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Jeff and Joe directed traffic with help from California Rare Fruit Grower volunteers who had been hard at work sucking dozens of pomegranates erectile dysfunction young men discount generic tadacip canada, 18 varieties in all. They’d prepared the tables so members and visitors could taste the arils glistening in little cups without having to do any of the messy pomegranate seeding work. The red, rusty, green-stippled fruits, leathery in their late fall covers, lay before us with their common name and orchard identification numbers. The nurserymen and growers seemed to know just what they were looking for in flavors, textures, and seed qualities, while I found myself wishing for better words than sweet, sweet/sour, sub-acid, tart. I marveled at the colors, size and flavors of the arils—coral, carmine, garnet, purply-plum, peachy pink—of the Turkmenistan varieties. I recognized my beloved Parfyanka and Girkanski—their taste as vivid as I’d remembered. People around me were saying words like tangy, astringent, refreshing, winy, hint of honey, words that opened up more of my palate. Jeff led a caravan of eager tasters into the orchards where we were let loose to stroll between the trees and sample and gather at will. In this transplanted paradise of pomegranates, the over-burdened limbs bent to the earth with their fruit as if begging, pick me, pick me. The cracking fruit released a heady perfume, color and fragrance spilling over, making me imagine the pomegranates’ distant home in the Sumbar River Valley. When I cut my finger on a rough stem, my blood was 94 the Incredible Pomegranate the color of the juice. I thought of Queen Persephone in Hades who ate the six seeds that were too beautiful to resist. They married her blood to the Lord of the Underworld and started the seasonal round. The purpose of the government’s gift was to promote biological diversity: the more home gardeners grew different and rarer varieties of pomegranates, the more chance these unusual fruit would survive and spread from grower to grower. I remembered Jeff saying, “It’s only a matter of time before a pest or blight hits monoculture,” referring to the single Wonderful variety grown by Paramount Farms. Sweetness trumped soft seeds, perhaps because the honey-crisp flavors were unexpected. In a few years, if the cuttings rooted and the trees did well in my northern California temperate zone, I would have my dream-come-true: Dr. Late afternoon of the Davis tasting, after having shucked the fruit the day before, I had a moment of feeling that too much of a good thing might be possible. But the person who truly had seen a million arils over the past week was Jeff Moersfelder, and he was still grinning at the end of the day. Gregory Levin’s collection from Garrigala in Turkmenistan before he knew anything about Dr. When the cuttings were released from quarantine, Moersfelder took great care of 95 Plant and Fruit the young plants, varieties with strange Russian and Turkmen names. He knew that they had come from afar and that it was his responsibility to help them flourish and become available to scientists, growers, nurseries and curious tasters in the future. Last year, the dozen Central Asian varieties Moersfelder selected for tasting for the first time stole the show. This year, he chose 18 varieties both from the Central Asian block and also from the older trees, and spent most of the week collecting, sorting, shucking and bagging them in cold storage for the 50 or more people expected to attend. Rain had been predicted but the morning of the tasting the sky was blue with feathery clouds, a perfect autumn day under a warm sun. The tables full of arils in their little cups glowed like gems, from the deep reds to the light pinks. Conditions in the orchard had been dicey all spring with a late, cold May rain that played tricks with pollination and maturation. The Central Asian varieties hadn’t produced as well nor ripened as fully as they had the year before. The longer-established varieties, mainly from the Chico collection, like Eve, Crab, and Cranberry had done better than many younger trees. Moersfelder speculated that these larger trees had used the later summer heat better, while some smaller trees hadn’t shaded fruit enough from sunburn and or stunted development. Kazake, one of the Turkmen varieties, had fruit half the size of last year, and very small arils, but the variety nevertheless retained its lovely, almost watermelon sweet taste. Levin’s Parfianka, with its thin seeds, deeply tangy/wine flavor, astringent and sweet in a single aril with a very thin seed. A surprising favorite was Crab, planted in the older block, not a Central Asian variety—big deep red fruit with excellent wine tart/sweet flavor. And David Karp, who had driven from the San Fernando valley with a Citron grower, introduced us to this very strange Biblical fruit. Iranian growers from the Central Valley brought their Savehs out after the tasting. The weather had delayed their full ripening as well, so the sugar hadn’t quite balanced the acid in the arils, but the purple black colors within the perfect red fruit were entrancing After the tasting, we were again allowed to roam in what is my heaven on earth, the Wolfskill pomegranate orchards. As I wandered among the trees, the heavy, ripe fruit, much of it cracked from rain, again made me think of too many 96 the Incredible Pomegranate children hanging on their mothers’ arms. They lingered to the last and had a picnic in the orchard, savoring the single sweet-as-crystallized-sugar “White Flower” that had stayed on the tree. The cut-off date each year is December 1, so be thinking about ordering later in 2007. He managed to get the pages, hand-typed on onion skin paper, out of Turkmenistan with Dr. There the book languished, not fully translated and with no funds to get the job finished. In late 2004, Richard Ashton of Oak Creek Orchard came upon the article I’d written in Orion and took upon himself the task of finding a translator to finish the project. There were delays but Pomegranate will be published in December of 2006 by Third Millennium Publishing, both in print and electronic edition. For example, #8 Azadi, was the favorite for three people and the least favorite of one. I suspect that one taster’s pleasant mild astringency is unpleasant bitterness to 98 the Incredible Pomegranate another. I counted first place, second place, and honorable mention (very good – third or fourth ranked where indicated. If not, it was usually easy to deduce a favorite and second favorite, and a particularly well liked one or two. Where a person ranked fruit equally, all fruit tied for points got the same rating. Favorite, second favorite, and honorable mention got 3, 2 and 1 point respectively. Take into account that I tasted these in the field and I also ate a few over a couple of days at home with my kids, so my perspective is a little different. Note also that we tasted one variety, Pink Tourmaline, which was selected from a wild growing tree up the north county someplace. It is good with soft seed, but not sufficiently distinguished from other similar ones. First place – 1 Second place – 3 Honorable mention – 2 = 11 I think this is perfectly luscious and refreshing. Is reputed to be particularly pest resistant, partly due to its short mostly closed calyx. First place –1 Honorable mention – 2 = 5 this is one that we got because the name was evocative. However they were a crunchy hard as opposed to woody/fiberous hardness in some varieties. First place — 3 Second place – 1 = 11 100 the Incredible Pomegranate this is the other one with no taste data. We got it because it is named after a Russian fairy tale character who is a big round dumpling that comes to life and goes through a series of adventures similar to our story of the Gingerbread Boy. In Russian you call something relatively big and round, like a large plump baby, a “Kolobok” after the fairy tale.

