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The radial artery and the antebrachial nerves are harvested to create the sensate phallus. A distal circumferential portion of the neophallus shaft is elevated and rolled to create the corona. Once joined together around a skin graft used for the neourethra, another skin graft is placed around the muscle. The groin flap with or without the iliac bone can be performed in either one or two stages. The twostage procedure is based on the superficial circumflex iliac artery and the deep circumflex iliac artery. The lateral and medial skin edges of the flap are sutured together, constructing a tube still attached to the body. The neourethra is reconstructed using a full thickness skin graft from the contralateral groin. Surgical Outcome after Penile Inversion Vaginoplasty: A Retrospective Study of 475 Transgender Women. LongTerm Outcomes of Rectosigmoid Neocolporrhaphy in Male-to-Female Gender Reassignment Surgery. Monstrey S, Selvaggi G, Ceulemans P, Van Landuyt K, Bowman C, Blondeel P, Hamdi M, De Cuypere G. Chest-wall contouring in female-to-male transsexuals: basic considerations and review of the literature. An Update on Genital Reconstruction Options for the Female-to-Male Transgender Patient: A Review of the Literature. Facial Feminization Surgery: Simultaneous Hair Transplant during Forehead Reconstruction. Selvaggi G, Hoebeke P, Ceulemans P, Hamdi M, Van Landuyt K, Blondeel P, De Cuypere G, Monstrey S. Monstrey S, Hoebeke P, Selvaggi G, Ceulemans P, Van Landuyt K, Blondeel P, Hamdi M, Roche N, Weyers S, De Cuypere G. Standards of care for the health of transsexual, transgender, and genderNonconforming people. The management of the patient with a major thermal injury requires an understanding of the pathophysiology, diagnosis, and treatment not only of the local skin injury, but also of the derangements that occur in hemodynamic, metabolic, nutritional, immunologic, and psychologic homeostatic mechanisms. Pathophysiology: Amount of tissue destruction is based on temperature (> 40° C) and time of exposure (Figure 1). Different charts are required for adults and children because of head-chest size discrepancy and limb differentials for ages birth to seven years (Figures 3 and 4). Depth: may be difficult to assess initially as injury can evolve and deepen over 24-48 hours a. Second degree: blisters present, red and painful (a) Superficial partial-thickness: involves epidermis and upper dermis (b) Deep partial-thickness: involves deeper dermis iii. Stasis (intermediate): vasoconstriction and ischemia (can improve or worsen, depending on treatment) iii. Location: face and neck, hands, feet, and perineum may cause special problems and warrant careful attention; often necessitate hospitalization and/or transfer to a burn center (See Table 2) 5. Inhalation injury: beware of burns occurring in enclosed spaces, singed nasal/facial hair, carbon particles in pharynx, hoarseness, conjunctivitis patients may not initially have any signs of airway compromise, so must have high index of suspicion. Classification of burns by depth 195 Degree Depth First Pink, brisk capillary refill, painful Second Superficial Epidermis, Pink, red, Variable Daily wound partialpapillary moist, 10-28 care, debride thickness (upper) edematous, days sloughed skin dermis brisk capillary refill, very painful Daily wound Deep Epidermis, White, pink, care, surgical partialreticular red, dry, no excision and thickness (lower) blanching, resurfacing dermis reduced sensation Third Full Epidermis, White, >21 Surgical thickness entire brown, dry, days excision and dermis leathery, no resurfacing blanching, insensate Fourth Full Epidermis, Exposed N/A Amputation, thickness entire deep tissue complex dermis, reconstruction fat, fascia, muscle, bone Table 1. Circumferential burns: can restrict blood flow to extremity, respiratory excursion of chest and may require escharotomies 10. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality. Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality.

