John T. Malcynski, M.D.

• Instructor of Surgery and Trauma
• Surgical Critical Care Fellow
• University of Pennsylvania
• Philadelphia, PA

Surgical and endovascular intervention is not indicated in patients with severe decrements in limb perfusion gastritis diet 0 carbs order 150 mg ranitidine with visa. Acute Limb Ischemia Acute limb ischemia is defined as a rapid or sudden decrease in limb perfusion that threatens limb viability (see Figure 6) gastritis reviews purchase ranitidine 150mg free shipping. Patients with acute limb ischemia and a salvageable extremity should undergo an emergency evaluation that defines the anatomic level of occlusion and that leads to prompt endovascular or surgical revascularization gastritis medicina natural order ranitidine pills in toronto. Patients with acute limb ischemia and a nonviable extremity should not undergo an evaluation to define vascular anatomy or efforts to attempt revascularization gastritis fiber buy ranitidine 300 mg on-line. Surveillance for Patients After Lower Extremity Revascularization Patients who have undergone revascularization procedures require long-term care and vascular follow-up to detect recurrence of disease at revascularized sites gastritis disease definition order ranitidine with amex, as well as development of new disease at remote sites gastritis zimt buy ranitidine 150 mg cheap. Duplex ultrasound is recommended for routine surveillance following femoral-popliteal or femoral tibial-pedal bypass using venous conduit. Minimum surveillance intervals are approximately 3 months, 6 months, 12 months, and then yearly following graft placement. Surveillance Program for Infrainguinal Vein Bypass Grafts Patients undergoing vein bypass graft placement in the lower extremity for the treatment of claudication or limb-threatening ischemia should be entered into a surveillance program. Patients who are smokers or former smokers should be asked about status of tobacco use at every visit. Patients should be assisted with counseling and developing a plan for quitting that may include pharmacotherapy and/or referral to a smoking cessation program. For all patients in the absence of contraindication, 1 or more of the following pharmacological therapies should be offered: varenicline, bupropion, and nicotine replacement therapy*. Onset of hypertension before the age of 30 years or severe hypertension after the age of 55. Unexplained atrophic kidney or size discrepancy between kidneys of greater than 1. Unexplained renal dysfunction, including individuals starting renal replacement therapy. Mesenteric Arterial Disease Acute intestinal ischemia may occur due to thromboembolism, a hypercoagulable state, arterial dissection, or nonocclusive low flow states. Patients with acute abdominal pain out of proportion to physical findings and who have a history of cardiovascular disease should be suspected of having acute intestinal ischemia. In contrast to chronic intestinal ischemia, duplex sonography of the abdomen is not an appropriate diagnostic tool for suspected acute intestinal ischemia. Percutaneous interventions (including transcatheter lytic therapy, balloon angioplasty and/or stenting) are appropriate in selected patients with acute intestinal ischemia caused by arterial obstructions. Arteriography is indicated in patients suspected of nonocclusive intestinal ischemia whose condition does not improve rapidly with treatment of their underlying disease. Treatment of the underlying shock state is the initial most important step in treatment of nonocclusive intestinal ischemia. Laparotomy and resection of nonviable bowel is indicated in patients with nonocclusive intestinal ischemia who have persistent symptoms despite treatment. Transcatheter administration of vasodilator medications into the area of vasospasm is indicated in patients with nonocclusive intestinal ischemia who do not respond to systemic supportive treatment, or in patients with intestinal ischemia due to cocaine or ergot poisoning. Chronic intestinal ischemia should be suspected in patients with abdominal pain and weight loss, without other explanation, especially those with cardiovascular disease. Duplex ultrasound, computed tomography angiography, and gadolinium enhanced magnetic resonance angiography are useful initial tests for supporting the clinical diagnosis of chronic intestinal ischemia. Diagnostic angiography, including lateral aortography, should be obtained in patients suspected of having chronic intestinal ischemia for whom noninvasive imaging is unavailable or indeterminate. Percutaneous endovascular treatment of intestinal arterial stenosis is indicated in patients with chronic intestinal ischemia. Surgical treatment of chronic intestinal ischemia is indicated in patients with chronic intestinal ischemia. Revascularization of asymptomatic intestinal arterial obstructions may be considered for patients undergoing aortic/renal artery surgery for other indications. Surgical revascularization is not indicated for patients with asymptomatic intestinal arterial obstructions, except in patients undergoing aortic/ renal artery surgery for other indications. Aneurysms of the Abdominal Aorta, Its Branch Vessels, and the Lower Extremities Arterial aneurysms share many of the same atherosclerotic risk factors and pose similar threats to life, limb, and vital organ function as occlusive artery disease. The presence of most common aneurysms can be suspected on the basis of an attentive physical examination and subsequently confirmed by noninvasive, widely available imaging studies. Patients with aneurysms or a family history of aneurysms should be advised to stop smoking and be offered smoking cessation interventions, including behavior modification, nicotine replacement, or bupropion. In patients with the clinical triad of abdominal and/or back pain, a pulsatile abdominal mass and hypotension, immediate surgical evaluation is indicated. In patients with symptomatic aortic aneurysms, repair is indicated regardless of diameter. Perioperative administration of beta-adrenergic blocking agents, in the absence of contraindications, is indicated to reduce the risk of adverse cardiac events and mortality in patients with coronary artery disease undergoing surgical repair of atherosclerotic aortic aneurysms. Beta-adrenergic blocking agents may be considered to reduce the rate of aneurysm expansion in patients with aortic aneurysms. For patients who have undergone endovascular repair of infrarenal aortic and/or iliac aneurysms, periodic long-term surveillance imaging should be performed to monitor for an endoleak, document shrinkage or stability of the excluded aneurysm sac, and to determine the need for further intervention. Repair can be beneficial in patients with infrarenal or juxtarenal abdominal aortic aneurysms 5. Endovascular repair of infrarenal aortic and/or common iliac aneurysms is reasonable in patients at high risk of complications from open operations because of cardiopulmonary or other associated diseases. Endovascular repair of infrarenal aortic and/or common iliac aneurysms may be considered in patients at low or average surgical risk. Intervention is not recommended for asymptomatic infrarenal or juxtarenal abdominal aortic aneurysms if they measure less than 5. Periodic long-term surveillance imaging should be performed to monitor for endoleak, confirm graft position, document shrinkage or stability of the excluded aneurysm sac, and determine the need