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The neuropathological change is of (adenoma sebaceum) in buttery malar distribution degenerationoftheposteriorcolumns 200 mg red viagra otc,corticospinaland occurring after the age of 3 buy discount red viagra 200mg line. Clinical features r A minority of patients develop cardiac or renal tu- r Progressive ataxia of all four limbs and trunk discount red viagra online master card. Splinting, exercise, physiotherapy and hibitors may improve left ventricular hypertrophy. Physiotherapy and orthopaedic intervention for skeletal deformity may be of benet. Tumours of the nervous system Prognosis Primary intracranial tumours Death is usual before the age of 40, mainly due to com- Denition plications of diabetes and heart disease. Primary tumours arise from the neuronal or support cells of the central nervous system. Hereditary motor and sensory neuropathy (CharcotMarieTooth Incidence disease) Primary brain tumours account for only 2% of all tu- mours (although metastases are the most common in- Denition tracranial tumour). The incidence appears to be rising, Peroneal muscular atrophy or CharcotMarieTooth only partly due to increased detection. Disease is a degenerative disorder of the peripheral nerves, motor nerve roots and spinal cord. Age Aetiology The age of presentation depends on the underlying his- Inherited condition in which both autosomal dominant tology. Overall, tumours peak around the age of 5060 and recessive and X-linked patterns are seen. This may also occur secondary to section of benign tumours is preferred; however, if surrounding oedema or arterial or venous compro- close to vital structures, e. However, r Chemotherapy is used for malignant astrocytoma, to brainstem, oor of the third ventricle and cerebellar trytoprolong survival by a few months. Slow growing tumour arising from the meningeal cov- ering of the brain and spinal cord. Biopsy is required for histological diag- nosis, although a radiological diagnosis may be suf- Age cient. Most are benign, with 10% behaving in a malig- r Astrocytomas have predominantly astrocytic cells. If they arise close to the skull they may Theyarecategorisedaccordingtotheirhistologicalap- erode the bone. Visual or hearing abnormalities may be present, depending on droglial components occur and are termed oligoas- the site. A parasagittal (falx) meningioma causes a characteris- tic pattern of bilateral leg weakness mimicking a spinal Aetiology cord lesion. Pathophysiology Angiography may be used for surgical planning, which Tumours do not metastasise but can spread locally by shows a delayed vascular blush due to arterial supply inltration. Macroscopy/microscopy Clinical features Meningiomas are rounded, rubbery lesions, composed Most patients present with focal neurological signs and of meningothelial cells with small foci of calcication headache or signs of raised intracranial pressure. The rapidity of onset of symptoms is often an indication of the aggressiveness of the tumour. As- r Glioblastoma muliforme tumours may be necrotic, trocytomas are usually highly vascular and enhance haemorrhagic masses due to rapid growth. They are with contrast in over two-thirds of cases (less often composed of pleomorphic cells. Surrounding oedema is commonly seen, but due to the diffuse inltration, Management r It is still unclear whether early complete surgical re- the limits of oedema often demarcate the limits of the tumour spread. For this reason, prior use of cor- moval of low-grade tumours that cause little or tran- ticosteroids can reduce the appearance of the size of sient neurology improves the prognosis; although the tumour. Even if the tumour is resectable, the high risk of recur- rence, together with the major morbidity of surgery Macroscopy/microscopy may mean debulking surgery only and treatment with r Astrocytomas are ill-dened pale areas which are not radiotherapy and/or chemotherapy. Seizures look like astrocytes and there are different histological are treated with anti-epileptic drugs. Joint swelling following an injury Symptoms may be acute due to a haemarthrosis or appear more slowly due to an effusion. Again this Joint disorders often have pain as their presenting fea- may be a mono, oligo/pauci or polyarthritis. Joint pain is described as arthralgia if there is no ac- bution of joint involvement should be elicited including companying swelling or as arthritis if the joint is swollen. The nature of the onset, duration, timing and timing and provoking and relieving factors are impor- exacerbating factors should be noted. Arthritis may involve a ated features such as joint instability should be enquired single joint (monoarticular), less than four joints (oligo about. The relationship to exercise may be important, as inamma- tory disorders are often worse after periods of inactivity Joint stiffness and relieved by rest, whereas mechanical disorders tend Joint stiffness is another presentation