional feels that informing the patient of the disclosure may place the health professional at risk of violence. Under such circumstances the health professional must consider how to appropriately manage such a situation (refer to section 3. In making a decision to report directly to the driver licensing authority, it may be useful for the health professional to consider:. Examinations requested by a driver licensing authority When a patient presents for a medical examination at the request of a driver licensing authority the situation is different with respect to confdentiality. The patient may present with a form or letter from the driver licensing authority requesting an examination for the purposes of licence application or renewal, or as a stipulation of a conditional licence. The completed form will generally be returned by the patient to the driver licensing authority, thus there is no risk of breaching confdentiality or privacy, provided only information relevant to the patient’s driving ability is included on the form. Privacy legislation All health professionals and driver licensing authorities should be aware of the Australian Privacy Principles8, and other privacy legislation applicable in their jurisdiction when collecting and managing patient information and when forwarding such information to third parties. If this cannot be achieved – for example, where there may be the possibility of the patient ceasing contact or avoiding all medical management of their condition – health professionals should be prepared to disqualify themselves and refer their patient to another practitioner. A diffcult ethical situation arises in the event that the health professional has reason to doubt the veracity of the information provided by a patient regarding their health, and their capacity to drive safely. With these additional inputs it may be possible to carefully discuss and reassess the situation with the patient, taking care to document the proceedings. In such circumstances the health professional may elect to refer the driver to another practitioner or may refer them directly to the driver licensing authority without a recommendation regarding ftness to drive. Driver licensing authorities recognise that it is their role to enforce the laws on driver licensing and road safety and will not place pressure on health professionals that might needlessly expose them to risk of harassment or intimidation. The health professional may refer the patient to the standards in this publication when dealing with such situations. Further information about managing patient–professional hostility is available via the Royal Australian College of General Practitioners website at <. Some drivers may seek to deceive health professionals about their medical history and health status and may ‘doctor shop’ for a desirable opinion. If a health professional has doubts about an individual’s reason for seeking a consultation, they should consider: 18 Assessing Fitness to Drive 2016 Roles and responsibilities. However, if doubt exists about a patient’s ftness to drive or if the patient’s particular condition or circumstances are not covered specifcally by the standards, review by a specialist experienced in the management of the particular condition is warranted and the general practitioner should refer the patient to such a specialist. In the case of commercial vehicle drivers, the opinion of a medical specialist is generally required for initial recommendation and periodic review of a conditional licence. This requirement refects the higher safety risk for commercial vehicle drivers and the consequent importance of expert opinion. In circumstances where access to specialists is limited, once the initial recommendation is made by a specialist, alternative arrangements for subsequent reviews by the general practitioner may be made with the approval of the driver licensing authority and with the agreement of the specialist and the treating general practitioner. General practitioners are in a good position to integrate reports from various specialists in the case of multiple disabilities to help the driver licensing authority make a licensing decision. An occupational physician or an authorised health professional may provide a similar role for drivers of commercial vehicles and their employers. For the purposes of this publication, the term ‘specialist’ refers to a medical or surgical specialist other than a general practitioner, acknowledging that Fellows of the Royal Australian College of General Practitioners have specialist status under current medical registration arrangements (refer to < Box 2: Telehealth All parties are encouraged to use telemedicine technologies such as videoconferencing to minimise the diffculties associated with limited access to specialists. People in telehealth-eligible areas of Australia have access to specialist video consultations under Medicare. This provides many patients with easier access to specialists, without the time and expense involved in travelling