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Primitive neuroectodermal tumors (PNET) : Causes, Symptoms & Treatments

What exactly are PNET?  Are they the same as medulloblastomas?

Yes and no. Under a microscope, PNET tumors appear to be similar to a tumor called medulloblastoma, and some will classify medulloblastoma as “PNET (cerebellum).” However, it has been demonstrated that medulloblastomas behave differently than PNET in other locations in the brain.

According to the World Health Organization (WHO), all undifferentiated tumors—regardless of location—are derived from common cells and are therefore classified as PNET.  To differentiate, their location is frequently indicated in parentheses. This separates medulloblastoma (PNET cerebellum) and pineoblastoma (PNET in the pineal region) from other PNET such as PNET in the supratentorial compartment (meaning occurring in the cerebrum) or in the spine.

What causes a PNET?

Researchers have not been able to find an identifiable cause or risk factors for PNET. There doesn’t appear to be a genetic predisposition, meaning the disease does not seem to run in families.

What are the symptoms of a PNET?

The symptoms of a PNET depend on the location of the tumor, and each child may experience symptoms differently.  Symptoms of a PNET in the supratentorial compartment usually arise quickly and last up to several weeks. These tumors are often seen in the older child or teenager.

Some common symptoms occur due to increased pressure within the brain, including:

  • headache (generally upon awakening in the morning)
  • vomiting
  • fatigue/lethargy
  • seizures

Pineoblastomas (PNET in the pineal region, a tiny organ near the center of the brain) are usually seen in young children. Common symptoms may include increased pressure in the brain, resulting in:

  • headache (generally upon awakening in the morning)
  • vomiting
  • fatigue/lethargy
  • eye movement problems and/or complaints of double vision, since the tumor is close to the nuclei (centers in the brain) that regulate eye movements and coordination

Symptoms of PNET of the spine may include:

  • back and/or leg pain
  • slow development of weakness in the legs
  • impairment of bowel and/or bladder function, including incontinence
The symptoms of a PNET may resemble other conditions or medical problems. Always consult your child’s physician for a diagnosis.
 What are the treatments for PNET?

Specific treatment for PNET will be determined by your child’s physician based on:

  • your child’s age, overall health and medical history
  • type, location, and size of the tumor
  • extent of the disease
  • your child’s tolerance for specific medications, procedures or therapies
  • how your child’s doctors expects the disease to progress
  • your opinion or preference

Treatment may include (alone or in combination):

  • surgery– first to obtain a biopsy for diagnosis and to remove the tumor. The surgeons will try to get as much as the tumor out as possible, since aggressive tumor removal is associated with better long-term outcome. Removing the whole tumor is usually possible in the supratentorial tumors, but less frequently accomplished in the tumors of the pineal region and rarely in the spine.
  • radiation therapy– if your child’s tumors have been incompletely removed or if they recur, radiation therapy may be recommended. This type of therapy uses high-energy rays (radiation) from a specialized machine to kill cancer cells and shrink tumors. Usually, the radiation therapy is delivered first, followed by the chemotherapy. In infants, or children under the age of 3, radiation therapy is withheld.
  • chemotherapy- a drug treatment that works by interfering with the cancer cell’s ability to grow or reproduce
  • ventriculoperitoneal shunt (also called a VP shunt)– a bypass, usually a type of tubing, that is placed in the head to drain excess cerebrospinal fluid (CSF) from inside the brain to space in the abdomen. A VP shunt helps control the pressure inside the brain.

If there is hydrocephalus (swelling of the brain) in a pineoblastoma, another procedure called an ETV (endoscopic third ventriculostomy) may be necessary. There have been reports of these tumors traveling through shunts into the peritoneal cavity; therefore, all efforts are made to avoid placement of a shunt in these children.

How is chemotherapy given?

Different chemotherapies may be given:

  • as a pill to swallow
  • as an injection into the muscle or fat tissue
  • intravenously (directly to the bloodstream, also called IV)
  • intrathecally (directly into the spinal column with a needle)

How is chemotherapy used?

This depends on many factors.  Some things to keep in mind:

  • A number of combinations of chemotherapy drugs are currently being used to stabilize and, in some cases, to shrink the size of the tumor.
  • Depending on the type of cancer, chemotherapy drugs may be given in a specific order.
  • Chemotherapy may be used alone for some types of cancer, or in conjunction with other therapy such as radiation or surgery.

Does chemotherapy come with bad side effects?

While chemotherapy can be quite effective in treating certain cancers, the agents do not differentiate normal healthy cells from cancer cells. Because of this, there can be many adverse side effects during treatment. Being able to anticipate these side effects can help your child, family and your child’s health care team prepare for and sometimes prevent these symptoms from occurring.

How are side effects managed?

The side effects of therapy will depend on the surgery and other treatments that have been performed, including radiation therapy to the brain and spine.

Treatment for these side effects may include physical and occupational therapy (if your child experiences weakness or sensory loss), and speech therapy (if her speech is impaired), all on either an inpatient or outpatient basis.