for further intervention in patients who have undergone endovascular repair of infrarenal aortic and/or iliac aneurysms. Open aneurysm repair is reasonable to perform in patients who are good surgical candidates but who cannot comply with the periodic long-term surveillance required after endovascular repair. Endovascular repair of infrarenal aortic aneurysms in patients who are at high surgical or anesthetic 53 Figure 11. Visceral Arterial Aneurysms Visceral artery aneurysms are insidious because they usually cannot be detected by physical examination and may be overlooked on radiographs or computed tomography/magnetic resonance scanning. Risk factors include portal hypertension, prior liver transplantation, and multiparous women. Open repair or catheter-based intervention is indicated for visceral aneurysms measuring 2 cm in diameter or larger in women of childbearing age who are not pregnant and in patients of either gender undergoing liver transplantation. Open repair or catheter-based intervention is probably indicated for visceral aneurysms 2 cm in diameter or larger in women beyond childbearing age and in men. Lower Extremity Arterial Aneurysms In general, lower extremity arterial aneurysms are considered to be significant when the minimum diameter reaches 3. Patients with a palpable popliteal mass should undergo an ultrasound examination to exclude popliteal aneurysm. Patients with anastomotic pseudoaneurysms or symptomatic femoral artery aneurysms should undergo repair. Surveillance by annual ultrasound imaging is suggested for patients with asymptomatic femoral artery true aneurysms smaller than 3. In patients with acute ischemia and popliteal artery aneurysms and absent runoff, catheter directed thrombolysis and/or mechanical thrombectomy is suggested to restore distal runoff and resolve emboli. In patients with asymptomatic enlargement of the popliteal arteries twice the normal diameter for age and gender, annual ultrasound monitoring is reasonable. In patients with femoral or popliteal artery aneurysms, administration of antiplatelet medication may be beneficial. Femoral Artery Pseudoaneurysms Femoral artery pseudoaneurysms may occur after blunt trauma, access for catheter-based procedures, injury resulting from puncture for drug abuse, or disruption of a previous suture line (see Figure 13). Patients with suspected femoral pseudoaneurysms should be evaluated by duplex ultrasonography. Initial treatment with ultrasound-guided compression or thrombin injection is recommended in patients with large and/or symptomatic femoral artery pseudoaneurysms. Reevaluation by ultrasound 1 month after the original injury can be useful in patients with asymptomatic femoral artery pseudoaneurysms smaller than 2. Withhold for at least 28 days non-small cell lung cancer, in combination with carboplatin and paclitaxel prior to elective surgery. Discontinue for Grade 3-4 o in combination with carboplatin and paclitaxel, followed by Avastin hemorrhage (5. Withhold if o in combination with carboplatin and paclitaxel or carboplatin and not medically controlled; resume once controlled. Discontinue for gemcitabine, followed by Avastin as a single agent, for platinum hypertensive crisis or hypertensive encephalopathy. Limitations of Use: Avastin is not indicated for adjuvant treatment of colon cancer [see Clinical Studies (14. Avastin, in combination with paclitaxel, pegylated liposomal doxorubicin, or topotecan, is indicated for the treatment of patients with platinum-resistant recurrent epithelial ovarian, fallopian tube or primary peritoneal cancer who received no more than 2 prior chemotherapy regimens. Avastin, in combination with carboplatin and paclitaxel, or with carboplatin and gemcitabine, followed by Avastin as a single agent, is indicated for the treatment of patients with platinum-sensitive recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer. Do not administer Avastin until at least 28 days following surgery and until adequate wound healing. Recurrent Disease Platinum Resistant the recommended dosage is 10 mg/kg intravenously every 2 weeks in combination with paclitaxel, pegylated liposomal doxorubicin, or topotecan (every week). The recommended dosage is 15 mg/kg intravenously every 3 weeks in combination with topotecan (every 3 weeks). Platinum Sensitive the recommended dosage is 15 mg/kg intravenously every 3 weeks, in combination with carboplatin and paclitaxel for 6 to 8 cycles, followed by Avastin 15 mg/kg every 3 weeks as a single agent until disease progression. The recommended dosage is 15 mg/kg intravenously every 3 weeks, in combination with carboplatin and gemcitabine for 6 to 10 cycles, followed by Avastin 15 mg/kg every 3 weeks as a single agent until disease progression. Refer to the Prescribing Information for atezolizumab prior to initiation for recommended dosage information. Administer all subsequent infusions over 30 minutes if second infusion over 60 minutes is tolerated. Perforation can be complicated by intra-abdominal abscess, fistula formation, and the need for diverting ostomies. The majority of perforations occurred within 50 days of the first dose [see Adverse Reactions (6. Serious fistulae (including, tracheoesophageal, bronchopleural, biliary, vaginal, renal and bladder sites) occurred at a higher incidence in patients receiving Avastin compared to patients receiving chemotherapy. Patients who develop a gastrointestinal vaginal fistula may also have a bowel obstruction and require surgical intervention, as well as a diverting ostomy. Discontinue in patients who develop gastrointestinal perforation, tracheoesophageal fistula or any Grade 4 fistula. In patients who experience wound healing complications during Avastin treatment, withhold Avastin until adequate wound healing. Do not administer for at least 28 days following major surgery and until adequate wound healing. Necrotizing fasciitis including fatal cases, has been reported in patients receiving Avastin, usually secondary to wound healing complications, gastrointestinal perforation or fistula formation. Across clinical studies, the incidence of Grades 3-5 hemorrhagic events ranged from 0. Do not administer Avastin to patients with recent history of hemoptysis of 1/2 teaspoon or more of red blood. Across clinical studies, the incidence of Grades 3-4 hypertension ranged from 5% to 18%. Treat with appropriate anti-hypertensive therapy and monitor blood pressure regularly. Continue to monitor blood pressure at regular intervals in patients with Avastin-induced or exacerbated hypertension after discontinuing Avastin. Withhold Avastin in patients with severe hypertension that is not controlled with medical management; resume once controlled with medical management. Discontinue in patients who develop hypertensive crisis or hypertensive encephalopathy. Symptoms usually resolve or improve within days after discontinuing Avastin, although some patients have experienced ongoing neurologic sequelae. In an exploratory, pooled analysis of patients from seven randomized clinical studies, 5% of patients receiving Avastin with chemotherapy experienced Grades 2-4 (defined as urine dipstick 2+ or greater or > 1 gram of protein per 24 hours or nephrotic syndrome) proteinuria. Of the 113 patients who reinitiated Avastin, 48% experienced a second episode of Grades 2-4 proteinuria. Nephrotic syndrome occurred in < 1% of patients receiving Avastin across clinical studies, in some instances with fatal outcome.