to major cities. Such assessments are particularly useful in borderline cases or where the impact on functionality is not clear. Advice regarding the availability and access to driver assessors is available from the local driver licensing authority and Occupational Therapy Australia (refer also to Appendix 10: Specialist driver assessors). Recommendations following assessment may relate to licence status, the need for vehicle modifcations, rehabilitation or retraining (refer to section 2. Driver training and rehabilitation providers have a role in supporting drivers to retain and regain skills as a result of injury or illness, and to adapt to vehicle modifcations. The choice of which standards to apply when examining a patient for ftness to drive is guided by both the type of vehicle. Generally, the commercial vehicle driver medical standards apply to drivers of heavy vehicles, public passenger vehicles or vehicles carrying dangerous goods. A dangerous goods driver licence is required for transport of dangerous goods in an individual receptacle with a capacity greater than 500 litres or net mass greater than 500 kilograms. The commercial vehicle driver standards are more stringent than the private standards and refect the increased risk associated with motor vehicle crashes involving such vehicles (refer to section 4. Commercial vehicle crashes may present a severe threat to passengers, other road users (including pedestrians and cyclists) and residents adjacent to the road. Such crashes present potential threats in terms of spillage of chemicals, fre and other signifcant property damage. Commercial vehicle drivers generally spend considerable time on the road, thus increasing the likelihood of a motor vehicle crash. They may also be monitoring various in-vehicle communication and work-related systems – a further factor that increases the likelihood of a crash. Crash data identifes that commercial vehicle drivers are more than twice as likely to be involved in a fatal crash compared with other drivers. On the other hand, crashes involving private vehicle drivers are likely to have less severe consequences. Therefore, to ensure that the risk to the public is similar for private and commercial vehicle drivers, the medical ftness requirements for the latter must be more stringent. This is required in order to reduce to a minimum the risk of crash due to long-term injuries or illnesses. The standards also acknowledge and allow for the variability in risk among different commercial vehicle drivers. The driver licensing authority will take into consideration the nature of the driving task as well as the medical condition, particularly when granting a conditional licence (refer to section 4. For example, the licence status of a farmer requiring a commercial vehicle licence for the occasional use of a heavy vehicle on his/her own property may be quite different from that of an interstate multiple combination vehicle driver. The examining health professional should bear this in mind when examining a patient and when providing advice to the driver licensing authority. In developing the standards, a number of approaches have been adopted to manage the increased risk associated with driving a commercial vehicle (refer to Table 3). These approaches include: 20 Assessing Fitness to Drive 2016 Licensing and medical ftness to drive. There are generally longer non-driving periods prescribed for commercial vehicle drivers compared with private vehicles, for example, after a seizure or heart attack.

The applicant should report frequency radial pulse blood pressure 90 buy 40mg benicar amex, duration prehypertension risks purchase generic benicar online, characteristics arrhythmia can occur when discount benicar 40mg line, severity of symptoms arteria networks corp discount 20mg benicar visa, neurologic manifestations heart attack blues buy benicar on line, whether they have been incapacitating prehypertension epidemiology consequences and treatment order 10 mg benicar free shipping, treatment, and side effects, if any. The applicant should describe the event(s) to determine the primary organ system responsible for the episode, witness statements, initial treatment, and evidence of recurrence or prior episode. Although the regulation states, an unexplained disturbance of consciousness is disqualifying, it does not mean to imply that the applicant can be certificated if the etiology is identified, because the etiology may also be disqualifying in and of itself. Is there a history of serious eye disease such as glaucoma or other disease commonly associated with secondary eye changes, such as diabetes? Under all circumstances, please advise the examining eye specialist to explain why the airman is unable to correct to Snellen visual acuity of 20/20. The applicant should report frequency and duration of symptoms, any incapacitation by the condition, treatment, and side effects. The applicant should provide frequency and severity of asthma attacks, medications, and number of