What is the expected outcome after treatment for PNET?

Since these tumors are so rare and hard to classify, it’s difficult to analyze outcome and survival rates. The overall 5-year survival of patients with PNET is between 50 and 60 percent, but is clearly worse among infants and pineoblastoma patients with incomplete tumor removal or poor response to radiation therapy.

What about progressive or recurrent disease?

Relapsed PNET is almost always fatal and there are no good chemotherapy or other curative therapies available. There are trials looking at bone marrow transplantation with aggressive chemotherapy and use of novel biologic agents, but most of these are currently experimental.

What is the latest research on PNET?

A variety of chemotherapeutic regimens have been evaluated in the treatment of newly diagnosed high-grade gliomas.

  • While studies in adults have suggested that procarbazine, vincristine and CCNU (PVC) produce modest responses in grade III gliomas, this has not been demonstrated for pediatric cases or for grade IV tumors.
  • Several other regimens have also produced responses, but none has improved survival.
  • Increased doses of chemotherapy in the setting of autologous bone marrow transplant have also not produced notable advantage.


Myopathy : causes, symptoms & treatments

What is myopathy?

Myopathy refers to any disease that affects muscle tissue. Diseases of the muscle result in weakness, inflammation, tetany (spasms), or paralysis. Myopathy can be the result of either inherited or acquired causes.

Acute “acquired” myopathies, such as acute stiffness, spasm, or cramp, are common. Others are linked to exposure to an infectious agent, such as viruses or bacteria, or are inherited. However, certain cases of myopathy have no known associated risk factors.

What are the symptoms of myopathy?

Myopathy causes dysfunction of the muscles due to inflammation or disease and can cause a number of symptoms. The symptoms can vary in intensity among individuals.

  • Cramping
  • Pain
  • Paralysis
  • Rigidity
  • Stiffness
  • Swelling
  • Wasting (atrophy)
  • Weakness

Symptoms that might indicate a serious condition are

  • Difficulty swallowing
  • Muscle twitching or cramps in tongue, shoulders or arms
  • Muscle weakness in ankles, feet or legs
  • Slurred speech
  • Sudden weakness on one side of the body
  • Trouble raising the toes and foot

What causes myopathy?

Myopathy refers to any disease that affects the muscle tissue. Diseases of the muscle result in weakness, inflammation, tetany (spasms), or paralysis. Myopathy can be the result of either inherited or acquired causes.

Inherited causes of myopathy

Myopathy may be due to genetic conditions. Examples of some genetic conditions that result in myopathy include:


  • Congenital myopathies, that are present at birth
  • Familial periodic paralysis
  • Glycogen storage disease of muscle (including Pompe’s disease)
  • Mitochondrial myopathies (abnormalities of the cellular components known as mitochondria)
  • Muscular dystrophy

Acquired or unknown causes of myopathy

Myopathy may have acquired or unknown causes. Examples include:

  • Common muscle cramps
  • Dehydration (loss of body fluids and electrolytes, which can be life threatening when severe and untreated)
  • Endocrine disorders
  • Infection
  • Myositis (muscle inflammation)
  • Neuron disorders (typically neuromuscular diseases)

What are the risk factors for myopathy?

A number of factors increase the risk of developing myopathy. Not all people with risk factors will get myopathy. Risk factors for myopathy include:

  • Certain infections
  • Family history of myopathy

How is myopathy treated?

Treatment for myopathy begins with seeking medical care from your health care provider. To determine whether you have myopathy, your health care provider will ask you questions and ask you to undergo diagnostic testing. It is important to follow your treatment plan for myopathy precisely and to take all of the medications as instructed.

Treatment options for myopathy will depend on the specific type of condition or disease. Acute conditions such as muscle cramping may need treatment to stabilize electrolyte balance, increase hydration, and reduce inflammation (for example, ice therapy). It also may need immobilization, rest, or anti-inflammatory medicines. Both acquired and inherited chronic myopathies require supportive therapy, such as physical therapy, bracing, or surgery, to decrease inflammation if appropriate, reduce symptoms, and increase function. Pain management may be needed; options include nonsteroidal anti-inflammatory agents such as ibuprofen (Advil, Motrin). Immune disorders affecting the muscles may be treated with immunosuppressive drugs to reduce inflammation such as methotrexate or corticosteroids such as prednisone.



Hyperthermic Intraperitoneal Chemotherapy(HIPEC) : Treatments & Advantages

What is HIPEC?

Hyperthermic intraperitoneal chemotherapy (HIPEC) is a highly concentrated, heated chemotherapy treatment that is delivered directly to the abdomen during surgery.

Unlike systemic chemotherapy delivery, which circulates throughout the body, HIPEC delivers chemotherapy directly to cancer cells in the abdomen. This allows for higher doses of chemotherapy treatment. Heating the solution may also improve the absorption of chemotherapy drugs by tumors and destroy microscopic cancer cells that remain in the abdomen after surgery.

