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Rafael H Llinas, M.D.

• Director, Neurology at Johns Hopkins Bayview
• Professor of Neurology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0015511/rafael-llinas

By the 16th week of gestation allergy treatment while pregnant buy rhinocort with amex, the of the penis resulting from embryologic defects in the prepuce and the glans are adherent allergy testing what to expect order rhinocort 200mcg free shipping. O nly a small per 55 development of the urethral groove and penile urethra centage of newborns have a fully retractable foreskin allergy treatment nj generic 200mcg rhinocort fast delivery. In hypospadias allergy medicine brands names order on line rhinocort, which affects approxi With growth, a space develops between the glans and mately 1 in 250 male infants, the termination of the ure foreskin, and by 3 years of age, approximately 90% of thra is on the ventral surface of the penis (the surface male children have retractable foreskins. Phim osis refers to a tightening of the prepuce or penile foreskin that prevents its retraction over the 58 glans. In paraphim osis, the foreskin is so tight and constricted that it cannot cover the glans, a condition that can constrict the blood supply to the glans resulting in ischemia and necrosis. Because the foreskin of many boys cannot be fully retracted in early childhood, it is important that the area be cleaned thoroughly. There is no need to retract the foreskin forcibly because this could lead to infection, scar ring, or paraphimosis. As the child grows, the foreskin becomes retractable, and the glans and foreskin should be cleaned routinely. If symptomatic phimosis occurs after childhood, it can cause dif culty with voiding or sexual activity. The condition is bilateral in 10% to Universal Free E-Book Store C H A P T E R 3 9 Disordersof the Male Genitourinary S ystem 1013 detection of a testicular malignancy by positioning the testis in a more easily palpable location. As a group, men with unilateral or bilateral cryptor chidism usually have decreased sperm counts, poorer quality sperm, and lower fertility rates than do men whose testicles descend normally. The likelihood of Ab d o m in a l decreased fertility increases when the condition is bilat eral. Early orchiopexy appears to provide some protec In g u in a l 60 tion of fertility. Undescended testes due to cryptor chidism should be differentiated from retractable testes Norma l that retract into the inguinal canal in response to an exaggerated cremaster muscle re ex. The testes develop intra-abdominally in the complications associated with cryptorchidism. Surgical prematurely or are small for gestational age have the treatment is the cornerstone of therapy. The cause of cryptor mation suggests that placement of the testes in the chidism in full-term infants is poorly understood. M ost scrotum should be accomplished by 1 year of age to cases are idiopathic, but some may result from genetic maximize the potential for fertility. Spontaneous descent often occurs dur include lifelong follow-up, considering the sequelae ing the rst 3 months of life, and by 6 months of age of testicular cancer and infertility. Spontaneous descent aware of the potential issues of infertility and increased rarely occurs after 4 months of age. On reaching puberty, boys In children with cryptorchidism, histologic abnor should be instructed in the necessity of testicular malities of the testes re ect intrinsic defects in the tes self-examination. The undescended testicle is normal at birth, but patho 54 logic changes can be demonstrated at 6 to 12 months. Changes Related to Aging There is a delay in germ cell development, changes in the spermatic tubules, and reduced number of Leydig Like other body systems, the male reproductive sys cells. These changes are progressive if the testes remain tem undergoes degenerative changes as a result of the undescended. When the disorder is unilateral, it also aging process; it becomes less ef cient with age. The may produce morphologic changes in the contralateral declining physiologic ef ciency of male reproductive descended testis. Compared ity, testicular torsion, malignancy, and the possible psy with the marked physiologic change in aging women, 54,59,60 chological effects of an empty scrotum. Indirect the changes in the aging man are more gradual and less inguinal hernias usually accompany the undescended drastic. Recognition of the not related directly to age because a man remains fertile condition and early treatment are important steps in pre into advanced age; 80 and 90-year-old men have been venting adverse consequences. The increased risk of testicular measurably different in structure and function from cancer is not signi cantly affected by orchiopexy, hor that of the younger man. Male sex hormone lev monal therapy, or late spontaneous descent after the age els, particularly testosterone, decrease with age, with of 2 years. H owever, orchiopexy does allow for earlier the decline starting later on average than in women. Phimosis is the condition in tosterone affect sexual energy, muscle strength, and w h ich th e fo re s kin is to o tig h t to p e rm it re tra ctio n the genital tissues. The seminiferous tubules, which pro testes include cryptorchidism or undescended duce spermatozoa, thicken and begin a degenerative testicles. Early diagnosis and treatm ent are process that nally inhibits sperm production, result im p o rta n t to