Viagra Sublingual

Daphne Ruth Friedman, MD

Associate Professor of Medicine
Member of the Duke Cancer Institute

https://medicine.duke.edu/faculty/richard-frothingham-md

Moreover erectile dysfunction qof order cheap viagra sublingual, no associa- onset of thyroid storm [123] erectile dysfunction doctors in orlando cheap viagra sublingual 100 mg free shipping, which can result in neu- tion was observed between the choice of medication to rotoxic effects [124] erectile dysfunction causes and remedies cheap viagra sublingual uk. Thyrotoxicosis can affect pharmacokinetics by Somnolence and coma can be caused by a variety of altering the absorption bpa causes erectile dysfunction cheap viagra sublingual 100 mg otc, distribution erectile dysfunction medicine list buy viagra sublingual line, metabolism erectile dysfunction and urologist discount viagra sublingual 100mg on line, and conditions, such as hypoxemia due to heart failure or excretion of drugs [122]; these effects may change shock, liver failure, renal failure, severe infection, cere- dynamically during the treatment of thyroid storm. Thyroid storm is often complicated multiple organs such as the liver and kidney, which can by these conditions; therefore, a differential diagnosis also affect pharmacokinetics. Because the underlying cerebrovascular disease or should be individually determined. Early confrmed in the initial care of acute disturbances in initiation of rehabilitation is recommended to prevent consciousness. The administration of vitamin B1 prior disuse muscle atrophy, especially in patients receiving to or at the same time as glucose injection is recom- mechanical ventilation [125]. A differential netics diagnosis for cerebrovascular disease, meningitis, met- Thyrotoxicosis does not have a pronounced effect abolic disorders, or poisoning should be constructed on the pharmacokinetics of diazepam [126], phenytoin Guidelines of thyroid storm management 1037 Fig. It is given intravenously at an initial dose of in thyrotoxic patients the effect of propofol is decreased 0. Amiodarone fbrillation in thyroid storm may be considered for patients with impaired left ven- tricular systolic function. Other beta1-selective oral drugs are also rec- been used to evaluate the risk of stroke onset. Tachycardia should be treated aggressively because selected as the frst choice treatment. If the heart rate the results of our nationwide survey revealed that is <150 bpm, landiolol or esmolol can be changed to an tachycardia? The results of our nationwide survey showed that seconds, and its dosage should be controlled appropri- atrial fbrillation in the presence of thyroid storm ately while monitoring the heart rate (~150? Thyroid Furthermore, a patient with thyroid storm and bron- hormones have been shown to increase the density of chial asthma was successfully managed with esmolol beta-adrenergic receptors and cyclic adenosine mono- [144]. Since the 1970s, many stud- due to the pathophysiology of thyroid storm, which ies suggested the usefulness of propranolol. However, is characterized by peripheral vasodilation associated most of these studies proposed the usefulness of beta- with increased beta-adrenergic action. One is its short elimination half-life roid storm had atrial fbrillation and 130 did not have (t1/2) and duration of action. Atrial fbrillation status was unknown in 90 onset of action of intravenous propranolol and esmolol patients, of whom 13 died. The presence of atrial fbril- are similar, their t1/2 and duration of action are mark- lation in thyroid storm was associated with signif- edly different. The t1/2 alpha and beta for proprano- cantly increased mortality in our nationwide surveys lol are 10 minutes and 2. The the t1/2 alpha and beta for esmolol are 2 minutes and 9 reported incidence of atrial fbrillation in thyrotoxicosis minutes, respectively [140]. Atrial fbrillation demonstrated that the effects of beta-blockade com- further accelerates systemic hemodynamic disturbances pletely disappeared 18 minutes after the infusion of and increases mortality in thyroid storm; therefore, car- esmolol (300? Digitalis is recommended for tachy- ing these novel oral anticoagulants may be reevaluated cardia-induced heart failure due to atrial fbrillation in the future based on new information. Treatment of acute congestive heart fail- with caution because of the possibility of digitalis ure in thyroid storm intoxication, especially in patients with renal dysfunc- tion. Hemodynamic monitoring using a Swan-Ganz cath- be monitored and the dose adjusted appropriately as eter is recommended for patients with acute congestive the patient becomes euthyroid. Calcium channel blockers (intra- as the sum of the points for each risk factor (1 point venous) should be considered if hypertension is for each of the frst 4 factors and 2 points for history present. Guidelines of thyroid storm management 1041 ii) Drug therapy: Adrenergic agonists should be [153]. The short-acting beta1-selective adren- and isosorbide dinitrate) in 4 patients; carperitide in ergic antagonists landiolol or esmolol may be 6 patients; furosemide in 5 patients; and unknown or considered when heart rate is? None of these agents were used atrial fbrillation is present, digitalis should be in 229 patients. Although the use of these Strength of recommendation: high agents was associated with signifcantly increased Quality of evidence: low mortality in our nationwide surveys (p<0. An artifcial heart?lung machine should be used assessed with the Fisher?s exact test, this result was before the development of irreversible multiple organ attributed to these agents being used in patients in crit- failure when hemodynamic status has not improved ical condition with a high likelihood of death. The treatment of Quality of evidence: low acute congestive heart failure in patients with thyroid storm has not been examined in detail. Evidence supporting the recommendations use of vasoconstrictor agents with or without diuret- 1. Acute congestive heart failure in thyroid storm of cyclic adenosine monophosphate with overstimula- should be treated according to the Guidelines for the tion of beta-adrenergic receptors. Artifcial heart?lung machines were used in 9 on an individualized basis, with consideration of the patients in our nationwide surveys [4]: 2 patients with pathophysiology of thyroid storm. Our nationwide surveys revealed that 5 of 9 patients 2 patients with class 2 disease, and 1 patient with treated with an artifcial heart?lung machine sur- unknown status. An artifcial heart?lung machine should be class 4 disease, and 1 patient each with class 3 disease, used before the development of irreversible multiple class 2 disease, and unknown status. Hemodynamic monitoring with a Swan-Ganz cath- opment of irreversible multiple organ failure. Treatment of gastrointestinal disorders primarily by improving thyrotoxicosis with limited use and hepatic damage in thyroid storm of anti-emetics. Gastrointestinal symptoms, including diarrhea, nau- emergency room to prevent gastric ulcers and acute sea, and vomiting, are associated with thyrotoxicosis, gastric mucosal lesions. Patients under mechanical heart failure, neurological disorders, and gastrointesti- ventilation and those with coagulopathy are at the high- nal infection. Although proven to be highly effective in rais- ventilation may be risk factors for gastrointestinal hem- ing gastric pH, recent studies, including a meta-analy- orrhage and mortality. Guidelines antagonists (H2As) are recommended for patients in issued by the Agency for Healthcare Research and these instances. Furthermore, acid-suppressive drugs wide surveys showed that patient prognosis is worse can cause hypomagnesaemia, vitamin B12 defciency, when total bilirubin levels are? Differential upper respiratory tract infection, pneumonia, and clini- diagnosis for the origin of hepatic dysfunction and cal fractures of the hip, spine, and wrist. Gastrointestinal disorders contribute to poorer prognosis in patients with Diarrhea is the most common gastrointestinal symp- thyroid storm. Treating a reduction in serum thyroid hormone levels could congestive heart failure could contribute to the recov- stop diarrhea without the use of specifc antidiarrheals. Ursodeoxycholic acid, Antidiarrheals are not necessary for many cases of thy- which relieves liver dysfunction, and Stronger Neo- roid storm with coma. Thyroid storm causes muscle Minophagen C, a glycyrrhizin-containing liver pro- weakness in the diaphragm and esophagus, and gas- tector, can