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Some meningiomas are located in areas that are surgically unresectable or that carry high risk of morbidity if aggressive resection is attempted purchase cheap malegra fxt plus on line erectile dysfunction self test. A treatment algorithm based on our current clinical evidence is shown in Figure 30 malegra fxt plus 160mg visa erectile dysfunction pump how do they work. J Neurosurg 80:195–201 eSource: Nutting C order cheap malegra fxt plus on-line erectile dysfunction wiki, Brada M, Brazil L et al (1999) Radiotherapy in the treatment of be- nign meningioma of the skull base. Int J Radiat Oncol Biol Phys 39:427–436 Chapter 30 Meningioma 883 Treatment of Atypical and Malignant Meningiomas Atypical and malignant meningiomas are more aggressive than are benign histologies, and they recur more frequently after complete or incomplete re- sections. Int J Radiat Oncol Biol Phys 34:817–822 Chapter 30 Meningioma 885 Treatment of Unresectable or Recurrent Meningioma External-beam radiation can be used for definitive treatment of unresectable meningiomas or if a patient refuses or cannot undergo surgery. In addition, recurrent tumors may be treated with definitive or adjuvant radiation (Table 30. Outcomes for both unresectable and recurrent tumors are in general less favorable (Table 30. Int J Radiat Oncol Biol Phys 39:427–436 fSource: Pourel N, Auque J, Bracard S et al (2001) Effcacy of external fractionated radiation therapy in the treatment of meningiomas: a 20-year experience. No consensus exists for inclusion of the dural tail, or areas of hyperostosis or involved bone in target volumes. For aggressive meningiomas, some data have suggested improved local control with higher doses, but this has not been verified. Lo Normal Tissue Tolerance Dose constraints for organs at risk vary, depending on the radiation treatment technique used (Table 30. Neurosurg Focus 14:e5 cSource: Metellus P, Regis J, Muracciole X et al (2005) Evaluation of fractionated ra- diotherapy and gamma knife radiosurgery in cavernous sinus meningiomas: treatment strategy. Neurosurgery 57:873–886 dCavernous sinus meningiomas Toxicities While fatigue, focal alopecia, and skin erythema may be acute toxicities as- sociated with radiation for meningioma, serious side effects are uncommon. Potential rare toxicities include cranial neuropathies, cerebral or brainstem necrosis, encephalomalacia, cerebrovascular events, second malignancies, and edema. Int J Radiat Oncol Biol Phys 76:S36–S41 Follow-Up Routine follow-up is important after definitive treatment because of the risk of local recurrence. Epidemiology and Etiology the annual incidence of malignant primary brain tumors in the United States is 22,000 cases. Multiple studies have addressed the association of cell phone use with the rise of primary brain tumors but to date, cell phone use in adults has not been shown to cause malignant glioma. N Engl J Med 359:492–507) Pathology Histology is critical in guiding treatment, and diagnosis can be obtained dur- ing definitive surgical resection or biopsy. Advances in image-guided ste- reotactic biopsy has allowed access to even eloquent locations in the brain, and with the rare exception of infiltrating pontine gliomas and some optic gliomas, a tissue diagnosis is imperative prior to instituting treatment; rarely, is “empiric” treatment indicated.

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Anorexia (loss of appetite) often is clinically dif?cult to complex etiology of eating disorders cheap 160mg malegra fxt plus amex impotence statistics. Other factors malegra fxt plus 160 mg without prescription erectile dysfunction when young, differentiate from weight loss without an effect of ap- such as dif?culty with food acquisition and social petite buy generic malegra fxt plus 160 mg impotence zantac. However, the diagnostic considerations and isolation, can be important in some patients, espe- workup usually are the same for both clinical prob- cially the elderly. Dementia and depression may cause signi?cant weight tion, including medication history, social history, and loss. These are more commonly seen in the elderly and psychological screening examination. The causes of are important considerations because these disorders anorexia and weight loss may be divided into ?ve major are potentially treatable. All cases of depression should groups: (1) medical conditions, (2) psychological con- be treated and reversible causes for dementia should ditions, (3) social factors, (4) age-related factors, and be sought. Alcoholism is a common cause of anorexia (5) anorexia nervosa and related eating disorders. Hypogeusia (diminished monly associated with anorexia, especially in elderly sense of taste) and decreased olfactory function may patients. Malabsorption syndromes can mimic eating disor- bulimia nervosa result from complex interactions of ders (e. Social and cultural factors play an important role in and nutritional consultants. Many medical complica- the attitudes and behaviors of eating and body im- tions may result from eating disorders; treatment of age. Again, his- sult from (1) abnormalities in preparing or delivering tory is usually helpful, but esophageal manometry and the food bolus to the esophagus (transfer or oropharyn- barium esophagography with ingestion of a barium- geal dysphagia), (2) structural abnormalities of the soaked marshmallow, cookie, or pill can establish the eti- esophagus (e. However, many pa- suggests a problem with oropharyngeal neuromuscular tients will ultimately require gastrostomy tube place- coordination. Measurement more often seen with malignancy or tight in?ammatory of the esophageal intraluminal pressures via manomet- strictures. In patients with a history or tempo- amplitude esophageal contractions; and (4) nonspeci?c ral medical history to suggest an oropharyngeal or motil- motility disorder—nontransmitted, triple-peaked, or si- ity disorder, the evaluation may begin with a barium multaneous contractions that do not meet criteria for the esophagram or modi?ed barium swallow. When endoscopy is performed and a speci?c etiology 95% of patients but is complicated by esophageal perfo- for dysphagia is determined, diagnosis-speci?c treat- ration in 2%–5% of cases. Other measures, including serial tradi- Active esophagitis and peptic strictures are treated tional bougienage, nitrates, and calcium channel block- with antisecretory agents, including H2-receptor an- ers, may provide some temporary but generally less ef- tagonists and proton pump inhibitors. Surgery (Heller myotomy) provides relief severe re?ux disease can cause dysphagia without ana- in 90% of patients when performed by an experienced tomic obstruction.

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