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This The palatine bones also have vertical processes that zygomatic arch is where another muscle of mastication are practically hidden from view on the intact skull best purchase for kamagra soft erectile dysfunction drugs walmart. These vertical processes form part of the posterior wall of the maxillary sinus in Figure 14-8 cheap kamagra soft online mastercard erectile dysfunction causes nhs. Generally speaking generic 100mg kamagra soft overnight delivery erectile dysfunction treatment options in india, it is bilaterally cranium via the foramen rotundum on their way to the symmetrical cheap kamagra soft 100 mg without a prescription impotence from blood pressure medication, and it contains all of the mandibular teeth. Human skull, left side: The lateral view of the mandible is shaded yellow, and the left zygomatic bone (of the cheek) is shaded purple. In this view, the vertical ramus and its two processes (condylar and coronoid processes) are evident. Also, the zygoma bone, the zygomatic process of the temporal bone, and the zygomatic process of the maxilla form the zygomatic arch. Therefore, the mandible is the only elevations overlying the roots of the canines are called bone of the skull that can move. The angle of the mandible is where the infe- the only visible movable articulations in the head. The bulky body of the mandible is the horizontal portion including the alveolar process that surrounds the mandibular teeth, and the two vertical processes extending to the base of the neurocranium (to the temporal bones) are called the rami (single is ramus). The mental nerve exits the mental tubercles lie on either side of the midline near mandible in an outward, upward, and posterior direc- the inferior border of the mandible. Place a flexible probe tuberance is centered on the midline between the two carefully into this canal of the mandible to confirm the mental tubercles but is about 10 mm superior. The mental foramen is located protuberance and the tubercles are more prominent on at practically the same level on most humans: 13 to men than on women. The was located distal to the apex of the second premolar buccal (or buccinator) nerve is located in the cheek just (17. The nerve molar root and must be distinguished from a periapical within the mandible (inferior alveolar nerve) gives off abscess (infection destroying bone near the root apex), a branch (mental branch of the inferior alveolar nerve) which may appear very similar to the normal mental that exits through this mental foramen to supply skin foramen. Ramus of the Mandible: Lateral Surfaces inferior and anterior from the mandibular foramen. The temporal crest is a ridge of bone extending from There are two processes on the superior end of each the tip of the coronoid process onto the medial surface ramus. The sec- tendon from the fibers of the wide, flat, fan-shaped tem- ond more rounded and posterior process of the ramus poralis muscle attaches here. This process is composed of a is most important as a radiographic, rather than an ana- bulky condyle head and a narrow neck that attaches the tomic, landmark. The sigmoid notch (also called the curved line somewhat inferior to the image of the exter- mandibular or semilunar notch) is located between nal oblique line. One The retromolar fossa is a roughened shallow fossa part of an important muscle of mastication, the lateral distal to the last molar and bounded medially by the pterygoid, attaches to the front of the neck of the condy- lowest portion of the temporal crest and laterally by the loid process in a depression called the pterygoid fovea external oblique ridge. The head of the mandibular condyle fits the lowest most anterior, and only horizontal, portion into and functions beneath the articular (glenoid) fossa of the retromolar fossa. The most posterior fibers of of the temporal bone (which is discussed in more detail the buccinator muscle (a pouch-shaped cheek muscle) later in this chapter). Two large muscles (the genio- nent opening located on the medial surface of the glossus and the geniohyoid) attach to these spines and ramus inferior to the sigmoid notch near the middle the elevated, roughened bone near them. It is the entrance into The mylohyoid ridge extends downward and for- the mandibular canal where the inferior alveolar ves- ward from the molar region to the genial tubercles. This is of the mouth, attaches from the mylohyoid ridge on where the inferior end of the sphenomandibular ligament the right medial