also be used; however, these drugs may tric wall motility dysfunction, which results in nau- induce further liver damage [160]. Severe liver failure induces reduced protein rial ketone body ratio (acetoacetate/3-hydoxybutyrate) synthesis, which results in coagulopathy, host defense <0. Three types of apheresis are used for acute disorders, and eventually multiple organ failure. In addition, hemodialysis could such as bilirubin, replace proteins such as coagula- support detoxifcation in liver failure [161]. Based on the results of our Strength of recommendation: strong national survey in Japan [4], we could not identify any Quality of evidence: low specifc drugs that affected liver function or mortality 2. Based on nationwide survey analyses, it is strongly in patients with thyroid storm. Increased oxygen consumption in hepatocytes Strength of recommendation: strong resulting in relative hypoxia in the perivenular region, Quality of evidence: low may be responsible for inducing hepatocyte damage in 3. Evidence supporting the recommendations principal treatment during the acute phase of thyroid Thyroid storm constitutes an endocrine emergency storm should focus on thyrotoxicosis and heart failure. Of 356 patients, 38 died and nosis of thyroid storm has never been evaluated in a 318 survived. Shock (53 of the patients who died, while in the 8 patients who cases) was the most common comorbidity [4]. A nationwide survey conducted by the Japan Multiple organ failure is another important comor- Society for Emergency Medicine at 178 hospitals in bidity of thyroid storm. Based on these fnd- survey and it is an independent risk factor for mortal- ings as well as our own, we strongly recommend that ity [4]. The pathogenesis of multiple organ failure has Sequential Organ Failure Assessment is another been divided into the following 2 mechanisms: 1) tis- scoring system for systemic conditions. It is calculated sue hypoxia induced by tissue hypoperfusion in shock based on 6 clinical indexes evaluating the respiratory, or hypotension and 2) decompensation or overcompen- coagulation, liver, cardiovascular, central nervous, and sation for systemic infammation induced by various renal systems. Each index has 5 grades, ranging from pathogens, such as during infection, leading to over- 0 to 4 [172]. The a coagulation disorder can progress to multiple organ odds ratio for death was 1. Although absolute values were as low as peutic strategy has not been established and the man- 2, sequential changes in this score can be useful for the agement of thyroid function is considered to be essen- assessment of the patient?s prognosis since this value tial. Palliative therapy for each type of organ failure is was associated with mortality. They include management A recent study reported the relationship between with a respirator for respiratory failure, hemodialysis thyroid dysfunction and coagulation disorders [130]. Several case reports multiple organ failure carries an especially high mor- also described patients with severe thyroid storm com- tality in thyroid storm. Among thyroid storm survivors, 318 15?19 ~25% death rate patients did not have any sequelae, while 29 patients 20?24 ~40% death rate had some sequelae. Half of the deaths were caused 25?29 ~55% death rate directly by heart failure and or multiple organ failure 30?34 ~75% death rate (Table 4) [4]. Most sequelae Table 6 Sequelae of thyroid storm consisted of neurological disorders, either central or Sequlae Number of patients peripheral (Table 6). Renal insuffciency 2 When analyzing data on patients who have died, we Psychosis 2 have to recognize the limitations of this survey. Since Hypothyroidism 2 this was a retrospective survey, all patients were treated Gastric ulcer 1 with some interventions, and some factors that were Others 3 well managed could not be detected as important risk Total 29 factors for mortality. Therefore, it is necessary to iden- tify factors indicating serious conditions at the initial assessment before the treatment. Comments tors indicating a serious condition on the basis of some No large-scale observational cohort studies have established indices that are associated with mortal- been conducted to date. These previous studies have draw- described in the previous section, both factors are corre- backs such as differences in treatments used or a small lated with mortality. The recent nationwide survey sup- score can be used as an alternative index of mortality. Although the Coma Scale score, age, serum creatinine, serum albu- fndings were considered to be reliable, limitations min, and base excess. The parameters independently included the study being cross-sectional in design and associated with the calculated Sequential Organ Failure that the clinical course of each patient was modifed Assessment score include the presence of ophthalmop- by treatment chosen based on the severity of thyroid athy, Glasgow Coma Scale score, shock, serum albu- storm. In ysis because these complications were controlled, so conclusion, age, Glasgow Coma Scale score, presence they did not have an effect on mortality. Since these factors may not have been detected or fully Guidelines of thyroid storm management 1047 treated, they could be identifed as risk factors. These the nationwide surveys provided the novel fnding fatal complications must be considered in the manage- that in about 20% of cases, thyroid storm originated ment of thyroid storm. In order to pre- the survey also provided pivotal information on vent the onset of thyroid storm in such cases, providing the sequelae of thyroid storm. It revealed that thyroid information to the general population about life-threat- storm frequently causes neurological sequelae and that ening thyroid storm may be important. In this regard, the clinical course Thyroid storm can be caused by several medical of neurological complications should be carefully fol- triggers such as radioiodine therapy, thyroidectomy, lowed. The mechanisms underlying this neurological and nonthyroid surgery in patients with uncontrolled involvement have not been fully elucidated. A laboratory investigation to dine therapy, but no patients who developed thyroid elucidate these mechanisms is warranted. Therefore, it is impor- tant to carefully monitor general patient condition and 10. Prevention of thyroid storm and roles thyroid hormone levels prior to and after radioiodine of defnitive treatment therapy. Patients who cannot tolerate these treatments Quality of evidence: low or respond poorly to them require preparation for sur- 2. Defnitive treatment of Graves? disease, either gery using all available means to normalize thyroid by radioiodine treatment or thyroidectomy, should hormone levels preoperatively, as mentioned above. The authors ence even after repeated education should be treated advocated early thyroidectomy to treat thyroid storm, by radioiodine treatment or thyroidectomy. In thyro- particularly in chronically ill older patients with con- toxic patients with potential triggering conditions for current cardio-pulmonary and renal failure who fail to thyroid storm, these triggering factors should be simul- respond to the standard intensive multifaceted therapy taneously treated. If the patient has a history of treatment for vascular system, and gastrointestinal tract present, it is Graves? disease, family history of thyroid disease, and important to consider the possibility of thyroid storm. Strength of recommendation: high Appropriate sampling of blood, urine, and sputum is Quality of evidence: low essential in patients with high fever. Guidelines of thyroid storm management 1049 nance imaging or brain computed tomography without underlying disease is required. Sedation may be intravenous contrast is required in patients with distur- required when neurological symptoms are attributed bances of consciousness. The presence of the cardiohemodynamic condition of a patient with factors that can precipitate thyroid storm should be thyroid storm is unstable (Fig. Future directions for clinical trials in We obtained a detailed clinical database of 356 thy- the management of thyroid storm roid storm cases between 2004 and 2008 after a nation- wide large-scale survey. Multiple Quality of evidence: low regression analysis demonstrated that independent risk 2. Therefore, in Strength of recommendation: strong order to improve the prognosis of patients with thyroid Quality of evidence: low storm, clinical trials are needed to determine the effec- tiveness of treatments for these comorbidities.