re d u ce th e ris k o f m a lig n a n cy a n d ing in a decrease of viable spermatozoa. The force of ejaculation also decreases because of a Like o t h e r b o d y s y s t e m s, t h e m a le r e p r o d u c t iv e reduction in the volume and viscosity of the seminal system undergoes changes as a result of the uid. The pubertal increases in the uid capac in vo lve ch a n g e s in e n d o crin e, circu la to ry, a n d ity of the gland remain throughout adulthood and neuromuscular function. After age 60 years, decrease, the size and rmness of the testes the walls of the seminal vesicles thin, the epithelium decrease, sperm production declines, and the decreases, and the muscle layer is replaced by connec prostate gland enlarges. Age-related changes in the penis consist of in e re ctile fu n ctio n re lathe d to d is e a s e s th a t brotic changes in the trabeculae in the corpus spon giosum, with progressive sclerotic changes in arteries accompany the aging process. Sclerotic changes also follow in the corpora cavernosa, with the condition becoming generalized in 55 to 60-year-old men. A 64-year-old man presents to his family physician including the presence of age-related diseases. H e is on multiple cardiovascular, respiratory, hormonal, neurologic, and medications for his heart disease. For example, vascular disease affects male potency because it may impair blood ow to the pudendal A. What additional information should be arteries or their tributaries, resulting in loss of blood obtained A 23-year-old man presents in the emergency tion, certain medications can have an effect on sexual department in severe distress. Why would this problem necessitate immediate gen levels show an increase in lean body mass and a diagnosis and surgical intervention Before testosterone replace ment therapy is initiated, all men should be screened 3. A 72-year-old man had a radical prostatectomy for prostate cancer and other androgen-related diseases. H e presents 5 years later administered every 2 to 4 weeks (a formulation taken having been lost to follow-up. What therapies are available for this contribute to a worsening of sleep apnea in men who are complication Universal Free E-Book Store C H A P T E R 3 9 Disordersof the Male Genitourinary S ystem 1015 24. Anomalies of the penis and urethra, and disorders and administration in older men. Universal Free E-Book Store Str ucture a nd Functio n o f the Fe ma le Re p ro d uctive Syste m C h a p t e r Exte r n a l G e n ita lia 40 Inthe r n a l G e n ita lia Va g i n a Ute rus a nd C e rvix Fa llo p ia n (Ute r in e) Tu b e s Ovaries Dis o rd e r s o fthe Menstrua l Cyclethe Hypotha la mic-Pituita ry Axis the Fe m ale Ovarian Hormones Ovarian Follicle Development and Ovulation Ge n it o u rin a ry En d o me tr ia l C h a n g e s Dis o r d e r s o f th e Fe m a le Re p r o d u ctive O r g a n s Sys tem Diso rd e rs o f the Exte rna l G e nita lia Ba r th o li n G la n d C y s t a n d Ab s c e s s Be n i g n a n d M a li g n a n t Di s o r d e r s o f th e Vu lva Vu l v o d y n i a Diso rd e rs o f the Va g ina isorders of the female reproductive system have Va g i n i t i s Dwidespread effects on physical and psychological Ca ncer of the Va gina function, including general health status, sexuality, and Disorders of the Uterine Cervix reproductive potential. This chapter provides a review of the structure and function of the female reproductive Cervicitis system and a discussion of disorders of the external and Pre ma lig na nt Le sio ns a nd C a nc e r o f the internal female reproductive organs, menstrual disor Cervix ders, and disorders of the breast. Diso rd e rs o f the Ute rus In fe c tio u s Di s o r d e r s o f th e Ute r u s a n d Pe lvic Structures Structure and Function of the En d o me trio s is Fe m a le Re p r o d u c t iv e S y s t e m Ad e no myo sis En d o me tria l C a n c e rthe female reproductive system consists of the external Ute rine Le io myo ma s 1,2 and internal genital structures. The external struc Diso rd e rs o f Ute rine Sup p o rt tures, or genitalia, are situated in the anterior part of the Diso rd e rs o f the O va rie s perineum, and the internal structures (vagina, uterus, Cystic Lesions of the O va ries fallopian tubes, and ovaries) are located in the pelvic Polycystic O va ry Syndrome cavity. Ovarian Cancer Me n str u a l Diso r d e r s Dysfunctiona l Menstrua l Cycles Ext e rn a l Ge n it a lia Ame no rrhe athe external genitalia, which are collectively referred to Dysmenorrhea as the vulva, include the mons pubis, labia majora, labia Premenstrua l Syndrome Disorders minora, clitoris, and perineal body. Because Menopa use a nd Aging Cha nges of their location, the urethra and anus usually are con Dis o r d e r s o f t h e Br e a s t sidered in a discussion of the external genitalia. Br e a s t S tr u c tu r e sthe mons pubis is a rounded, skin-covered fat pad located anterior to the symphysis pubis. Running pos Be n i g n Di s o r d e r s teriorly from the mons pubis are two elongated, hair In a mma tory Disorders covered, fatty folds, the labia m ajora. The labia majora Be n i g n Ep i th e li a l Di s o r d e r s enclose the labia m inora, which may be smaller than the Br e a s t C a n c e r labia m ajora and are composed of skin, fat, and some Dethe ctio n erectile tissue. The clitoris is located below the clitoral Dia g no sis a nd C la ssi ca tio n hood, which is formed by the joining of the two labia Tr e a t m e n t minora to form the prepuce.