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Although the majority of anomalies are detected in the second or third trimester, some major birth defects can be diagnosed already in the first trimester. Measurement of the nuchal translucency between 11 and 14 weeks of gestation can be used as an early screening tool for aneuploidy, fetal congenital heart disease, and other structural anomalies. Although many birth defects can be diagnosed prenatally, some major and many minor anomalies are not detected until birth (or later). In general, major anomalies are generally more likely to be detected before birth than minor abnormalities, but some major anomalies-such as congenital heart disease and orofacial clefts-have relatively low detection rates despite routine prenatal screening. In addition to the nature of the ultrasound facility and the experience of the sonographer or sonologist, ultrasound detection rates can also be affected by maternal factors, such as obesity and abdominal wall scarring, which can make it difficult to see fetal structures prenatally. Furthermore, some anomalies cannot be detected early in gestation either because the structure is not developed at the time the ultrasound is performed or because the abnormality may develop after the scan was done. Aside from two-dimensional ultrasound, what other imaging tools can be used to diagnose anomalies prenatally? Fetal echocardiogram is recommended in all cases of suspected fetal congenital heart disease as well as in women at increased risk of fetal cardiac anomalies. Usefulness of additional fetal magnetic resonance imaging in the prenatal diagnosis of congenital abnormalities. The severity of clinical presentation is modulated by the degree of bidirectional flow from superficial anastomoses. Complications specific to the recipient twin are polycythemia, systemic hypertension, biventricular cardiac hypertrophy, and congestive heart failure. The donor twin is at risk for growth failure, anemia, high-output cardiac failure, and hydrops. Both twins are at increased risk of congenital anomalies, in utero demise, and cerebral palsy. When cardiac output is compromised, maternal antiarrhythmic therapy may be initiated. If the fetal arrhythmia remains refractory, direct fetal therapy with antiarrhythmic medications may be considered. Cystic adenomatoid malformation volume ratio predicts outcome in prenatally diagnosed cystic adenomatoid malformation of the lung. Congenital diaphragmatic hernia: an evaluation of the prognostic value of the lung-to-head ratio and other prenatal parameters. Congenital diaphragmatic hernia: An evaluation of the prognostic value of the lung-to-head ratio and other prenatal parameters. The major neonatal diseases that may benefit from fetal intervention are listed in Table 2-2. Fetal intervention for congenital diaphragmatic hernia is currently investigational. What are the key principles in determining the potential value of a prenatal therapy for a fetal anomaly? What are the major considerations for fetal intervention in cases of congenital cardiac lesions? Right-sided lesions n Pulmonary atresia/severe pulmonary valve stenosis with intact ventricular septum: In utero balloon valvuloplasty may preserve cardiac function by decompressing the right ventricular load and ensuring adequate right-sided heart blood flow and right ventricular growth. The procedure is currently used for the delivery and management of fetal airway compromise resulting from extrinsic mass compression or intrinsic airway defect. Maternal mirror syndrome is a preeclampsia-like state that occurs in the setting of fetal hydrops; other terms that are used interchangeably are Ballantyne syndrome and pseudotoxemia. Although the symptoms are similar to those of true preeclampsia, mothers with this syndrome typically exhibit anemia caused by hemodilution rather than hemoconcentration and do not commonly develop thrombocytopenia. Amniocentesis is a procedure that involves the aspiration of amniotic fluid from the amniotic sac during pregnancy. It is generally carried out with a spinal needle (20­22 gauge) in a transabdominal approach, using a sterile technique under continuous ultrasound guidance. National Institutes of Child Health and Human Development National Registry for Amniocentesis Study Group. Amniocentesis can be classified by the time in the pregnancy when it is done and by its indication.

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Effects of changes in airway pressures and timing on the respiratory waveform and mean airway pressure (Paw). Pressure waveform and ventilator settings for mechanical ventilation in severe hyaline membrane disease. Furthermore, gadgets do malfunction, so continue to use your eyes and ears to verify that the "numbers" are believable. Many modern infant ventilators have the ability to display flow and pressure waveforms, which should help diagnose or confirm the problem. Manual ventilation may be appropriate if a circuit or ventilator problem is suspected, but be careful not to use excessive pressure, which may cause lung injury. Periventricular leukomalacia is associated with hypotension and with marked respiratory alkalosis. Hypercarbia, hemodynamic impairment, and air leak caused by incomplete exhalation occur when the expiratory time is too short to allow complete exhalation before the next mechanical breath occurs. This situation is most likely to occur in infants who have increased airway resistance, such as is seen in meconium aspiration with acute airway obstruction or in chronic lung disease in which airway edema, copious secretions, and bronchospasm are present. What is a time constant, and why is it important to consider when ventilating a newborn infant? A time constant is the product of lung compliance and airway resistance (Tc = R Ч C). Conceptually, time constants reflect the time it takes for gas flow to cease and pressure to be fully equilibrated between the large airways and the alveoli when a sudden pressure change is applied to the airway opening (three time constants are needed for 95% equilibration). In addition, time constants are also a function of size (total compliance, not compliance per kilogram, is used). Consequently, large subjects such as adults or horses have long time constants, and small premature infants and hummingbirds have short time constants. Time constants are a major determinant of resting respiratory rate, which turns out to fall exactly where work of breathing is lowest. This is why adults at rest breathe at a rate of 14 breaths per minute, term infants breathe at 40 breaths per minute, and small premature infants breathe at about 60 breaths per minute. In infants with acute respiratory distress, tachypnea is a reflection of shorter time constants as lung compliance decreases because of various causes. Asthmatics, on the other hand, prefer to breathe rather slowly because of their prolonged expiratory phase. The bottom line is this: Consider the underlying disease process and its pathophysiology before making decisions about ventilator settings. A percentage change in pressure in relation to the time (in time constants) allowed for equilibration. As a longer time is allowed for equilibration, a higher percentage change in pressure occurs. Optimize oxygen delivery and prevent hyperoxia and hypoxia (by carefully adjusting FiO2 levels). A/C ventilation is a form of mechanical ventilation in which the infant triggers the ventilator to cycle with each breath. With a small triggering effort, therefore, the baby can achieve a much higher level of ventilatory support than with spontaneous breathing. It has become the most common way to initiate mechanical ventilation therapy in these clinical situations. With synchronized intermittent mandatory ventilation, the loops are either triggered by the patient or the ventilator. In A/C mode, every breath that the infant takes triggers a ventilator breath-that is, every breath is supported. Why does hand ventilation with a bag often work when mechanical ventilation is failing? In a crisis it is frighteningly easy to inadvertently generate pressures above 40 cm H2O. This approach allows you to continue to use the monitoring function of the ventilator to provide feedback regarding the tidal volume and other parameters, and it provides controlled and accurate pressure delivery.