usually associated to be worse on exercise and relieved by rest. A full systems enquiry is necessary as are characteristic of rheumatoid arthritis but may oc- many disorders have multisystem involvement. Less than 10 minutes in sensation including tingling or numbness are often of stiffness is common in osteoarthritis compared with due to abnormalities in nerve function. Establishment of iacstiffnessisaparticularfeatureofankylosingspondyli- the distribution helps to differentiate peripheral nerve tis. Locking of a joint is a sudden inability to complete damage from nerve root damage. Loss of function is im- amovement, such as extension at the knee caused by a portant as therapy aims to both relieve pain and establish mechanical block such as a foreign body in the joint or necessary function for daily activities. Seropositivity allows prediction of severity and the need for earlier aggressive therapy and Although some of the available tests used in diagnosis increases the likelihood of extra-articular features. Combin- ing tests may allow a clinical diagnosis to be conmed Joint aspiration (see Table 8. Rheumatoid factor: These are antibodies of any class Unexplained joint swelling may require aspiration to directed against the Fc portion of immunoglobulins. The aspiration itself may be of therapeu- The routine laboratory test detects only IgM antibodies, tic value lowering the pressure and relieving pain. It is which agglutinate latex particles or red cells opsonised often coupled with intra-articular washout or instilla- with IgG. It is the presence of these IgM rheumatoid tion of steroid or antibiotic as appropriate. Examina- factor antibodies that is used to describe a patient as tion of the synovial uid may be of diagnostic value (see seropositive or seronegative. Local spread from a soft tissue infection atively birefringent, whereas the crystals of pseudogout may also occur. Previously Haemophilus inuenzae was seen in young children, Many modalities of joint imaging and direct visualisa- but it is now rare due to vaccination. Patients with tion are used to diagnose and follow the course of mus- sickle cell anaemia are prone to osteomyelitis due to culoskeletaldisordersandareoftenusedincombination. The ndings in individual conditions will be described r Direct spread from local infection may occur with later.

Pathophysiology Fluid accumulating within the closed pericardium may reduce ventricular lling and hence cause compromise Pathophysiology of the cardiac output (cardiac tamponade) cheap red viagra master card. Once the space between the pericardium and the heart becomes full of uid the ventricles are prevented Clinical features from lling properly during diastole thus reducing the Heart sounds are soft and apex beat is difcult to pal- cardiac output buy cheap red viagra on-line. If the effusion accumulates quickly order 200 mg red viagra otc, features of low cardiac output failure usually appear. Slow accumula- tion of uid is often well tolerated until very large due to Clinical features distension of the pericardial sac. The pulse is of low volume and reduced on inspi- r Chest X-ray often shows an enlarged globular heart, ration (pulsus paradoxus). Oliguria or anuria develops which may have very clear borders (because cardiac rapidly and eventually there is hypotension and shock. If the tamponade is haemodynamically compromising the Management diagnosis may have to be clinical, but ideally an echocar- This is determined by the size and haemodynamic ef- diogram is done immediately on suspicion. The relief following pericardiocentesis is often Management temporary, so a ne catheter should be inserted for con- Bed rest and eradication of the acute infection, i. Prognosis Disorders of the myocardium Depending on the aetiology the prognosis is usually good,althoughachroniccardiomyopathymayoccasion- Myocarditis ally result. Denition An acute or chronic inammatory disorder of the my- Cardiomyopathies ocardium. These are diseases of the heart muscle, which may be primary (intrinsic to myocardium) or secondary (due Aetiology to an external or systemic cause). Myocarditis is often a feature of a systemic infection but r Primary cardiomyopathies include dilated cardiomy- occasionally septicaemia may lead to focal suppurative opathy, hypertrophic cardiomyopathy and restrictive lesions. Protozoa: Trypanosoma cruzi (Chagas disease), Toxo- r Secondary cardiomyopathies occur when ventricular plasma gondii. Dilated cardiomyopathy Clinical features Myocarditis is an acute illness characterised by fever and Denition cardiac failure. Patients often experience chest pain due Progressive ventricular dilatation with normal coronary to an associated pericarditis. Most cases are idiopathic but are often assumed to fol- low an undiagnosed viral myocarditis. Other factors: The myocardium shows an acute inammatory reaction r Genetic: Single gene mutations and skeletal muscular with interstitial oedema and