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However in severe lactose intolerance, the lactose content should be determined before prescribing. The amount of lactose varies according to manufacturer, product, formulation, and strength. Security and validity of prescriptions the Councils of the British Medical Association and the Royal Pharmaceutical Society have issued a joint statement on the security and validity of prescriptions. Where there is any doubt about the authenticity of a prescription, the pharmacist should contact the prescriber. If this is done by telephone, the number should be obtained from the directory rather than relying on the information on the prescription form, which may be false. A Patient Group Direction is a written direction relating to the supply and administration (or administration only) of a licensed prescription-only medicine (including some Controlled Drugs in specific circumstances) by certain classes of healthcare professionals; the Direction is signed by a doctor (or dentist) and by a pharmacist. Health and safety When handling chemical or biological materials particular attention should be given to the possibility of allergy, fire, explosion, radiation, or poisoning. Care is required to avoid sources of heat (including hair dryers) when flammable substances are used on the skin or hair. Substances, such as corticosteroids, some antimicrobials, phenothiazines, and many cytotoxics, are irritant or very potent and should be handled with caution; contact with the skin and inhalation of dust should be avoided. This does not apply to items directed to be used as required-if the dose and frequency are not given then the quantity to be supplied needs to be stated. When several items are ordered on one form the box can be marked with the number of days of treatment provided the quantity is added for any item for which the amount cannot be calculated. Although directions should preferably be in English without abbreviation, it is recognised that some Latin abbreviations are used. The age and the date of birth of the patient should preferably be stated, and it is a legal requirement in the case of prescription-only medicines to state the age for children under 12 years. Wherever appropriate the prescriber should state the current weight of the child to enable the dose prescribed to be checked. When decimals are unavoidable a zero should be written in front of the decimal point where there is no other figure. Care should be taken to ensure children receive the correct dose of the active drug. Therefore, the dose should normally be stated in terms of the mass of the active drug. When doses other than multiples of 5 mL are prescribed for oral liquid preparations the dose-volume will be provided by means of an oral syringe, (except for preparations intended to be measured with a pipette). The names of drugs and preparations should be written clearly and not abbreviated, using approved titles only; Sample prescription Abbreviation of titles In general, titles of drugs and preparations should be written in full. This will enable any suitable product to be dispensed, thereby saving delay to the patient and sometimes expense to the health service. Prescribers should avoid creating their own compound names for the purposes of generic prescribing; such names do not have an approved definition and can be misinterpreted. Special care should also be taken to avoid creating generic names for modified-release preparations where the use of these names could lead to confusion between formulations with different duration of action. Extemporaneous preparations A product should be dispensed extemporaneously only when no product with a marketing authorisation is available. Every effort should be made to ensure that an extemporaneously prepared product is stable and that it delivers the requisite dose reliably; the child should be provided with a consistent formulation regardless of where the medicine is supplied to minimise variations in quality. In many cases it is preferable to give a licensed product by an unlicensed route. When tablets or capsules are cut, dispersed, or used for preparing liquids immediately before administration, it is important to confirm uniform dispersal of the active ingredient, especially if only a portion of the solid content. It is important to ensure that the appropriate supporting information is available at the earliest opportunity. The direction that a preparation should be recently prepared indicates that deterioration is likely if the preparation is stored for longer than about 4 weeks at 15­25°C. The term water used without qualification means either potable water freshly drawn direct from the public supply and suitable for drinking or freshly boiled and cooled purified water.