How it works

Before patients receive HIPEC treatment, doctors perform cytoreductive surgery to remove visible tumors within the abdomen. Cytoreductive surgery is accomplished using various surgical techniques. Once as many tumors as possible have been removed, the heated, sterilized chemotherapy solution is delivered to the abdomen to penetrate and destroy remaining cancer cells. The solution is 41 to 42 degrees Celsius, about the temperature of a warm bath. It’s circulated throughout the abdomen for approximately 1 ½ hours. The solution is then drained from the abdomen and the incision is closed.

HIPEC is a treatment option for people who have advanced surface spread of cancer within the abdomen, without disease involvement outside of the abdomen.

Advantages of HIPEC

  • Allows for high doses of chemotherapy
  • Enhances and concentrates chemotherapy within the abdomen
  • Minimizes the rest of the body’s exposure to the chemotherapy
  • Improves chemotherapy absorption and susceptibility of cancer cells
  • Reduces some chemotherapy side effects

Rotator Cuff Injury: Symptoms & Treatments

A rotator cuff injury can be painful and reduce range of motion.


The pain associated with a rotator cuff injury may:

  • Be described as a dull ache deep in the shoulder
  • Disturb sleep, particularly if you lie on the affected shoulder
  • Make it difficult to comb your hair or reach behind your back
  • Be accompanied by arm weakness

When to see a doctor

Shoulder pain that is short-lived may be evaluated by your family doctor. See your doctor right away if you have a sudden loss of motion after an injury — you could have a substantial rotator cuff tear. If you have pain lasting longer than a few weeks or you’ve been formally diagnosed with a rotator cuff tear, you need to be seen by a shoulder specialist, because some of the surgical procedures are time sensitive.


Rotator cuff disease may be the result of either a substantial injury to the shoulder or to progressive degeneration or wear and tear of the tendon tissue. Repetitive overhead activity, heavy lifting over a prolonged period of time, and the development of bone spurs in the bones around the shoulder may irritate or damage the tendon.

Risk factors

The following factors may increase your risk of having a rotator cuff injury:

  • Age. As you get older, your risk of a rotator cuff injury increases. Rotator cuff tears are most common in people older than 40.
  • Certain sports. Athletes who regularly use repetitive arm motions, such as baseball pitchers, archers and tennis players, have a greater risk of having a rotator cuff injury.
  • Construction jobs. Occupations such as carpentry or house painting require repetitive arm motions, often overhead, that can damage the rotator cuff over time.
  • Family history. There may be a genetic component involved with rotator cuff injuries as they appear to occur more commonly in certain families.


Without treatment, rotator cuff disease may lead to permanent stiffness or weakness and may result in progressive degeneration of the shoulder joint.

Although resting your shoulder is necessary for your recovery, keeping your shoulder immobilized for a prolonged time can cause the connective tissue enclosing the joint to become thickened and tight (frozen shoulder).

Conservative treatments — such as rest, ice and physical therapy — sometimes are all that’s needed to recover from a rotator cuff injury. If your injury is severe and involves a complete tear of the muscle or tendon, you might need surgery.


If conservative treatments haven’t reduced your pain, your doctor might recommend a steroid injection into your shoulder joint, especially if the pain is interfering with your sleep, daily activities or exercise. While such shots are often helpful, they should be used judiciously, as they can contribute to weakening of the tendon.


Physical therapy exercises can help restore flexibility and strength to your shoulder after a rotator cuff injury. Sometimes it is possible to eliminate pain and restore function without surgery.


Many different types of surgeries are available for rotator cuff injuries, including arthroscopic tendon repair, open tendon repair, bone spur removal, tendon transfer and shoulder replacement.

Arthroscopic tendon repair

In this procedure, surgeons insert a tiny camera (arthroscope) and tools through small incisions to reattach the torn tendon to the bone. Arthroscopic tendon repair can provide restoration of the patient’s normal anatomy with a relatively pain-free procedure.

  • Open tendon repair

In some situations, an open tendon repair may be a better option. In these types of surgeries, your surgeon works through a larger incision to reattach the damaged tendon to the bone. Open tendon repairs typically have a longer recovery time than that seen with more minimally invasive procedures done arthroscopically.

one spur removal

If an overgrowth of bone is irritating your rotator cuff, this excess bone can be removed and the damaged portion of the tendon can be smoothed. This procedure is often performed using arthroscopy, where a fiber-optic camera and special tools are inserted through tiny incisions.

Tendon transfer

If the torn tendon is too damaged to be reattached to the arm bone, surgeons may decide to use a nearby tendon as a replacement.

  • Reverse shoulder replacement

Massive rotator cuff injuries may require shoulder replacement surgery. To improve the artificial joint’s stability, an innovative procedure (reverse shoulder arthroplasty) installs the ball part of the artificial joint onto the shoulder blade and the socket part onto the arm bone.