cellular inltration. Investigations Many systemic diseases may cause the clinical features r Chest X-ray shows cardiac enlargement with signs of of dilated cardiomyopathy, e. Left ventricu- lar failure causes an elevated end-diastolic pressure with coronary artery disease, as this may present similarly resultant increase in pressure within the pulmonary cir- without any history of angina or myocardial infarct. Clinical features r Management Symptoms are dependent upon the degree of cardiac r General measures include bed rest, uid restriction failure. Tachycardia boembolicdiseaseorapresenceofintracardiacthrom- is common and low perfusion results in peripheral bous should be anti-coagulated. Severe cases may vascular shutdown (small thready pulse, cold extrem- benet from anti-coagulation without other risk fac- itiesandperipheralcyanosis). Ankle Prognosis and/or sacral oedema, mild hepatomegaly and jaun- Theprognosisisverypoor. Youngpatientsmaybetreated dice, due to hepatic congestion or tricuspid regurgita- with cardiac transplantation. Hypertrophic cardiomyopathy Macroscopy/microscopy The ventricles are dilated (left more than right), the Denition chamber walls are thin and the muscle poorly contrac- Hypertrophicorhypertrophicobstructivecardiomyopa- tile. Complications Aetiology Atrial brillation is common, particularly in alcoholic r Half the cases are due to an autosomal dominant in- cardiomyopathy, and bouts of ventricular tachycardia herited point mutation of the myosin heavy chain, may occur. Mural thrombosis may occur in either ven- which codes for a component of the cardiac muscle tricle with the associated risk of systemic embolisation. This may raphy cannot obtain adequate views particularly in result in obstruction to the outow of the left ventricle, apical hypertrophy. Clinical features Hypertrophic cardiomyopathy often presents similarly Management r -blockade is the mainstay of treatment as this lowers to aortic stenosis with dyspnoea, angina, syncope, or sudden death. Initially the pulse is jerky with a rapid outow due to hypertrophy, in the late stages ob- prevent ventricular arrhythmias and there is increas- struction results in a slow rising pulse. This may pertrophied septal wall (myotomy/myectomy) is in- be varied by dynamic maneouvres or drugs that can al- dicated with, where necessary, a mitral valve replace- ter the degree of functional obstruction. Surgical intervention is usually reserved for sound is often heard caused by ventricular lling due to severely symptomatic patients. ItisassociatedwithWolff diuretics should only be used with care as these in- ParkinsonWhite Syndrome. Prognosis Macroscopy/microscopy Factors suggesting a worse prognosis include young age Hypertrophy is asymmetrically distributed. Disorganised branching of abnormal, short, thick muscle bres, in which there are large nuclei. Pathophysiology Inltrativediseasecausingadecreaseinventricularcom- Incidence pliance (increase in stiffness) affecting the myocardium. The result is a failure of relaxation during diastole, im- pairment of ventricular lling and compromise of car- Aetiology diacoutput. Valvesmayalsobeaffectedbytheunderlying Although infective endocarditis may occur on normal disease. Enlarged liver, ascites and peripheral The clinical pattern is dependent on the infective organ- oedema may all be seen. It is an upper Thrombus formation is common, and arrhythmias and respiratory tract commensal. Differentiation from r There are many other rarer bacterial causes and fungal constrictive pericarditis using these methods can be dif- causes include Candida, Aspergillus and Histoplasma. Denitive diagnosis may require cardiac catheter- The disease is also dependent on the portal of entry, and isation and cardiac biopsy. Low-dose diuretics and vasodila- r Central lines and intravenous drug abuse (tricuspid tors may provide some relief from symptoms. Pathophysiology Prognosis The clinical picture of infective endocarditis is a balance The condition is commonly progressive. The result is either an r Splinter haemorrhages, linear dark streaks seen in the acute infection or a more insidious (subacute) course. The disease process predisposes to the forma- mucosa of pharynx and retinal haemorrhages may tion of thrombus with the potential for emboli. Cytokine be seen (Roths spots are haemorrhages with a pale generation causes fever. Afever and a new or changing murmur is endocardi- r Full blood count shows an anaemia with neutrophilia. Urine cultures may be required to identify r Acute bacterial endocarditis presents with fever, new aurinary tract infection, and renal ultrasound may be or changed heart murmurs, vasculitis and infective indicated to demonstrate a renal abscess. Severe acute heart failure may occur due to r Chest X-ray may show heart failure or pulmonary in- chordal rupture or acute valve destruction. General signs: r Malaise, pyrexia, anaemia and splenomegaly, which Complications may be tender.