Diagnosis erectile dysfunction icd 10 buy viagra sublingual 100mg amex, controversies and management of hemolysis impotence meds discount viagra sublingual american express, elevated liver enzymes and low platelet count erectile dysfunction treatment new delhi order generic viagra sublingual. Clinical outcomes after platelet transfusions in patients with thrombotic thrombocytopenic purpura erectile dysfunction vacuum pump reviews generic 100mg viagra sublingual amex. Platelet transfusions in heparin-induced thrombocytopenia: a report of four cases and review of the literature erectile dysfunction juice recipe generic 100 mg viagra sublingual mastercard. Thrombosis and hemorrhage in heparin-induced thrombocytopenia in seriously ill patients erectile dysfunction newsletter purchase generic viagra sublingual from india. Factors influencing 20-hour increments after platelet transfusion Transfusion 1991; 31: 392-6. The clinical impact of platelet refractoriness : correlation with beeding and survivl. Prior antiplatelet therapy, platelet transfusion threrapy, and ouycome after intracerabral bleeding. Thrombocytopenia after second exposure to abcicimab is caused by antibodies that recognize abcicimab coated platelets. A review of transfusion risks and optimal management of perioperative bleeding in cardiac surgery. Reduced platelet activity is associated with early clot growth and worse 3- month outcome after intracerebral hemorrhage. Effects of desmopressin on thrombogenesis in aspirin-induced platelet dysfunction. Circulation and distribution of autotransfused fresh, liquid preserved and cropreserved baboon platelets. Normalization of platelet activity in clopidrogel-treated subjects (J Thrombosis Haemostasis 2006;5: 82-90. Leukocyte depletion of random single donor platelet transfusions does not prevent secondary human leukocyte antigenalloimmunization and refractoriness: a randomized prospective study. Leukocyte reduction and ultraviolet B irradiation of platelets to prevent alloimmunization and refractoriness to platelet transfusions. Non-fatal intravascular hemolysis in a pediatric patient after after transfusion of a platelet unit with high titer anti-A. Acute intravascular hemolysis secondary to out-of group platelet transfusion Transfusion 2000; 40:9002-6. Is it necessary to administer anti-Rh-D to prevent Rh-D immunization after transfusion of D+ platelet concentrates. Risk of anti-D alloimmunization after transfusion of platelets from D+ donors to D-negative recipients. Control of bleeding in patients with immune and non- immune thrombocytopenia with aminocaproic acid. Low haematocrit and prolonged bleeding time in uraemic patients: effect of red cell transfusions. Antifibrinolytic therapy with amino caproic acid for the control of bleeding in trombocytopenic patients. Pihusch M, Bagigalupa A, Szer J, Von Depka M, Gaspar-Blaudschun B, Hyveled L, Brenner B. Improved response of patients refractory to random-donor platelet transfusions by intravenous gammaglobulin. A randomized placebo- controlled trial of intraveneus gammaglobulin in alloimmunized thrombocytopenic patients. High-dose intravenous gammaglobulin in alloimmunized platelet transfusion recipients. High-dose intravenous gammaglobulin in alloimmunized platelet transfusion recipients. Improved response of an Rh- positive patient with aplastic anemia to donor platelet transfusions with intravenous anti-D Rhesus antibodies. High-dose intravenous gammaglobulin improves responses to single donor platelets in patients refractory to platelet transfusion. A randomized trial comparing the effect of prophylactic intravenous fresh frozen plasma, gelatin or glucose on early mortality and morbidity in preterm babies. Ten years of prophylactic treatment with fresh frozen plasma in a child with chronic relapsing thrombotic thrombocytopenic purpura as a result from congenital deficiency of von Willebrand factor cleaving protease. Challenges in the management of infantile factor H associated hemolytic uremic syndrome. Guideline for the investigation and initial therapy of diarrhea-negative hemolytic uremic syndrome. A classification of hemolytic uremic syndrome and thrombotic thrombocytopenic purpura and related disorders. The diagnostic dilemma of thrombotic thrombocytopenic purpura/hemolytic uremic syndrome in the obstetric triage and emergency department: lessons from 4 tertiary hospitals. Pregnancy associated hemolytic Blood Transfusion Guideline, 2011 273 273 uremic syndrome revisited in the era of complement gene mutations. Methylene blue photoinactivated plasma vs fresh frozen plasma as replacement fluid for plasma exchange in thrombotic thrombocytopenic purpura. Thrombotic trombocytopenic purpura: report of 16 cases and review of the literature. Improved survival in thrombotic thrombocytopenic purpura-hemolytic uremic syndrome. How I treat patients with thrombotic thrombocytopenic purpura-hemolytic uremic syndrome. Plasma exchange with solvent/detergent-treated plasma of resistant thrombotic thrombocytopenic purpura. Solvent/detergent-treated plasma suppresses shear-induced platelet aggregation and prevents episodes of thrombotic thrombocy topenic purpura. The treatment of thrombotic thrombocytopenic purpura: plasma infusion or exchange? Influence of type of exchange fluid on survival in therapeutic apheresis for thrombotic thrombocytopenic purpura. Methylene blue-photoinactivated plasma vesus quarantaine fresh frozen plasma in thrombotic thrombocytopenic purpura: a multicentric, prospective cohort study. Cryosupernatant as replacement fluid for plasma exchange in thrombotic thrombocytopenic purpura. Comparison of plasma exchange with plasma infusion in the treatment of thrombotic thrombocytopenic purpura. Cryosupernatant and solvent-detergent fresh-frozen plasma (Octaplas) usage at a single centre in acute thrombotic thrombocytopenic purpura. Successfull treatment of thrombotic microangiopathy after haematopoietic stem cell transplantation with rituximab. Effectiveness of therapeutic plasma exchange in the 1996 Lanarkshire Escherichia coli O157:H7 outbreak. The clinical features, risk factors and outcome of thrombotic thrombocytopenic purpura occurring after bone marrow transplantation. Rutiximab therapy for thrombotic thrombocytopenic purpura: a proposed study of the Transfusion Medicine/Hemostasis linical Trials Network with a systematic review of rituximab therapy for immune mediated disorders. Cancer- and drug-associated thrombotic thrombocytopenic purpura and hemolytic uremic syndrome. Quinine-induced immune thrombocytopenia associated with hemolytic uremic