side of the mandible to the ridge on attaches to the mandible. Mandible, medial surface: Notice the important mandibular foramen, as well as ridges, fossa, and processes. Chapter 14 | Structures that Form the Foundation for Tooth Function 393 gwal] fossa is found just superior to the mylohyoid part because it is shaped like a large fish scale), and also ridge and lateral to the genial tubercles on each side. A shal- the parietal and frontal bones that were discussed ear- low submandibular fossa is found just inferior to the lier. The temporal fossa is where the superior end of mylohyoid ridge in the premolar and molar regions. On the inferior border of the mandible, a shal- temporal bones to the parietal bones. It is within these fossae that the condyloid processes of the mandible articulate with the temporal bones on the base of the neurocranium. Each mandibular fossa The temporal bones are a pair of complex bones that can be divided into two parts by the petrotympanic form part of the sides and base of the neurocranium fissure (Fig. Laterally, the temporal fossa (outlined tympanic fissure) is the important articular fossa (or in Fig. Each articular fossa has a ridge of bone temple region of the face formed primarily by the lateral forming its anterior border, which is called the articu- part of the temporal bone (also called the squamous lar eminence. Human skull, left side: The lateral surface of the left temporal bone is shaded blue. Note its squamous part, as well as its processes: mastoid, styloid, and zygomatic. Human skull: inferior surface, with half of the mandible removed on the right side of the drawing. Note the zygomatic process forming part of the zygomatic arch and the mandibular and articular fossa and articular eminence. The small portion of the midline vomer bone (shaded yellow) is seen separating the right and left halves of the nasal passageways. This arch shape of bones, seen from tion of the temporal bone through the internal acoustic beneath in Figure 14-16, is the attachment of one end of meatus (Fig. The the infratemporal space through the stylomastoid fora- prominent mastoid process or portion (Fig. This petrous portion of the tem- is the attachment for one end of a major neck muscle, poral bone contains the auditory canal with the minute the sternocleidomastoid muscle. You can feel the bump bones of hearing known as the malleus, incus, and sta- of the mastoid process behind your ear lobe. The carotid canal is the passageway of the inter- the inferior surface of the temporal bones but more nal carotid artery into the brain case, and the jugular medial is the styloid process (Fig. Part of human skull: bones lining the inside of the neurocranium with the temporal bones in blue. The thick petrous portion of these bones contains the very small bones of the inner ear (incus, stapes, and malleus). Along with other scrolled processes of the ethmoid bone described The vomer bone is a midline bone that, along with the earlier, they increase the area of mucous membrane vertical projection of the ethmoid bone, forms the nasal inside the nasal cavity to warm and moisten air that we septum. The hyoid bone is not connected to the bones rymal) are small rectangular bones at the medial corner of the skull except via soft tissue.

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If lef heart bypass is to be used kamagra soft 100 mg low cost erectile dysfunction treatment supplements, the lef atrium and dis- tal aorta or common femoral artery can be cannulated purchase online kamagra soft erectile dysfunction dr mercola. New technologies Afer applying clamps cheap 100 mg kamagra soft amex erectile dysfunction videos, the hematoma is entered and the injury identified buy generic kamagra soft 100mg erectile dysfunction treatment new orleans. A small injury can occur to the poste- Managing injuries to the thoracic aorta requires signifi- rior-medial aspect of the aorta and not be readily visible, cant incisions. While patients with penetrating injuries thus the aorta may need to be opened to visualize this to the aorta ofen present in extremis, those with blunt small injury. Injuries involving less than 50% of the cir- injuries may present in stable condition because of a con- cumference of the aorta can ofen be repaired primarily tained pseudoaneurysm. Statistically however, approximately other devastating injuries such that definitive aortic 85% of repairs require an interposition graf [8]. For these patients, the option of extent of the injury is determined, the distal aortic