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In Denmark generic red viagra 200mg free shipping, the government can access farm-specifc data more freely discount red viagra 200mg overnight delivery, but the public must make a special request to access it 200mg red viagra with mastercard. Data Collection The following recommendations encompass a discussion of the essential data that should be collected (See Box D), potential sources of data, as well as options for metrics that synthesize the available data and allow for comparisons of antibiotic use. However, the agency has no system in place to collect ongoing and comprehensive use data, nor does it have any stated intention to build such a system. Development of unifed data collection systems in Denmark and the Netherland has been critical to their success in reducing antibiotic use (over baseline levels) by 47% and 64%, respectively. That system should be mandatory, not voluntary, and should be comprehensive enough to encompass certain essential data. Data Collection Efforts to Denmark and the Netherlands The limited data on antibiotic use in U. Both countries have robust, proftable meat and poultry industries where they raise animals in intensive, industrial-style operations not unlike those in the U. Both have adopted policy and practice changes that have helped to signifcantly curtail unnecessary antibiotic use in food animal production. In each country, the changes include improved monitoring of antibiotics sold and used in food-producing animals as well as surveillance to identify patterns of resistance in people, retail meat and in food-producing animals. Antibiotic sales, use and surveillance information for each country also are integrated into a 123,124 single annual report. The enhanced systems for collecting and integrating data in the two countries have informed additional policy interventions over time by identifying areas in need of improvement. They also have made it possible to benchmark how well veterinarians and/or farms use antibiotics relative to their peers. These systems have been crucial in enabling the countries to reach their antibiotic use goals and reduction targets as well as keep antibiotic resistance in animal populations at low levels. Denmark Responding to public concern about levels of antibiotic use in food-producing animals, and possible impacts on human health, Denmark began taking a series of important steps in 1995, including improving data collection. Later that year, industry and government together set a goal for reducing antibiotic use by 50% within fve years. Certain minimum data are essential to capture a meaningful picture of how and why antibiotics are being used in animal agriculture. Ideally, the following additional information also would be collected to provide a more complete understanding of use and resistance patterns: Dose of the antibiotic administered; Production class (dairy cattle vs. Until a better system is put into place to collect more data States and private actors in the U. For example, Californias efforts to eliminate unnecessary and inappropriate law addressing antibiotic use in livestock includes a use, as well as to allow for comparisons with other requirement to monitor antibiotic sales and usage. This measures the could collect and report use information to amount of antibiotics sold per amount of livestock the public, as they do in the Netherlands. The longer-term goal should be to transition marketers and buyers also can help increase to use of an animal defned daily dose metric, a drug transparency by requiring suppliers either to report and animal species-specifc measure that requires the antibiotic use to them directly, or to participate in collection of additional data. Enhancing Surveillance and Data Integration to Inform Antibiotic Use Policy The previous section described three streams of data currently being collected in the U. Individually, each data stream provides some meaningful information, but the usefulness of the data is shortchanged by a failure to combine the different data streams into an integrated analysis to provide a more comprehensive picture of antibiotic use in food-producing animals. In addition, there is a lack of uniformity between agencies in terms of which indicator species they monitor (see Table 4). And now There are two key reasons to sequence the genes colistin-resistant bacteria, likely enriched by overuse of bacteria such as E. Second, these bacteria Enhancing Surveillance and Data are more commonly found in livestock and other Integration environments so resistance trends are more easily monitored in these bacteria. Reports from both countries also contain additional information such as yearly Finally, transmissible plasmids have been discovered livestock/production data (such as that available recently on U. When genes that are resistant to both of these medicines eventually land on the same plasmid, and Recommendation No. Later detection, on the other hand, may least eight are bacteria that have been detected both result in being able to recognize that a problem in U. We therefore recommend livestock associated antibiotic-resistant bacteria the following specifc expansions: have been found to colonize the nasal passages of swine and poultry workers, and also can cause skin 