visits to the hospital and/or emergency room. For other lung conditions, a detailed description of symptoms/diagnosis, surgical intervention, and medications should be provided. The applicant should describe the condition to include, dates, symptoms, and treatment, and provide medical reports to assist in the certification decision-making process. These reports should include: operative reports of coronary intervention to include the original cardiac catheterization report, stress tests, worksheets, and original tracings (or a legible copy). Part 67 provides that, for all classes of medical certificates, an established medical history or clinical diagnosis of myocardial infarction, angina pectoris, cardiac valve replacement, permanent cardiac pacemaker implantation, heart replacement, or coronary heart disease that has required treatment or, if untreated, that has been symptomatic or clinically significant, is cause for denial. Issuance of a medical certificate to an applicant with high blood pressure may depend on the current blood pressure levels and whether the applicant is taking anti-hypertensive medication. The Examiner should also determine if the applicant has a history of complications, adverse reactions to therapy, hospitalization, etc. If a surgical procedure was done, the applicant must provide operative and pathology reports. If a 33 Guide for Aviation Medical Examiners procedure was done, the applicant must provide the report and pathology reports. A medical history or clinical diagnosis of diabetes mellitus requiring insulin or other hypoglycemic drugs for control are disqualifying. The applicant should provide history and treatment, pertinent medical records, current status report and medication. An established diagnosis of epilepsy, a transient loss of control of nervous system function(s), or a disturbance of consciousness is a basis for denial no matter how remote the history. Like all other conditions of aeromedical concern, the history surrounding the event is crucial. Substance dependence; or failed a drug test ever; or substance abuse or use of illegal substance in the last 2 years. The Examiner should take a supplemental history as indicated, assist in the gathering of medical records related to the incident(s), and, if the applicant agrees, assist in obtaining psychiatric and/or psychological examinations. A careful history concerning the nature of the sickness, frequency and need for medication is indicated when the applicant responds affirmatively to this item. Because motion sickness varies with the nature of the stimulus, it is most helpful to know if the problem has occurred in flight or under similar circumstances. If the person has received a military medical discharge, the Examiner should take additional history and record it in Item 60. It is helpful to know the circumstances surrounding the discharge, including dates, and whether the individual is receiving disability compensation. The fact that the applicant is receiving disability benefits does not necessarily mean that the application should be denied. The Examiner should inquire about the place, cause, and date of rejection and enter the information in Item 60. It is helpful if the Examiner can assist the applicant with obtaining relevant military documents. For each admission, the applicant should list the dates, diagnoses, duration, treatment, name of the attending physician, and complete address of the hospital or clinic. The applicant must name the charge for which convicted and the date of the conviction(s), and copies of court documents (if available). If additional records, tests, or specialty reports are necessary in order to make a certification decision, the applicant should so be advised. If the applicant does not wish to provide the information requested by the Examiner, the Examiner should defer issuance. The applicant must report any disability benefits received, regardless of source or amount. The Examiner must document the specifics and nature of the disability in findings in Item 60. Visits to Health Professional Within Last 3 Years the applicant should list all visits in the last 3 years to a physician, physician assistant, nurse practitioner, psychologist, clinical social worker, or substance abuse specialist for treatment, examination, or medical/mental evaluation. The applicant should list visits for counseling only if related to a personal substance abuse or psychiatric condition. The applicant should give the name, date, address, and type of health professional consulted and briefly state the reason for the consultation. Multiple visits to one health professional for the same condition may be aggregated on one line. When an applicant does provide history in Item 19, the Examiner should review the matter with the applicant. The Examiner will record in Item 60 only that information needed to document the review and provide the basis for a certification decision. If the Examiner finds the information to be of a personal or sensitive nature with no