Novalis Tx Radiation Therapy for Cancer Treatment

Novalis Tx Radiation Therapy

Novalis Tx is a radiosurgery system that is one of the most advanced cancer treatments available. Radiosurgery is a highly precise form of radiation therapy that uses a beam of energy shaped to match the outline of the tumor. It delivers energy precisely where it is needed.

The Novalis Tx uses a radiation beam that rotates around the patient. It can send energy anywhere in the body, from almost any direction.

Because the Novalis Tx is so precise, your doctor can be confident that the best possible treatment dose is delivered while healthy tissue is protected. The focused beam can even adapt to your breathing, making it effective for treating some lung cancers.

Other radiosurgery systems use a circular beam. Because most tumors have an irregular shape, the circular beam cannot cover them completely. Radiation treatment is not as precise.

Novalis Tx radiation therapy for cancer

Novalis Tx radiosurgery is used to treat brain, spine and other cancers.

Brain tumors treated with Novalis Tx include:

  • Craniopharyngiomas
  • Gliomas
  • Skull base meningiomas
  • Brain tumors in children
  • Brain cancer that has recurred (come back) after treatment
  • Other types of cancer that have spread to the brain.

Other tumors treated with Novalis Tx radiosurgery include:

  • Lung, liver and prostate cancer
  • Spinal cancer
  • Pituitary gland tumors
  • Acoustic neuromas

Novalis Tx radiation therapy can also treat seizures, Parkinson’s disease and other non-cancerous conditions.

Benefits of Novalis Tx radiosurgery

Precise radiation therapy

Using advanced imaging and computer systems, the Novalis Tx radiosurgery system shapes the radiation beam around your tumor. Novalis Tx radiation therapy even adapts to breathing and other body movements.

Benefits of shaped beam treatment include:

  • The best possible treatment dose for the entire tumor
  • Healthy tissue is protected
  • Radiation treatments are safe, complete and accurate

With Novalis Tx, the shaped radiation beam moves around you, and the radiosurgery treatment bed is fully adjustable. Both the beam and your position can be adjusted so radiation only reaches the area needing treatment.

Faster radiation treatments

Because the Novalis Tx radiosurgery system is so precise, treatment can often be delivered faster than with other forms of radiation therapy.

  • Treatment time can be as little as 15 to 20 minutes
  • More comfortable than other radiosurgery treatment options
  • Less chance of body movement, making treatment more accurate
  • Treatment can be as short as a single day

At the OHSU Knight Cancer Institute, your doctor and healthcare team will work with you to decide if a single Novalis Tx radiosurgery treatment or series of treatments is right for you.

Personalized cancer treatment

The Novalis Tx radiosurgery system can be used to deliver a wide range of treatments. This ensures that you get the best treatment for your condition. Other radiosurgery devices only deliver one type of treatment.

  • Novalis Tx can deliver a more powerful dose to treat tumors deep inside the body or brain
  • Some tumors previously considered untreatable can be helped with Novalis Tx

Novalis Tx radiosurgery is a comfortable, non-invasive treatment

With some forms of radiation therapy, patients wear a frame to keep the head still during treatment. The Novalis Tx system offers frameless radiosurgery, which is more comfortable for most patients. Depending on the area needing radiosurgery, you might wear a custom-fit mask to keep your head in the best position for treatment.

In most cases, treatment with Novalis Tx is not painful. You do not need anesthesia. Every patient responds differently to treatment, but many patients are able to get back to their normal routines a few hours after Novalis Tx radiosurgery.

After treatment, you might feel slightly tired, dizzy or have a headache. Ask someone to drive you home after your treatment. If you have questions or experience any side effects, talk to your cancer treatment team.


Fetal Echocardiography : Uses, Symptoms & Treatments

When Is Fetal Echocardiography


Not all pregnant women need a fetal echocardiogram. For most women, a basic ultrasound will show that all four chambers of their baby’s heart have developed. Your obstetrician may recommend that you have this procedure done if previous tests detected an abnormal heartbeat in the fetus.

You may also need this test if:

  • your unborn child is at risk for a heart abnormality or other disorder present at birth
  • you have a family history of heart disease
  • you already have a child with a heart condition
  • you’ve used drugs or alcohol during your pregnancy
  • you’ve taken certain medications or been exposed to medications that can cause heart defects, such as medications used to treat epilepsy or prescription acne drugs
  • you have other medical conditions, including rubella, type 1 diabetes, lupus, or phenylketonuria, which is an inability to break down an important amino acid called phenylalanine

Some obstetricians can perform this test themselves. Usually, an experienced ultrasound technician, or ultrasonographer, performs the test. A cardiologist who specializes in pediatric medicine will then review the results after your test is finished.

What Happens During the Examination?

This test is similar to a routine pregnancy ultrasound. If it’s performed through your abdomen, it’s called an abdominal echocardiography. If it’s performed through your vagina, it’s called a transvaginal echocardiography.