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Comprehensive smoke the Internet into account erectile dysfunction dr. hornsby generic tadacip 20mg mastercard, remain to the lungs without combustion. The mass media convey and promote e-cigarettes as low tary interventions such as smoking new information and remind people harm alternatives to smoking. The bans in private homes, which reduce about knowledge they already pos safety and effcacy of this product exposure of children to second sess but have forgotten or are ig as a cessation aid is under study. Regular more attention is paid to tobacco in tential role of e-cigarettes in reduc efforts are needed to remind the the mass media, the more quitting ing smoking is unclear [30], but population of the health benefts of related activity occurs [36]. The Chinese government owns the and expanded laws for the control China has weak text-only package world’s largest tobacco company. China is the largest producer and tection of minors, and bans on to Very cheap brands discourage consumer of tobacco, with about bacco promotion, and have issued smokers from attempting to quit. In 1997, Beijing Despite some bans on direct tobac One third of all cigarettes smoked hosted the 10th World Conference co advertising, there is heavy expo in the world are smoked in China. More than bacco monopoly, coupled with an tobacco control is included in both 70% of the population are regularly effective taxation policy. Smoking puts great pressures on common to most countries, and in gov/gtssdata/Ancillary/DataReports. International Tobacco Control Policy costs of tobacco use in China co monopoly has jurisdiction over Evaluation Project (2012). Television advertise programmes that these groups tend the profle of the issue and make ments can convey a much more to view, and is at least as effective the harms more personally relevant, engaging message than compa in infuencing these groups as in thus encouraging smokers to quit rable pack warnings, but smokers infuencing smokers in more socio and others not to start or resume are exposed to them far less often. Part of the preven Although advertising is expensive, it Smokers in less-advantaged socio tive effect seems to stem from dis can reach large numbers of people economic groups may also require gust associated with the unattractive quite cheaply per person infuenced, more intensive assistance if they and disfguring aspects of disease so it is very cost-effective. Having linked to smoking, rather than from the mass media are effective the issue of smoking prominent in anxiety about future harms. Anti in reaching smokers in lower socio the mass media can also motivate smoking advertisements appear to economic groups, especially when health professionals by making have their effects by essentially the the advertising is both designed to them more aware and also more Chapter 4. As and the success rates increase with noted above, reference to smoking increased involvement, up to sev behaviour in the media drives peo eral sessions [40,42]. The effective ple to seek help, as does product ness of such interventions is direct specifc advertising. To achieve the ly related to their intensity, typically highest cessation rates requires measured by the amount of sup a population of smokers who are port, at least up to about four sub motivated to quit, who are prepared stantial sessions, but beyond that, to use the best possible help, and who are able to access aids that will there is little evidence that even maximize success. Uptake of help, more intensive interventions are ef particularly advice-based help, re fective. Intensive advice-based pro mains low, even when services are grammes are increasingly delivered subsidized or free. This is probably via the telephone rather than face due to a combination of beliefs that to-face. Use of automated advice “I should be able to do this by my programmes, consisting of tailored self” and deep ambivalence about personalized advice on the Internet change in relation to tobacco use and/or short, frequent advice mes and other dependencies. Use of sages to mobile phones, is mark services is also infuenced by the edly increasing. For likely to raise the issue with their tomated intelligent programmes are example, in the United Kingdom, clients. Combining advice-based there is much greater use of face which includes the Internet and mo programmes with medication gives to-face services than there is of a bile telephony, provides both huge the best results as the two seem to well-organized and readily avail challenges and opportunities for have largely independent effects able network of other services. There is no evidence of re However, in most other countries come from the diffculty of regulat duced relapse associated with any that have systems to provide help, ing any pro-smoking activity. If so, different strategies are quired if signifcant progress is to be Cessation aids needed to help those who survive made in tobacco control [2]. There There is now a range of effec the diffcult early weeks to maintain are huge challenges. In low and tive medications for smoking ces cessation in the long term, which middle-income countries, govern sation when used for periods of is the ultimate challenge. These this aspect is rarely subject to sometimes lack the infrastructure medications, which include nico specifc investigation, population to support policy. In high-income tine itself (as nicotine replacement based studies indicate that a small countries, smoking is increasingly therapy) plus three other drugs (bu percentage of ex-smokers continue concentrated among less-advan propion, varenicline, and cytisine, to use nicotine replacement therapy taged socioeconomic groups, fur which impinge on different aspects in the long term. Much of the brain’s reward system), are all rently hold the most promise of be remains to be done, but progress is demonstrably effective. Nicotine Tob Res, 14:1382– on smokers’ beliefs about ‘light/mild’ on Tobacco Advertising, Promotion and 1390. A comprehensive examination cessation outcomes (data from the the Case for Abolition. Understanding Hard store concentration on individual level to Maintain Behaviour Change: A Dual 34. Global Tobacco Surveillance System Science, Policy, and Public Health, 2nd Collaborating Group (2005). Pharmacological interventions for smoking and their success in adult general. Middleton Isabelle Romieu (reviewer) Earlier chapters in this Report (see signifcantly larger reductions in dia Summary Chapter 2. In trials, weight loss and in obesity and physical inactivity may than 3000 overweight or obese in creased physical activity have re be related to the development of dividuals with impaired glucose tol duced the risk of diabetes among some forms of cancer (see “Energy erance were randomly assigned to participants. The goals of ment programmes typically epidemiological studies suggest that the lifestyle intervention included produce weight losses of about physical activity and weight loss can weight loss of at least 7% of initial 7–10% of initial body weight after lower breast cancer risk and improve body weight (by decreasing dietary 6–12 months of treatment, and survival, evidence that researchers fat intake, reducing total caloric in increasingly include extended have suggested warrants further clini take, and increasing physical activ care sessions. To develop such studies, it these goals, a 16-session core cur clude reducing caloric intake by is important to understand the basic riculum was delivered to participants approximately 500–1000 kcal strategies that might be used to help individually over the frst 6 months of (2000–4000 kJ) per day and in individuals change their weight and/ the study, with continuing contact (at creasing participation in moder or their physical activity, and the type least once every 2 months) during the ate-intensity physical activity to of results that can be achieved. Behavioural weight management Outcomes of behavioural early (after an average of 3. The strongest evidence Of participants in this arm, 49% ed guidelines are being evaluat comes from the Diabetes Prevention achieved the 7% weight loss goal ed in relation to reduced cancer Program, a multicentre randomized at 6 months and 37% at the fnal incidence in relevant trials. On average, physical activity that behavioural weight loss led to increased to 224 minutes per week Chapter 4. An 8-year-old girl from the Rayerbazar area of Dhaka, Bangladesh, breaks cardiovascular risk factors were through the ribbon during a race. Positive experiences and attitudes to physical activity greater in the intensive lifestyle in may lead to long-term benefits in relation to diabetes and cancer. Indications of possible cancer related benefts of behavioural weight loss programmes have been evi dent for more than a decade. Thus, a randomized trial of a physical activity-based weight management programme in breast cancer survi vors (n = 68) demonstrated larger weight losses in the treatment group compared with the control group (5. Furthermore, within participants assigned to the treatment group, par 74% of participants at week 24 and intensive lifestyle intervention or the ticipation in physical activity was sig 67% at the fnal visit. The lifestyle inter nifcantly associated with favourable Although they are relatively mod vention was similar to that used in changes in interleukin-6 levels. Weight loss was meal replacement products were pro Behaviour-based weight loss pro the dominant predictor of the reduced vided to increase adherence to the grammes, such as those used in incidence of diabetes. These programmes focus on were still apparent, although there 6 months, seen 3 times per month helping individuals make long-term were no longer any differences in for months 7–12, and then seen or changes in both their eating and weight loss between the three arms. This to be an independent predictor of style intervention arm had lost an av approach assumes that providing in cancer mortality (beyond body mass erage of 8. Rather, it is these trials may be benefcial for low sive lifestyle intervention group had important to help people understand ering cancer mortality. Behavioural efts, have been confrmed recently control group at both 1 year and treatment programmes then focus in another clinical trial, called Look 4 years. Nature, 489:318– of 30% non-signifcantly reduced and have markedly lower cancer 321. This extended intake relative to caloric expendi and ultimately their body weight. Thus, behavioural interven been shown to improve long-term tions typically focus on lower Format of behavioural weight outcomes [8]. Groups are typically ing caloric intake – typically by loss programmes led by a multidisciplinary team of approximately 500–1000 kcal Typically, behavioural weight loss nutritionists, exercise physiologists, (2000–4000 kJ) per day – while programmes are offered in group set and behavioural therapists.