syndrome. Quinine- induced immune thrombocytopenia with hemolytic uremic syndrome: clinical and serological findings in nine patients and review of literature. Sunitinib induced hypertension, thrombotic microangiopathy and reversible posterior leukencephalopathy syndrome. Thrombotic microangiopathy in the cancer patient including those induced by chemotherapeutic agents. Transplantation-associated thrombotic thrombocytopenic purpura and hemolytic uremic syndrome. Incidence and clinical course of thrombotic thrombocytopenic purpura due to ticlopidine following coronary stenting. Interventions for haemolytic uraemic syndrome and thrombotic thrombocytopenic purpura. Set up Following a general introduction about adverse effects of transfusion of blood components and the differential diagnosis and treatment of acute transfusion reactions (7. Chapter 9 discusses the requirements that a hospital must meet concerning the monitoring of the transfusion chain, such as having access to a functioning blood transfusion committee, a haemovigilance official, a haemovigilance employee, and a training and further education program for all those involved in the transfusion chain. For this guideline, it was decided to divide according to cause, namely into non-infectious and infectious complications. In addition, the categorisation into acute symptoms during or within 24 hours of the transfusion and non-acute symptoms more than 24 hours after the transfusion is also used. All acute reactions except those due to bacterial contamination are non-infectious. Acute reactions require an acute diagnostic and if necessary treatment policy. For this reason, we will first focus on the diagnosis and treatment of acute transfusion reactions. Itching/urticaria: - If there are no anaphylactic symptoms (such as glottis oedema, hypotension, shock): consider administering an anti-histamine. The recommendations provided below are based on the opinions of experts and international guidelines (evidence level 4). A nurse must observe the patient for 5 to 10 minutes after starting the transfusion of each new unit. Clearly define which parameters should be monitored (heart rate, temperature, blood pressure, etc. In the case of a (suspected) transfusion reaction other than itching or urticaria, the transfusion should be stopped and the unit disconnected if necessary, in consultation with the treating physician. Rapid and targeted examination by the blood transfusion laboratory is also required. The treating physician should be contacted for the differential diagnosis and treatment of acute transfusion reactions. It is recommended that the treating physician follows the above-mentioned algorithm (7. For more detailed recommendations for (suspected) specific reactions: see paragraph 7. If anaphylactic symptoms (such as glottis oedema, hypotension, shock) are present: disconnect the unit immediately, connect a neutral infusion solution (e. Before disconnecting the unit, it should first be sealed (?clamped?), in order to prevent the reflux of blood from the patient to the donor unit. If the blood component is disconnected, it should be returned to the blood transfusion laboratory as soon as possible for further examination. The hospital must provide instructions for disconnection, transport & storage conditions, and the method of sampling and these instructions must be followed. Reporting: Transfusion reactions must first be reported to the treating doctor and the blood transfusion laboratory. The blood sample for compatibility testing (also called cross-match blood) must be stored for seven days at a maximum of 4 ?C to 8 ?C for testing of possible transfusion reactions. Systematic training of nurses in the field of prevention, recognition and treatment of transfusion reactions is indicated. In addition to a haemovigilance official, each hospital should also have a haemovigilance nurse/employee. An important task of the haemovigilance nurse/employee is the training of all people involved in the prescription and administration of blood components (see Chapter 9. The working group is of the opinion that haemovigilance should encompass both transfusions of (short shelf-life) blood components and blood-saving techniques. Incompatible units of plasma and platelet concentrates can also cause haemolysis due to antibodies and in rare cases can cause an acute haemolytic transfusion reaction. Activation of the complement system causes the release of anaphylatoxins (C5a, C4a, C3a), serotonin and histamine, which in turn cause some of the clinical symptoms associated with an acute haemolytic transfusion reaction. Various mechanisms activate the clotting cascade and this Blood Transfusion Guideline, 2011 281 281 results in disseminated intravascular coagulation. The release of haemoglobin in plasma results in haemoglobinuria; the acute renal insufficiency is caused primarily by renal ischaemia (Rudmann 1995, Mollison 1997). Fortunately, the acute haemolytic transfusion reaction is rare, but the true incidence is hard to determine due to under-reporting and the diagnosis can also be missed because the clinical symptoms are not specific. The clinical symptoms of an acute haemolytic transfusion reaction can occur even after transfusion of a minimal amount of incompatible blood; however, the most severe reactions are usually seen after transfusion of larger quantities (> 200 mL). The most common symptoms are fever and cold shivers, but sometimes a transfusion reaction starts with a feeling of general malaise and back pain. In addition, dyspnoea, a light-headed feeling, pain at the infusion site or chest pains and nausea can occur. The most severe cases are accompanied by hypotension and shock, acute renal insufficiency with anuria and a (strongly) elevated tendency to bleed due to disseminated intravascular coagulation. In unconscious patients or patients under general anaesthesia, an increased tendency to bleed can be the first (or only) symptom of an acute haemolytic transfusion reaction. Differential diagnosis should include auto-immune haemolytic anaemia, cold agglutinin syndrome and non-immunological causes such as transfusion of a strongly haemolytic erythrocyte concentrate (e. C Rudmann 1995, Mollison 1997 Acute haemolytic transfusion reactions are rare, but can be very severe and are usually the result of administrative errors in the transfusion procedure. The risk of a fatal reaction occurring depends, among other factors, on the amount of transfused blood, the clinical condition of the Level 3 patient, and the time lapsed between the start of the transfusion and the start of the treatment.