Any skill level not met will require re-training before the staff person can provide mealtime supports again allergy elimination 200mcg rhinocort with amex. Feeding Plan Skills: Demonstrate proper solid food preparation technique for texture/consistency food penicillin allergy treatment gonorrhea rhinocort 200 mcg with mastercard. List prescribed diet: Ensures proper positioning with meal allergy medicine interactions 200 mcg rhinocort with mastercard. Describe position: Provides supervision as prescribed allergy symptoms children 100 mcg rhinocort with visa. What supervision level is ordered: Follows feeding plan as written and demonstrates proper feeding technique (observe staff supporting and/or feeding the person for minimum of 15 minutes). Nourishment cup milk* cup milk* cup milk* cup pudding cup pudding cup pudding Bold / italicized items indicate difference from the regular diet. Listed below are the food groups, recommended daily intake, and suggestions for each group for a dysphagia diet: Fluid Intake: Recommended Liquids: Water, 100% juices, decaffeinated tea Avoid: Caffeinated beverages, whole or 2% milk, beverages with 8 ounce servings lumps, pulp, or seeds (6-8 per day) Tips: Dilute juices and sodas with water, offer beverages between meals to promote adequate hydration Grains: Recommended Foods: Well moistened 100% whole wheat bread, pancakes, French toast, pureed bread mixes, cooked (breads, cereals, pastas) cereal, mashed potatoes (with gravy, butter, sour cream), pasta 1 ounce servings (well cooked) (6 per day) Foods to Avoid: Dry toast/crackers, rice, dry cereals, cooked cereals with lumps or seeds, white or enriched flour, white bread Vegetables: Recommended Foods: Moist, well cooked vegetables, tomato paste or sauce without seeds, tomato juice or vegetable juice (V*) cup servings Foods to Avoid: Tomato sauce with seeds, cooked corn, raw, (5 per day) hard vegetables, celery, asparagus and other tough, stringy vegetables Tips: Add vegetable/tomato juice for desired consistency 50 Fruits: Recommended Foods: Fruit juices (100% juice), soft, peeled fresh fruit (peaches, cantaloupe), canned fruit, well mashed fresh 1 cup servings bananas, and natural applesauce (2 per day) Foods to Avoid: Whole fruits, stringy or high pulp fruits (papaya, pineapple, mango), uncooked dry fruits (prunes, apricots), fruit leather, fruit roll ups, grapes (skin is hard to chew/swallow), oranges Tips: Add fruit juice for desired consistency Dairy/Milk: Recommended: Milk, yogurt, pudding and cheese (as recommended by your speech language pathologist) 1 cup servings Foods to Avoid: Yogurt with nuts or fruit chunks or seeds; hard or (3 per day) chunk cheeses Tips: Cheese can be used in cooking Meat/Protein: Recommended Foods: Eggs, hummus, softened tofu, meats cooked to desired consistency 3 ounce servings Foods to Avoid: Whole/ground meats, tough dry meats, fish with (2 per day) bones, chunky peanut butter, hot dogs, bacon Tips: Add gravy, sauce, or broth to meats, fish, poultry when pureeing Fats/Oils/Sweets: Recommended Foods: Butter, margarine, ketchup, smooth jellies/jams, puddings, mayonnaise, smooth sauces Use sparingly Foods to Avoid: Seeds, nuts, sticky foods, chunky/seedy jelly/jam, chewy candy Tips: Add condiments for flavor Tips to Increase Nutritional Density of Food When pureeing foods, rather than using water, use milk or cream for more protein and energy Whole milk can be fortified by adding milk powder (4 tbsp. There is more to pureeing entrees and side dishes than effectively changing the consistency of normal foods and maintaining their original flavor. By taking a little extra time, pureed food can be made attractive as well as delicious and nutrition. The Level 1: Dysphagia Pureed diet requires foods with a soft mashed potato or pudding-like consistency. Appropriate pureeing techniques require minimal addition of liquids thus concentrating nutritional value. Use of a food processor will require the addition of less liquid than the use of a blender. Thickened foods appear more appetizing and will support a sauce as a nutritious eye-appealing garnish. Also, thickened foods are easier for individuals to hold on a spoon and self-feed. Thickeners can be added directly to pureed foods in the processor or added as a slurry made by combining the thickener and liquid and gradually adding to the food while processing. When processing or blenderizing foods, be sure to scrape down the sides of the blender or processor with a rubber spatula at least once to incorporate all bits of food and thickener. The smallest chunk of food can be very uncomfortable and even life-threatening to a patient/resident with dysphagia. If it doesnt taste good to the cook, it wont taste good to the patient/resident either. Set up a pureed diet taste panel to be sure all foods taste good and have the appropriate consistencies before serving. Weigh or measure the number of drained portions required for the standardized recipe. Add measured amounts of hot liquid for cooked foods and cold liquid (if required) for cold foods and process until there is a smooth consistency. Measure and add commercial thickener, stabilizer, or shaping/enhancing product as directed in the recipe and process until blended. Serve with appropriate scoop number or divide equally to provide number of portions planned in step #2 above. It is recommended that Certified Dietary Managers or consultants in facilities receive continuing education on food preparation for modified consistency foods. Commercially Prepared Pureed Foods Commercially prepared pureed foods are another option for individuals with dysphagia. These foods are formulated in a laboratory utilizing industrial manufacturing equipment resulting in smooth textures of all foods. Commercial thickening agents are added to the pureed food, processed, and dispensed into the desired molded shape. Techniques for Improving Acceptance Feeding individuals with dysphagia requires extra care and consideration. Start simple and build a puree program that will allow you to be creative and serve attractive meals. Aroma Good smelling food and a pleasant atmosphere may increase appetite and improve consumption. Layering/Swirling Swirling vegetables together is simple and makes a great plate presentation; peas and carrots are striking together and taste great. Piping Place pureed food into a pastry bag and pipe for a lovely