11a. Expand surveillance for emerging resistance and soft tissue infections in workers, as well as other using next generation sequencing technology. These sequencing efforts should be transmitted from food-producing animals/retail be expanded to a wider array of bacteria, including meat to people have been characterized by several E. The agencies should set up a publicly accessible database or make use of existing databases for the timely release of genome sequencing data. Beyond the federal level, state veterinary laboratories have an important role to play in improved surveillance by publicly reporting on resistance found among food producing animals. For example, in 2016, the MinnesotaVeterinary Diagnostic Laboratory published fndings on resistance in Salmonella from clinical samples from 2006 to 2015 in swine and cattle. Conclusion 35 Conclusion Antibiotic resistance is an urgent public health threat that demands immediate action. Drug-resistant infections are on the rise, making antibiotics less effective and putting routine and common and life-saving procedures in jeopardy. Antibiotic resistance is changing the practice of modern medicine by compromising our ability to treat sick people and animals. It is estimated that by 2050 a person will die every three seconds from a drug- resistant infection and $100 trillion in global economic productivity will have been lost. However, this report focuses specifcally on antibiotic use in food-producing animals because 70% of medically important antibiotics sold in the U. This Commission wants to keep the existing arsenal of antibiotics effective for as long as possible. Our recommendations are steps that will help ensure that on-farm use of medically important antibiotics is monitored and reduced, and that there will be adequate surveillance of the development and spread of antibiotic resistant bacteria. Success, we believe, depends on leadership that builds on approaches that have proven successful elsewhere. While state and federal policymakers have important roles to play, action is need from all stakeholders. Health professionals and hospitals, as well as food companies and other major meat and poultry purchasers also have key roles to play. Steps must be taken today to help ensure that our existing supply of antibiotics stay as effective as possible, now and for future generations. Centers for Disease Control and Prevention Journal of Pharmacology & Pharmacotherapeutics. New England Journal Environmental Health, The Committee on Infectious of Medicine.

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Urine should be sent for microscopy and culture buy cheap red viagra 200 mg online, ur- gently if infection is suspected buy cheap red viagra 200mg. Therefore purchase 200mg red viagra free shipping, if there is doubt, one of the ing is needed, to avoid hypotension or prerenal failure following may be required: during this phase. This is very useful, par- ticularlyinacuteobstructionbeforethereisdilatation, Pelviureteric junction obstruction as it shows contrast held up by the obstruction and (idiopathic hydronephrosis) may show the lesion as a space-lling defect such as a radio-lucent stone or a papilla. Aetiology/pathophysiology r As part of the management percutaneous nephros- The cause is unknown. The mechanism of development of which may be exacerbated by drinking large amounts myeloma kidney is via a direct toxic effect on re- of uid, for example it may become symptomatic for nal tubular cells and blockage of the tubules and col- the rst time in students who drink large quantities of lecting ducts by the paraprotein. Occasionallythe may develop amyloidosis and renal tubular acidosis as hydronephrosis is so marked that it can mimic ascites. In some cases, it is asymptomatic and diagnosed in- r Amyloidosis: This condition may be systemic or con- cidentally when an ultrasound is performed for another ned to the kidneys and is an important cause of reason. Itcancauseproteinuria,nephrotic trasound scan, or in childhood during investigation of syndrome and renal failure. There is delayed passage of glomerulonephritis from minimal change disease, to contrast, which is not overcome by administration of membranous nephropathy, to proliferative glomeru- diuretics. Early treatment with immunosup- pression regimes such as plasmapheresis, high dose Prognosis steroids and cyclophosphamide can improve renal It is not possible to predict how much function will re- function. Thrombotic thrombocytopenic purpura haemolytic uraemic The kidney in sytemic disease syndrome r Hypertension: See page 73. This causes a focal segmen- toxin (also called Shiga toxin) produced by Escherichia tal glomerulonephritis. Some This has markedly improved with the advent of plasma develop proteinuria later in life due to progressive exchange. Chronic renal failure occurs in a substantial glomerulosclerosis, occasionally leading to renal fail- number of patients. However, the prognosis for these patients is ex- cellent with no reduction in life expectancy. Congenital disorders of the kidney Renal hypoplasia r Simple renal hypoplasia is when the kidney is smaller Congenital malformations of the than normal, but the structure and histology of the kidney kidney is normal, although the nephrons may be Denition slightly small. Congenital