Optic nerve hypoplasia, familial bilateral

It is recommended that the esti- observed impotence vs sterile 100mg viagra sublingual amex, further cytoreductive surgery may be ad- mated radiation dose to the bone marrow be less visable to avoid symptomatic radiation thyroiditis than 2 Sv (200 rem) (73) Blood and whole-body and increase the probability of complete ablation erectile dysfunction ugly wife generic viagra sublingual 100 mg without a prescription. In general 131Ither- pression impotence 20 years old discount viagra sublingual 100mg on-line, retention of 131I in the body at 48 h should apy is less effective in bulky disease with a diameter be less than 4 erectile dysfunction zocor buy generic viagra sublingual 100mg online. Hemodialysis is not a contraindication to method has been published to correct for differen- 131I therapy (32) erectile dysfunction causes in young men cheap viagra sublingual online amex. For children erectile dysfunction beat buy 100mg viagra sublingual free shipping, most pediatric nuclear physicians 131I therapy, the dose rate from the patient at 1 m modify the activity to be administered on a weight should be recorded as required by the relevant re- basis so that the pediatric activity equals the adult gulatory authority or institutional policy. The pa- activity that would be given under the same clinical tient should be informed of any prolongation of circumstances multiplied by the patient weight in the home radiation safety plan if a higher dose rate kilograms and divided by 70. For staging purposes, patients should undergo A short intrathyroidal or body effective 131I half- whole-body scintigraphy approximately 3?7 d af- life can be a source of failure of 131I therapy in ter treatment. Oral administration of lithium value for staging, patient management, and pre- carbonate inhibits the liberation of thyroidal thy- diction of the response to 131I therapy (100?104). Serum lithium levels should be overall recurrence rate for thyroid cancer ap- monitored to avoid toxicity. There are no double- proaches 20%, and up to 10% of recurrences blind outcome studies on lithium, and its use adds may occur after 20 y, long-term follow-up of the another layer of complexity to the therapeutic pro- patient is required, both to maintain appropriate cedure. The identity and activity of radiation protection vary among states and countries, the radiopharmaceutical to be administered should with many guidelines being more stringent than those be documented in writing on the appropriate form. When no individual member of the public is likely vided with a copy of the signed consent form. Individual Agreement contains tables of activities not likely to cause States may have speci? Some radiation meters mea- unnecessary radiation exposure to family members sure exposure rates in milliroentgens per hour, but and members of the public. Written instructions for low?linear energy transfer radiation (including must be provided to reduce the radiation dose both b-particles and most x-rays and g-rays), the exposure to the patient and to members of the public and may rate at 7 mR/h will be equivalent to the dose rate be required in some jurisdictions (109). In this application, dose to red marrow is of more clinical interest, as clinically signi? Information about possible pla- 8 350 1,300 cental crossover of this compound was included in the calculations. In a study where the patients were to sleep alone and avoid prolonged personal Prolonged use of public transportation is discour- contact for 2 d after therapy, 65 household members aged for the? Pregnant women and may not be able to assess full compliance with title children may have about 10 min of zero distance per 10 of Code of Federal Regulations part 35. There are no other restric- Most experts recommend that both men and tions on the patient being with other adults. Infants women wait 6?12 mo after 131I therapy before trying and small children requiring feeding, changes of to conceive a child, although there are no reliable clothing, and similar care from the treated parent data on the validity of this suggested interval. Although telephone mouthpieces and patient about the time and distance to stay away other devices touched frequently may have minimal from others. Radiation surveys of the thyroid gland 131I contamination detected on them, this is not a on personnel administering 131I are performed peri- health hazard because of the minute amount of ra- odically, depending on local regulations and institu- diation present compared with ambient background tional policy. Disposable plates and utensils are not a written document stating they have been given only unnecessary but, if used, can trigger sensitive a radioactive substance, the date of administration, waste facility alarms; dishes and utensils should the name of the radiopharmaceutical, and the activ- not be shared before washing. It is unnecessary to ity administered in the event that it is detected by wash the patient?s laundry separately. Interactions of 131I with other forms of diagnosis down to avoid contamination in the toilet area. Therefore, external-beam radiation, if determine the need for a change in patient man- clinically and emergently indicated, need not be agement but also to determine whether these delayed. The toxicity, acute and late, is likely to be preablation and pretherapy imaging techniques additive within the? The diagnostic role of alternative imaging agents combination external-beam therapy with radiopharma- for thyroid cancer, such as 123I, 124I, and 99mTc. Theroleof124I in thyroid dosimetry, and the Skeletal metastases that are painful or are a threat to ef? The necessity of 131I therapy for low-risk papillary 131I, be treated with bone-seeking b-emitting radio- cancers less than 1. The frequency and length of long-term follow- will vary with the effective half-life and administered up after 131I therapy for thyroid cancer in a va- activity of the therapeutic 131I. Standardization of 131I dosimetry to deliver strategies for minimizing volatilization or inhalation a therapeutic dose to hyperfunctioning thyroid of volatilized iodine during dosage preparation and glands or ablative radiation doses to thyroid administration should be used?for example, venting remnants after thyroidectomy. Stabilized forms of ra- mCi]) for patients with serum thyroglobulin dioactive iodine, in wide use in the United States, elevation but negative iodine scintigraphy should not require these precautions, which remain a results. The effectiveness of suggested protocols in pre- Standards of the Joint Commission. The report to the referring physician should include the indication for therapy, the 131I administered activity, a nota- doseinfo-radar. The effectiveness of achieve minimum exposure while maintaining diagnostic radioactive iodine for treatment of low risk thyroid cancer: a systematic analysis accuracy and therapeutic ef? Revised American Thyroid Asso- ciation management guidelines for patients with thyroid nodules and differen- techniques should be used when appropriate. Minimizing radiation in papillary thyroid cancer: development of a reliable prognostic scoring system dose is especially important in children, and exposure to the in a cohort of 1779 patients surgically treated at one institution during 1940 public is always a consideration (111). Graves? disease and radioiodine therapy: iodine-131 treatment as an alternative to surgery in patients with a very large is success of ablation dependent on the achieved dose above 200 Gy? Adverse effects related to thio- carcinoma: comparison of microscopic and macroscopic disease. High dose 131I therapy for the treatment of hyper- tic implications of papillary thyroid microcarcinoma. Release of individuals containing unsealed byproduct material or implants con- 44. Cancer mortality following