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At this level erectile dysfunction korean ginseng order 20 mg tadacip otc, it is noticed that only the variables such as marital status and educational level remained associated with oral cancer (Table 5). Alcohol consumption among the individuals of case and control groups, Feira de Santana, Bahia, Brazil, 2002–2012 (n = 381). Synergistic consumption of tobacco and alcohol among individuals of case and control groups, Feira de Santana, Bahia, Brazil, 2002–2012 (n = 381). Such variables were kept in the model, and then, the proximal group variables such as smoking and drinking were added. The variables cigarettes/day, frequency of alcohol intake, and the synergistic consumption of tobacco and alcohol were selected to compose the last level of multivariate analysis, because the simultaneous inclusion of all the vari ables of smoking and alcohol consumption led to collinearity in the multivariate model. On the other hand, more important than the type of alcoholic beverage are the quantity of alcohol consumed and the duration of this habit. It is important to mention that it is difcult to size the consumption of alcohol, because the individuals ingest diferent types of alcoholic drinks and are inaccurate in reporting alcohol intake doses30. The simul taneous consumption of tobacco and alcohol increases the risk of oral cancer by 6 to 15 times31. Individuals who smoke more than 40 cigarettes per day and who consumed more than 30 standard drinks per week showed a 38 times higher risk of developing oral cancer when compared with those who abstain from such substances32. Tobacco and alcohol are the most carcinogenic potential factors, despite the multifactorial aspect of the disease33. The authors attribute this occurrence to a higher exposure to tobacco and alcohol among men. With regard to social variables, we detached the variables such as marital status and edu cational level. On the frst, we observed that individuals without a partner (single, divorced and widow) were associated with the outcome on the frst level of multivariate analysis. Regarding the anatomical location of the tumor, we found that the most afected sites were the tongue (40. With regard to the limitations of the study, we emphasize the incompleteness of medical records, which gen erated data losses. Another limiting aspect and likely to occur in case control studies is the issue of recall bias, where being sick can infuence the responses to certain questions. In addition, we reinforce that the generalization of this study results is limited to the indi viduals treated at the Oral Injury Reference Center of the Brazilian northeast. Oral cancer is a public health problem, with high rates of morbidity and mortality. Knowledge of the epidemiology and the factors associated with this disease is the key to planning the prevention programs, which will favor the reduction of these adverse indicators that afect the population. Despite the known roles of tobacco and alcohol in causing this disease, epidemiological studies have shown that, even after adjusting for these risk factors, there is still a residual efect of social conditions on the risk of oral cancer37. Therefore, it is necessary to conduct more research in order to evidence the impact that social conditions impose on the complex causal chain of oral cancer. In addi tion, it was concluded that the synergistic consumption of tobacco and alcohol increases the risk of developing this cancer. Sociodemographic factors were not associated with oral cancer after adjustment for smoking and alcoholism. Perfl da national level: just a question of smoking and alcohol incidência e da sobrevida de pacientes com carcinoma drinking prevalence? Estimativa 2014: Incidência de Câncer no indivíduos jovens: análise citomorfométrica. Perfl do paciente consumption of alcohol in the oral cavity: relationship portador de carcinoma epidermóide da cavidade bucal, with oral cancer. Clinical-Pathological Parameters in paradigma da saúde bucal em pacientes com câncer Squamous Cell Carcinoma of the Tongue. Características Características clínicas, epidemiológicas e microscópicas epidemiológicas de casos de câncer de boca registrados do câncer bucal diagnosticado na Universidade Federal em hospital de Uberaba no período 1999-2003: um de Alfenas. Auris Nasus Larynx em cidade de médio porte na Região Sudeste do Brasil, 2009; 36(4): 450-6. Aprova diretrizes e normas regulamentadoras de the cultural and social context of oral and pesquisas envolvendo seres humanos. Brasília: Conselho pharyngeal cancer risk and control among Hispanics Nacional de Saúde; 2012. Oral cavity cancer: the importance of a standardized case Oncol 2004; 40(3): 304-13. Rev Bras Cancerol 2009; drinking in oral and pharyngeal cancers: A case-control 55(3): 229-36. Case-control study of squamous cell cancer of the Navarro A, Cerero-Lapiedra R, González-Hernández oral cavity in Denmark. A review of the Received on: 01/19/2015 relationship between alcohol and oral cancer. L az arus,P h D,C C C -S P,B R S -S N Y U V oice C enter Departm entofO tolaryngology N ew Y ork U niversity S ch oolofM edicine Director,H earing & S peech Departm ent B ellevue H ospitalC enter S peech P ath ologistR ole T eam m em berproviding inputregarding potentialeffects oftreatm enton voice, speech and sw allow ing Determ ine patient’s levelofunderstanding ofupcom ing treatm ent P rovide inform ation to patientregarding S L P /patientroles during/post-treatm ent M anage voice,speech and sw allow ing problem s L az arus M iltonDance M gmtof SwallowinginTreated H & N Pt10. P reventionofbarium aspirationduring videofluoroscopic swallowing studies:value ofch ange inposture. P resented at th e A nnualS peech -L anguage-H earing A ssociationM eeting,M iam i,F L. A ugm entationofdeglutitive upperesoph agealsph incter opening inth e elderly by exercise. P osterpresented atth e A m ericanS peech -L anguage-H earing A ssociation A nnualm eeting,P h iladelph ia,P A. S wallowing and voice effects ofL ee S ilverm anV oice Treatm ent(L S V T):A pilotstudy. F lap R econstruction* 284 treated oralcancerpatients exam ined prim ary closure vs. S wallowing afterm ajorsurgery forth e oral cavity ororoph arynx:A prospective and longitudinalassessm entof patients treated by m iscrovascularsofttissue reconstruction. Effects ofradioth erapy with or with outch em oth erapy ontongue strength and swallowing. X R T did notim pactQ O L T um orsite – pts w ith B O T C A h ad h igh erQ O L scores th an ph aryngealw allC A L az arus M iltonDance M gmtof SwallowinginTreated H & N Pt10. Over the coming years, the incidence of age-related chronic diseases such as cancer is expected to continue to increase. Phytochemicals, which are non-nutritive chemicals found in plants