malformations of the kidney are not uncom- r Oligonephronic renal hypoplasia (also called oligo- monly found on antenatal screening and in newborns. The prog- and the risk is higher in those with a previous family nosis is poor for these patients, although there may history. Chromosomal abnormalities account for a pro- be some initial improvement in renal function over portion, but most are sporadic. The fetal kidneys develop when the ureteric bud comes into contact with the metanephric blastema caudally Dysplasia (failure of differentiation) (in the pelvic area), signalling it to form nephrons The kidney develops abnormally with primitive tubules and the collecting system. By 1416 weeks, most r Horseshoe kidney the kidneys remain fused at of the amniotic uid consists of fetal urine. Then the the upper (10%) or lower (90%) poles to form a kidneys have to migrate rostrally, to lie in the lumbar horseshoe-shapedstructure. These anatomical abnormalities may be symptomless, r Bilateral agenesis is rare and incompatible with life. In pregnancy, low pelvic kidneys can interfere Disorders of the bladder with labour. Age r Atresia: Failure of the ureteric bud to canalise, associ- Increases with age ated with renal dysplasia. An ectopic M > F ureter often arises from a duplex kidney, which may be associated with vesicoureteric reux. The causes of bladder outow obstruction are shown in Surgical re-implantation of the ureter may be indi- Table 6. Overtime,theblad- Benign prostatic hyperplasia der distends, then the ureters (causing hydroureters) and Denition nally the renal pelvises. Often there may be an un- Hyperplasiaoftheprostateisacommoncauseof bladder derlying chronic obstruction for example an enlarged outow obstruction. Clinical features The symptoms depend on the speed of onset and degree Age of obstruction. Acute obstruction (acute urinary retention) causes se- vere discomfort, due to a wish to void urine, without Sex the ability to do so. There is complete anuria, although there may be small amounts of urine voided due to overow in- Aetiology continence. However, polyuria and/or nocturia may Pathophysiology be symptoms of the loss of concentrating ability of the Androgens appear to act on the periurethral area of the tubules, which can occur in long-standing obstruc- prostate McNeals transition zone to stimulate hyper- tion. At 3040 years there is microscopic evidence, by 50 years it Macroscopy is macroscopically visible, by 60 years the clinical phase Dilation above the obstruction. The obstruction is due to both direct impingement Complications of the enlarged prostate on the urethra and also the dy- As aresultofchronicobstruction,thebladderdilatesand namic smooth muscle contraction of the prostate, pro- fails to empty fully, dened as >50 mL residual urine static capsule and bladder neck. Nodules Management formedofhyperplasticglandularacinidisplaceandcom- Relief of the obstruction is usually by insertion of a uri- press the true prostatic glands peripherally forming a nary catheter, followed by treatment of the underlying false capsule. It seems to be more effec- Benign epithelial proliferation with large acini, smooth tive in those with very large prostates and its effects muscleandbroblastproliferation. The procedure involves removal Complications of prostatic tissue using electrocautery via a resecto- Bladder decompensation due to chronically increased scope from within the prostatic urethra, under general residualvolumes(urineretainedaftervoiding),theblad- or spinal anaethesia. Post-operatively patients require der may become less contractile, lowering ow rates fur- a three-way catheter and continuous bladder irrigation ther. Obstruction may lead to dilated ureters and kid- to reduce the risk of clot retention until haematuria is ney(hydroureter,andhydronephrosis). Investigations Antibiotic prophylaxis is usually given to prevent Itisimportanttoexcludeothercausesof bladderoutow urinary tract infection. Between10and15mL/second,combined bladder neck contracture or urethral stricture requir- pressure/ow studies may be done to exclude those ing surgery or dilatation, incontinence. The disad- Other options (not widely available) include: vantage of the latter, is that urinary catheterisation is r Stent which is cost-effective in those with a short required. Denition r Finasteride is a 5 alpha reductase inhibitor which in- Urinary incontinence is the involuntary loss of urine hibits the conversion of testosterone to dihydrotestos- from the urethra. It is also useful, but generally less effective for and functional impact on the individual. This is mainly due to detrusor instability/over- 30% of women <65 years but only up to 5% of men <65 activity. Rates are much higher in certain settings such as care of r Overow incontinence is continual or unprecipitated the elderly institutions (up to 45%) and psychiatric care leakage without urge. Bladder outow obstruction may lead Age to overow incontinence due to bladder decompen- Increases with age. Rare causes include spinal cord compression affecting the sacral segments (S2, 3 and 4) or the conus medullaris. F > M Acomprehensive examination is important and can avoid the need for specialist tests.

By Y. Navaras. Oregon Institute of Technology.

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