treatment for to iodine-131 ablation in patients with well-differentiated thyroid cancer. Radioiodine treatment of Graves? disease: an assess- imaging of differentiated thyroid carcinoma. Near-lethal respiratory failure after recombinant nodular goiter: recombinant human thyrotropin allows the reduction of radio- human thyroid-stimulating hormone use in a patient with metastatic thyroid iodine 131I activity to be administered in patients with low uptake. Simple, rapid thyroid function testing with 99mTc pertechnetate aging before radioiodine ablation in differentiated thyroid carcinoma. Self- erized method of measuring 99mTc-pertechnetate uptake for routine assessment of stunning in thyroid ablation: evidence from comparative studies of diagnostic thyroid structure and function. The nonimpact of thyroid stunning: thyrotoxicosis: management guidelines of the American Thyroid Association and remnant ablation rates in I-131-scanned and nonscanned individuals. Anatomical distribution and tigraphy in assessing radioiodine breast uptake before ablation in postpartum sclerotic activity of bone metastases from thyroid cancer assessed with F-18 women with thyroid cancer. Best Pract Res Clin Endocri- tigraphy to assess potential breast uptake of I-131 before radioiodine therapy in nol Metab. Optimum recombinant human thyrotropin dose on postsurgical radioiodide ablation therapy in patients with differentiated thy- in patients with differentiated thyroid carcinoma and end stage renal disease. Effect of iodinated contrast media patients with thyroid cancer for 131I scintigraphy or therapy by 1-3 weeks of on thyroid function in adults. A comparison of 1850 (50 mCi) and 3700 tiated thyroid carcinomas treated with iodine-131. European consensus for the management of patients with differentiated thy- J Clin Endocrinol Metab. Five-year survival is similar in thyroid regimens frequently exceed maximum tolerated activity levels in elderly pa- cancer patients with distant metastases prepared for radioactive iodine therapy tients with thyroid cancer. Reducing the risk of 131I-induced-sialadenitis: the role of pilo- Lack of impact of radioiodine therapy in Tg-positive, diagnostic whole body carpine. Radiation victim management and the hematologist in the cancer after 13I I ablative therapy. Lithium as a potential adjuvant to 131I therapy of metastatic well differentiated thyroid carcinoma. Differen- computed tomography/computed tomography of the neck and thorax in post- ablation 131I scintigraphy for thyroid cancer. Testicular dose and fertility in management of patients with differentiated thyroid carcinoma. Five months? follow-up of patients with and ablation in female children and adolescents; long-term risk of infertility and without iodine-positive lymph node metastases of thyroid carcinoma as dis- birth defects. Diagnosis and dosimetry in differen- Council on Radiation Protection and Measurements; 2006. Therapeutic administration of 131I Oak Ridge Associated Universities; 1992:179?187. They have not been copyedited, nor have they appeared in a print or online issue of the journal. This process may lead to differences between the accepted version of the manuscript and the final, published version. Many of those exposed were children younger than 10 years of age, the population most vulnerable to radiation exposure. This exposure put those children at risk for thyroid and parathyroid disease and cancer of the thyroid. The health care community should be able to medically evaluate the health effects resulting from past exposure to releases of I-131. The health care community should be prepared to handle their patients? health effects from acute unintentional or intentional this monograph is one in a series of releases of I-131. See page 3 for more information about continuing medical education credits, continuing nursing education units, continuing education units, and continuing health education specialist credits. Summary of Initial and Follow-Up Visits for Patients Identified accuracy and currency of the information presented, but makes no claim that the as Exposed to I-131 in Previous Years. Summary of Recommended Maximum Concentrations of I-131 the condition and managing the treatment of patients potentially exposed to in Specific Media and for Occupational Exposure. It is not, however, a substitute for the professional judgment of a health care provider. The document We would like to extend a special thank you to the members of the Hanford must be interpreted in light of specific community and others who provided input and comments on this document. Each content expert for this case study indicated no conflict of interest to disclose with the case study subject matter. Each physician should claim only those hours of credit that he/she actually spent in the educational activity. If you have registered in this system before, please use the same login and password. If you have not previously registered in this system, please provide the registration information requested. Questions with more than one answer will instruct you to ?indicate all that are true. You will be able to immediately print your continuing education certificate from your personal transcript. Complete the evaluation questionnaire and posttest, including your name, mailing address, phone number, and e-mail address, if available. To receive your continuing education credit, you must answer all of the questions. You will receive an award certificate within 90 days of submitting your credit forms. She is worried that this condition could be passed on to her that has slowly grown over the daughter, who is pregnant. The family history reveals that the woman lives with her husband of 41 years; her daughter, born in 1963, who is 6 months pregnant; and her daughter?s husband. They have lived in your community for the last 12 years, in a single home in a low income area of town. The patient?s past medical history is noncontributory, and her family Pretest history is unremarkable. Her father died at age 84 of a myocardial (a) Which organ system is infarction, and her mother died of colon cancer at age 77. The patient has considered the critical organ no family history of thyroid disease or of other endocrine disease. She does not have any past workplace or (c) What are the most significant hobby chemical exposures, and she has not received any therapeutic health effects from exposure to radiation exposures. Ours may be exposures of the past, but those of us exposed as children, when we were most vulnerable to radioactive harm, are still alive and some of us have developed exposure health outcomes. I-131 is normally present at low levels in hospital nuclear Many people in the United States, especially those living near or working medicine departments, in at weapon production facilities, such as the Hanford Nuclear Reservation, patients administered were unknowingly exposed to multiple sources of I-131, including fallout. The existing national security policies kept that I-131 is produced during information from reaching the American public. Iodine 127 (I-127) is the only naturally occurring iodine or plutonium atoms undergo isotope, and it is the only nonradioactive (stable) iodine isotope. All other fission, about iodine isotopes (I-123, I-125, I-129, I-131, and I-135) are radioactive. Since 1944, when the first production atomic reactor came into service, large amounts of I-131 have been periodically released into the atmosphere. I-131 was released to the atmosphere as a gas during nuclear weapons production (1945?1980s), aboveground nuclear tests (1951?1962), medical isotope production, medical administrations to patients, and unintentional releases. Multiple releases over time could have maintained constant or repetitive high levels the main sources of I-131 in of radioactivity, particularly around weapon production facilities.