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Trainees will focus on the mandatory, optional and preferential techniques and methods used in this field, as well as their related quality assurance aspects. Introduction the nuclear medicine technologist plays a critical role in the routine practice of nuclear medicine, since the quality of work and care taken during diagnostic studies determines the ultimate diagnostic capability of the test being performed. In many countries, the importance of training technologists has been poorly understood, and consequently the professional development of this group has lagged behind that of others. As a result, there are many technologists working in nuclear medicine who have had little or no formal training. Both the availability and the role of technologists vary considerably from country to country. As nuclear medicine expands, there is a greater need to formalize training programmes in each country. Role of the nuclear medicine technologist the primary role of the nuclear medicine technologist is to perform diagnostic studies. Ideally, this involves understanding the overall procedure and taking responsibility for all aspects of the study (except for clinical interpretation). The breadth of responsibility varies in different countries, with an overlap of responsibilities between different professional groups. Where comprehensive training is established, the tasks undertaken by a technologist are likely to include the following: - Dose calibration; - Radiopharmaceutical preparation and quality control (subject to local legislation); - Patient preparation; - Image acquisition; - Full study analysis; - Electronic display of data and hard copy; - Routine instrument quality control. Technologists are also likely to have responsibilities in management (personnel and data), teaching and research. Although, in several countries, they may have only a very specific repetitive duty to perform, the trend is for technologists to take on overall responsibility for the execution of studies. In this manual the term technologist will be reserved for persons who have direct contact with patients and fulfil the roles outlined above; the term technician will be reserved for individuals who undertake maintenance of instrumentation or work in laboratories. General education of nuclear medicine technologists In many countries, the lack of structured training has resulted in the employment of a broad range of individuals, from elementary school leavers to science graduates. It has recently been suggested that the minimum level of education should be at school higher certificate level (equivalent to the entry level for tertiary education and usually taken at 18 years of age). In many countries, technologists enter the field after completion of a tertiary course in a different medical specialty. They are usually well equipped to deal with the technical component of the work, but will normally require additional courses in relevant medically oriented subjects. It should be noted that full-time academic courses in nuclear medicine technology, as now commonly offered, tend to include a range of subjects that broaden the education of students. What needs to be recognized is that, in order to fulfil their role, technologists require a reasonable educational background. Specific nuclear medicine courses In many countries where nuclear medicine has developed to the stage of there being a continuous demand for nuclear medicine technologists, specific courses have been established. These vary from country to country and generally include the following options: (a) (b) Full-time certificate, diploma or degree courses specifically for nuclear medicine; Courses designed to provide training in diagnostic imaging (radiography) that contain a significant component of nuclear medicine; 38 2. The establishment of these courses has usually evolved over several years, driven by continual growth in the field. Usually the development span has evolved by the introduction of part-time certificate courses that eventually become full degree courses. Accompanying this development has been the establishment of professional societies specifically for technologists as well as the growing representation of technologists in more general societies. Nevertheless, in many countries the establishment of specialized courses and development of the profession has been slow. The difficulty is that there needs to be a critical mass of persons able to teach nuclear medicine and a definite demand for new employees before courses can be justified. Most persons who are qualified to teach are already working full-time in the clinical practice of nuclear medicine, and have little time available for teaching. Furthermore, small clinical departments are often geographically remote from established centres, and it may not be practical for students to attend formal lectures. Student numbers tend to be small given a relatively slow turnover of staff in established departments. In many countries, nuclear medicine has developed without the establishment of specialized courses, with new technologists simply gaining experience on the job.