In the great majority of the cases the lesion is Laboratory test to establish the diagnosis is his topathologic examination gastritis workup order ranitidine master card. The lesion generally heals spontane lower lip gastritis diet karbo generic 300mg ranitidine with visa, buccal mucosa chronic active gastritis definition purchase 150 mg ranitidine mastercard, retromolar pad gastritis symptoms bad breath purchase ranitidine 300mg mastercard, parotid ously without treatment within 4 to 10 weeks gastritis diet questions buy 300 mg ranitidine otc. The cause of the lesion is unknown chronic gastritis nsaids cheap ranitidine 300 mg otc, although the theory of ischemic ne crosis after vascular infarction seems acceptable. The lesion has a sudden onset and clinically may present as a nodular swelling that later leads to a painful craterlike ulcer with irregular and ragged border (. Other Salivary Gland Disorders Sialolithiasis Sialadenosis Sialoliths are calcareous deposits in the ducts or Sialadenosis is a rare noninflammatory, nonneo the parenchyma of salivary glands. The subman plastic enlargement of the parotid and rarely the dibular gland sialoliths are the most common submandibular glands. The exact etiology remains (about 80%), followed by parotid gland, sublin unknown but the disorder has been found in gual glands, and minor salivary glands. Clinically, it presents as bilateral painless swelling of the parotids that usu a painful swelling of the gland, especially during ally recurs (. When the sialolith is located at the soft, and diminishing salivary secretion may occur. The differential diagnosis includes infectious Laboratory test to establish the diagnosis is his sialadenitis. It is usually present in associa tion with systemic diseases, such as tuberculosis, sarcoidosis, lymphoma, and leukemia. Therefore the meaning of the syndrome is theoretical and the diagnosis of the underlying disease has to be es tablished. Xerostomia Laboratory test to determine xerostomia are the salivary flow rate, sialography, histopathologic Xerostomia is not a nosologic entity, but a symp examination, scanning, and serologic tests. The an etholetrithione have been used to stimulate most common causes of xerostomia are drugs salivary gland secretion. Clinically, the oral mucosa is dry, red, cracked, and the epithelium becomes atrophic (. Tumor-like Lesions Pyogenic Granuloma the differential diagnosis includes peripheral giant cell granuloma, peripheral ossifying fi Pyogenic granuloma is a common granulation tis broma, leiomyoma, hemangioma, hemangio sue overgrowth in reaction to mild irritation. Histopathologic examination is Clinically, pyogenic granuloma appears as a pain helpful. The lesion is soft and has a tendency to hemorrhage spontaneously or after slight irritation. The gingiva is the most common site of involvement (about 70%), followed by the tongue, lips, buccal mucosa, palate, etc. Pregnancy Granuloma Postextraction Granuloma Pregnancy granuloma occurs during pregnancy Postextraction granuloma, or epulis granuloma and is clinically and histopathologically identical tosa, is a pyogenic granuloma that characteristi to pyogenic granuloma. It is usually located on the cally appears in the tooth socket after tooth gingiva and appears after the first trimester. The cause is usually the cally, it appears as a single pedunculated mass presence of a foreign body, such as bone seques with a smooth surface and red color (. The differential diagnosis includes pyogenic granuloma and peripheral giant cell granuloma. During pregnancy, it can be removed under local anesthesia if it causes discomfort. Fistula Granuloma Clinically, it appears as a well-circumscribed pedunculated or sessile tumor of dark red color Fistula granuloma is a pyogenic granuloma that is that is hemorrhagic and often ulcerated (. It usually appears on the gingiva, but it can also be found at an edentulous area (. It is not a true neoplasm, but Laboratory test helpful for diagnosis is his a tissue reaction to local irritation occurring dur topathologic examination. Congenital Epulis of the Newborn the differential diagnosis includes the melanotic neuroectodermal tumor of infancy, pyogenic Congenital epulis of the newborn is a rare non-neo granuloma, and fibroma. Surgical excision, although spontane commonly on the maxilla and occurs about ten ous regression has been reported. Clinically, it is present at birth, and it appears as an asymptomatic solitary pedunculated tumor of red or normal color, which ranges from a few millimeters to a few centimeters in diameter (. Natsume, N, Suzuki T, Kawai T: the prevalence of cleft lip A clinicopathologic study of 105 cases. Suzuki M, Sakai T: A familial study of torus palatinus and Plast Reconstr Surg 47:138, 1971. A clinical, histological and microradiographic Fraser F, Warburton D: No association of emotional stress or study with special reference to oral manifestations. Acta vitamin supplement during pregnancy to cleft lip or palate in Derm Venerol (Stockh) 55:387, 1975. J Am Acad Der the enamel, dentine, cementum and the dental pulp: His matol 15:1301, 1986. A Kolas S, Halperin V, Jefferis K, et al: the occurrence of torus report of the oral and haematological findings in nine cases. Bazopoulou E, Laskaris G, Katsabas A, Papanicolaou S: Laskaris G, Hatziolou E, Vareltzidis A: Rear hair on the tip Familial benign acanthosis nigricans with predominant, of the tongue. Oral Laskaris G, Drikos G, Rigopoulos A: Oral-facial-digital syn Surg 44:706, 1977. Selected Bibliography 343 Thormann J, Kobayasi T: Pachyonychia congenita Jadassohn Sewerin I: A clinical and epidemiologic study of morsicatio Lewandowsky: A disorder of keratinization. Sklavounou A, Laskaris G: Eosinophilic ulcer of the oral Vassilopoulou A, Laskaris G: Papillon-Lef6vre syndrome: mucosa. J Dent Child, September Triantafyllou A, Laskaris G: Unusual foreign body reaction of October:388, 1989. Bergendal T, Isacsson G: A combined clinical, mycological and histological study of denture stomatitis. Int J Oral Surg 6:75, Giunta J, Tsamsouris A, Cataldo E, et al: Postanesthetic 1977. Acta Ondontol Scand 32 Nordenram A, Landt H: Hyperplasia of the oral tissues in (Suppl. Lambardi T, Fiore-Donno G, Belser U, Di Felice R: A report of three unusual cases. Radiation-Induced Injuries Laskaris G, Satriano R: Drug-induced blistering oral lesions. J Oral Pathol Giunta J, Zablotsky N: Allergic stomatitis caused by selfpoly 15:468, 