Abdominal Echocardiography

An abdominal echocardiography is very much like an ultrasound. You’ll be asked to lie down and expose your belly. An ultrasound technician will apply a special lubricating jelly to your skin. This prevents friction so that the ultrasound transducer, which is a device that sends and receives sound waves, can be rubbed on your skin. The jelly also helps transmit the sound waves.

The transducer sends high-frequency sound waves through your body. The waves echo as they hit a dense object, such as your unborn child’s heart. Those echoes are then reflected back into a computer. The sound waves are too high-pitched for the human ear to hear.

The technician will move the transducer all around your stomach to get images of different parts of your baby’s heart.

After the procedure, the gel will be cleaned off your abdomen. You can then continue with your normal activities.

Transvaginal Echocardiography

For a transvaginal echocardiography, you’ll be asked to undress from the waist down and lie on the exam table. A technician will insert a small probe into your vagina. From there, the probe will use sound waves to create an image of your baby’s heart.

A transvaginal echocardiography is typically used in earlier stages of pregnancy. It may provide a clearer image of the fetal heart.

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Are There Any Risks Associated with This Exam?

There are no risks associated with the echocardiogram because it uses ultrasound technology and no radiation.

What Do the Results Mean?

During your follow-up appointment, your doctor will explain the results to you, answer any questions you might have, and refer you to any appropriate resources or specialists needed to treat your unborn child’s condition.

Generally, normal results mean that no cardiac abnormality was found. If your doctor finds an issue, such as a heart defect, rhythm abnormality, or other problem, you may need to have more tests, such as a fetal MRI or other high-level ultrasounds. You may also need to have this test done more than once or go in for additional testing if your doctor thinks something else could be wrong.

It’s important to remember that an echocardiography can’t always be used to diagnose every condition. Some problems, such as a hole in the heart, are difficult to see even with advanced equipment. Your doctor will explain what the test can and cannot di

Why Is This Test Important?

Abnormal results from a fetal echocardiography can be inconclusive or require that you get more testing to figure out what might be wrong. Once a diagnosis is determined, you can better manage your pregnancy and prepare for delivery. Information from this test will help you and your doctor plan any treatments that may need to happen after delivery, such as correctional surgery. You can also get the support and counseling you need to make good decisions for the remainder of your pregnancy.


Double Vision : Causes, Symptoms & Treatments

What is double vision?

Double vision is the perception of two images of a single object seen adjacent to each other (horizontally, vertically, or obliquely) or overlapping. Double vision is medically termed diplopia. Polyplopia is the perception of three or more images of a single object overlapping each other.

What causes double vision?

There are dozens of causes of double vision ranging from benign to life-threatening. Therefore, it is important for the doctor to carefully review the history and the examination to determine the cause and initiate appropriate treatment when necessary. Sometimes, emergency treatment is needed.

Most causes of monocular diplopia stem from poor focusing of light by the eye. Refractive errors (myopia, hyperopia, astigmatism) are common. Dry eye (from a variety of causes such as meibomitis, Sjögren’s syndrome, and decreased tear production following refractive surgery) can produce diplopia that varies with blinking. Cataracts (clouding of the natural lens) and posterior capsule opacification (after cataract surgery) are common in people over 60 years of age. Other conditions that interfere with proper focusing of light include corneal irregularity from swelling or scars and retinal conditions, such as epiretinal membranes. Rarely is the underlying cause a medical emergency in cases of monocular diplopia.

Binocular diplopia on the other hand is produced by a misalignment of the eyes, which can be caused by life-threatening conditions. For example, aneurysms, strokes, trauma (head injury), and brain swelling (such as from brain cancer) can interfere with the nerves that control the extraocular muscles. The extraocular muscles move the eyes in different direction of gaze, much like the strings on a marionette, and when one or more muscle is weakened or paralyzed, it is referred to as cranial nerve palsy. In multiple sclerosis, lesions in regions of the brain that control eye alignment may result in diplopia that varies over time. Guillain-Barré syndrome can produce diplopia from restricted eye movement due to nerve damage. Migraineheadaches can cause a sudden but temporary eye misalignment. Diseases such as myasthenia gravis can interfere with the communication between the nerves and the eye muscles to cause diplopia. And the eye muscles themselves can be damaged or compressed by conditions such as Graves’ disease (often associated with thyroid disease), orbital inflammations, vascular disease (as seen with diabetes and high blood pressure), and others. Following traumatic fracture of the orbital bones, muscles and orbital tissue may be trapped in the fracture, leading to restriction of eye movement in certain directions of gaze. Sometimes the cause is relatively harmless, such as when the eye muscles or neurologic signals to the muscles weaken with fatigue or illness. Inability to align the eyes when focusing on a near object (convergence insufficiency) is a common benign cause of intermittent binocular diplopia that can often be treated with prism glasses.


What are the symptoms and signs of double vision?

Images may appear to overlap each other or may appear adjacent to each other. Diplopia may vary depending on the direction of gaze or with tilting or turning of the head.