relevancy to flying safety, it should be recorded in Item 60 as follows: 36 Guide for Aviation Medical Examiners "Item 19. The Examiner must list the facts, such as dates, frequency, and severity of occurrence. Although there are no medical standards for height, exceptionally short individuals may not be able to effectively reach all flight controls and must fly specially modified aircraft. Since height is commonly measured in centimeters, divide height in centimeters by 100 to obtain height in meters. If the Examiner finds the condition has become worse, a medical certificate should not be issued even if the applicant is otherwise qualified. The head and neck should be examined to determine the presence of any significant defects such as: a. The external ear is seldom a major problem in the medical certification of applicants. Discharge or granulation tissue may be the only observable indication of perforation. Mobility should be demonstrated by watching the drum through the otoscope during a valsalva maneuver. Pathology of the middle ear may be demonstrated by changes in the appearance and mobility of the tympanic membrane. An upper respiratory infection greatly increases the risk of aerotitis media with pain, deafness, tinnitus, and vertigo due to lessened aeration of the middle ear from eustachian tube dysfunction. If the condition is not a threat to aviation safety, the treatment consists solely of antibiotics, and the antibiotics have been taken over a sufficient period to rule out the likelihood of adverse side effects, the Examiner may make the certification decision. The same approach should be taken when considering the significance of prior surgery such as myringotomy, mastoidectomy, or tympanoplasty. An applicant with unilateral congenital or acquired deafness should not be denied medical certification if able to pass any of the tests of hearing acuity. It is possible for a totally deaf person to qualify for a private pilot certificate. The student may practice with an instructor before undergoing a pilot check ride for the private pilot’s license. If the applicant is unable to pass any of the above tests without the use of hearing aids, he or she may be tested using hearing aids. The nose should be examined for the presence of polyps, blood, or signs of infection, allergy, or substance abuse. The Examiner should determine if there is a history of epistaxis with exposure to high altitudes and if there is any indication of loss of sense of smell (anosmia). Anosmia is at least noteworthy in that the airman should be made fully aware of the significance of the handicap in flying (inability to receive early warning of gas spills, oil leaks, or smoke). Evidence of sinus disease must be carefully evaluated by a specialist because of the risk of sudden and severe incapacitation from barotrauma. The mouth and throat should be examined to determine the presence of active disease that is progressive or may interfere with voice communications. Gross abnormalities that could interfere with the use of personal equipment such as oxygen equipment should be identified. Any applicant seeking certification for the first time with a functioning tracheostomy, following laryngectomy, or who uses an artificial voice-producing device should be denied or deferred and carefully assessed. The worksheets provide detailed instructions to the examiner and outline condition-specific requirements for the applicant. For example, if the medication is taken every 4-6 hours, wait 30 hours (5x6) after the last dose to fly. Some conditions may have several possible causes or exhibit multiple symptomatology. Transient processes, such as those associated with acute labyrinthitis or benign positional vertigo may not disqualify an applicant when fully recovered. Examination Techniques For guidance regarding the conduction of visual acuity, field of vision, heterophoria, and color vision tests, please see Items 50-54. The examination of the eyes should be directed toward the discovery of diseases or defects that may cause a failure in visual function while flying or discomfort sufficient to interfere with safely performing airman duties. It is recommended that the Examiner consider the following signs during the course of the eye examination: 1. Other — clarity, discharge, dryness, ptosis, protosis, spasm (tic), tropion, or ulcer. It is suggested that a routine be established for ophthalmoscopic examinations to aid in the conduct of a comprehensive eye assessment. Cornea — observe for abrasions, calcium deposits, contact lenses, dystrophy, keratoconus, pterygium, scars, or ulceration. Size, shape, and reaction to light should be evaluated during the ophthalmoscopic examination. Lens — observe for aphakia, discoloration, dislocation, cataract, or an implanted lens. Retina and choroid — examine for evidence of coloboma, choroiditis, detachment of the retina, diabetic retinopathy, retinitis, retinitis pigmentosa, retinal tumor, macular or other degeneration, toxoplasmosis, etc. Motility may be