and food, have emerged as modulators of key cellular signaling pathways exerting proven anticancer effects. The challenge now is to develop personalized supplements comprised of specific phytochemicals for each clinical situation. This will be possible once a better understanding is gained of the molecular basis explaining the impact of phytochemicals on human health. The aim of the present literature review is to summarize current knowledge of the dietary phytochemicals with proven antitumor activity, with a special emphasis placed on their molecular targets. Also discussed are the limits of existing research strategies and the future directions of this field. These conditions are approaching epidemic and 4) clinical intervention studies in specific popula status in many parts of the world,1,2 and nutrition is the tion groups, based on existing molecular scientific most important non-genetic contributor to them. Indeed, several food components have been identified as the present literature review summarizes current promoters or inhibitors of these diseases. In this sense, knowledge of the effect of dietary phytochemicals in phytochemicals constitute the major group with benefi cancer prevention and treatment, with a particular focus cial effects. The challenge now is to develop dietary on their molecular targets; it also addresses existing supplements that can help prevent or delay the onset of research strategies for phytochemical application and nutrition-related diseases in specific population groups. To that end, various data this will be possible once a better understanding is bases were consulted,mainly within a timeframe covering gained of the molecular basis for the ways in which 1994–2012. The following key words were used in the these components affect human health, as well as of initial search strategy: phytochemical, plant, diet, natural the specific populations or conditions to which they product, cancer, tumor, and chemoprevention; the search apply. In this context, the following areas of research was augmented by a profound exploration of each spe are gaining special relevance: 1) application of the cific phytochemical compound. Key words: cancer, dietary phytochemicals, nutrigenomics, nutritional supplements, polyphenols, prevention, therapy doi:10. The strategy Dietary phytochemicals can be classified depending on would be further validated using animal models and might their chemical structure, botanical origin, biological also benefit from computation of molecular docking to properties, biosynthesis, etc. Finally, specific clinical key data fields were recently reported summarizing the trials would have to be designed that consider the targeted available specific phytochemical databases,34 including pathways that are altered in patients with specific types of online databases of agents and diets ranked by efficacy in cancer.

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Pathology Probably related to various structures in the neck or pos System terior part of the scalp on the symptomatic side (C2/C3 Nervous system erectile dysfunction doctors boise idaho buy tadacip. Age of Onset: usu and rather stereotyped, the pathology varies in that pa ally in the decades corresponding with the occurrence of thology in the lower part of the neck may also be the carcinoma of the lung. It is usually progressive, requiring narcotics Combination of unilateral headache, ipsilateral diffuse for relief, and becomes excruciating unless properly shoulder or arm pain, reduced range of motion in the managed. Differential Diagnosis Common migraine, hemicrania continua, spondylosis of Associated Symptoms the cervical spine. Other unilateral headaches, such as the cervical sympathetic is involved with a Homer’s cluster headache, are less important in this respect. Atrophy of the small muscles of the hand, ulnar sensory Code loss, ulnar paresthesias and pain, and Homer’s syn 033. The diagnosis is made on chest X-ray by the appearance of a tumor in the superior sulcus. Electromy References ography will demonstrate denervation in the appropriate Bogduk, N. Definition Summary of Essential Features and Diagnostic Cri Progressively intense pain in the shoulder and ulnar side teria of the arm, associated with sensory and motor deficits the essential features are unremitting, aching pain of and Homer’s syndrome due to neoplasm. Homer’s der, or elbow, in time expanding to the whole ulnar side syndrome occurs associated with damage to T1 and C8 of the arm. Exacerbations of sharp lancinating pain in Page 96 and occasional neurological loss; the diagnosis is made pain is generally aggravated by exercise and relieved by by chest X-ray demonstrating tumor at the apex of the rest. Rarely, peripheral vascular insufficiency syndromes are Code found, and occasionally, the subclavian axillary vein 102. X4a complex can be compressed, and the patient presents with swelling and blueness consistent with symptoms of Reference venous obstruction. Color change may also (includes Scalenus Anticus Syndrome, Cervical Rib appear with other maneuvers. This is performed by maximal extension of the chin and deep Definition inspiration with the shoulders relaxed forward and the Pain in the root of the neck, head, shoulder, radiating head turned towards the suspected side of abnormality. Due to compression of the Obliteration of the pulse, or at least diminution, should brachial plexus by hypertrophied muscle, congenital occur. This sign is not always found and may occur in bands, post-traumatic fibrosis, cervical rib or band, or normal individuals also. Angiograms are indicated when there is an arterial or venous obstruc Site tion but are very poor diagnostic maneuvers, the milder Ipsilateral side of head, neck, arm, and hand. Age of Onset: the thoracic outlet syndrome is characteristically found Usual Course in young to middle-aged adults but may affect older the usual course is one of continued persistent discom adults also. Physiotherapy may strengthen the shoulder girdle root of the neck, or shoulder, and radiates down the arm, and relieve symptoms, and this should be tried at first, but it may also affect the head. The ulnar aspect of the but ordinarily symptoms will persist until the entrapment arm is the most commonly involved, but the pain may of the plexus is relieved. The pain occurs irregularly, usually Complications include arterial compression with throm with activity. The distribution of the paresthesias or pain in the shoul Pathology der or arm is varied and can be associated with a particu A variety of anatomical abnormalities will compress the lar nerve root, or with many nerve roots. Often it is neurovascular bundle at the thoracic outlet and may rather baffling in that it cannot readily be related to spe cause this syndrome. Hemiplegia