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Metastatic brain tumors present in the same way as other cerebral neoplasms, ie, with increased intracranial pressure, with focal or diffuse disturbance of cerebral function, or with both of these manifestations Indeed, in patients with a single cerebral lesion, the metastatic nature of the lesion may only become evident on histopathologic examination In other patients, there is evidence of widespread metastatic disease, or an isolated cerebral metastasis develops during treatment of the primary neoplasm The most common source of intracranial metastasis is carcinoma of the lung; other primary sites are the breast, kidney, and gastrointestinal tract Most cerebral metastases are located supratentorially Laboratory and radiologic studies used to evaluate patients with metastases are those described for primary neoplasms They include MRI and CT scanning performed both with and without contrast material Lumbar puncture is necessary only in patients with suspected carcinomatous meningitis (see below) In patients with verified cerebral metastasis from an unknown primary, investigation is guided by symptoms and signs In women, mammography is indicated; in men under 50, germ cell origin is sought since both have therapeutic implications In patients with only a single cerebral metastasis who are otherwise well, it may be possible to remove the lesion and then treat with irradiation; the latter may also be selected as the sole treatment In patients with multiple metastases or widespread systemic disease, the prognosis is poor; stereotactic radiosurgery, whole-brain radiotherapy, or both, may help in some instances, but in others treatment is palliative only

Kaal EC et al Therapeutic management of brain metastases Lancet Neurol 2005 May;4(5):289 98 [PMID: 15847842] Stafinski T et al Effectiveness of stereotactic radiosurgery alone or in combination with whole brain radiotherapy compared to conventional surgery and/or whole brain radiotherapy for the treatment of one or more brain metastases: a systematic review and meta-analysis Cancer Treat Rev 2006 May;32(3): 203 13 [PMID: 16472924]

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The diagnosis is confirmed by examination of the cerebrospinal fluid Findings may include elevated cerebrospinal fluid pressure, pleocytosis, increased protein concentration, and decreased glucose concentration Cytologic studies may indicate that malignant cells are present; if not, spinal tap should be repeated at least twice to obtain further samples for analysis CT scans showing contrast enhancement in the basal cisterns or showing hydrocephalus without any evidence of a mass lesion support the diagnosis Gadolinium-enhanced MRI frequently shows enhancing foci in the leptomeninges Myelography may show deposits on multiple nerve roots Treatment is by irradiation to symptomatic areas, combined with intrathecal methotrexate The long-term prognosis is poor only about 10% of patients survive for 1 year and palliative care is therefore important (see 5)

Corticosteroids should be applied sparingly to the dermatitis twice daily and rubbed in well Their potency should be appropriate to the severity of the dermatitis In general,

Akdis CA et al; European Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology Diagnosis and treatment of atopic dermatitis in children and adults: European Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL Consensus Report J Allergy Clin Immunol 2006 Jul;118(1):152 69 [PMID: 16815151] Boguniewicz M et al Atopic dermatitis J Allergy Clin Immunol 2006 Jul;118(1):40 3 [PMID: 16815136] Brown S et al Atopic and non-atopic eczema BMJ 2006 Mar 11;332(7541):584 8 [PMID: 16528081] Williams HC Clinical practice Atopic dermatitis N Engl J Med 2005 Jun 2;352(22):2314 24 [PMID: 15930422]

response Occasionally, adding tar preparations such as LCD (liquor carbonis detergens) 10% in Aquaphor or 2% crude coal tar may be beneficial 4 Maintenance treatment Once symptoms have improved, constant application of effective moisturizers is recommended to prevent flares In patients with moderate disease, weekend only use of topical corticosteroids can prevent flares

The SAP system uses two billing plans One is called milestone billing, which is a final billing in full at a particular milestone according to items sold or services rendered An example of this would be a project milestone, such as the completion of an architect s blueprint, for which the service is invoiced The alternative billing plan is periodic billing Periodic billing uses a predefined date proposal, which bills the customer at periodic intervals An example of this would be billing for rental of an object

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