1986. Selected Bibliography 345 Nathanson D, Lockhart P: Delayed extraoral hypersensitivity Gorsky M, Silverman S Jr, Chinn H: Burning mouth syn to dental composite material. Holmstrup P, Axel T: Classification and clinical manifestations of oral yeast infections. J Oral Pathol 10:398, Marks R, Simons M: Geographic tongue a manifestation of 1981. Lindhe J: Textbook of Clinical Periodontology: Munksgaard, Maragou P, Ivanyi L: Serum zinc levels in patients with Copenhagen, 1983. Int J Oral Sklavounou A, Laskaris G: Frequency of desquamative gin Maxillofac Surg 17:106, 1988. Oral Surg Dupre A, Christol B, Lassere J: Geographic lip: A variant of 56:405, 1983. J Oral Pathol Med 20:425, treatment with combined local triamcinolone injections and 1991. Diagnosis, prevention Fenerli A, Papanikolaou S, Papanikolaou M, Laskaris G: and treatment. Med J Malay vulgaris: Clinical, histologic and immuniostochemical sia 4:302, 1977. J Oral Surg papillomavirus type 13 and focal epithelial hyperplasia of the 38:841, 1980. Odontostomatol Prog 32:68, Seifert G, Donath K, Gumberz C: Mucozelen der Speicheldrii 1978. Extravasation-Mucozelen (Schleimgranulome) and Re Laskaris G, Papanicolaou S, Angelopoulos A: Focal epithelial tentions-Mucozelen (Schleim-Retentionscysten). An update of the classification and diagnostic criteria of oral Oral Surg 58:667, 1984. Oral Ficarra G: Oral lesions of iatrogenic and undefined etiology Surg 71:714, 1991. J Oral Pathol Med 22:235, croanatomy of the lateral border of the tongue with special 1993. Oral Oncol, Eur J Cancer tion: A new side-effect of azidothymidine therapy in patients 2813:39, 1992. Bacterial Infections Oda D, Me Dougal L, Fritsche T, Worthington P: Oral histo Abell E, Marks R, Wilson J: Secondary syphilis: A plasmosis as a presenting disease in acquired immunodefi clinicopathological review. Zachariades N, Papanikolaou S, Koundouris J: Scrofula: A Holst E, Lund P: Cervico-facial actinomycosis. Medicine Almeida O, Jorge J, Scully C, Bozzo L: Oral manifestations of (Baltimore) 56:457, 1977. Aronson K, Soltani K: Chronic mucocutaneous candidosis: A Malden N: An interesting case of adult facial gangrene (from review. A the hard palate: First clinical sign of undiagnosed pulmonary clinicopathologic study. Oral Surg 62:262, Budtz-Jorgensen E: the significance of Candida albicans in 1986. Oral Surg 47:323, Borradori L, Saada V, Rybojad M, et al: Oral intraepidermal 1979. Friedman-Birnbaum R, Bergman R, Aizen E: Sensitivity and Sun A, Wu Y-C, Liang L-C, Kwan H-W: Circulating immune specificity of pathergy test results in Israeli patients with complexes in recurrent oral ulcers. Oral Surg prognosis for dermatomyositis, with special refference to its 16:551, 1963. Arch Dermatol sialographic findings of parotid glands and histopathologic 120:941, 1984. J Oral Pathol Med Aboobaker J, Bhogal B, Wojnarowska F, et al: the localiza 19:81, 1990. Furue M, Iwata M, Tamaki K, Ishibashi Y: Anatomical dis Albrecht M, Banoczy, Dinya E, Tamas G Jr: Oceurence of tribution and immunological characteristics of epidermolysis oral leukoplakia and lichen planus in diabetes mellitus. J Invest Dermatol 97:259, Imamura S, Yanase K, Taniguchi S, et al: Erythema mul 1991. Pediatr Dermatol 8:288, zation of basement membrane components in mucous mem 1991. Acta Kawasaki T, Kosaki F, Okawa S, et al: A new infantile acute Derm Venereol (Stockh) 64:70, 1984. J Am Kazmierowski J, Wuepper K: Erythema multiforme: Immune Acad Dermatol 23:1275, 1990. Laskaris G, Sklavounou A: Warty dyskeratoma of the oral Prost C, Colonna De Leca A, Combemale P, et al: Diagnosis mucosa. Cicatricial pemphigoid in a 6-year-old child: Report of a case Laskaris G, Triantafyllou A, Economopoulou P: Gingival and review of the literature. Ophthalmolog between linear IgA disease and benign mucous membrane ica1183:122, 1981. Oral Surg Kostmann R: Infantile genetic agranulocytosis: A review with 76:453, 1993. J Oral Pathol Logothetis J, Economidou J, Costantoulakis M, et al: Med 21:326, 1992. Oral Surg 23:573, cleidocranial dysplasia: A rare combination of genetic ab 1967. Oral Kerem B, et al: Identification of the cystic fibrosis gene: Surg 62:524, 1986. Nutritional Disorders Occurence and oral involvement in six adolescent and adult Afonsky D: Stomatitis in nutritional deficiences. Int J Oral Bovopoulou O, Sklavounou A, Laskaris G: Loss of intercellu Surg 3:256, 1974. Anatomy, pathophysiology and clinical miologic and histologic study of oral cancer and leukoplakia description. Diagnostic procedure and comprehen microscopic study of epithelial surface patterns. Silverman S Jr, Gorsky M, Lozada F: Oral Leukoplakia and malignant transformation: A follow-up study of 257 pa tients. Chierci G, Silverman S Jr, Forsythe B: A tumor registry study Surgery 23:670, 1948. Acta Derm Venereol [Suppl] (Stockh) low-grade adenocarcinoma of minor salivary glands: A 85:77, 1979. Proc Hirshberg A, Leibovich P, Buchner A: Metastases to the oral Finn Dent Soc 71:58, 1975. Oral of mucous membranes: A clinicopathologic study of 13 cases Surg 71:708, 1991. Oral Surg 58:413, Triantafyllou A, Laskaris G: Clear cell adenocarcinoma of the 1984. Am J nant fibrous histiocytoma, myxoid variant metastatic to the Patho132:83, 1956. Laskaris G, Papavasiliou S, Bovopoulou O, Nicolis G: Associ Am J Roentgenol Radium Ther Nucl Med 123:471, 1975. Laskaris G, Triantafyllou A, Bazopoulou E: Solitary plas macytoma of oral soft tissues: Report of a case and review of literature. Oral Surg topathologic features of a series of 464 oral squamous cell 41:441, 1976. Tirelli U, Carbone A, Monfardini S, et al: Malignant tumors in Oral Surg 45:246, 1978.