from stroke secondary to vascular Social and Physical Disabilities thrombosis and propagation of the clot may occur. The the patients are often unable to work because of dys function of the extremity involved. Page 97 Summary of Essential Features and Diagnostic Main Feature Criteria Age of Onset: usually in the fifth, sixth, and seventh Patients with this syndrome suffer from compression of decades-corresponding to the occurrence of carcinoma the brachial plexus for which many causes exist. Pain Quality: the pain teristically, they develop pain and paresthesias in the is usually described as a continuous dull ache or a con upper extremity, sometimes associated with headache. It may radiate up into the neck or down into the most common diagnostic criteria are tenderness the anterior chest wall. An expanding lesion in the hu over the brachial plexus in the neck, reproduction of the merus may radiate into the forearm. The cardinal feature pain by the maneuver of abduction and external rotation is acute exacerbation of the pain by any movement of of the arm, and pain on stretching the brachial plexus. Differential Diagnosis Associated Symptoms Differential diagnosis includes cervical rib, cervical os Pain at rest usually responds to nonsteroidal anti teoarthritis, Pancoast’s tumor, aneurysm of the sub inflammatory drugs and narcotic analgesics. Pain secon clavian artery, tumors of the brachial plexus, cervical dary to movement is sometimes relieved by internal disk, adenopathy or tumor of other supraclavicular struc fixation. Both types of pain may respond to radiation tures, metastatic cancer to the cervical spine. However, Cervical Rib or Malformed First both of these tests may be normal in the setting of severe pain. A pathological fracture in the shaft of the diagnosis and differential diagnoses are the same. The humerus severely exacerbates pain on movement, and only variation from the scalenus anticus syndrome is the this usually requires treatment with internal fixation. The code is the same and the reference for this syndrome is Social and Physical Disability the same. Definition Differential Diagnosis Dull aching pain in the shoulder girdle or upper extrem It is important to rule out referred pain to the shoulder ity due to tumor infiltration of bone. Definition Associated Symptoms Pain in the thyroid gland, aggravated by palpation and Hoarseness; dysphagia, when local spread has occurred. Complications System Stridor progressing to respiratory obstruction; dys Endocrine system. Main Features Social and Physical Disability Localized sharp or dull, aching or burning, occasionally Loss of voice following surgical treatment. Essential Features Associated Symptoms Persistent hoarseness, with soreness or pain supervening. A painful irritation in the throat on air flow during breathing, coughing, and swallowing due to tuberculous Code lesions. Definition Main Features An aching soreness in the throat, aggravated by swal Now rare. Local in larynx; spreads to ear (otalgia); con lowing, with hoarseness and dysphagia. In advanced cases there is severe pain in the laryngeal and pharyngeal area, System which may radiate to the ear. Associated Symptoms Main Features Hoarseness; cough; purulent sputum; night sweats and Initially, there is a complaint of sore throat, with irrita fever; weight loss. The pain spreads to the ear Signs (otalgia), possibly because of the involvement of the Inflammation of larynx; ulceration of larynx; chest vagus nerve. For explanatory material on this section and on section G, Spinal and Radicular Pain Syndromes of the Lumbar, Sacral, and Coccygeal Regions, see pp. Absolute confirmation relies on Definition obtaining histological evidence by direct or needle bi Cervical spinal pain associated with a metabolic bone opsy. I (S)(R) cates that this condition as diagnosed radiologically is Osteoporosis of Age causally associated with spinal pain. Osteoporosis of Some Known Cause Other than Age the condition of “spondylosis” is omitted from this Code 132. Definition Cervical spinal or radicular pain associated with a con Diagnostic Features genital vertebral anomaly. Imaging or other evidence of arthritis affecting the joints of the cervical vertebral column. I (S)(R) Diagnostic Features Rheumatoid Arthritis Imaging evidence of a congenital vertebral anomaly Code 132. Although they may be associated with pain, Osteoarthritis the specificity of this association is unknown. Clinical Features Diagnostic Features Spinal pain located on the lower cervical region. Cervical spinal pain for which no other cause has been found or can be attributed.

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The lesions tive erectile dysfunction in young age purchase tadacip 20mg with mastercard, since the lesions may disappear within a few are whitish or have normal color and smooth months or they may become inactive. Of the fungal infections, oral can Both types are almost equally likely to manifest. The have been reported in immunosuppressed subjects prevalence rate is about 5 -10%. Sporadic cases of oral of the lesion remain unclear, the Epstein-Barr ulcerations due to cytomegalovirus have also virus seems to play an important role. Perioral molluscum con Clinically, hairy leukoplakia presents as a whit tagiosum may also occur (Fig. Hairy leuko ish, slightly elevated, nonremovable lesion of the plakia is a common oral mucosal feature that has tongue, often bilaterally. In is characterized by a fiery red band along the addition, very rarely lesions may occur at other margin of the gingiva (Fig. Their size varies from a few millimeters not respond to plaque control measures or root to several centimeters and cannot be used to pre planing and scaling. Multiple sites of involve characterized by localized acute, painful ulcero ment may occur. The lesion may oral lesions in the early phases appear as a red or extend to contiguous tissues (Fig. Furthermore, oral infections with Mycobac terium avium intracellulare, Mycobacterium tuber culosis, Escherichia coli, Actinomyces israelii, and Klebsiella pneumoniae have rarely been reported. Later, solitary or multiple lobulated tumors with Neurologic Disturbances or without ulceration may be the most prominent clinical feature (Fig. Bacterial Infections Necrotizing Ulcerative Gingivitis Necrotizing Ulcerative Stomatitis Necrotizing ulcerative gingivitis chiefly affects Necrotizing ulcerative gingivitis may on occasion young persons. Although the precise causative extend beyond the gingiva and involve other areas agents are unknown, fusiform bacillus, Borrelia of the oral mucosa, usually the buccal mucosa vincentii, and other anaerobic microorganisms opposite the third molar. In disease is either sudden or insidious, and it is these cases the subjective complaints and objec