clamp endovascular repair may be considered. Patients with blunt aortic injury and early devices were adapted from other uses or fabricated a stable, contained hematoma in the face of other limiting locally. The original experience was described in patients associated injuries can be considered for delayed man- in whom the repair was performed in a semi-elective agement. There have been some reports of small position must be made for proper access to these injuries. Blunt disruption of the descending thoracic aorta typically occurs distal to the lef subclavian References artery orifice. During an endovascular repair, the endo- graf ofen routinely traverses the subclavian artery ori- 1. The early seven hundred sixty cardiovascular injuries in 4459 patients: results of using stent-graf technology to manage acute epidemiologic evolution 1958–1988. Ann Surg 1989; 209: blunt aortic injuries appears favorable, however long- 698−705. Penetrating likely best managed by a team approach led by a surgeon injuries of the aortic arch and its branches. Ann Thorac Surg with significant experience in both endovascular and 1993; 55: 586−592. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. McGraw-Hill, New York, existing neurological or vascular deficits which should be 2004: 141−157. Intravas a negative outcome (complication or death) is common cular migratory bullets. Computed tomography as a screening exam in patients with suspected blunt aortic injury. Thoracic aortic injury: how predictive is mechanism and is chest computed tomo- Injuries involving the aortic arch are ofen fatal, with graphy a reliable screening tool? A prospective study in death occurring at the scene of an accident or during 1561 patients. Arch Surg 1998; 133: bral infarcts associated with repair of thoracic aortic dis- 1084−1088. Anesthesiology cephalic trauma: should angiography be supplanted by 1995; 82: 1474−1506. Acute trau- rupture of the thoracic aorta: should one always operate matic rupture of the thoracic aorta treated with endoluminal immediately? Traumatic aortic descending thoracic aorta: repair with use of endovascular transections: eight-year experience with the “clamp-sew” stent-grafts. Clamp/repair: a traumatic pseudoaneurysm of the thoracic aorta in a a safe technique for treatment of blunt aortic injury to patient with concomitant intracranial and intra-abdominal the descending thoracic aorta. Traumatic intentional stent-graft coverage of the subclavian artery aortic rupture: twenty-year metaanalysis of mortality and during endovascular thoracic aortic repairs. Isolated high- Introduction grade atherosclerotic innominate artery lesions are rare, as innominate artery stenosis is ofen associated with disease Atherosclerotic occlusive disease is by far the most of the common carotid or the subclavian arteries. Proximal frequent cause for intervention on the aortic arch branch innominate artery lesions are frequent in patients with vessels, although other pathological processes, such as atherosclerosis of the aortic arch. In some patients, a large trauma, Takayasu’s arteritis, giant cell arteritis and radia- distal posterior innominate artery plaque extends far into tion arteritis can also cause lesions that require surgical the right subclavian or common carotid arteries [25,26]. During the past decade, endovascular inter- The Joint Study of Extracranial Occlusive Disease ventions using angioplasty and stents have improved rap- reported on 4748 patients with symptomatic cerebrov- idly, and now they represent the first line of treatment of ascular disease who underwent aortic arch and cerebral stenotic lesions of aortic arch vessels caused by atheroscle- angiography [23,24]. Open surgical reconstructions, discussed in subclavian artery was most frequently stenotic (12. Incidence Symptomatic atherosclerotic occlusive disease of the aor- tic arch vessels is an uncommon disease. Similar numbers have also been it is also difficult to relate specific neurological symptoms reported by other authors [27]. Global cerebral ischemia, however, may rarely arise if multiple aortic arch vessels Causes are occluded, and it can present with orthostatic drop atacks. In surgical series, however, patients pre- upper extremity symptoms is frequently microembolism senting with symptomatic arch vessel disease are younger [30,31]. Upper extremity has been identified as a risk factor in 78–100% of patients ischemic symptoms include muscle fatigue (arm claudica- with atherosclerotic aortic arch vessel occlusive disease tion), rest