General overview Recently research on work-life balance has been undertaken in particular by the Department of Demography and Geodemography at Charles University gastritis root word order ranitidine, by the Department of Gender Studies at the Sociological Institute of the Academy of Science gastritis japanese purchase genuine ranitidine on-line, and by the working group on family policy in the Research Institute for Labour and Social Affairs gastritis morning nausea buy ranitidine master card. The current family policies in the Czech Republic are compared with those in other developed countries from the perspective of work-life balance diet plan for gastritis sufferers purchase ranitidine 300mg fast delivery. Prague: Gender Studies Detailed analysis of the recent changes in family policies in the Czech Republic is given within the context of the lack of opportunities for Czech women with children under three years of age to work full or part time atrophic gastritis symptoms uk purchase ranitidine cheap. Experiences with childcare facilities in selected 91 European countries are discussed with particular attention to reforms in Germany and Austria gastritis diet ø?ëýã cheap ranitidine 150 mg fast delivery. Research Institute for Labour and Social Affairs the aim of the project is to propose new forms of childcare facilities to extend the current insufficient supply, in order to enable women to make a choice. Current leave and other employment-related policies to support parents Note on terminology: Graviditetsorlov is the leave to be taken by the mother before birth, Barselsorlov the leave reserved for the mother after birth, Fdreorlov the leave reserved for the father after birth, and Forldreorlov the leave available for both parents after birth. However, in the law the four leave schemes bear the same name Barselsorlov, or literally Childbirth Leave, because they technically all originate from the same law on leave. Workers with temporary contracts are excluded only if they are not eligible for unemployment benefit. There is no additional leave for multiple births as the right to Maternity (and Paternity and Parental) leave is related to the event of birth and not the number of children born. About 75 per cent of the workforce are covered by such collective agreements, and these workers receive compensation during leave from their employer up to their former earnings, i. To help employers finance these costs, different leave reimbursement funds have been set up. Several municipal employers set up identical funds in the following years, and in 2005 it was made obligatory for all municipal employers. Depending on the industry in question, the funds also cover full or parts of the Parental leave. The report concluded that the funds seem to be beneficial for women although employers did not believe that the fund had made them change their view on hiring women and also that more men seemed to 94 take up leave as a consequence of receiving payment during leave. Employers tended to be more positive towards men taking leave than earlier and generally were positive towards the fund. Eligibility Anyone in a recognised partnership, including same-sex partnerships. Thus, in a survey from 2006, 85 per cent of the fathers reported 92 receiving full earnings during Paternity leave (Olsen, 2007). This is an individual entitlement; however, although each parent can take 32 weeks of leave, each family can only claim 32 weeks of paid leave. Flexibility in use Between eight and 13 weeks can be taken later; any further period must be agreed with the employer. The benefit level is reduced over the extended leave period, so that the total benefit paid equals 32 weeks at the full rate of benefit. Three weeks of this Parental leave with pay is for the father, three weeks for the mother and three weeks for the parents to share the weeks for the mother and the father respectively were quotas and therefore lost if not used. If both parents work in the state sector they are now entitled to leave with full payment for 6+6+6 weeks after Maternity leave, in all 14 weeks of Maternity leave and 18 weeks of Parental leave, all with full payment, a total of 32 weeks. Six weeks is earmarked for the mother, six weeks for the father and six weeks can be shared. As presented in the section on take-up of leave, this earmarked leave for fathers seems to have resulted in a significant higher take-up among fathers working in the municipal sector. Other employment-related measures Adoption leave and pay For adoptive parents the same regulations for Parental leave apply as for other parents, with the exception that two of the 48 weeks must be taken by both parents together. Time off for the care of dependants One day to care for a sick child, two days for public employees, for every time a child is ill. Relationship between leave policy and early childhood education and care policy the maximum period of paid post-natal leave available in Denmark is 14 months, if parents take the option of a longer Parental leave period with a lower benefit payment; leave at 100 per cent of earnings subject to a ceiling lasts for 11 months. Any policy recommendations must not result in increased expenditure for the state or employers, and the committee must also consider the related consequences for single parents and same-sex parents. Maternity leave the present statistics on leave take-up do not provide data on the proportion of mothers using Maternity leave. However, in a survey conducted in 2006 among parents of children born in 2005, 99 per cent of mothers had taken Maternity leave. In the same survey, nearly all mothers reported that they experienced no negative reaction from the employer when taking leave; 95 per cent reported that they experienced no problems with the workplace when they wanted to take leave. However, recent newspaper reports citing the major trade unions refer to an increase since the financial crisis in the number of women being made redundant during Maternity and Parental leave. Most of these cases end in a settlement where the woman is offered compensation, often six to nine months earnings. The most recent statistics from 2009 show that 61 per cent of Danish fathers take the two weeks Paternity leave they 94 are entitled to (Danmarks statistik, 2012). Parental leave Statistics on the share of fathers and mothers who take-up Parental leave is also not available; however recent statistics from 2010 and 2011 show that Danish fathers on 95 average only take 7. The 2006 survey data showed that among parents of children born in 2005, 24 per cent of fathers took Parental leave and 94 per cent of mothers. Twenty-three per cent of fathers started their leave before the Maternity leave expired, i. Two-thirds (68 per cent) of two parent families took all the 32 weeks of Parental leave to which they were entitled. Among single parents, 73 per cent took 32 weeks; as Olsen notes, this is interesting because single parents in the Nordic countries tend to take shorter leave periods, often due to the loss of income (Olsen, 2007). Among the men, public employees accounted for two-thirds (67 per cent) of Parental leave takers even though they only make up 48 per cent of those entitled to Parental leave. This may be because they receive