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Coronal sections (5 μm thick) were mounted on glass slides and stained with thionin/acid fuchsin for morphological analysis menstrual flow is actually deteriorating femara 2.5 mg discount. When using paraffin-embedded sections it is beneficial to perform antigen retrieval before adding the antibody. After blocking, sections were incubated with primary antibodies (see below) for 24 hours. The following day all unbound antibody was washed off and the biotinylated 69 Brain tumors in children secondary antibody was added for one hour at room temperature (goat anti rabbit biotinylated secondary antibodies). Endogenous peroxidase activity was blocked, and visualization was performed using an avidin–biotin– peroxidase solution. Since neuroinflammation has been suggested to contribute to the reduced neurogenesis after radiotherapy (Monje et al. They develop from embryonal yolk sac myeloid progenitors and enter into the brain very early in embryonic development (Ginhoux et al. We used the ionized calcium-binding adapter molecule 1 (Iba1) monoclonal antibody as a microglia marker. Several different antibody dilutions were tested, and the optimal dilution for cell counting was chosen. In a separate experiment we explored the effect on blood glucose levels from eight hours of fasting. The treatment groups were anaesthetized and put in chambers submerged in temperature-controlled water baths for eight hours, replicating the conditions from the first irradiation experiment (but without being irradiated). After eight hours the animals were decapitated and blood was collected in a capillary tube from the neck vessels. Comments the brain development in P9 rats corresponds to an infant in humans (Semple et al. Since radiotherapy (especially craniospinal radiotherapy) seldom is used in children below 3-4 years of age, and practically never in newborn children, the choice of P9 rats is not ideal when translating our findings to children receiving radiotherapy. The rationale behind this choice was to make 71 Brain tumors in children the results comparable to the previous experiments. The single dose of ionizing radiation is also different from the radiotherapy practice in humans, where the total dose is delivered in multiple daily fractions, (usually every week-day, over a period of weeks). We could not replicate this however, for different practical reasons: 1) multiple procedures are more stressful for the animals, 2) the risk of introducing an infection to the animal facility increases when bringing them back and forth, 3) multiple sedations using tribromoethanol is not recommended due to its inflammatory properties. The same analysis was used to compare the non-irradiated hemispheres between groups. There was no significant difference in body temperature between the animals in the normothermia group and the non-irradiated control group. The blood glucose levels decreased in the irradiated groups compared to controls, due to the eight-hour separation from the dam, but there was no significant difference between the normo and hypothermia groups. Furthermore, this area differed also between the normo and the hypothermia groups, with a significantly larger size in the hypothermia group (mean 0. B) For comparison, the areas of the non-irradiated (contralateral) hemispheres were also measured. The reason for this selective protection is unclear, although consistent with previous findings (Fukuda et al. It could due to different sensitivities to irradiation, or differences in cell turn-over between the regions. Although the body temperatures in the hypothermia group reached hypothermic levels (mean body temperature 32. During the experiment, it was observed that the animals tended to clump together in the temperature-controlled container, something that probably helped them preserve body heat and lessened the cooling effect. Although the border between these two areas is somewhat arbitrary, 77 Brain tumors in children this might reflect an underlying mechanism yet to be elucidated. The strengths of this study is the randomized design with blinded evaluation of the effect of hypothermia on the proliferative areas of the rodent brain. A limitation of our study is that we studied the potential protective effect of hypothermia at one time point only, and that we did not characterize the proliferating cells further. International collaborative trials for recurrent medulloblastoma are needed and should be encouraged. These should preferably be based on biological sampling of recurrent tumors, and use the results to guide therapy. Tumor biopsy in that context is less ethically problematic, since the procedure leads to an immediate benefit for the patient (guided therapy), as well as the research community (more knowledge). Continued research in tumor (molecular) biology will hopefully provide further insight into how tumor cells avoid being killed by therapy, and how to best close their escape routes. In fact, evidence suggests Lithium could have a protective effect on hippocampal neurogenesis after irradiation, and reduce cognitive side effects (Zhou et al. Finding effective ways to mitigate the long term side effects after childhood brain tumor treatment is important, since they can have a severe impact on the survivors’ daily life. There is growing evidence that exercise is beneficial to cognition, and exercise interventions are an interesting option for this patient group. But 79 Brain tumors in children there are challenges in finding interventions that are easily managed, fun to do, and can be performed on a long term basis. Interventions should probably be a combination of different activities, varying over time, to enhance participation and reduce attrition. The value of active video gaming deserves further exploration, and future research should focus on games that stimulate both physical activity and cognition. Support by Internet coaching is a resource efficient way of doing studies, but perhaps not easily transferred to large-scale clinical practice. Building Internet-based communities of brain tumor survivors could however be a method to stimulate rehabilitation activities, with the added value of decreasing social isolation. In view of the rapid technical development, already available virtual reality solutions will probably soon be less expensive, and could be an interesting option to explore further. Using hypothermia after radiotherapy to mitigate the harmful effects on neurogenesis needs further study before it can be used in a clinical setting. Since radiotherapy is given over a period of weeks, the method has obvious practical challenges as well, although not unsurmountable provided the gain from the intervention is large enough. Recurrent 80 Magnus Sabel tumors appeared at a median interval of 26 months from primary diagnosis, with 8 % late relapses (> 5 years after primary diagnosis). Patients with isolated posterior fossa relapses survived longer compared to patients with other relapse patterns. The histological subgroup or biological factors (at primary diagnosis) had no impact on time in first remission, relapse pattern, or survival after relapse. An intervention with active video gaming and regular on line coaching achieved an enjoyable, near daily exercise of moderate intensity in pediatric brain tumor survivors. The method was feasible and compliance was good, but the overall physical activity levels were not significantly increased. The mechanism for the protective effect and the reason for the selective effect on the neurogenic areas needs further study, as well as the effect of post-irradiation hypothermia on brain tumors. I especially want to thank: All patients that participated in the studies, and their families. Birgitta Lannering, professor, tutor, and mentor that introduced me to pediatric neuro-oncology as well as research. I am so grateful for these past years working beside you, sharing the good times and the bad. Thank you for your friendship, guidance, encouragement, and well-controlled impatience. Without you, this thesis would probably not been completed for another year or so (at least). Thank you for your friendship, humor and positive attitude, and for sharing your vast knowledge in the field of neurogenesis. Thank you for your rapid e-mail responses, and well formulated, encouraging comments. Thank you for your friendship and support, your caring and helpful feedback, and for sharing your knowledge in the rehabilitation field. Anette Sjölund, for co-authorship and invaluable help in managing the Wii study, and especially for your coaching efforts and help to coordinate both the Wii-study and clinical work.