One of the most critical features to determine is whether the diplopia is monocular or binocular. In monocular diplopia, the double vision is caused by a condition within one or both eyes and does not resolve when one eye is covered. In binocular diplopia, the eyes are misaligned. Each eye sees a single image when working alone, as when one eye is covered, but when both eyes are open the brain perceives two adjacent images.

How do health-care professionals diagnose the cause of double vision?

A thorough evaluation of double vision begins with a detailed history of the diplopia, including onset (gradual or sudden), duration, frequency (intermittent or constant), and variability with head position or eye gaze, noting any associated symptoms (pain, headache, nausea, and weight loss among others), and a complete history of past and current medical conditions. The physical examination includes measuring the visual acuity in each eye and assessing whether the diplopia is monocular or binocular. Careful examination of the eyes’ alignment in various head positions is performed if the diplopia is binocular. A complete eye examination, which may include dilating the eyes, is performed to look for any ocular or orbital abnormalities. Particular attention is paid to the pupils and eyelid position if a neurologic cause is suspected. In some instances, specialized imaging (topography, CT, MRI, etc.) and other tests are needed to further investigate possible causes. When a life- or vision-threatening cause is suspected, time may is of the essence.

What is the treatment for double vision?

Once the underlying cause has been determined, treatment is tailored to the underlying condition.

Diplopia stemming from refractive errors (myopia, hyperopia, astigmatism) can be corrected with glasses or contact lenses. Dry eyes are treated with artificial tears, punctal plugs, warm compresses, and a variety of other treatments. Cataracts are removed with surgery, and posterior capsule opacification (after cataract surgery) is treated with laser. It is uncommon for the cause of monocular diplopia to be a medical emergency.

Binocular diplopia on the other hand can be caused by life-threatening conditions, and emergency treatment may be necessary. This is particularly the case with aneurysms, head trauma, stroke, and other neurologic conditions. Any onset of diplopia with accompanying neurologic symptoms such as headache, nausea, dizziness, loss of balance, etc., should be evaluated immediately.

Diplopia produced by chronic diseases (see causes above) may subside with treatment of the underlying disease. If eye muscles are engorged (such as from Graves’ disease) or entrapped (as after traumatic orbital fracture), surgery of the muscles or surrounding tissue may correct the problem.

Convergence insufficiency, or inability to align the eyes when focusing on a near object, is a common benign cause of intermittent binocular diplopia when reading. It can improve with eye exercises (“pencil pushups” prescribed by the eye doctor).

Often glasses with prisms can be worn to correct binocular diplopia. If the diplopia is expected to resolve, temporary prisms (Fresnel prisms) can be added to glasses and later removed when the eyes realign.

Different types of fibroids and it’s treatments

What are the different types of fibroids?

There are many different types of fibroids. Depending on their size and location, fibroids can present with a wide range of symptoms.

Fibroids can be divided into submucosal, intramural or subserosal:

  • Submucosal fibroids: These fibroids are located just underneath the endometrium, or lining of the uterus, and protrude into the uterine cavity.  Submucosal fibroids can vary in how much of the fibroid protrudes into the uterine cavity and how much is in the muscle of the uterus. They often cause heavy bleeding and long periods, but they can also cause irregular bleeding.

  • Intramural fibroids:  These fibroids are found predominantly in the myometrium, or muscle of the uterus. Depending on their size and location, these fibroids can also extend toward and distort the uterine cavity or protrude outside the uterus.  Intramural fibroids can be asymptomatic (causing no symptoms), cause bleeding abnormalities, or cause pressure and bulk symptoms.
  • Subserosal fibroids: These fibroids are located near the outside of the uterus.  They can be partially in the myometrium (muscle of the uterus) or hanging off the outside of the uterus. They can cause bulk symptoms such as bladder or rectal pressure.

What symptoms do fibroids cause?

Most fibroids cause no symptoms at all. Depending on their size, location and number, fibroids can become significantly problematic.

Some common symptoms associated with fibroids include:

  • Abnormal uterine bleeding, heavy or long periods
  • Bulk and pressure symptoms
  • Bladder pressure, frequent urination
  • Rectal pressure, constipation
  • Infertility or recurrent miscarriages/pregnancy loss
  • Pregnancy complications
  • Pain
  • Anemia

What are the treatment options for fibroids?

There is a wide range of treatment options for fibroids.  Many factors influence treatment choice.  These include symptoms, fibroid location, size and number, age, reproductive plans and a woman’s preferences.

There is medical management:

  • Gonadotropin-releasing hormone agonists (GnRH agnosits):This medication is given as an injection (shot), either every month or every three months, and puts you in a temporary state of menopause. While on the medication the fibroids shrink. Once the medication is stopped, the fibroids usually re-grow and symptoms return. GnRH agonists are usually used to prepare women for surgery or to bridge women close to their natural menopause. GnRH agonists are not usually used for long-term treatment.