plate presentation. Molding To mold you will need to use a thickener or a shaping/enhancing product. These are a few simple ideas to keep in mind when serving modified consistency foods. Beautiful plate presentations and good tasting foods will help you maintain good consumption and ultimately good nutritional status. They are designed to thicken liquids for persons with swallowing disorders and to add body and definition to foods. Commercial thickeners can be added to cold pureed foods such as salads, fruits, and desserts and to hot foods to create a mashed potato-like consistency. Commercial shaping products or puree enhancers can help to form pureed foods into a more defined shape. These enhancers improve the appearance, flavor, and nutrition of hot pureed foods. Foods prepared with these products can be molded, sliced, cut into squares, or scooped. Shaped products have to be cooked to set after they are pureed, which limits them to use in hot foods only, such as meats, sandwiches, vegetables, casseroles, or breakfast foods. It is also possible to use shaping products to create a variety of plate presentations such as swirling foods together or layering combination dishes for visual appeal. Guidelines for Thickening Liquids Liquids sometimes need to be thickened as a result of swallowing difficulties. Thickened liquids are recommended for those individuals who are at risk of aspiration. The following consistencies are recommended, based on the individual patients needs. The liquid should be adequately thick enough so that a straw will stand upright in the liquid. There are commercially available products specifically designed to thicken liquids. Commercially available products include Thick & Easy, Thick-it, Thick-it 2, Thicken Right and Simply Thick. Most of these are cornstarch based products which can generally be used to thicken hot or cold items. Simply Thick is a gel which can be used with hot or cold items as well as nutritional supplements and dairy products. All of the products are available in large cans; some are available in pre-measured packets designed to thicken 4 ounces of liquid to either a nectar or honey thickness. The recommended procedure for thickening liquids is to add small amounts of the thickener while stirring briskly using a straw, wire whisk or fork. Continue to add thickener and stir briskly until the liquid reaches the appropriate thickness. Bread crumbs may also be used to thicken foods such as soups, pureed vegetables and casseroles. Fresh slices of bread, any kind without seeds or shells, can be finely ground in a food processor or chopper. Fruit puree (applesauce, blenderized fruits or jarred baby fruits) can be added to juices. Pureed vegetables can be used to thicken soups but will not thicken as much as the bread crumbs. When thickened liquids are recommended, it is important to remember that all liquids need to be thickened. Hot cereals might be a good alternative to cold cereals until liquids are swallowed easier. Milk shakes can be made by adding a little instant pudding to the shake; this will help to keep the liquid thickened as it warms. Because both Jello and ice cream melt with our body temperature, use of these products should be reviewed with the speech pathologist. Foods That Melt at Room Temperature Foods that melt at room temperature should be considered liquids and should not be given to people who are supposed to have their liquids thickened to a honey or pudding consistency.

Incomplete ascertainment of autism cases in young child populations is the largest source of predictable bias in prevalence surveys; however food allergy symptoms quiz buy generic rhinocort from india, this bias has allergy testing shellfish rhinocort 100 mcg lowest price, if anything allergy medicine home remedies discount rhinocort 100 mcg online, worked against the detection of an upward trend in recent surveys allergy testing age buy rhinocort once a day. Comparison of autism rates by year of birth for specific geographies provides the strongest basis for trend assessment. Such comparisons show large recent increases in rates of autism and autistic spectrum disorders in both the U. Reported rates of autism in the United States increased from,3 per 10,000 children in the 1970s to . In the United Kingdom, autism rates rose from,10 per 10,000 in the 1980s to roughly 30 per 10,000 in the 1990s. Reported rates for the full spectrum of autistic disorders rose from the 5 to 10 per 10,000 range to the 50 to 80 per 10,000 range in the two countries. A precautionary approach suggests that the rising incidence of autism should be a matter of urgent public concern. With most subsequent rounds of shots, a child would continue to get some aluminum throughout the first two years. Funding dedicated to vaccine promotion is not broken out separately but is within the $500+ million vaccine operations budget. May 25, 2004 Collusion Seen After Release of Flawed Vaccine-Autism Report SafeMinds. Riddled with conflicts of interest, Institute of Medicine releases report derived from flawed data, says National Autism Association. This is due to a small percentage of studies reflecting information in multiple areas. A+D (Original Ointment) is a registered trademark of Schering-Plough Healthcare Products, Inc. Prevacid is a registered trademark of Novartis Prilosec is a registered trademark of AstraZeneca, Sodertalje, Sweden Prolacta is a registered trademark of Prolacta Bioscience, Inc. James Adams and his Itradition of generating practical, up-to-date and evidence-based guidelines that provide bedside clinicians with a ready reference for patient care. The editors, section editors, and various authors have worked hard to preserve relevant material from the guidelines and add new relevant information. Community neonatology colleagues, nurse practitioners, dietitians, and fellows are all members of author teams now. It ensures consistency of care among the large number of clinicians in our Newborn Center and at multiple locations in the Houston area. It has been, and will remain one of the most valuable resources and a distinguishing asset of the Neonatology Section. As the Service Chief and Section Head of Neonatology, it has been my honor to support the team of editors and authors who have worked hard to bring us this distillation of evidence, experience, and clinical wisdom. The Baylor Neo Guidelines, as this