clinically characterized by ulceration and necrosis tive general phenomena may be more intense. The characteristic clinical feature is necrosis of the gingival margins Cancrum oris, or noma, is a rare but very serious and interdental papillae and the formation of a destructive disease usually involving the oral tis crater. Clinically, cancrum oris frequently starts stomatitis, scurvy, leukemia, and agranulocytosis. Smear and histopathologic involves the cheeks, lips, and the underlying bone, examination may sometimes be helpful. The gangrenous ulcers are covered with antibiotics active against anaerobic bacteria are whitish-brown fibrin and debris. Management of the the differential diagnosis includes lethal midline underlying gingivitis must follow the acute phase. Bacterial Infections Streptococcal Gingivostomatitis Scarlet Fever Streptococcal gingivostomatitis is a debatable dis Scarlet fever, or scarlatina, is an acute infection, ease caused by B-hemolytic Streptococcus. It is a caused by group A streptococci, which produce rare entity and the etiologic role of streptococci is erythrogenic toxin. It is usually a disease of child controversial because it is not clear whether strep hood. After an incubation period of 2 to 4 days, tococcal infection is the primary cause or whether there is pharyngitis, fever, chills, headache, it represents a secondary infection of preexisting malaise, vomiting, nausea, and lymphadenopathy. The disease is usually localized on the the rash, which appears 1 to 2 days after the onset gingiva and rarely in other oral areas (Fig. It first appears on the upper redness, edema of the gingiva, and patchy superfi trunk and quickly spreads within 2 to 3 days. The cial, round, or linear erosions covered with a face is infrequently involved, with few papules and white-yellowish smear. The disease is localized and rarely red, edematous, and the tongue may be covered involves the entire gingival tissues. Later, hyper submandibular lymphadenopathy are also pres trophy of the fungiform papillae follows, giving ent. The diagnosis is usually made on clinical givostomatitis and necrotizing ulcerative gin grounds. Penicillin or erythromycin is indi cated, but therapy is best left to the pediatrician. Erysipelas Erysipelas is an acute skin bacterial infection due nearly always to group A streptococci. However, in cases of facial erysipelas the redness and edema may extend to the vermilion border and the lip mucosa (Fig. Clinically, erysipelas is charac terized by a shiny, hot, edematous, bright red, and slightly elevated plaque that is sharply demarcated from the surrounding healthy skin and may show small vesicles. The differential diagnosis includes herpes zoster, angioneurotic edema, and contact dermatitis. Scarlet fever, red and edematous tongue, partially covered by a thick white coating. Bacterial Infections Oral Soft-Tissue Abscess Acute Suppurative Parotitis Acute abscess of the oral soft tissues of nondental Acute suppurative infection of the parotid glands origin is uncommon. Usually, infectious micro is usually unilateral and most frequently appears in patients more than 60 years of age, although it organism, such as Staphylococcus aureus, B-hemo-lytic Streptococcus, and rarely other microorgan may also occur during childhood. Low local or general resistance to infec infection, which may be hematogenous or spread tion is an important predisposing factor. Laboratory tests to confirm the diagnosis are the differential diagnosis includes obstructive bacterial cultures and histopathologic examina parotitis, mumps, chronic specific infections, tion. Peritonsillar Abscess Treatment consists of appropriate antibiotic ad Peritonsillar abscess is usually a complication of ministration. Clinically it appears as a large soft swel ling of the tonsil and the adjacent area, with redness and pus draining at the late stage (Fig. Bacterial Infections Acute Submandibular Sialadenitis Klebsiella Infections Acute suppurative infection of the submandibular Klebsiella pneumoniae is a Gram-negative bacillus gland is relatively rare compared with the fre found among the normal oral flora and gastroin quency of analogous infections of the parotid testinal tract. Staphylococcus aureus, Staphylococcus the systems mainly involved while other anatomic pyogenes, Streptococcus viridans, and other bac areas are rarely infected. The the infection are diabetes mellitus, immunosup microorganisms may reach the submandibular pression, and treatment with antibiotics to which gland, either through the gland duct or the blood Klebsiella is resistant. Clinically, it presents as a painful swelling, Klebsiella infection of the oral cavity is a very usually unilateral, associated with tenderness and rare phenomenon which may occur in patients induration of the area under the angle and the undergoing cancer chemotherapy and those with body of the mandible (Fig. Intraorally, oral lesion appears as an abnormally deep ulcer inflammation of the orifice of the duct is a com with a necrotic center covered by a thick brown mon finding. Buccal Cellulitis Cellulitis is a common cutaneous inflammation characterized by diffuse involvement of the soft tissues due to infection. A thin, watery exudate spreads through the cleavage planes of the inter stitial tissue spaces. The predominant infectious organisms are Staphylococcus aureus, B-hemolytic Streptococci, and less frequently Gram-negative and anaerobic microorganisms. Cellulitis due to Hemophilus influenzae type B occurs commonly in the buccal soft tissues of infants. Clinically, buccal cellulitis has a variable onset and presents as a diffuse, firm, ill-defined erythematous swelling associated with warmth and pain (Fig. The differential diagnosis includes erysipelas, acute parotitis, angioneurotic edema, insect bites, and trauma. Laboratory tests helpful to establish the diagnosis are blood cultures, needle aspiration, or rarely, biopsy. Surgical incision and drainage is indicated if antibiotic therapy is unsuccessful. Acute submandibular sialadenitis, swelling under the angle and the body of the mandible. Buccal cellulitis, ill-defined erythematous swelling on the skin of the face of a 2-year-old girl. Klebsiella infections, deep ulcer covered by a thick brown-whitish pseudomembrane. Bacterial Infections Pseudomonas Infections Primary Syphilis the primary lesion of acquired syphilis is the Several strains of Pseudomonas have been iden chancre. It is usually localized on the genitalia, but tified the most common strain being P. Pseudomonas aeruginosa is an opportunistic extragenitally (anus, rectum, fingers, nipples, pathogen infecting mostly individuals with defect etc. Direct oro immunity while rarely causing disease in healthy genital contact (fellatio or cunnilingus) is the usual individuals.