pain, ulceration of the fingertips and Raynaud’s [8,9,11]. High-grade stenosis or occlusion of the undergo surgical aortic arch vessel reconstruction has subclavian artery (or, less commonly, the innominate been between 18% and 57% in different reports [11,12]; artery) is usually responsible for upper extremity claudi- most series, however, have had a relatively equal distri- cation and rest pain, while atheroembolism is more com- bution of men and women [5−10,12−16]. Because aor- monly associated with ulceration of the finger tips and tic arch vessel arteritis is more prevalent in women, the Raynaud’s phenomenon. It is a unique characteristic of series that includes more patients with burned-out arteri- atheroembolism originating from the innominate artery tis and superimposed atherosclerosis tend to have higher that the patient presents with simultaneous right upper frequencies of women. This ‘sub- clavian steal’ phenomenon is a collateral response and may result in significant shunting of blood from the cer- Presentation ebral circulation towards the upper extremity. Subclavian steal can be frequently demonstrated with radiographic Atherosclerotic occlusive disease of the aortic arch vessels images in otherwise asymptomatic patients with signifi- can cause symptoms by affecting the cerebral circulation, cant subclavian or innominate artery lesions [24,32,33]. The pathomech- Subclavian steal syndrome develops when arm exercise anism of symptoms is either atheroembolism or a low- increases blood flow through this collateral pathway to flow state. True An embolic source, such as an ulcerated plaque, in the subclavian steal syndrome is rare. In many cases of docu- common carotid arteries may lead to ischemic events in mented subclavian steal syndrome, the proximal sub- the anterior cerebral circulation and produce either hemi- clavian artery occlusion is associated with concomitant spheric symptoms, such as a transient ischemic atack or extracranial arterial occlusive disease [34] and symptoms a stroke, or eye symptoms, such as amaurosis fugax. If the atributed to ‘subclavian steal’ may well be caused by the embolic process originates from the subclavian artery, it synchronous carotid or vertebral artery disease. Another can cause vertebral ischemia and manifest in dizziness or presentation is ‘coronary steal’, which manifests in tran- vertigo, numbness of the ipsilateral face and contralateral sient myocardial ischemia in patients with proximal limbs, perioral numbness, diplopia, hoarseness, dysar- subclavian disease and ipsilateral internal mammary to thria, dysphagia, or drop atack. Innominate artery lesions can be the source of atheroembolism in both the anterior and posterior circu- Diagnosis lation. These principles notwithstanding, the location of the embolic source does not always precisely correspond A thorough history and physical examination can estab- with the anterior vs. Because of the high auscultation of the upper anterior chest and neck will pro- prevalence of coronary artery disease in patients who vide much information in patients with aortic arch dis- harbor lesions of the aortic arch vessels, pre-operative ease.

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It is extremely important to ask about chronic use of topical nasal decongestants to rule out rhinitis medicamentosa quality 100 mg kamagra soft erectile dysfunction doctor austin. If allergic rhinitis is suspected cheap kamagra soft online master card erectile dysfunction vacuum pump india, a nasal smear for eosinophils and serum IgE antibodies can be done purchase kamagra soft now erectile dysfunction blood pressure medications side effects. A patient with acute nausea and vomiting and diarrhea almost always has viral or bacterial gastroenteritis although acute appendicitis generic 100 mg kamagra soft visa erectile dysfunction after radical prostatectomy treatment options, cholecystitis, and pancreatitis must be kept in mind. This symptom lends itself well to anatomic analysis, particularly by the target method illustrated on page 312. Starting from the top and working to the bottom, and at the same time cross-indexing this with etiologies (Table 46), one can review the most important causes of vomiting. In the esophagus, achalasia, esophageal diverticulum, reflux esophagitis, and carcinoma are important, although they are more likely to produce dysphagia (see page 128). In the stomach, gastritis, gastric ulcers, and 608 gastric carcinoma are important causes of vomiting. A polyp, carcinoma, or ulcer at