handbook is fondly referred to , is meant to serve as a resource for neonatology fellows, pediatric housestaff, nurse practitioners, nurses and other clinicians who care for sick neonates in Baylor-affiliated hospitals. This body of work is reflective of general principles, concepts, and treatment recommendations that are agreed upon by the authors, editors, and section members. When appropriate, national guidelines are cited to help with the decision-making process. Also, regional traits unique to the southeast Texas or Houston are considered when appropriate. The guidelines are reviewed and revised annually (or more frequently as needed) as new evidence and recommendations for clinical care become available. Users should refer to the most recent edition of these guidelines, which may be downloaded for free from Physician publications tab of the Baylor Neonatology website ( Our guidelines cite the quality of evidence and the strength of our recommendations whenever possible. Our chapter authors and section editors have worked hard to create the content you see within and will monitor their areas of clinical interest for emerging evidence that may be of value to the bedside clinician caring for a sick neonate. Each new admission and all significant new developments must be discussed with the fellow on call and with the attending neonatologist on rounds. All users of this material should be aware of the possibility of changes to this handbook and should use the most recently published guidelines. Allied health contributors are all members of the Texas Childrens Hospital staff. Infectious Disease section was written with the advice of the Pediatric Infectious Disease Section, in particular, Drs. Frequency of such testing may vary from every 1 to 2 weeks in the sick, tiny premature infant on positive pressure support to once a month or less in a healthy, normally growing premature infant. Efforts should be made to cluster such routine sampling with other laboratory tests. A pressor agent such as dopamine is preferable to birth weight between 7 and 14 days of age. If respiratory distress develops or performed at intervals recommended by the American Academy pulmonary function subsequently deteriorates, the infant should of Pediatrics. If hospital discharge or transfer to another be intubated and given early rescue surfactant (within first 2 neonatal unit or hospital is contemplated before retinal hours). Rapid should have an initial developmental consultation and evaluation improvement in lung compliance necessitates close monitoring before discharge. Rapid extubation after surfactant administration complications requiring catheter removal range from 5. Duration not on positive pressure ventilation) should be started on of catheterization and catheter position are the most commonly caffeine citrate (20 mg/kg loading dose followed by 5 to 10 associated risk factors. The appropriate central position is mg/kg maintenance dose) within the first 10 days of life. One prospective observation should be continued until drug therapy for apnea of prematurity study of 100 neonates using serial ultrasound demonstrated: is no longer needed. Severe complications do occur in available) during the first 12 hours of life to babies less than or infants with appropriate catheter position. If a suboptimal catheter position must be used for initial stabilization, obtain alternate access as soon as possible. Avoid infusion of medications or hyperosmolar solutions if not in central position. A Cochrane database systematic review concluded < 1000g or < 26 weeks the high position resulted in fewer vasospastic, ischemic and thrombotic complications as compared to low lying catheters. Insertion to correct estimated depth does not guarantee proper position of catheter tip. The procedure of umbilical catheter placement is not complete until there is clear radiographic documentation of optimal catheter position. Maintenance of Umbilical Catheters in an Optimal Position Umbilical catheters, even if optimally placed, may become displaced if patient is moved, the abdomen becomes distended or if they are not secured well.

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Biopsies are obtained in a number cytes allergy shots zostavax best rhinocort 200 mcg, monocytes allergy treatment 2013 safe 100mcg rhinocort, granulocytes allergy medicine mucinex buy generic rhinocort, and natural killer cells of ways allergy shots death cheap 100mcg rhinocort with mastercard, including needle biopsy; endoscopic methods, 2,3 and immature variants of these cells. The two Fine needle aspiration involves withdrawing cells and that have proved most useful as tumor markers are alpha attendant uid with a small-bore needle. M odern imaging techniques have also enabled are encountered in people with primary liver cancers the method to be extended to deeper structures such as and have also been observed in some testicular, ovarian, the pelvic lymph nodes and pancreas. Carcinoembryonic In some instances, a surgical incision is made from antigen normally is produced by embryonic tissue in the which biopsy specimens are obtained. Excisional biop gut, pancreas, and liver and is elaborated by a number sies are those in which the entire tumor is removed. The of different cancers, including colorectal carcinomas, tumors usually are small, solid, palpable masses. Nearly all markers can be elevated in benign conditions, and most are not elevated in the early stages of malignancy. Immu nohistochem ist ry inv Furthermore, they are not in themselves speci c enough olves the use of monoclonal antibodies to facilitate 3 to permit a diagnosis of a malignancy, but once a malig the identi cation of cell products or surface markers. Extremely elevated lar under the microscope, but must be accurately iden levels of a tumor marker can indicate a poor prognosis or ti ed because their treatment and prognosis are quite the need for more aggressive treatment. Many cancer markers tends to decrease with successful treatment and patients present with metastasis. Immunochemistry can Cy t o lo g ic, His t o lo g ic, a n d Ge n e -Pro lin g also be used to detect molecules that have prognostic or Me tho ds therapeutic signi cance. For example, detection of estro Cytologic and histologic studies are laboratory meth gen receptors on breast cancer cells is of prognostic and ods used to examine tissues and