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There is no difference in local control erectile dysfunction laser treatment quality tadacip 20 mg, fve-year cause specifc and fve-year absolute survival when surgery with or without radiotherapy is compared to radiotherapy with or without neck dissection in patients with tonsillar and base of tongue carcinoma. There is no evidence to support the routine use of concurrent chemotherapy with radiotherapy in early oropharyngeal cancer. If appropriate expertise is available it may be possible to treat patients with small oropharyngeal tumours with a combination of external beam radiotherapy and interstitial 242,243,426 3 brachytherapy. Although the incidence of occult metastases in the lymph nodes of the neck of patients with oropharyngeal cancer is high (>50%),68,150-152 there is no randomised controlled evidence showing that prophylactic treatment of the neck improves survival. If the primary is in the base of tongue 17% of patients may have level v nodal involvement, and 55% may have bilateral involved nodes. Neck recurrence rates following selective procedures in patients with clinically N0 neck compare favourably with those achieved by more extensive neck dissection. D Patients with small accessible tumours may be treated by a combination of external beam radiotherapy and brachytherapy in centres with appropriate expertise. D In patients with well-lateralised tumours prophylactic treatment of the ipsilateral neck only is required. D bilateral treatment of the neck is recommended when the incidence of occult disease in the contralateral neck is high (tumour is encroaching on base of tongue or soft palate). D Postoperative radiotherapy should be considered for patients with clinical and pathological features that indicate a high risk of recurrence. If external beam radiotherapy is used as the primary modality of treatment, concurrent administration of chemotherapy results in a 23% reduction in the risk of death at fve years 1++ when compared with radiotherapy alone. D Patients with advanced oropharyngeal cancer may be treated by:  primary surgery (if a clear surgical margin can be obtained)  an organ preservation approach. D Patients treated by primary surgery who have a clinically node positive neck should have a modifed radical neck dissection. D Postoperative chemoradiotherapy to the primary site and neck should be considered for patients treated by primary surgery who show high risk pathological features. A where radiotherapy is being used as a single modality without concurrent chemotherapy or cetuximab, a modifed fractionation schedule should be considered. D  Patients with N1 disease should be treated with chemoradiotherapy followed by neck dissection where there is clinical evidence of residual disease following completion of therapy. D In patients with a small primary tumour, locally advanced nodal disease may be resected prior to treating the primary with defnitive chemoradiotherapy and the neck with adjuvant chemoradiotherapy. Choice of therapeutic option for patients with early cancer of the oral cavity should be determined by the tumour’s site and extent, the patient’s general condition and preference and availability of local expertise. It is important to consider the treatment related morbidity, and likely cosmetic and functional outcome of treatment, as well as tumour control, when making decisions about treatment. Small and superfcial tumours of the oral cavity may be cured either by surgical resection or radiation. A high rate of occult nodal metastases (20-40%) is reported in patients with oral cavity tumours and a clinically N0 neck. On histological examination of elective neck dissection specimens extracapsular spread is reported in a high number of clinically occult nodes. A threshold depth below which prophylactic neck treatment can safely be omitted cannot be determined. D Patients with early oral cavity cancer may be treated by:  surgical resection, where rim rather than segmental resection should be performed, where possible, in situations where removal of bone is required to achieve clear histological margins  brachytherapy in accessible, well demarcated lesions. D Re-resection should be considered to achieve clear histological margins if the initial resection has positive surgical margins. Radiotherapy delivered postoperatively to selected patients at high risk of locoregional recurrence 178,195,289-292 289,292 3 may improve locoregional control and survival (see section 7. The administration of cisplatin chemotherapy concurrently with postoperative irradiation results in signifcantly better locoregional control307,308 and survival307 than with radiotherapy alone 1++ particularly if there is extracapsular spread and/or positive surgical margins. Recurrence rates following radical radiotherapy alone in locally advanced oral cavity cancer may be higher than in other head and neck sites. Choice will depend on individual factors relating to the patient and tumour, and the preference of the surgeon and the patient (see section 7. Nodal size predicts response to radiotherapy193,198 and it may be possible to treat patients with 196,198 3 a single node <3 cm by radiotherapy or chemoradiotherapy alone. N2 and N3 disease is better treated by a combination of surgery and chemoradiotherapy (or radiotherapy in those unable to tolerate chemotherapy) rather than by either modality alone (see sections 5. D Patients with resectable disease who are ft for surgery should have surgical resection with reconstruction. D  Patients with node positive disease should be treated by modifed radical neck dissection. A Radical external beam radiotherapy with concurrent cisplatin chemotherapy should be considered when:  the tumour cannot be adequately resected  the patient’s general condition precludes surgery  the patient does not wish to undergo surgical resection. D  Patients with N1 disease who are receiving radiotherapy to the primary tumour should be treated with chemoradiotherapy where there is clinical evidence of residual disease following completion of therapy. The administration of cisplatin chemotherapy concurrently with postoperative irradiation results in signifcantly better locoregional control307,308 and survival307 than with radiotherapy alone in 1++ patients with extracapsular spread and/or positive surgical margins. A Pilocarpine (5-10 mg three times per day) may be offered to improve radiation-induced xerostomia in those patients with evidence of some intact salivary function, providing there are no medical contraindications to its use. A During follow up, routine supplementation with beta carotene is not recommended. Dental extractions in irradiated bone have much higher healing complication rates, and this is exacerbated by adjuvant 2+ chemotherapy. Dental implants into either remaining bone or in free transfer vascularised bone grafts are a 3 well established method of oral/dental rehabilitation. The failure rate of implants is higher in 4 irradiated bone, especially in smokers. Oral/dental rehabilitation should be carried out by specialist practitioners with a working knowledge of the principles of radiotherapy and surgery. C Dental extractions in irradiated jaws should be carried out in hospital by a specialist practitioner. Untreated or poorly managed dysphagia adversely affects quality of life, interferes with cancer treatment and may lead to life threatening conditions, such as aspiration pneumonia. Aspiration + 2 is also common after partial laryngectomy especially if the arytenoid cartilage is included in the resection. One study showed a third of patients with advanced cancer who were treated with chemoradiation 2+ had aspiration pneumonia. Speech and language therapy is effective in improving the intelligibility of patients undergoing 494 2+ glossectomy and major resection. C where communication problems are likely to occur, patients should be seen by a specialist head and neck speech and language therapist soon after diagnosis and before treatment commences. In patients who have had a laryngectomy, tracheoesophageal and/or oesophageal speech should be taught by a speech therapist. C Patients undergoing laryngectomy should have specialist speech and language therapy to restore voice either by a tracheoesophageal voice prosthesis and/or oesophageal speech. C Patients with communication impairment should have access to a speech and language therapist. A retrospective review of preoperative risk assessment for gastrostomy tube placement, reported signifcant factors for patients requiring nutritional support. Gastrostomy feeding is safe and effective and gastrostomy tubes must be placed by a trained practitioner. One study suggested prophylactic placement in patients receiving intensive chemoradiation or radiotherapy. There is some evidence that maximum psychological support should continue for three months post-radiotherapy. One systematic review described using a checklist at clinic check in to screen for at-risk patients pre-diagnosis so that early support could be offered. Interviews with people attending a self help group following laryngectomy highlighted problems that they experienced, such as talking on the telephone and getting along with their families. One study reported that patients suffering from disfgurement who attended a support group had lower life happiness. Women seemed to have more depressive symptoms but also seem 2+ to beneft more from support. Patient information leafets about risk factors, prevention and early detection + 1 of oral cancer increased knowledge, decreased anxiety and increased patients’ intention to have an oral cancer screen. The study also showed that patients are not able to absorb other 3 information that is given at the same time as their diagnosis.