assessed by having the applicant follow a point light source with both eyes, the Examiner moving the light into right and left upper and lower quadrants while observing the individual and the conjugate motions of each eye. The Examiner then brings the light to center front and advances it toward the nose observing for convergence. End point nystagmus is a physiologic nystagmus and is not considered to be significant. An applicant will be considered monocular when there is only one eye or when the best corrected distant visual acuity in the poorer eye is no better than 20/200. Although it has been repeatedly demonstrated that binocular vision is not a prerequisite for flying, some aspects of depth perception, either by stereopsis or by monocular cues, are necessary. It takes time for the monocular airman to develop the techniques to interpret the monocular cues that substitute for stereopsis; such as, the interposition of objects, convergence, geometrical perspective, distribution of light and shade, size of known objects, aerial perspective, and motion parallax. In addition, it takes time for the monocular airman to compensate for his or her decrease in effective visual field. A monocular airman’s effective visual field is reduced by as much as 30% by monocularity. A monocular airman’s reduced effective visual field would be reduced even further than 42 degrees by speed smear. For the above reasons, a waiting period of 6 months is recommended to permit an adequate adjustment period for learning techniques to interpret monocular cues and accommodation to the reduction in the effective visual field. Applicants who have had monovision secondary to refractive surgery may be certificated, providing they have corrective vision available that would provide binocular vision in accordance with the vision standards, while exercising the privileges of the certificate. The use of contact lens(es) for monovision correction is not allowed:  the use of a contact lens in one eye for near vision and in the other eye for distant vision is not acceptable (for example: pilots with myopia plus presbyopia). Additionally, designer contact lenses that introduce color (tinted lenses), restrict the field of vision, or significantly diminish transmitted light are not allowed. Binocular bifocal or binocular multifocal contact lenses are 54 Guide for Aviation Medical Examiners acceptable under the Protocol for Binocular Multifocal and Accommodating Devices. Binocular airman using multifocal or accommodating ophthalmic devices may be issued an airman medical certificate in accordance with the Protocol for Binocular Multifocal and Accommodating Devices. Orthokeratology (Ortho-K) is the use of rigid gas-permeable contact lenses, normally worn only during sleep, to improve vision through reshaping of the cornea. It is used as an alternative to eyeglasses, refractive surgery, or for those who prefer not to wear contact lenses while awake. The correction is not permanent and visual acuity can regress while not wearing the Ortho-K lenses. There is no reasonable or reliable way to determine standards for the entire period the lenses are removed. The limitation must use Ortho-K lenses while performing pilot duties must be placed on the medical certificate. The Examiner should deny or defer issuance of a medical certificate to an applicant if there is a loss of visual fields or a significant change in visual acuity.

Presigmoid dural opening continues temporally and suboccipitally with stitch ligation of the superior petrosal sinus heart attack and vine cover best benicar 20mg. The tentorium is cut under the microscope behind the trochlear nerve and in front of the vein of Labbé 168 Presigmoid approach | 5 169 5 | Sitting position – Supracerebellar infratentorial approach 5 arteria rectalis media order 10mg benicar overnight delivery. Patients with septal defects of the heart hypertension xanax order benicar online now, pracerebellar infratentorial approach; and (b) such as patent foramen ovale blood pressure medication safe for pregnancy purchase benicar amex, and blood ¹ow the posterior midline approach into the fourth across this defect have a much higher risk for ventricle and the foramen magnum region blood pressure just before heart attack benicar 40mg cheap. Also patients with signi¨mon is heart attack from weed buy benicar 20 mg free shipping, that the patient is kept in sitting pocant cervical spine disease require extra causition. The advantages of the sitting position tion to avoid spinal cord compression injury. The disadvantages on the During sitting position, an even closer coother hand include risks of air embolism, myeoperation between the neurosurgeon and the lopathy of the cervical spine, and hypotension. Especially older patients with heart inform the neurosurgeon, who reacts without A 170 Sitting position – Supracerebellar infratentorial approach | 5 5. Indications any delay and takes appropriate counteraction the supracerebellar infratentorial approach is measures (Table 5-1). In