cells. Several sampling therapeutic signi cance because these tumors respond to approaches are available including cytologic smears, tis antiestrogen therapy. The Pap smear is a cytologic the advantage of analyzing a large number of molecu method that consists of a microscopic examination of a lar changes in cancer cells to determine overall patterns properly prepared slide by a cytotechnologist or patho of behavior that would not be available by conventional logist for the purpose of detecting the presence of abnor means. The technique uses gene chips that can perform Universal Free E-Book Store C H NeoplAasia 149 P T E R 7 miniature assays to detect and quantify the expression of Surgery 2 large numbers of genes at the same time. The type of surgery to be tion to identifying tumor types, microarrays have been used is determined by the extent of the disease, the loca used for predicting prognosis and response to therapy, tion and structures involved, the tumor growth rate and examining tumor changes after therapy, and classifying 2 invasiveness, the surgical risk to the patient, and the hereditary tumors. If the tumor is small and has well-de ned margins, Staging and Grading ofTumors the entire tumor often can be removed. If, however, thethe two basic methods for classifying cancers are grad tumor is large or involves vital tissues, surgical removal ing according to the histologic or cellular characteristics may be dif cult if not impossible. Both methods are used to determine the Ra d ia t io n Th e ra p y course of the disease and aid in selecting an appropriate Radiation can be used as the primary method of treat treatment or management plan. It can also be used as a palliative treatment ferentiation and the number of mitoses. The closer the to reduce symptoms in persons with advanced can tumor cells resemble comparable normal tissue cells, cers. It is effective in reducing the pain associated with both morphologically and functionally, the lower the bone metastasis and, in some cases, improves mobility. Radiation therapy exerts its effects through ioniz-the clinical staging of cancers uses methods to deter ing radiation, which affects cells by direct ionization of mine the extent and spread of the disease. The signi cant criteria into tissue and give up their energy by producing fast used for staging that vary with different organs include moving electrons. These electrons interact with free or the size of the primary tumor, its extent of local growth loosely bonded electrons of the absorber cells and sub (whether within or outside the organ), lymph node sequently produce free radicals that interact with criti 2,3 involvement, and presence of distant metastasis. Cell damage can be sublethal, in which case node involvement, and M for metastasis), which was a single break in the strand can repair itself before the developed by the Union for International Cancer Control, next radiation insult. To some Cancer Treatm ent extent, however, radiation is injurious to all rapidlythe goals of cancer treatment methods fall into three proliferating cells, including those of the bone marrow categories: curative, control, and palliative. This common modalities are surgery, radiation, chemother results in many of the common adverse effects of radia apy, hormonal therapy, and biotherapy. The treatment tion therapy, including infection, bleeding, and anemia of cancer involves the use of a carefully planned pro due to loss of blood cells, and nausea and vomiting due gram that combines the bene ts of multiple treatment to loss of gastrointestinal tract cells. In addition to its modalities and the expertise of an interdisciplinary team lethal effects, radiation also produces sublethal injury. N ormal tissue is usually able l N b 11 to recover from radiation damage more readily than is 10 cancerous tissue. In other instances, a multidrug 10 ated by a linear accelerator or cobalt-60 machine at a Dis e a s e in clinica l re mis s ion distance and aimed at the patients tumor; brachyther 8 10 apy, in which a sealed radioactive source is placed close l 7 to or directly in the tumor site; and systemic therapy, in 10 mouth or injected into the tumor site. Unlike surgery and Experimentally, drug resistance can be highly speci c to 10 0 radiation, cancer chemotherapy is a systemic treatment differing structures occurs. This type of resistance often 102 that enables drugs to reach the site of the tumor as well as distant sites. Chemotherapeutic drugs may be used as 1 10 the primary form of treatment, or they may be used as 1 2 3 4 5 Cycle s of che mothe ra py part of a multimodal treatment plan. Relationship between tum or cell survival and cer, acute and chronic leukemia, Burkitt lymphoma, administration of chemotherapy. By the time many cancers reach a what would occur if the last cycle of therapy were omitted: despite complete clinical remission of disease, the tumor size that is clinically detectable, the growth fraction has ultimately would recur. Th e Am e rica n Ca n ce r S o cie tys size through the use of surgical debulking procedures or Clin ica l On co lo g y. Thus, surgery or radiation ther apy may be used to increase the effectiveness of chemo therapy, or chemotherapy may be given to patients with no overt evidence of residual disease after local treat Cancer chemotherapy drugs may be classi ed as ment. Drugs are between tumor cell survival and drug dose is exponen cell cycle speci c if they exert their action during a spe a single agent and is usually based on genetic changes in tial, with the number of cells surviving being propor ci c phase of the cell cycle. For this when cells are in the resting state as well as when they are reason, multiple courses of treatment are needed if the dividing. Chemotherapy drugs that have similar structures A major problem in cancer chemotherapy is the and effects on cell function usually are grouped together, development of cellular resistance. Combination chemotherapy has been found to be more effective than treatment with a single drug. With this method, several drugs with different mechanisms of action, metabolic pathways, times of onset of action transporter genes involved in drug ef ux. Drugs, drug containers, and administration 60 effective against the tumor and synergistic with each equipment require special disposal as hazardous waste. The maximum possible drug doses usually are used to