Hamartoma sebaceus of Jadassohn

As with other health professionals erectile dysfunction massage techniques buy viagra sublingual 100 mg cheap, the more specific content of the forensic pathologist?s duty is to exercise at least a reasonable degree of care and skill in his or her work erectile dysfunction treatments vacuum cheap viagra sublingual online mastercard, that is impotence quoad hoc meaning order viagra sublingual 100 mg line, in the production of valid and useful observations and conclusions erectile dysfunction doctors buffalo ny best buy for viagra sublingual. In assessing what is a reasonable degree of care and skill erectile dysfunction 45 year old male buy viagra sublingual in india, reference can be made to the practice of colleagues of similar training and expertise erectile dysfunction age 18 purchase discount viagra sublingual on-line. However, such practice is sub-standard if it 17 Forensic AutopsyForensic Autopsy does not produce reliable and valid results. What this means in practical terms requires an understanding of the basic aims of the forensic autopsy. This will, on occasions, involve attendance at the scene of death preferably with the body in situ. As forensic pathology is essentially a visual exercise, this involves a dependence on good quality, and preferably, colour photography. In cases where forensic pathology is particularly central to the resolution of the issues (especially homicides, suspicious deaths, deaths in custody), the ability of the case to be independently reviewed by another forensic pathologist at another time becomes crucial. It will be possible in some circumstances, where this aim is not met, for doubt to be cast over the original findings. As these aims demonstrate, the responsibility of the forensic pathologist is for much more than the conduct of the autopsy. The autopsy is a subset, some would say the foundation, of the overall medico- legal death investigation, and all of this falls within the responsibility of the forensic pathologist. Imaging techniques, as valuable as they are, are some distance from being able to distinguish normal post-mortem phenomena from pathology, or to make histological diagnoses and perform toxicological, biochemical and microbiological tests, for example. But they are not, and probably never will be, a replacement for the autopsy in the remaining cases. The authority to require a post-mortem examination lies with the Public Prosecutor. It must however be understood that family members frequently object to post-mortem examinations. Forensic doctors must deal with the family in an empathetic way to help them understand the reasons for requiring a post-mortem examination and to address their concerns about what will happen to the body and the burial arrangements. The two most common concerns raised by family members with regards to their objections to post- mortem examinations are violation of the sanctity of the body and delay in burial of the body. Islam is very strict in giving due respect to the deceased, whether Muslim or not. The act of breaking the deceased?s bones is thus 18 Forensic AutopsyForensic Autopsy regarded as an act of torture as mentioned in the Hadith. This is because such an act is generally a malevolent one and does not produce any benefit. It is a medical and scientific examination of the dead body by an authorised medical practitioner with its aims directed towards justice and the public good. It is important that the forensic doctor patiently explains the above to the family and helps to allay their fears and objections. Family members must be assured that the body will be treated with respect at all times. Every effort should be made by the Public Prosecutor and the forensic doctors to minimise delays including, if sufficient resources are available, performing autopsies outside ordinary working hours. This requires all homicides and suspicious deaths (including deaths in prison or police custody and following illegal abortions) to be reported to the Public Prosecutor who will then inform the forensic doctor. Furthermore, certain categories of death may also be reported to the Public Prosecutor who may inform the forensic doctor. Intentional or unintentional harm including, for example, suicides and road traffic or other accidents. The Public Prosecutor is the only entity entitled to appoint the doctor deemed appropriate for the task. Doctors involved with the treatment of the deceased prior to his death, or who are related to the deceased will be excluded from appointment. When the post-mortem examination is complete the Public Prosecutor issues a ruling to deliver the body to the family to allow the burial to proceed. The doctor, especially in cases of deaths in custody, suspicious deaths and homicides, should attend the scene of the death/crime scene to perform a preliminary review of the body prior to the movement and transfer of the body to the mortuary. The doctor should express his/her condolences to the family for the loss of their loved one and acknowledge their shock and pain. While the examination of the scene is not discussed elsewhere, the following is a summary of the functions of the forensic doctor at the scene of death in the State of Palestine:. The family must be allowed to make inquiries and their questions carefully answered, since it is early in the investigation, while maintaining the appropriate independence and respecting privacy and confidentiality. Due care is taken to ensure there are no delays relating to the external examination of the body at the scene. The forensic doctor should also advise on the necessity of involving forensic science experts to take necessary photographs and to take control of any physical evidence based on a ruling by the Public Prosecutor. If the Public Prosecutor has authorised an autopsy, the forensic doctor must inform the family about the procedures he/she will undertake and the goal of these procedures. If the family refuses an autopsy or does not desire one, the necessity of the autopsy should be explained, and they must be allowed to meet with the Public Prosecutor in charge of the case if they so request. The Public Prosecutor along with the forensic doctor, the forensic science experts, the police and anyone else involved or present at the crime scene, must co-operate to ensure that there will be no addition, removal, change or distortion of any physical or other conditions within the location of the death or crime scene. The formal examination and autopsy of the body shall be undertaken by the appointed doctor at the facility designated for this purpose. When the body is admitted to the mortuary, the allocated sequential case number for the State of Palestine will be attached to the body Family members shall not be permitted to attend the autopsy. However, the family can request approval from the public prosecutor for a doctor (preferably one with some knowledge of autopsy and pathology) to represent the family at the autopsy. Where there is no need to preserve the clothes and 20 Forensic AutopsyForensic Autopsy personal belongings and send them to the crime laboratory, they are placed in a special bag to be returned to the family. A list of these belongings should be recorded and retained with the record of the case. In relation to exhumation, preparation must be undertaken to identify the grave or tomb, the position of body placement therein and any items situated on or near the body in the grave. The forensic doctor shall organise the examination along with the Public Prosecutor, ensure proper identification of the remains, receive and control samples and physical evidence and deliver these to the competent entities for the necessary examinations to be conducted. The body/skeletal remains should not be delivered to the family for burial until the Public Prosecutor has issued a ruling after completion of the required examination. Any procedures meeting the needs of the family, such as allowing them to conduct the washing procedures (ghusl), and any other actions in preparation for burial, should be facilitated. The identification