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The volume of the whole gland is up to 20 ml in females and 25 ml in males and is determined by adding the volumes (V) of both lobes erectile dysfunction drugs india tadacip 20 mg, each calculated from the formula: V = 05. Parathyroid glands Usually, normal parathyroid glands cannot be found by ultrasound. Oesophagus The cervical oesophagus can be seen in longitudinal scans behind the thyroid as a tubular or target-like structure if this area is scanned with the transducer moved to the lef-hand side to avoid the shadow of air within the trachea (Fig. Vessels The large vessels (the carotid artery and the jugular vein) are behind the sternocleidomastoid muscles and lateral to the thyroid gland. The jugular vein shows as an oval shape and may collapse in certain phases of respiration or from the pressure of the transducer. High-frequency ultrasound frequently demonstrates normal lymph nodes, which are usually oval, with a maximum diameter of 8 mm. In older people, the pattern becomes increasingly echo rich due to fatty degeneration, mostly starting from the hilus (see Fig. The lymph nodes of older people are more difcult to detect because of their low contrast with the surrounding sof tissue. The normal vessels, which branch out symmetrically from the hilus (‘hilar vascularity’), can be evaluated with high-resolution power Doppler. They are important as anatomical landmarks and serve as a reference point for evaluating the echo pattern of the thyroid. Normal lymph node (arrow) between vessels (Jv (jugular vein), Ca (common carotid artery)) and muscle (Smm (sternocleidomastoid muscle)). The oval shape and the echo-rich hilus are characteristic Pathological findings Thyroid Congenital abnormalities Failure of the thyroid to descend during embryogenesis leads to an ectopic thyroid or to an abnormal lobe in the midline (pyramidal lobe). Endemic goitre (iodine-deficiency goitre) Endemic goitre is very common in areas of iodine defciency. Enlargement of the thyroid is a lifelong disorder in which the thyroid is enlarged with a homogeneous, echo-rich pattern in the early stage of the disorder (Fig. Degenerative alterations, such as cystic degeneration of the nodules and calcifcation, may also occur. Autoimmune disorders of the thyroid A common sonographic fnding in autoimmune disorders of the thyroid is an echo poor pattern. Grave-Basedow disease In this disease, autoantibodies against the thyroid-stimulating hormone receptor stimulate the thyroid in the same way as the hormone. The younger the patient, the more characteristic are the symptoms of hyperthyroidism. Typical inhomogeneous and echo-rich pattern Ultrasound can be used to visualize a moderately enlarged thyroid with a characteristic echo-poor, homogeneous or slightly inhomogeneous pattern corresponding histologically to hyperplastic but empty follicles (Fig. The fow in the feeding arteries is rapid, at more than 100 cm/s; a decrease to less than 40 cm/s on treatment is interpreted as a sign of a good prognosis. Focal lesions (nodules) within the echo-poor thyroid in Grave-Basedow disease are independent of the basic disease and should be considered separately. Autoimmune thyroiditis (Hashimoto thyroiditis) In this disease, lymphoplasmacellular infltration slowly destroys the gland. This infltration causes an echo-poor pattern of the thyroid, which develops over a long time. In the initial stage, the gland may be slightly enlarged; in the later (atrophic) stage, however, the thyroid becomes small with a volume of less than 10 ml (Fig. Colour Doppler ultrasound demonstrates hypervascularity, which is not as marked as in Grave-Basedow disease. The moderately enlarged thyroid shows a characteristically echo-poor pattern without contrast with the muscles (m, M). Toxic adenoma, toxic goitre The proliferation of autonomic cells, stimulated by iodine defciency, leads to autonomic, toxic nodules or a difuse functional autonomy causing hormone production independent of stimulation by thyroid-stimulating hormone. When the volume of the autonomic tissue is greater than 5−10 ml (depending on the iodine supply), hyperthyroidism results. The incidence of this type of hyperthyroidism is, therefore, higher than that of Grave-Basedow disease in areas of iodine defciency. The disorder develops in a long-standing simple goitre and is seen mainly in the elderly (Fig. Note: (a) the echo-poor pattern (B-scan) of the small gland; (b) hypervascularity (power Doppler). Smm, sternocleidomastoid muscle; Ca, common carotid artery; Jv, jugular vein a b Fig. The Doppler technique demonstrates hypervascularity (compared with the surrounding tissue) within the nodule and a halo consisting of vessels. Warm or toxic nodules may show a more echo-rich pattern in up to 30% of people, and hypervascularity may be missing in regressive nodules. Currently, there are no reliable sonographic signs to indicate the warm or toxic nature of a nodule. Highly diferentiated carcinomas of the thyroid are also hypervascular but without a halo. Hypothyroidism In adults, hypothyroidism is a consequence of the loss of thyroid tissue caused by thyroiditis, radiation therapy to the neck, radioiodine ablation or surgical resection of the thyroid. Symptoms such as tenderness, swelling and redness are more ofen caused by pyogenic infammation of the sof tissue around the thyroid. Ultrasound demonstrates dislocation of the thyroid and infammation of the sof tissue (see below). Subacute thyroiditis (giant cell thyroiditis, de Quervain thyroiditis) is thought to be viral in origin, because this disease ofen follows respiratory tract infections. An irregular echo pattern caused by blurred echo-poor, nodular lesions is reported in a few cases. The border of the slightly echo-poor infamed area is better seen in the longitudinal scan. A typical event is the sudden onset of pain coupled with a palpable swelling caused by bleeding into the cyst. Ca, common carotid artery; Jv, jugular vein; Smm, sternocleidomastoid muscle a b Solid nodules Nodules in the thyroid are found in up to 50% of asymptomatic persons. Nevertheless, diferentiation of benign and malignant nodules is a challenge in the ultrasonic diagnosis of the thyroid. Benign lesions True adenomas are encapsulated, grow slowly and are mainly microfollicular. Warm or toxic adenomas are highly diferentiated and can accumulate iodine independently of thyroid-stimulating hormone regulation (see above). Depending on the follicular structure, adenomas are mostly echo poor (microfollicular, Fig. An echo-poor halo (B-scan) with vessels around the nodule is characteristic of a benign adenoma and is, therefore, best demonstrated with colour Doppler. Hyperplastic nodules develop over several years in cases of endemic goitre, caused by the diferential growth ability of the thyroid cells. Owing to their normofollicular or macrofollicular structure, they are ofen echo rich with an echo-poor halo. Degenerative alterations, such as cystic parts or calcifcations, are common, causing a complex sonographic pattern with echo-free areas and strong echoes (Fig. Adenoma (21 mm) with a complex echo pattern caused by calcifcation, regressive cystic components and an echo-poor halo Fig. Echo-rich nodule (8 mm) and echo-poor nodule with halo (19 mm) Malignant tumours Papillary and follicular carcinomas are the commonest thyroid carcinomas (ca. Anaplastic carcinoma is less common, especially in areas with no iodine defciency (ca. Metastases, mainly from lung cancer and malignant lymphomas, may involve the thyroid gland. An extremely echo poor pattern is found in malignant lymphomas and anaplastic carcinomas. Interruption of the thyroid capsule and infltration of the surrounding tissue can be visualized.