full earnings during leave or because they are working in more gender-mixed workplaces; some men in the private sector only receive full earnings for part of the Parental leave period. Among those men who do not take leave, 88 per cent were employed in the private sector and this suggests that they have more difficulties taking leave and/or poorer rights. The take-up of leave seems in the survey related to the educational level of both men and women. In those families where the woman takes the greatest part of the leave, the mother tends to have a low educational level and the father is unskilled, or the reverse; in these families, women typically take 99 per cent of total Parental leave weeks. Self-employed workers, both men and women, tend in general to take fewer weeks of leave. This is confirmed in register data from Statistics Denmark, looking into couples who became parents in 2006. The higher the educational level of the father, the more Parental leave he 94 Danmarks statistik (2012) Dagpenge ved fodsel 2011, Nyt fra Danmarks statistik no 120, marts 2012. Danmarks Statistik (2012b) Statistiske efterretninger: Dagpenge ved graviditet, fodsel og adoption 2011. Recent statistics show that fathers in management positions are the fathers taking most leave (Statistics Denmark, 2012). The 2006 survey suggests that along with educational level, wages, workplace culture and age also seem to be important factors when men and women negotiate who should take Parental leave and these seem to be common factors for both the public and private sectors. Moreover according to the survey, there seems to be agreement on the division of leave between men and women; 98 per cent of women and 98 per cent of men stated that they and their partner agreed on how to divide the leave period. They also seem to agree on what is important to consider when dividing leave between parents; among the considerations that affect the division of leave weeks, couples mentioned: their work/educational situation (men 45 per cent, women 30 per cent), their finances (39/28 per cent), the child (32/25 per cent), desire to reconcile work and family life (28/27 per cent), equality between parents (22/8 per cent), and day care of the child (11/5 per cent) (Olsen, 2007). The possibility for flexibility in taking part-time leave or postponing leave may be attractive, especially for fathers. The 2006 survey found that 36 per cent of women on leave and 6 per cent of men on leave made use of some form of flexibility in the leave law: 21 per cent of women and 4 per cent of men postponed periods of leave to be taken later, 12 per cent of women and 3. The survey also revealed that 27 per cent of men and 42 per cent of women reported a lack of information on leave rights. This is supported by other studies, which conclude that the fact that leave entitlements are given by several different levels (law, collective agreements 97 Danmarks statistik (2008) Fdre med hojere jobs holder lngere barselorlov. Thirty seven per cent of men and 23 per cent of women in the survey from 2006 were in favour of the re-introduction of quotas in Parental leave. The higher support among fathers is related to a wish for more back-up when they discuss leave-taking with their employer or with colleagues (Olsen, 2007). Leave take-up in total In addition to the (relatively) limited statistics referred to above, the available statistics presenting the present leave situation look across the entire leave period (Maternity, Paternity and Parental leave) and the data are presented here. Data for the 102 period 2010-2011 show a small drop in the number of days that fathers take when both the mother and father take up leave, from 38 days on average in 2010 to 36 days in 2011. Mothers on the other hand increased their average number of leave days from 292 days in 2010 to 295 days in 2011, i. On the other hand, taking the perspective of the child, an increasing proportion of children experience both father and mother taking leave, 56 per cent in 2011 compared with 49 per cent in 2010; 25 per cent of children in 2011 experienced only the mother taking leave, 311 days on average. For 8 per cent of children only the father took leave, 36 days on average, Finally, 11 per cent of children had parents who had no entitlement to receive the cash 103 benefit (Danmarks statistik, 2013). The recent information on leave use also shows a general decline in leave take-up from 2009 to 2010 among Danish fathers, regardless of whether they were unskilled, skilled or professionals, but it seems to affect fathers especially in the private sector (Ugebrevet A4 104 2013). Kobenhavn: Danmarks statistik 104 Ugebrevet A4 (2013) Krisen tvinger ffidre vk fra barsel. General overview Although there are quite extensive statistics on the use of leave, Danish research into the take-up of leave and the reconciliation of work and family life is only limited. As leave entitlement in Denmark is offered in legislation (parental leave is sharable with the partner), collective agreements and at company level. This means that Danish fathers must individually negotiate leave with the mother and at the work place. In this chapter of the report, the Nordic childcare policies are characterized and compared with other European countries. This chapter investigates the changes in family policies in the last decades and their consequences across a number of Nordic countries. The focus of the project is leave for parents in the Nordic countries and the study of politics, policies and practices. The book focusses on the policies, practices and discourses on fatherhood in the Nordic countries, with contributions from a number of members of the international leave network and edited by G. Maternity leave (rasedus-ja sunnituspuhkus) (responsibility of the Ministry of Social Affairs) Length of leave (before and after birth) One hundred and forty calendar days: between 30 and 70 days can be taken before birth of a child. If less than 30 days leave is taken before the expected birth, leave is shortened accordingly. Payment and funding Hundred per cent of average earnings, calculated on employment in the previous calendar year, with no ceiling on payments. The minimum wage (320 per month) is paid to mothers who did not work during the previous calendar year but have worked prior to the birth of a child. All employers and self-employed pay a payroll tax of 33 per cent for each employee; 13 per cent is for health insurance, 20 per cent for pension insurance). Self-employed people qualify for maternity benefit on the same conditions as workers. Payment and funding One hundred per cent of earnings, calculated by the employer, with a ceiling of six times average earnings. Flexibility in use Can be taken during two months before or two months after the birth of a child. Payment and funding Two types of benefit are available to all families who meet the eligibility conditions, whether or not parents take Parental leave.