ensure the maximum cell kill within the range Ho rm o n e a n d An t ih o rm o n e Th e ra p y of toxicity tolerated by the host for each drug. Routes H ormonal therapy consists of administration of drugs of administration and dosage schedules are carefully designed to deprive the cancer cells of the hormonal sig designed to ensure optimal delivery of the active forms nals that otherwise would stimulate them to divide. It is of the drugs to the tumor during the sensitive phase of used for cancers that are responsive to or dependent on the cell cycle. Among the tumors that are known to be respon Ch e m o t h e ra p y S id e Effe c t s. Unfortunately, chemo sive to hormonal manipulation are those of the breast, therapeutic drugs affect both cancer cells and the rapidly prostate, and endometrium. Other cancers, such as proliferating cells of normal tissue, producing undesir Kaposi sarcoma and renal, liver, ovarian, and pancreatic able side effects. Some side effects appear immediately cancer, are also responsive to hormonal manipulation, or after a few days (acute), some within a few weeks but to a lesser degree. With neutropenia, of the organ responsible for the hormone produc there is risk for developing serious infections, whereas tion that is stimulating the target tissue. Pharmacologic sup which stimulates platelet production) has shortened the pression of circulating hormone levels can be effected period of myelosuppression, thereby reducing the need through pituitary desensitization, as with the admin for hospitalizations due to infection and decreasing the istration of androgens, or through the administration need for blood products. Another class of of the vomiting is related to the emetic potential of the drugs, the arom atase inhibitors, is used to treat breast particular drug. These symptoms can occur within min cancer; these drugs act by interrupting the biochemi utes or hours of drug administration and are thought to cal processes that convert the adrenal androgen andro be due to stimulation of the chemoreceptor trigger zone 62 stenedione to estrone. H ormone receptor function can be altered by thethe chemoreceptor trigger zone responds to the level administration of pharmacologic doses of exogenous of chemicals circulating in the blood. The acute symp hormones that act by producing a decrease in hormone toms usually subside within 24 to 48 hours and often receptors or by antihormone drugs (antiestrogens and can be relieved by antiemetic drugs.

It consists of dimers of three different polypeptide chains [(A) (B) ] held together at the N termini by disulfide bonds allergy treatment 4 syphilis buy rhinocort 200mcg lowest price. Thrombin cleaves the charged tufts (releasing fibrinopeptides A and B) allergy forecast hanover pa purchase on line rhinocort, and fibrinogen becomes fibrin allergy medicine you have to sign for generic rhinocort 200mcg free shipping. As a result of the loss of charge allergy medicine and caffeine buy rhinocort cheap online, the fibrin monomers are able to noncovalently associate in a staggered array, and a soft (soluble) fibrin clot is formed. The complete picture of physiologic blood clotting via the formation of a hard fibrin clot is shown in Figure 34. Inactivating proteins Proteins synthesized by the liver and by the blood vessels themselves balance the need to form clots at sites of vessel injury with the need to limit their formation beyond the injured area. It inactivates free thrombin by binding to it and carrying it to the liver 34. Once bound, the protease cleaves a peptide bond in the serpin causing a conformational change that traps the enzyme in a covalent complex. Thrombomodulin, an integral membrane glycoprotein of endothelial cells, binds thrombin, thereby decreasing thrombins affinity for fibrinogen and increasing its affinity for protein C. Thrombomodulin, then, modulates the activity of thrombin, converting it from a protein of coagulation to a protein of anticoagulation, thereby limiting the extent of clotting. The fibrin clot is cleaved by the protein plasmin to fibrin-degradation products 34. Plasminogen, secreted by the liver into the circulation, binds to fibrin and is incorporated into clots as they form. Streptokinase (from bacteria) also activates plasminogen and works on both free and fibrin-bound plasminogen. Lipoprotein(a) [Lp(a)] also contains kringle domains and, thus, competes with plasminogen for binding to fibrin. The potential to inhibit fibrinolysis may be the basis for the association of elevated Lp(a) with increased risk for cardiovascular disease (see p. Aggregation Activation causes dramatic changes in platelets that lead to their aggregation. Coagulation is accomplished through formation of a clot (thrombus) consisting of a plug of platelets (thrombocytes) and a meshwork of the protein fibrin 34. Platelet activation involves changes in shape (discoidal to spherical with pseudopodia) and degranulation, the process by which platelets release the contents of their storage granules. The initial loose plug of platelets (primary hemostasis) is strengthened by the fibrin meshwork (secondary hemostasis). Warfarin, a synthetic analog of vitamin K used clinically to reduce clotting, inhibits the enzyme vitamin K epoxide reductase that regenerates the functional reduced form. Disorders of platelets and coagulation proteins can result in deviations in the ability to clot. Patients on aspirin therapy and those with thrombocytopenia have alterations in platelet function and number, respectively, and not in the proteins of the clotting cascade. Symptomatic deficiencies in clotting factors will present with a decreased ability to clot (coagulopathy). Thrombomodulin binds thrombin and converts it from a protein of coagulation to one of anticoagulation by decreasing its activation of fibrinogen and increasing its activation of protein C. The adhesion phase is mediated by the binding of platelets to von Willebrand factor via glycoprotein Ib. Adenosine diphosphate is released from activated platelets, and it itself activates platelets. The publisher makes no representation, express or implied, with regard to the accuracy of the information contained in this book and cannot accept any legal responsibility or liability for any errors or omissions that may be made. A catalogue record for this book is available from the British Library Contents Preface vi Interactions