many institutions the used to reach lesions located at the pineal resitting position was earlier used regularly but gion and the tectum of the midbrain. We use gradually went out of fashion due to the fear the supracerebellar infratentorial approach of complications. All we can say is that in Helmost often for pineal region lesions, since this sinki the sitting position is being used regularly, approach evades most of the large draining safely and e©ectively in all those cases where veins of the pineal region located superior to we see a true bene¨t o©ered by the position the direction of this approach. We position, the gravity pulls on the cerebellum, take only simple practical precautions and minwhich falls down and exposes this region. Utmost vigilance is required when operating on such a pathology near the transverse sinus and con¹uence of sinuses. Positioning the supracerebellar infratentorial approach Placing the patient in a sitting position is a can be carried out either as a direct midline demanding task and requires an experienced approach or a paramedian approach. There are several key factors that need used the midline approach quite frequently, but always to be remembered (Table 5-1). The acnowadays we have switched almost exclusively tual practical tricks may vary from department to the paramedian approach. Here we describe in detail how median approach there are several advantages the sitting position is executed in Helsinki. The compared to the classical midline supraceresitting position requires special equipment and bellar approach. In position or forward somersault position, with addition, there is no need to extend the cranithe upper torso and the head bent forward and otomy over the sinus con¹uens in a paramedian downward (Figure 5-7a). During surgery, the approach, which decreases the risk of possible operating table is often tilted even further forvenous damage and air embolism. The greatward to gain optimal view into the posterior est disadvantage of the paramedian approach fossa along the tentorium. If not, as is usually the case with chilit rises steeply upwards especially close to the dren, then one or several extra cushions need midline. Without this free shoulder zontal providing good viewing angle even to margin, the optimal approach angle from cauthe most cranial portions of the posterior fossa. This is less tiring for the neurosurgeon than if the pushes the upper body and shoulders forward. The May¨eld head frame is then ¨xed to the trapeze clamp system and all the joints are the patient is placed on the operating table tightened, and the locking screw on the head so that there are two table elements supportframe is locked. The whole upper body and pelvis to keep the ankles in neutral position and to rests on a large suction mattress. The sitting position is the only shell protecting the whole upper body and preposition where we routinely prefer to use Mayventing any undesired slipping or sliding. There is one extra joint on the May¨eld table with thick tape to prevent the upper body clamp that makes head positioning easier for from falling forward during extreme forward the sitting position. The neurosurgeon the head position varies slightly depending on then holds the head until the position is ¨nalthe planned approach. Irrespective of the apized and the head frame ¨xed to the trapeze proach, the neck is always ¹exed forward. At least two ¨ngers should ¨t beble into anti-Trendelenburg position while sitween the chin and the sternum. The head is rotated One burr hole is placed about 3 cm lateral from 5–10° to the side of the planned approach, the midline over the occipital lobe superior without any lateral tilt. In older patients with tightly attached dura a second With the patient in the proper position, a preburr hole can be placed inferior to the transcordial Doppler device is attached over the right verse sinus. The dura is carefully detached with atrium and all the joints of the clamping sysa curved dissector especially along the transtem are checked once more to make sure that verse sinus. All the pressure points need made to detach a 3-4 cm diameter bone ¹ap to be covered with pillows. Both cuts start from the burr is paid to peroneal nerve at the lateral aspect hole, they curve sideways and join caudally of the knee which can easily get compressed exposing about 2 cm of the dura below the if the knees fall outward. Skin incision and craniotomy prepared for the use of tack-up sutures at the end of the procedure. A straight skin incision is planned 2–3 cm lateral from the midline (Figure 5-7b). The incision When detaching the dura and performing the starts about an inch cranial from the external craniotomy, the most critical area is the site of occipital protuberance (the inion) and extends the sinus con¹uens; its lesion may cause fatal caudally towards the level of the cranio-cervicomplications, and all e©orts should be made cal junction. For a right-handed neurosurgeon to preserve it as well as both transverse