Maternity leave (responsibility of the Department for Business gastritis juice fast 150mg ranitidine with visa, Innovation and Skills) Length of leave (before and after birth) Fifty-two weeks gastritis diet õàðòèÿ 150 mg ranitidine sale. A woman can start to take her leave from 11 weeks before the beginning of the week the baby is due gastritis diet sheet order ranitidine 300mg online. Medium and large employers can claim back 92per cent from the Exchequer and small employers can claim back 103 per cent gastritis diet treatment inflammation generic 150mg ranitidine free shipping. Flexibility in use the mother can opt to start her leave at any point from 11 weeks before the beginning of the week the baby is due until the baby is born gastritis diet in hindi safe 300 mg ranitidine. Women who have recently left work gastritis symptoms causes buy discount ranitidine on-line, changed jobs, or are self-employed may be eligible for this payment. To qualify, they must have worked for 26 weeks out of the 66 preceding the expected week of childbirth and have earned at least 30 per week on 13 of these weeks. They must have worked continuously for their employer for 26 weeks by the end of the fifteenth week before the start of the week the baby is due and remain employed into the week before the leave is due to start. If they do not, and the employer cannot accommodate the change, the father will have to take the leave on the dates he originally told his employer. For example, in 2007, 53 per cent of workplaces with five or more employees offered extra-statutory Maternity leave and 16 per cent provided additional 204 payments (Hayward et al. Paternity leave (responsibility of the Department for Business, Innovation and Skills) Length of leave Two weeks. Parental leave (responsibility of the Department for Business, Innovation and Skills) Length of leave Eighteen weeks per parent per child. Parents of a disabled child may take this leave up until the child is 18 years old. Flexibility in use Leave may be taken in blocks or in multiples of one week, (unless the child is disabled. Other employment-related measures Adoption leave and pay 205 Department of Trade and Industry, Parental leave, summary guidance. There is also a right to paid Paternity leave for an adopter not taking adoption leave (if they meet the eligibility criteria). Flexible working: the right to request and the duty to consider Employees who have parental responsibility for a child aged 16 and under, a disabled child under 18 years or who care for a spouse, partner, civil partner, relative or other adult living with them have a legal right to apply to their employers to work flexibly. Employees need to have worked for their employer continuously for 26 weeks before applying. Changes in policy since April 2012 (including proposals currently under discussion) Over the last year lobby groups (business, parent and child welfare organisations) have continued to debate leave and flexible working in response to the Consultation on Modern 208 Workplaces: flexible parental leave, flexible working, annual leave and equal pay proposed by the new coalition Government after it was elected in 2010. The Bill completed its committee stage on 25 April 2013, after a second reading debate on 25 February 2013. The Bill is wide-ranging, covering many areas beyond Shared Parental leave and flexible working. These earlier 211 proposals were to reduce the length of Maternity leave (currently 52 weeks) and pay (currently 39 weeks, mostly at a low flat rate) to 18 weeks; and to reclassify the remainder of existing Maternity Leave as Parental Leave. Proposals for the new Parental leave included: four weeks of paid Parental leave exclusive to each parent to be taken in the first year. By contrast, the Children and Families Bill introduced in February 2013 included the following proposals: Retention of Maternity leave duration to 52 weeks and Paternity leave duration to two weeks. This leave would be termed Shared Parental Leave (it is replacing a similarly designed 208 Department for Business, Innovation and Skills (2011) Modern Workplaces. Instead mothers must commit to a return to employment date in the future when she will end her maternity leave. It cannot be taken in a day mode or on a flexible part-time basis, although parents could take alternating weeks and there is provision for parents to take leave together. That is, partners taking Statutory Shared Parental Pay will be paid at the lesser of 90 per cent of earnings or the flat rate of 136. These tests replicate existing ones (for paternity leave and maternity allowance) and the government expects them to be well-understood. Paragraphs (2) to (4), which set out the current statutory procedure, are being repealed. The same Clause introduces a duty for employers to deal with applications for flexible working in a "reasonable manner". This is to be supplemented by a statutory Code of Practice, which has not yet been published. Instead there is a proposal to extend paternity pay through secondary legislation at a later date. Regulation 2 amends section 80F of the 1996 Act to extend the right to request a contract variation to employed agency workers who are returning to work from a period of parental leave. Following a review it will fall to the Secretary of State to consider whether the relevant provisions should remain as they are, or be revoked or be amended. A further instrument would be needed to revoke the relevant provisions or to amend them. Due to devolved government, England, Scotland, Wales and Northern Ireland each have distinct education, health and legal systems. This would change if there was a vote for independence in a referendum in Scotland in September 2014. There is much political interest in the Nordic approach to welfare in Scotland, which might imply an increased generosity of leave in the future. However, when the Scottish Government launched its National