Other hormone treatments, including:

  • Progestins (oral, by injection or intra-uterine device [IUD]), oral contraceptive pills, androgenic agents (such as danazol) and anti-estrogens (such as raloxifene) have been used to try to control heavy bleeding in women with fibroids. However, these medications do not consistently decrease the size of the fibroids or uterus and are usually ineffective in reducing the amount of bleeding.

There is surgical management:

  • The surgical procedures provided at the MIGS Center combine current technology, and medical and surgical expertise to treat fibroids on an outpatient basis.
  • Myomectomy is a surgical procedure in which only the fibroids are removed, preserving the uterus. As an alternative to hysterectomy, one advantage of a myomectomy is that with the uterus in place, childbearing remains an option. A disadvantage of a myomectomy is that when the uterus remains in place, fibroids can recur, sometimes requiring additional surgery.


Fibroids can be removed by hysteroscopic myomectomy, laparoscopic myomectomy or an open abdominal myomectomy.

  • Hysteroscopic myomectomy is a technique used to remove fibroids that are submucosal. A hysteroscope, a thin tube containing a video camera, is passed through the cervix and into the uterus. The fibroid is then removed by shaving it out. There are no incisions with a hysteroscopic myomectomy. It is a day surgery procedure (you typically leave the hospital 1 hour after the completion of the procedure) with a 1-day recovery period.
  • Laparoscopic myomectomy is a technique used to remove fibroids that are intramural (deep in the muscle of the uterine wall), subserosal or pedunculated(on the outside of the uterus).  This minimally invasive technique uses a laparoscopic technique to remove the fibroids through very small incisions. It is a day surgery procedure (you typically leave the hospital 1-2 hours after the completion of the procedure) with a 1-2 week recovery period.
  • Open myomectomy uses a traditional large abdominal incision to remove the fibroids. Most fibroids can be removed by minimally invasive techniques; the use of the open method is limited to women with specific situations where laparoscopic or hysteroscopic removal of fibroids is not appropriate.
  • Uterine Artery Embolization/Uterine Fibroid Embolization (UAE/UFE) is performed by an interventional radiologist.  The blood flow to the uterus and/or fibroid is blocked, leading to necrosis and a gradual shrinkage of the fibroid.
  • MR-Guided Focused Ultrasound uses ultrasound energy to heat and destroy the fibroid causing gradual shrinkage of the fibroid.
  • Fibroids can be treated with a hysterectomy, which involves removing the uterus with the fibroids. The hysterectomy can typically be done in a minimally invasive way.

Intestinal Failure: Causes, Symptoms and Treatments

If you have intestinal failure, you may receive all or most of your nutrients and calories intravenously through total parenteral nutrition (TPN). TPN is given through a catheter placed in the arm, groin, neck or chest. Patients on TPN may live for many years, but long-term use of TPN can result in serious complications, such as bone disorders, central venous catheter infections and liver disease. Our goal is to restore intestinal function to minimize and ultimately eliminate the need for TPN. Unfortunately, not every patient can be weaned from TPN. In these cases, we work to optimize the use of TPN and decrease the risk of complications.


Patients who may benefit from being treated at the Intestinal Rehabilitation and Transplantation Program include:

Adults with intestinal failure caused by:

  • Desmoid tumor, a benign growth of tissue that can develop in the abdomen
  • Fistulae or an abnormal duct that connects an abscess, cavity or hollow organ to the body surface or to another hollow organ
  • Inflammatory bowel disease, such as Crohn’s disease where chronic inflammation occurs in the intestines
  • Multiple intestinal surgeries resulting in adhesions, motility problems that may lead to abnormal intestinal contractions and spasms
  • Pseudoobstruction that impairs gastrointestinal motility despite the absence of an actual obstruction
  • Radiation enteritis, a disorder of the large and small bowel that occurs during or after a course of radiation therapy to the abdomen, pelvis or rectum
  • Refractory celiac disease, also known as sprue, a digestive disease that damages the small intestine and interferes with absorption of nutrients from food
  • Superior mesenteric artery/vein thrombosis
  • Trauma
  • Tumor resection
  • Volvulus or an abnormal rotation of the intestine


The Intestinal Rehabilitation and Transplantation Program offers a wide range services for adults and children. The type and length of treatment differs for each patient, depending on the needs and goals.

Services include:

  • Counseling and education about intestinal rehabilitation
  • Drug and diet modification to train the small intestine to absorb more nutrients
  • Consultations to help assess and correct nutrient deficiencies and prevent damage to kidneys, bones and liver
  • Management of TPN to avoid complications
  • Placement and management of catheters in veins called central venous lines
  • Surgery, such as bowel lengthening and tapering that can help increase bowel length and nutrient absorption
  • Intestinal transplants
  • Consultations with doctors caring for patients with intestinal failure

For patients dependent on TPN, the program provides services to help patients:

  • Reduce or eliminate the need for TPN
  • Reduce complications associated with TPN
  • Decrease diarrhea and/or vomiting
  • Gain weight
  • Decrease the need for intestinal transplantation


Acne: Causes and Treatments

Acne, medically known as Acne Vulgaris, is a skin disease that involves the oil glands at the base of hair follicles. It commonly occurs during puberty when the sebaceous (oil) glands come to life – the glands are stimulated by male hormones produced by the adrenal glands of both males and females.