the pylorus is most likely to produce vomiting because of gastric outlet obstruction. In the large bowel, ulcerative colitis, amebiasis, and neoplasms should be considered. Mesenteric thrombosis can cause vomiting regardless of which portion of the intestine it involves. Acute viral or bacterial enteritis is associated with nausea and vomiting, but almost invariably there is diarrhea in botulism, salmonellosis, and shigellosis. In the next circle in the target one encounters cholecystitis and cholelithiasis, pancreatitis, gastrinomas, pancreatic cysts, peritonitis, and myocardial infarction. The next circle contains the vestibular apparatus (Ménière disease), the brain (e. The target method has served us well, but a biochemical evaluation of vomiting should also be done because many foreign substances or natural body substances occurring in high or low concentrations in the blood may affect the vomiting centers or cause a paralytic ileus. Thus uremia, increased ammonia and nitrogen breakdown products in hepatic disease, and hypokalemia and hyperkalemia may cause vomiting. When intractable nausea and vomiting develops following the flu, consider Reye syndrome. Vitamin A intoxication may cause increased intracranial pressure and vomiting in children. Physiologically, the symptoms of vomiting should suggest obstruction, either functional or mechanical. Almost any drugs can cause nausea and vomiting, especially digoxin, nonsteroidal anti-inflammatory drugs, aspirin, iron preparations, and narcotics. The association of other symptoms and signs is essential in pinpointing the diagnosis of vomiting. For example, vomiting with tinnitus 613 and vertigo suggests Ménière disease, whereas vomiting with hematemesis suggests gastritis, esophageal varices, and gastric ulcers. Vomiting with significant abdominal pain will most likely be due to appendicitis, cholecystitis, pancreatitis, or intestinal obstruction. Gastroscopy and esophagoscopy are often indicated in the acute case, but an exploratory laparotomy should not be delayed if the patient’s condition is deteriorating and pancreatitis has been excluded. In infants with duodenal atresia, a flat plate of the abdomen will show a “double bubble” sign. As with any mass, a neck mass may be due to the proliferation of tissues in any of the anatomic structures, a displacement or malposition of tissues or anatomic structures, or the presence of fluid, air, bleeding, or other substances foreign to the neck. Visualize the anatomy of the neck and think of the skin, thyroid, lymph nodes, trachea, esophagus, jugular veins, carotid arteries, brachial plexus, cervical spine, and muscles. Thus, taking thyroid enlargement, hypertrophy and cystic formation (endemic goiter), hyperplasia (Graves 614 disease), neoplasm (adenomas and carcinomas), thyroiditis (subacute or Hashimoto), cyst (colloid type), and hemorrhage come to mind. Lymph nodes may be enlarged by many inflammatory diseases, but when they present as an isolated mass they are usually infiltrated with Hodgkin lymphoma or a metastatic carcinoma from the thyroid, lungs, breast, or stomach. Tuberculosis, actinomycosis, and other chronic inflammatory diseases may present this way. Tracheal enlargement is rarely a problem in differential diagnosis, but bronchial cleft cysts may present as a mass. Pulsion diverticula are the main masses of esophageal origin, but carcinoma of the esophagus may involve the upper third on rare occasions. There is rarely a problem distinguishing jugular veins from a mass of other origin. Carotid or subclavian artery aneurysms are distinguished by their pulsatile nature; occasionally, an aortic aneurysm may be felt in the neck. When there is severe atherosclerotic disease of the carotids, one or both may be felt as a “lead pipe” in the neck. Any neoplasm that metastasizes to the cervical spine may spread into the neck; a plasmacytoma is likely to do this in multiple myeloma. Abnormal accumulations of fluid, air, or other substances in colloid cysts and bronchial cleft cysts have already been mentioned, but what about carbuncles, sebaceous cysts, and angioneurotic edema? Cystic hygromas present from birth contain a serous or mucoid material and may be huge. Approach to the Diagnosis The clinical picture will help to determine the diagnosis in many cases. For example, a neck mass with hemoptysis suggests carcinoma of the lung with metastasis to the lymph node. If the mass increases in size after swallowing food or liquid, an esophageal diverticulum is likely. If the mass is suspected to