sinusa right-sided approach is more convenient if es. The medial border of the craniotomy should the target is located in the midline or lateralbe left about 10 mm lateral from the midline. The muscles are split in a verThere are usually several venous canals running tical fashion all the way down to the occipital inside the bone close to the sinus con¹uence. A curved retractor is used By keeping the craniotomy lateral to this region, to spread the wound from the cranial directhere is much less risk of opening the venous tion. Even with diathermia and the occipital bone is exposed these preventive measures, a sudden decrease (Figure 5-7d). A second curved precordial Doppler device is indicative of an air retractor can be used to get a better exposure embolism. In such a situation the bone ¹ap and additionally a third smaller curved retracshould be promptly removed, and the damaged tor can be used caudally. Compression of the jugular veins only about 3–4 cm of bone below the level of by the anesthesiologist is extremely helpful in the transverse sinus, so that the exposure does localizing the bleeding site. While sealing one not have to extend anywhere near the foramen possible bleeding site, the rest of the wound magnum. Meticulous waxing of the craniotomy edges closes the venous channels inside the bone, which 177 5 | Sitting position – Supracerebellar infratentorial approach Figure 5-7 (f). In general, the reor several sutures as sutures do not accidenaction to possible air embolism needs always tally slide o© like. In midline, there are usually no major bridging our series, we have had no major complications veins obstructing the view. With the situation under bellar vein and draining veins coming from the control, we proceed with the surgery, we do not surface of the cerebellum are typically close to abandon the procedure. In case there is a vein obstructing the approach the dura is usually opened under the microscope towards the pineal region it may be necessary to avoid accidental injuries of the sinuses. The to coagulate and cut it, preferably closer to dura is opened in a V-shaped fashion with the the cerebellum than to the tentorium. Also the remaining dural edges more di¬cult to treat if severed accidentally are lifted with sutures placed over the cranilater during some of the critical steps of the otomy dressings to prevent both oozing from dissection. It is better to save as many of the the epidural space as well as compression of draining veins as possible to prevent venous inthe cortical cerebellar veins (Figure 5-7g). If this sinus is accibridging veins between the cerebellum and the dentally opened, it does not bleed profusely in tentorium have been coagulated and cut, the the sitting position unlike in the prone position. Exposure of the precentral more carefully than in other positions cerebellar vein, and coagulation and cutting. Utmost care is needed close to venous of this vein if needed, clears the view so that sinuses due to high risk of air embolism the vein of Galen and the anatomy beneath it. Bridging veins should be left intact as part of the operation, and sometimes the thick much as possible adhesions associated with chronic irritation of. Close to pineal region the dissection the arachnoid caused by the tumor makes this should start laterally dissection step very tedious. Perfect hemostasis throughout the of the posterior choroidal artery and the preprocedure, no oozing is allowed central cerebellar vein the orientation towards other anatomic structures becomes easier. Special care is needed not to damage the posterior choroidal arteries during further dissection. The use of high magni¨cation is crucial as well as the proper length of instruments. All the same rules for direction, and the possibility of adjusting the sitting position and risks apply as for the suview by rotating the table forward even further. The anesthesiologic principles of the prone position requires placing the head well sitting position were reviewed in section 3. Positioning tends more caudally; (d) the transverse sinuses are not exposed, the craniotomy is placed bethe positioning is almost identical to that of low their level; and (e) the craniotomy extends the supracerebellar infratentorial approach to both sides of the midline. As with the supracerebellar infratentorial approach, our sitting position is more like a forward somer5. The only di©erence for the low midline apthis approach provides excellent visualization of proach is that the head is not rotated. With this approach it is ing are carried out in the same way as already possible to enter into the fourth ventricle from described above (see section 5. We usually use the skin incision is placed exactly on the midthis low posterior fossa midline approach to line (Figure 5-8b). It starts just below the level access midline tumors of the fourth ventricle, of the external occipital protuberance and exvermis and the cisterna magna region, such tends caudally all the way down to the C1–C2 as