of that person is verified and his/her personal information recorded in the relevant registry. At the hospital, if the body is regarded as visually identifiable, the relative/s is/are then accompanied to the examination room to view the body. At the same time (except in cases of homicide, suspicious death and where the body is not suitable), after the identity of the body has been confirmed, family members can touch the body and be left alone with the body for a few minutes. When identification cannot be established with the assistance of the family and further tests are required, the family members and the public prosecutor are informed and the body cannot be released until identity is established. A notification of death is handed to the person who identified the body, and this is recorded in the registry. If not at the scene of the death, this usually takes place at the mortuary within the hospital. The situation can become tense when a ruling is issued by the Public Prosecutor to transfer the body for an autopsy, as the family often objects to this. Despite the fact that the decision for an autopsy is issued by the Public Prosecutor, the family often attributes this decision to the forensic doctor. They then approach the forensic doctor to try and persuade him/her that there is no need for an autopsy, that the death is the result of fate and that they are ready to do anything, and sign any document, in order to prevent the autopsy of their loved one. Paying condolences to the family for the loss of their loved one and empathetically acknowledging their shock and pain. Setting out for the family the benefits of the autopsy which will assist in determining the circumstances of the death of their loved one. When the truth about the death becomes known, the family will not become suspicious about the circumstances of the death later and can address possible rumours from neighbours, acquaintances or those who hold animosity towards the family. It should be explained that this is not desirable, but they can ask to be represented by a doctor and this will probably be permitted by the Public Prosecutor. Any procedures in the interests of the family are facilitated and simplified to reduce confrontation with the family. Usually, the family asks the doctor responsible for the autopsy about the cause and circumstances surrounding the death. Depending on the circumstances, other details relating to the death may or may not be communicated. For example, in criminal cases, care needs to be taken to avoid interfering with the investigation. In the mortuary, it is knowledge about the deceased?s death (including any preceding illness). This is a very important function for justice, for the deceased?s family and for the wider community. The community should expect high standards in the operation of its forensic mortuaries. These expectations should be met by medical and technical staff who provide a professional service. The service should provide reliable, valid results and conclusions about the death in a manner which is respectful of the deceased and his or her family. The only way this can be done, so that everyone involved has the same understanding, and so that responsibility and therefore accountability is clear, is for the requirements of these components to be documented. Together with processes for implementing improvements and correcting mistakes or near misses, the documents thus created will make up the mortuary?s Quality Manual, and describe the mortuary?s Quality System. It takes time to develop Quality System documentation and processes and train staff in their usage. Significant institutional commitment, leadership from the institution head and allocation of resources are essential prerequisites. Expanding on the brief list above, the elements of the system could include, and would not be limited to: 23 Forensic AutopsyForensic Autopsy 3. There are numerous local conditions and constraints, not least available resources, which will lead to reasonable variations in approach. However, one important aspect the concept of universal precautions does need to be understood in detail. Universal precautions are precautions that should be taken by all staff and everyone attending the mortuary. They protect against the transmission of disease by aerosols, direct contact with body fluids, or by sharp injury, all of which are significant hazards in a mortuary. Universal precautions in the mortuary are implemented through dress regulations and safety practices. All those 1 present in the mortuary, as well as staff or visitors (for example medical students or police), should be schooled in universal precautions. The presence on staff of exudative or weeping skin lesions, especially involving the face and hands, should preclude involvement in an autopsy. Advance consideration needs to be given, as to whether it is appropriate or not for trainee pathologists or technicians to undertake such cases, and if so, what is the required preparation and training. Lassa Fever) or arthropod borne viral fevers require microbiological security over and above that available in routine mortuaries. Autopsies in these cases should not be performed unless in purpose designed facilities (of which there are very few in the world) by staff trained in the use of those facilities and the associated techniques. However, particularly with Ebola, it is possible that such deaths may appear unannounced or unexpectedly at the mortuary before anyone realises what the deceased was suffering from. As mentioned above, universal precautions are implemented through dress regulations and safety practices. Service heads should consult with mortuary staff in the development and implementation of operational regulations. These will take into account local issues such as the geography and layout of the mortuary and the categories of staff and visitors requiring access. A document specifying the dress regulations and safety practices needs to be developed and implemented through training and communication. The dress regulations and safety practices outlined below focus on biological and infectious hazards. For chemical and radiological hazards, specific information relevant to mortuary practice is difficult to find. The regulations may be consistent throughout the mortuary, or vary for different parts of the mortuary and for different categories of people (e. No person should be permitted in the mortuary without complying with the dress regulations. The senior staff member in the mortuary at the time should ensure that all visitors comply with dress regulations. Additional cut-proof glove/chain mail glove (worn on the non-dominant hand, the hand not using the scalpel during all eviscerations and dissections) 1 There should not be casual visitors in the mortuary. The result of this consideration needs to be recorded, approved by the responsible person, communicated to staff and implemented. For higher level security, the mortuary should keep the following additional items on hand if possible: full body disposable suits (e. Tyvek suits), hoods that cover the head (except face) and shoulders, over boots (which cover boots to knee level) and respirators. A good safety system will specify entry and exit paths in and out of the autopsy room that keep ?clean areas? and ?work areas? separate.

Generic viagra sublingual 100 mg without prescription. Do You Have Erectile Dysfunction?.

References

Walter LC, Bertenthal D, Lindquist K, et al: PSA screening among elderly men with limited life expectancies, JAMA 296(19):2336n2342, 2006.
Hill GE, Alonso A, Spurzem JR, et al: Aprotinin and methylprednislone equally blunt cardiopulmonary bypass-induced inflammation in humans, J Thorac Cardiovasc Surg 110:1658-1662, 1995.
Ceyham M, Kanra G, Yilmaz Y, et al. Rabies (diagnosis and discussion). Am J Dis Child 1992;146:1215.
Danielsson L, Hernborg J. Clinical and roentgenologic study of knee joints with osteophytes. Clin Orthop Relat Res 1970; 69:302-12.
Vergnon JM, Vincent M, Perinetti M, et al: Chemotherapy of metastatic primary cardiac sarcomas. Am Heart J 1985; 110:682-684.