be an enlarged lymph node, exploration and biopsy may be appropriate. One can 616 now see that the diagnostic workup can be developed by visualizing the anatomy of the area. First, the anatomic components are distinguished, then the various etiologies are 618 applied to each (Table 48). Moving from the skin to the spinal cord layer by layer, we encounter the fascia, muscles, arteries, veins, brachial and cervical plexus, and lymph nodes. Finally, there is the cervical spine encircling the spinal cord and meninges and designed to allow uninfringed exit of the cervical nerve roots. The skin may be involved by herpes zoster, cellulitis, contusions, and lacerations. In the muscle and fascia, one encounters fibromyositis, dermatomyositis, and trichinosis as well as traumatic contusions and pulled or torn ligaments (strains). Remember Ludwig angina, which is a painful swelling under the chin caused by the spread of a dental abscess to the neck! The muscles may be involved by tension headache, poor posture, and occasionally by epidemic myalgia. Torticollis causes painful spasms, but the jerking of the neck makes the condition obvious.

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T e main analysis used Cox proportional hazard models to calculate hazard ratios (Hrs) and 95% Cis to determine associations between Bmd change and risk of incident major os- teoporotic fractures order kamagra soft american express erectile dysfunction treatment bayer. Unconditional regression models with roC curves were used to compare models assessing risk of osteoporotic fracture using baseline Bmd and Bmd changes cheap 100mg kamagra soft fast delivery impotence mental block. A net reclassifcation index was used to quantify change in risk classifcation between the frst and second Bmd measures (high risk = individual with hip fracture risk of ≥3% or major osteoporotic fracture risk of ≥20%; otherwise discount 100mg kamagra soft overnight delivery erectile dysfunction injections, low risk) purchase kamagra soft on line erectile dysfunction jogging. T e initial measurement occurred between 1987 and 1991 with a dual- photon absorptiometer. Follow-up measurement occurred between 1992 and 1999 with a dual-energy x-ray absorptiometer. T e majority (91%) of partic- ipants had Bmd measures on two diferent scanners and adjustments were made using cross-calibration of the two scanners. Follow- Up: Until death, through 2009, or 12 years of follow-up (median follow-up period of 9. Endpoints: Primary outcome was hip fracture or major osteoporotic frac- ture, including fracture of the hip, spine, forearm, or shoulder (Figure 35. Change in risk Classification from First to Second Bmd measure Fracture during No Fracture during Follow- up Follow- up Net reclassifcation index for 3. Criticisms and Limitations: T e majority of participants had Bmd measured on two diferent machines, making misclassifcation errors possible. T ere was no confrmation of major osteoporotic fractures by using medical records; thus, some of the associated outcomes may have been misclassifed. With the exception of estrogen, there was no data on the use of bisphosphonates or other osteoporosis medications. Given the timing of this study, most participants were probably untreated for osteoporosis, and the results may not generalize to a treated population. T e study population was mostly white, making gen- eralizability to other racial/ethnic groups difcult. Finally, many frail, elderly Framingham study patients did not return to have multiple measures of Bmd and were excluded from this analysis. She is in good health and is currently only taking one medi- cation to treat her mild hypertension. T e patient is concerned about not being on preventive medications like her friends are, and wonders if she should have a repeat dexA scan. Suggested Answer: While on average most older Americans are geting serial dexA scans about every 2 years, this study suggests that a second Bmd test within 4 years’ time is unlikely to change clinical management, especially among individuals with mild bone loss at baseline (mild osteopenia). However, there is likely litle added value from a repeat test afer just 2 years from her baseline test, and you should inform the patient that there would likely be no clinical management change based on a repeat dexA scan at this time. Year Study Began: 2003 Year Study Published: 2008 Study Location: 14 italian universities and civic hospitals. Who Was Excluded: Patients <18 years of age; pregnant; or with a history of venous thromboembolism, life