medulloblastomas, pilocytic astrocytomas, level. It is For lateral lesions in the posterior fossa we preimportant to remember that the posterior fossa fer the lateral park bench position. The advan drops steeply towards the foramen magnum, 183 5 | Sitting position – Approach to the fourth ventricle and foramen magnum region Figure 5-8 (b). The bone is thicker split with diathermia all the way to the occipiaround the foramen magnum and it might be tal bone (Figure 5-8c). One large curved retracnecessary to thin it further down along the tor is placed from cranial and the other from craniotome cut before the bone ¹ap can be caudal direction. Finger paltachments to the atlanto-occipital ligament, pation is used to identify the level of the fowhich often need to be cut with scissors. Damramen magnum as well as the spinous process age to the epidural venous plexus is most likely of the C1, which is partially exposed with blunt to happen during this step, so extra caution is dissection using cottonoid balls. With the bone removed we should be ing the muscles and exposing the bone close able to distinguish medial aspects of both cereto the foramen magnum, care is needed not to bellar tonsils as well as the medulla oblongata, accidentally cut into the vertebral artery. The other problem may be the large venous epidural siA high-speed diamond drill or a small rongeur nuses at the foramen magnum. If the posterior is used if needed to remove bone in the latatlanto-occipital ligament is cut accidentally, eral direction on both sides to expose the fothese veins may start to bleed heavily. Few drill holes are prepared to be used with tack-up sutures At this point the occipital bone should be exduring closure. We do not routinely remove the posed all the way down to the foramen magspinous process or the lamina of C1 vertebra. One burr hole is placed about 1 cm parIn our experience, the total removal of C1 arch amedian to the midline, well below the level does not provide any additional bene¨t regardof the transverse sinus (Figure 5-8d). In older ing the exposure of the lower posterior fossa, patients with densely attached dura another but carries signi¨cant morbidity. It is performed burr hole can be placed on the opposite side only when truly necessary in lesions that exof the midline. The the dura is opened under the operating microdura should be released all the way towards scope in X-like fashion. A critical region to reshaped dural leaf is cut from the midline below lease the dura from is next to the burr hole the occipital sinus, everted caudally and attowards and over the midline overlying the octached tightly to the muscles with a suture to cipital sinus and the falx cerebelli. The cuts are made in cranio-lateral direction on ¨rst one curving slightly lateral and down to both sides over the cerebellar tonsils avoiding the foramen magnum. All the dural over the midline to the opposite side and then leafs are lifted up with sutures placed over the curves laterally and caudally to the foramen craniotomy dressings. These two cuts are not joined and been satis¨ed with a single reversed V-shaped 10–20 mm of bone is left between them at the dural opening with the base towards the foforamen magnum. Arachnoid memcranial edge with a large rongeur, is everted brane of the cisterna magna is often still intact 185 5 | Sitting position – Approach to the fourth ventricle and foramen magnum region Figure 5-8 (c). With the dura open, also the arachnoid membrane is opened as a ¹ap with the base caudally and it is attached to the caudal dural leaf with a hemoclip(s) (Figure 5-8h). This is to prevent the arachnoid membrane from ¹apping inside the operation ¨eld during the whole procedure. Then, under high magni¨cation of the microscope, the cerebellar tonsils are gently pushed apart and the caudal portion of the fourth ventricle can be entered. By tilting the table forward, good visualization of the upper parts of the fourth ventricle and even the aqueduct can be obtained. We cases the neuronavigator may be helpful in will not go through indications for surgical planning the approach trajectory. Even if one could reach erate more than 300 patients with intracranial the actual aneurysm with the subtemporal apaneurysms, more than half of them with rupproach, especially after cutting the tentorium, tured ones. Over the last 20 years the catchthe true problem in basilar bifurcation aneument area of our department has remained rysms is proximal control. During control one often needs to make much more this time the number of ruptured aneurysms extra work, but it is generally time well spent. The basilar trunk and the vertebrobasiof incidentally found aneurysms, and also the lar junction aneurysms at the middle third of policy for preventive treatment of these lesions the clivus, are the most di¬cult to approach. The presigmoid approach is often the only option and the clipping of the aneurysms is further hampered by the perforators arising from 6.

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