between herbal medicines Abbreviations viii and conventional drugs 6 Variability of herbal medicines 6 General Considerations 1 Mechanisms of interactions 7 Structure of the publication 1 Pharmacokinetics 7 Data selection 2 Cytochrome P450 isoenzymes 7 Nomenclature 2 Drug transporter proteins 9 Incidence of herbal medicines interactions 2 Pharmacodynamic interactions 10 Who uses herbal medicines And what alternative and safer drugs can be used worth producing a book dedicated to this information; instead Stockleys Herbal Medicines Interactions follows the same As a group dedicated to the study of drug interactions, and easy-to-read format as our other publications, with the text the provision of clinically relevant data (aided by the large organised into a series of individual monographs, all with a number of practising pharmacists we have on our team), we common format. A pharmacopoeia published in the field of herbal medicines, and is a member section is also included for those herbal medicines, dietary of a number of bodies that consider many aspects of herbal supplements and nutraceuticals that have entries in the medicine use, such as the British Pharmacopoeia Commis latest editions (at time of press) of the British Pharmaco sion. In addition, we have added the simple, intuitive Herbal medicines are, more than ever, receiving attention, ratings system that users of Stockleys Interaction Alerts both from the public and healthcare professionals alike, with and Stockleys Drug Interactions Pocket Companion will many countries now undertaking registration schemes for already be familiar with. However, healthcare professionals still As with all Stockley products, the text is written for a freely admit their lack of knowledge in this area, and surveys worldwide audience. Terminology has been carefully con suggest that patients often rely on friends and family for sidered and international terms have been added where it advice about herbal medicines. As always, the Editorial team have had assistance from Our aim, as ever, has therefore been to critically evaluate the many other people in developing this publication, and the published literature and present it in a familiar, easy-to Editors gratefully acknowledge the assistance and guidance handle format, so that the busy healthcare professional can that they have provided. Birla, Karl Parsons, Tom Whitaker and Darren Searson, who vi Preface vii have worked tirelessly in transforming our data into a we are indebted to Julie McGlashan and Elizabeth King, and useable output. For more details about these digital a number of other projects, and continues to provide products please visit: We are also grateful for the support of useful comments, which help us to develop the product to both Paul Weller and Charles Fry. Anyone who wishes to important part of all products bearing his name, and we are contact us can do so at the following address: most grateful for the feedback that he provided on this new stockley@rpsgb. Clinical evidence, detailing the interaction and citing thethe basic issues involved in assessing the importance of clinical evidence currently available. Although this data to those for interactions between conventional drugs, but for doesnt always extrapolate to the clinical situation it can herbal medicines the picture is complicated by their very be used to provide some idea of the likelihood and nature: they are complex mixtures themselves and there is potential severity of an interaction. It has been deliberately also a lack of reliable information about their occurrence and kept separate from the clinical data, because this type of relevance. Mechanism, to allow an understanding as to why the interaction data have been set out here, and why, as well as interaction may occur. As with all Stockley products, providing guidance on how to manage anthe monographs interaction is our key aim. This publication includes over 150 herbal medicines, nutraceuticals or dietary supplements. Constituents Stockley Interactions Alerts and Stockleys Drug Interactions Pocket Companion. Pharmacokinetics interactions, we have chosen to illustrate the worst-case scenario. These ratings are combined to produce one of five symbols: London: Elsevier; 2002. For interactions that have a life-threatening outcome, or More than 550 interactions monographs are included, each where concurrent use is considered to be best avoided. Instead we the same synonym has been used for more than one herbal chose internationally recognisable symbols, which in testing medicine and, where we are aware of this, we have been were intuitively understood by our target audience of careful to highlight the potential for confusion. This interact in their own right, but which are prevalent in a nomenclature is not meant to imply any preference, it is just number of herbal medicines, the most common example of simply a way of being clear about which preparation we are this being the flavonoids. Because so many herbs contain a multitude of synthetic coumarins used as anticoagulants. The same rigorousthe incidence of interactions between herbal medicines and approach that is used to produce Stockleys Drug Inter nutritional supplements with conventional drugs is not yet actions has been applied here, although with some notable fully known, and there is no body of reliable information differences, particularly in the selection of data for inclusion. Even reliability, and this is even more the case when considering in the case of St Johns wort, which is now commonly interactions between herbal medicines and conventional known to interact with a number of drugs, the clinical drugs. Indeed those that there are have already been may be due to under-reporting or unrecognised interactions, included in Stockleys Drug Interactions. We have included scaremongering guesswork, hallowed by repeated quotation them because they appear in other reference sources for until they become virtually set in stone. These have to be evaluated very carefully before interaction reports associated them. However, even prescription purchase of herbal remedies, but it is known numbers of people taking supplements is not accurately that, in 2003, European countries spent almost $5 billion (at known, although over the past 10 years several studies have manufacturers prices) on non-prescription herbal medi been carried out to try to assess this.