Treatment should be applied to the whole body including the scalp, neck, face, and ears. Particular attention should be paid to the webs of the fingers and toes and lotion brushed under the ends of nails. It is now recommended that malathion and permethrin should be applied twice, one week apart; in the case of benzyl benzoate in adults, up to 3 applications on consecutive days may be needed. It is important to warn users to reapply treatment to the hands if they are washed. Patients with hyperkeratotic scabies may require 2 or 3 applications of acaricide on consecutive days to ensure that enough penetrates the skin crusts to kill all the mites. The itch and eczema of scabies persists for some weeks after the infestation has been eliminated and treatment for pruritus and eczema may be required. A topical corticosteroid may help to reduce itch and inflammation after scabies has been treated successfully; however, persistent symptoms suggest that scabies eradication was not successful. Crab lice Permethrin and malathion are used to eliminate crab lice (Pthirus pubis); permethrin is not licensed for treatment of crab lice in children under 18 years. An aqueous preparation should be applied, allowed to dry naturally and washed off after 12 hours; a second treatment is needed after 7 days to kill lice emerging from surviving eggs. All surfaces of the body should be treated, including the scalp, neck, and face (paying particular attention to the eyebrows and other facial hair). Parasiticidal preparations Dimeticone coats head lice and interferes with water balance in lice by preventing the excretion of water; it is less active against eggs and treatment should be repeated after 7 days. It is also active against head lice but the formulation and licensed methods of application of the current products make them unsuitable for the treatment of head lice. Permethrin is also effective against crab lice but it is not licensed for this purpose in children under 18 years. Malathion, an organophosphorus insecticide, is an alternative, but resistance has been reported. Benzyl benzoate is licensed for the treatment of head lice but it is not recommended for use in children. Head lice infestation (pediculosis) should be treated using lotion or liquid formulations only if live lice are present. A contact time of 8­12 hours or overnight treatment is recommended for lotions and liquids; a 2-hour treatment is not sufficient to kill eggs. In general, a course of treatment for head lice should be 2 applications of product 7 days apart to kill lice emerging from any eggs that survive the first application. Leucopenia developing 2­3 days after starting treatment of burns patients is reported usually to be self-limiting and silver sulfadiazine need not usually be discontinued provided blood counts are monitored carefully to ensure return to normality within a few days. Serious skin reactions With oral use Discontinue treatment in progressive skin rash (including Stevens-Johnson syndrome and toxic epidermal necrolysis). Topical application With topical use Treatment should be discontinued if side effects are severe. With oral use Manufacturer advises use only if potential benefit outweighs risk-no information available. Creme Rinse (head lice) not licensed for use in children under 6 months except under medical supervision. Liquid stearyl alcohol), propylene glycol Aciclovir (Non-proprietary) Aciclovir 50 mg per 1 gram Aciclovir 5% cream 2 gram G Ј0. Atopic eczema is the most common type and it usually involves dry skin as well as infection and lichenification caused by scratching and rubbing. Management of eczema involves the removal or treatment of contributory factors; known or suspected irritants and contact allergens should be avoided. Skin dryness and the consequent irritant eczema requires emollients applied regularly (at least twice daily) and liberally to the affected area; this can be supplemented with bath or shower emollients. The use of emollients should continue even if the eczema improves or if other treatment is being used. Topical corticosteroids are also required in the management of eczema; the potency of the corticosteroid should be appropriate to the severity and site of the condition, and the age of the child. Mild corticosteroids are generally used on the face and on flexures; the more potent corticosteroids are generally required for use on lichenified areas of eczema or for severe eczema on the scalp, limbs, and trunk. Treatment should be reviewed regularly, especially if a potent corticosteroid is required. In children with frequent flares (2­3 per month), a topical corticosteroid can be applied on 2 consecutive days each week to prevent further flares.

For overall survival, only stable disease (compared to progressive disease) was a significant predictor. Patients eligible included those with one resected brain metastasis (with a resection cavity under 5 cm) with up to an additional 3 unresected metastases (each under 3 cm). Patients were excluded if there was prior cranial radiation, leptomeningeal metastases, lesions within 5 mm of the optic chiasm or within the brain stem or germ cell, small-cell, or lymphoma histologies. Patients were stratified according to age, duration of extracranial disease control, number of brain metastases, histology, and diameter of resection cavity and treatment center. One hundred ninety-four (194) patients were included in the study with a median follow up of 11. On the other hand, there was no difference in functional independence change from baseline at 6 months. A nomogram for predicting distant brain failure in patients treated with gamma knife stereotactic radiosurgery without whole brain radiotherapy. The palliation of brain metastases: final results of the first two studies by the Radiation Therapy Oncology Group. A phase 2 trial of stereotactic radiosurgery boost after surgical resection for brain metastases. Multi-institutional nomogram predicting survival free from salvage whole brain radiation after radiosurgery in patients with brain metastases. Cavity-directed radiosurgery as adjuvant therapy after resection of a brain metastasis. Stereotactic irradiation of the postoperative resection cavity for brain metastasis: a frameless linear accelerator-based case series and review of the technique. Three or more courses of stereotactic radiosurgery for patients with multiple recurrent brain metastases. Post-operataive stereotactic radiosurgery versus observation for completely resected brain metastases: a single centre, randomised, controlled, phase 3 trial. Postoperative radiotherapy in the treatment of single metastases to the brain: a randomized trial. Surgery or radiosurgery plus whole brain radiotherapy versus surgery or radiosurgery alone for brain metastases. For an individual who undergoes mastectomy, post-mastectomy radiation therapy is medically necessary when any of the following are present: 1. For an individual who undergoes local excision (lumpectomy, breast conservation surgery) adjuvant partial or whole breast radiotherapy is medically necessary Up to 38 fractions, including the boost, is medically necessary. A photon boost with multiple fields is medically necessary (these photon boosts are often planned using a complex isodose technique [77307]). Partial breast radiotherapy is medically necessary in those individuals with clinical criteria conforming to published guidelines of one of the major societies. Acceptable techniques include 3D © 2018 eviCore healthcare. The same techniques used in the treatment of early stage breast cancer with up to 25 fractions, if a boost is utilized, are medically necessary Early stage breast cancer is typically treated with mastectomy with or without radiotherapy to the chest wall, or breast local excision followed by radiotherapy. Indications for postmastectomy radiotherapy are controversial but include the presence of multiple positive axillary lymph nodes, positive or narrow margins (< 1 mm), or large primary tumor size (> 5 cm). In some women over the age of 70 who have been diagnosed with invasive breast cancer, radiation therapy may be safely omitted, especially if they have comorbidities. Primary therapy for women with metastatic breast cancer (M1 stage) is systemic therapy. However, if there is symptomatic breast or chest wall disease, a short course of radiotherapy may alleviate symptoms. It is not appropriate to deliver more than 20 fractions in that setting (or 25 fractions if a boost is included). Evidence is limited with regard to the role of locoregional radiotherapy for M1 stage disease in the absence of symptomatic locoregional disease. Locoregional radiation therapy may be appropriate for women who initially present with metastatic disease but after surgery and/or chemotherapy are found to have no clinical evidence of disease.