Acne is not dangerous, but can leave skin scars. Human skin has pores (tiny holes) which connect to oil glands located under the skin. The glands are connected to the pores via follicles – small canals. These glands produce Sebum, an oily liquid. The sebum carries dead skin cells through the follicles to the surface of the skin. A small hair grows through the follicle out of the skin. Pimples grow when these follicles get blocked, resulting in an accumulation of oil under the skin.

Causes of acne

Nobody is completely sure what causes acne. Experts believe the primary cause is a rise in androgen levels – androgen is a type of hormone. Androgen levels rise when a human becomes an adolescent. Rising androgen levels make the oil glands under your skin grow; the enlarged gland produces more oil. Excessive sebum can break down cellular walls in your pores, causing bacteria to grow.

Some studies indicate that a susceptibility to acne could also be genetic. Some medications that contain androgen and lithium may cause acne. Greasy cosmetics may cause acne in some susceptible people. Hormone changes during pregnancy may cause acne either to develop for the first time, or to recur.

The types of acne pimples

Hair follicle with acne
Human skin has pores (tiny holes) which connect to oil glands located under the skin. The glands are connected to the pores via follicles – small canals. These glands produce Sebum, an oily liquid. The sebum carries dead skin cells through the follicles to the surface of the skin.
  • Whiteheads – remain under the skin and are very small
  • Blackheads – clearly visible, they are black and appear on the surface of the skin. Remember that a blackhead is not caused by dirt. Scrubbing your face vigorously when you see blackheads will not help
  • Papules – visible on the surface of the skin. They are small bumps, usually pink
  • Pustules – clearly visible on the surface of the skin. They are red at their base and have pus at the top
  • Nobules – clearly visible on the surface of the skin. They are large, solid pimples. They are painful and are embedded deep in the skin
  • Cysts – clearly visible on the surface of the skin. They are painful, and are filled with pus. Cysts can easily cause scars


How common is acne?

Dermatologists (skin specialists) say that approximately three-quarters of 11 to 30 year-olds will get acne at some time. Acne can affect people of all races and all ages. It most commonly affects adolescents and young adults, although there are people in their fifties who still get acne. According to Brown University, USA, approximately 17 million Americans are estimated to have acne at any one time.

Although acne affects both men and women, young men suffer from acne for longer – probably because testosterone, which is present in higher quantities in young men, can make acne worse.

Treating mild acne :

The majority of people who get acne will develop mild acne. This can usually be treated with OTC (over-the-counter) medications. OTC medications can be bought at a pharmacy without a doctor’s prescription. They are usually applied to the skin – topical medicines.

Most acne OTC products may contain the following active ingredients:

  • ResorcinolResorcinol helps break down blackheads and whiteheads. It is a crystalline phenol and comes from various resins. Resorcinol is also used for treating dandruff, eczema and psoriasis.
  • Benzoyl PeroxideBenzoyl Peroxide kills bacteria and slows down your glands’ production of oil. Benzoyl peroxide is a white crystalline peroxide used in bleaching (flour or oils or fats) and as a catalyst for free radical reactions. It works as a peeling agent, accelerating skin turnover and clearing pores, which in turn reduces the bacterial count in the affected area.
  • Salicylic AcidSalicylic Acid helps break down blackheads and whiteheads, also reduces shedding of cells which line the follicles of the oil glands, effective in treating inflammation and swelling. Salicylic acid is a white crystalline substance which is also used as a fungicide, or in making aspirin or dyes or perfumes. It causes the epidermis to shed skin more easily, prevents pores from becoming blocked while at the same time allowing room for new cells to grow. It is commonly added to shampoos used for treating dandruff.
  • SulfurSulfur helps break down blackheads and whiteheads. Sulfur, in its native form, is a yellow crystalline solid. Sulfur has been used for centuries for treating acne, psoriasis and eczema. Scientists are not sure how sulfur works to help skin diseases. We do know that elemental sulfur does oxidize slowly to sulfurous acid, which is a mild reducing and antibacterial agent.
  • Retin-ARetin-A helps unplug blocked pores. Retin-A contains Tretinoin, an acid from of vitamin A, also known as all-trans retinoic acid (ATRA). Tretinoin is also used for the treatment of acute promyelocytic leukemia. Retin-A has been used widely to combat aging of the skin, and it also acts as a chemical peel.
  • Azelaic AcidAzelaic Acid strengthens cells that line the follicles, stops oil eruptions, reduces bacteria growth. It is a saturated dicarboxylic acid found naturally in wheat, rye, and barley. Azelaic acid also mops up free radicals, which reduces inflammation. It is useful for patients with darker skin who have dark patches on their face (melasma), or whose acne spots leave persistent brown marks.