Parenting Strategy in October 2012, there was no mention of Parental leave in this document. Take-up of leave this section relies on the most recent publicly available national data: the Maternity and 213 Paternity Rights and Women Returners Survey 2009/10 (Chanfreau et al. Telephone interviews took place with 2, 031 mothers and 1, 253 fathers who had worked in the 12 months prior to the birth of their child, 12 to 18 months after the birth. Maternity leave According to the 2009/10 survey, the mean length of Maternity leave taken by women increased from 32 weeks in 2006 to 39 weeks in 2008; that is by approximately two months in the space of two years. Duration of maternity pay and length of Maternity leave taken are positively associated, particularly for economically disadvantaged women. The last group, who received no maternity pay, had the least advantageous employment conditions. These updated findings are in line 215 with the earlier survey by Smeaton and Marsh (2006). Of those taking time off, 49 per cent took statutory Paternity leave only, 25 per cent statutory leave plus other paid leave, 18 per cent other paid leave only and 5 per cent unpaid leave. Those taking statutory paternity leave were most likely to take the statutory two weeks (50 per cent); 34 per cent took less than two weeks and 16 per cent more than two weeks. The odds of taking Paternity leave were significantly higher for men working in the public sector and where there were family friendly arrangements available in the workplace. Large private and public sector organisations were most likely to give full payment for longer periods of paternity leave. Small and medium size private sector employers were most likely to pay the minimum statutory rate. Parental leave Provision and take-up of statutory Parental leave data are not systematically reported in the 2009/2010 survey. Instead paid and unpaid informal Parental leave is reported on as a form of family-friendly arrangement. Other employment-related measures Information on take-up of other employment-related entitlements, such as use of flexible working, is taken from survey evidence since there is no requirement for employers to report on this. At both time periods the awareness of the right to request flexible working was lower in those employed in routine and manual occupations. In 2011, 22 per cent of employees reported requesting a change to working arrangements in the last two years (most commonly, women, parents and those with caring responsibilities). Although the methodology was different, this refuse rate is higher than that reported by employers in an earlier survey (40 per cent of employers report receiving requests in the previous 12 months, with only nine per cent of these requests refused (Hayward et al. There is limited research on these statutory entitlements, and also only limited official information on take-up, with none on unpaid leave entitlements. The longest established entitlement is Maternity leave and pay, introduced in 1976, and there have been a number of studies over time (in 1979, 1988, 1996, 2002 and 2005) looking at the use of this entitlement and showing how this has increased as more women use leave to maintain 216 Hooker, H. A conceptual analysis of the concept of care as used in different European countries and discussion about the problems in transferring its use to Asian contexts. It examines patterns in the context of an expansion of childcare and other improvements in reconciliation measures. Fathers, work and families in twenty-first century Britain: beyond the breadwinner model This study aims to profile the work and family life of fathers in a European context. It draws on secondary analysis of four large-scale datasets; Understanding Society, the European Labour Force Survey, the European Social Survey and the British Household Panel Study. Very little is known about how parents who work evenings, nights and weekends organize their child-care or about the impact this has on child well-being. The team will be comparing the experiences of parents working standard and non-standard hours as a way of distinguishing what the main differences between these groups are in terms of issues they face in finding appropriate child-care, and the child-care arrangements they have access to . To contact authors of country notes, go to membership-list of members page on website. Current leave and other employment-related policies to support parents Note on leave policy: there is no statutory right to any of the types of leave or other statutory measures covered in country notes. These provide workers with partial compensation (about the same level as unemployment insurance benefit, i. These benefits are funded by employee contributions, and benefit levels are adjusted annually as wages increase. All workers who contribute to the programme have the opportunity to draw benefits. Changes in policy since April 2012 (including proposals currently under discussion) A number of states are continuing to discuss possible paid family leave programs. Paid sick leave programs are also under discussion at both the state and city level. About 80 per cent of working parents between the ages of 18 to 54 years have access to at least some paid leave either through statutory provision, collective agreements or individual workplace policies, especially older workers. Thus though the law provides de facto Parental leave entitlements, studies have 222 223 224 225 found that it has had generally small effects on leave usage by new mothers and little or no effects on leave usage by new fathers (footnotes 9 and 10). The fact that the law extended coverage but had so little impact on usage suggests that there are limits to the extent to which families are willing and able to use unpaid leave. Kamerman continues to carry out a programme of research on comparative Maternity, Paternity, Parental, and family leave policy studies and monitors developments in the advanced industrialised countries, the countries in transition to market economies, and developing countries. Kahn) co directs the Columbia University Clearinghouse on Child, Youth, and Family Policies that provides up-to-date information on child-related leave policies (among other child and family policies). Jane Waldfogel, Columbia University School of Social Work; Wen-Jui Han, New York University; Christopher Ruhm, University of Virginia.

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