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The patient then performs a push-up as if they were in the prone position while the clinician observes scapular motion. The inferior pole of the scapula will rotate medially and away from the chest wall if serratus anterior weakness is present. Although less commonly reported, traction injuries to the nerve can also occur as a result of a fall on the shoulder with the neck rotated towards the contralateral shoulder or from excessive traction placed on the arm. Spinal accessory nerve palsy has been reported to occur concomitantly with long thoracic nerve palsy-thus, both nerves should be evaluated during physical examination. The nerve exits the brain stem, travels inferiorly through the jugular foramen of the skull, and receives contributions from the C2, C3, and C4 nerve roots as it enters the posterior triangle of the neck. The posterior triangle is bordered anteriorly by the sternocleidomastoid muscle, posteriorly by the trapezius muscle and inferiorly by the inferior belly of the omohyoid muscle just before its insertion along the distal 1/3 of the clavicle. The most prominent physical examination findings include scalloping of the lateral neck as a result of upper trapezius atrophy and subtle scapular winging that is reproduced when the patient shrugs the shoulders against resistance (see. More specifically, scapular winging in the setting of accessory nerve palsy manifests as increased lateral scapular tilt and superomedial displacement of the inferomedial border. In any patient with scapular winging, dyskinesis or periscapular weakness, testing for signs of subacromial impingement is necessary since scapular malposition may decrease the space available for the rotator cuff tendons to pass beneath the acromion (see Chap. Provocative tests are available for testing each of the three divisions of the trapezius muscle and are discussed in detail in Chap. Clinically, it is more useful to simply have the patient shrug their shoulders against resistance to elicit pathologic lateral scapular winging. The first part of the artery is proximal and medial to the pectoralis minor tendon, the second part of the artery is deep to the pectoralis minor tendon, and the third part of the artery is distal and lateral to the pectoralis minor tendon. Wright [39] suggested that hyperabduction of the arms, as which occurs during the latecocking phase of the throwing motion [55, 124], produces compression of the second part of the axillary nerve from the overlying pectoralis minor muscle. Turbulent blood flow from intimal hyperplasia, aneurysmal dilatation, and intimal dissection results in eventual arterial thrombosis and, potentially, distal embolization [55]. Since then, many other causes of axillary artery thrombosis have been reported such as shoulder dislocations [125], radiation therapy [126], nearby surgical procedures [127], and arteritides [128], among many others. The axillary artery is anatomically divided into three parts according to its orientation relative to the pectoralis minor muscle. The first portion lies proximal and medial to the muscle, the second portion lies deep to the muscle, and the third portion lies distal and lateral to the muscle. Thrombosis in this area can result in distal embolization and resulting ischemia (most commonly 264 10 Neurovascular Disorders 10. When distal embolization has occurred, the patient may also complain of claudication, night pain, and a cold sensation distal to the embolus. Physical examination should always include a thorough neurovascular examination including capillary refill and the palpation of distal pulses. However, regardless of the test result, arteriography is necessary to definitively establish the diagnosis of arterial thrombosis. Kunkel and Machleder [130] showed evidence that hyperabduction of the arms produced subclavian vein occlusion in 21/25 patients (84 %) with confirmed effort thrombosis. For example, many patients present with a gradual increase in swelling with dull shoulder and arm pain over a period of several days. Swelling may also induce paresthesias as a result of increased hydrostatic pressure and resulting ischemia of peri-neural arterial branches. Some patients also develop mottling and discoloration of the extremity in more severe cases. Treatments that involve preservation of venous patency, such as anticoagulation therapy and venous stents, are most likely to produce the best outcome in these patients [131, 132]. The condition is commonly associated with repetitive overhead activities and, therefore, is often referred to as "Effort Thrombosis. Most patients who present with the condition are young athletes who may participate in overhead sports such as baseball, tennis, or swimming [129]. Lateral rupture of the cervical intervertebral discs: a common cause of shoulder and arm pain.