expectancy <3 months, or ongoing anticoagu- lation (>48 hours), mandatory anticoagulation indication (e. How Many Patients: 2,098 Study Overview: Prospective randomized multicenter study. Study Intervention: Patients were randomized to either 2-point ultrasound (proximal veins only, n = 1,045) or whole-leg ultrasound (n = 1,053). T e 2- point ultrasound strategy involved using a 5–10 mHz linear probe with com- pression at the common femoral vein at the groin and the popliteal vein at the popliteal fossa. Whole-leg ultrasound utilized color doppler technology to evaluate the entire deep venous system, from the groin to the ankle (no com- pression beyond the proximal veins). Physicians experienced in vascular ultrasound performed all diagnostic evaluations. Follow- Up: T ree-month follow-up interview, physical examination, and/or ultrasound for patients with normal ultrasound fndings. Compression ultrasonography limitations include the need for serial tests if the frst ultrasound is negative, and missed isolated thrombi in the iliac veins or proximal portions of the femoral veins. Other Relevant Studies and Information: • T e major diference between the 2-point ultrasound strategy and whole-leg ultrasound strategy is that the later evaluates the calf veins. Since it’s afer hours, no dedicated vascular sonographer is on duty, and the night-shif radiology technologist can only perform a standard 2- point lower extremity ultrasound. Serial 2-point ultrasonography plus d-dimer vs whole-leg color-coded doppler ultrasonography for diagnosing sus- pected symptomatic deep vein thrombosis: a randomized controlled trial. A randomized trial of diagnostic strate- gies afer normal proximal vein ultrasonography for suspected deep venous throm- bosis: d-dimer testing compared with repeated ultrasonography. Withholding anticoagu- lation afer a negative result on duplex ultrasonography for suspected symptomatic deep venous thrombosis. Current diagnosis of venous thromboembo- lism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Funding: T e Cochrane Collaboration, an independent, nonproft organi- zation supported by governments, universities, hospital trusts, charities, and donations. Year Study Began: T e earliest trial began in 1963 and the most recent began in 1991. Year Study Published: T e results of the individual trials were published during the 1970s, 1980s, 1990s, and 2000s. Study Location: T e trials were conducted in Sweden, the United States, Canada, and the United Kingdom. Which Trials Were Included: a total of 11 randomized trials were identi- fed using an exhaustive search strategy; however, 3 were not eligible for in- clusion because of methodological limitations and 1 was excluded due to bias. Women in the screening group were invited for 2–9 rounds of screening, depending on the trial. Summary of Key Findings, 13 Years of Follow-Up Outcome Relative Risk with Screening (95% Confdence Intervals) Breast Cancer Mortality all 7 trials 0. Criticisms and Limitations: Many of the individual trials included in this meta-analysis sufered from methodological faws. Some of these faws may have biased the results in favor of the screening group while others may have biased the results in favor of the controls: • In many cases women assigned to the control groups appeared to be systematically diferent from those assigned to the screening groups. For example, in the two-County trial more women in the control group than in the screening group had been diagnosed with breast cancer prior to the start of the trial. T e physicians who determined the cause of death for study subjects were frequently aware of whether the subjects had been assigned to the screening versus control groups, and it is possible that their judgments were infuenced by this knowledge. Furthermore, few autopsies of patients who died were performed, and therefore many of the cause-of-death determinations may have been inaccurate. Because it presumably takes several years before the benefts of screening are apparent, it is unlikely this would have substantially afected the trial results. Still, it is possible that mammograms among controls partially obscured the benefts of screening. Breast cancer treatments have improved in recent years, and some experts believe that with current treatment options, the benefts of early detection of breast cancer may be smaller. Summary and Implications: Most of the trials of screening mammog- raphy have considerable methodological flaws.

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