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Navigational Note: Duodenal fistula Asymptomatic Symptomatic women's health center wooster ohio purchase discount femara online, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition: A disorder characterized by an abnormal communication between the duodenum and another organ or anatomic site. Navigational Note: Duodenal perforation Invasive intervention not Invasive intervention Life-threatening Death indicated indicated consequences; urgent operative intervention indicated Definition: A disorder characterized by a rupture in the duodenal wall. Navigational Note: Dyspepsia Mild symptoms; intervention Moderate symptoms; medical Severe symptoms; operative not indicated intervention indicated intervention indicated Definition: A disorder characterized by an uncomfortable, often painful feeling in the stomach, resulting from impaired digestion. Navigational Note: Enterocolitis Asymptomatic; clinical or Abdominal pain; mucus or Severe or persistent Life-threatening Death diagnostic observations only; blood in stool abdominal pain; fever; ileus; consequences; urgent intervention not indicated peritoneal signs intervention indicated Definition: A disorder characterized by inflammation of the small and large intestines. Navigational Note: If reporting a known abnormality of the colon, use Gastrointestinal disorders: Colitis. If reporting a documented infection, use Infections and infestations: Enterocolitis infectious. Enterovesical fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition: A disorder characterized by an abnormal communication between the urinary bladder and the intestine. Navigational Note: Esophageal fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition: A disorder characterized by an abnormal communication between the esophagus and another organ or anatomic site. Navigational Note: Esophageal hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition: A disorder characterized by bleeding from the esophagus. Navigational Note: Esophageal perforation Invasive intervention not Invasive intervention Life-threatening Death indicated indicated consequences; urgent operative intervention indicated Definition: A disorder characterized by a rupture in the wall of the esophagus. Navigational Note: Esophageal varices Self-limited; intervention not Transfusion indicated; Life-threatening Death hemorrhage indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition: A disorder characterized by bleeding from esophageal varices. Navigational Note: Fecal incontinence Occasional use of pads Daily use of pads required Severe symptoms; elective required operative intervention indicated Definition: A disorder characterized by inability to control the escape of stool from the rectum. Navigational Note: Gastric fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition: A disorder characterized by an abnormal communication between the stomach and another organ or anatomic site. Navigational Note: Gastric hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition: A disorder characterized by bleeding from the gastric wall. Navigational Note: Gastric perforation Invasive intervention not Invasive intervention Life-threatening Death indicated indicated consequences; urgent operative intervention indicated Definition: A disorder characterized by a rupture in the stomach wall. Navigational Note: Gastroesophageal reflux Mild symptoms; intervention Moderate symptoms; medical Severe symptoms; operative disease not indicated intervention indicated intervention indicated Definition: A disorder characterized by reflux of the gastric and/or duodenal contents into the distal esophagus. It is chronic in nature and usually caused by incompetence of the lower esophageal sphincter, and may result in injury to the esophageal mucosal. Navigational Note: Gastrointestinal fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition: A disorder characterized by an abnormal communication between any part of the gastrointestinal system and another organ or anatomic site. Navigational Note: Gingival pain Mild pain Moderate pain interfering Severe pain; inability to with oral intake aliment orally Definition: A disorder characterized by a sensation of marked discomfort in the gingival region. Navigational Note: Hemorrhoidal hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition: A disorder characterized by bleeding from the hemorrhoids. Navigational Note: Ileal fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition: A disorder characterized by an abnormal communication between the ileum and another organ or anatomic site. Navigational Note: Ileal hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition: A disorder characterized by bleeding from the ileal wall. Navigational Note: Ileal perforation Invasive intervention not Invasive intervention Life-threatening Death indicated indicated consequences; urgent operative intervention indicated Definition: A disorder characterized by a rupture in the ileal wall. Navigational Note: Intra-abdominal hemorrhage Moderate symptoms; Transfusion indicated; Life-threatening Death intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition: A disorder characterized by bleeding in the abdominal cavity. Navigational Note: Jejunal fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition: A disorder characterized by an abnormal communication between the jejunum and another organ or anatomic site. Navigational Note: Jejunal hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition: A disorder characterized by bleeding from the jejunal wall. Navigational Note: Jejunal perforation Invasive intervention not Invasive intervention Life-threatening Death indicated indicated consequences; urgent operative intervention indicated Definition: A disorder characterized by a rupture in the jejunal wall. Navigational Note: Lower gastrointestinal Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death hemorrhage not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition: A disorder characterized by bleeding from the lower gastrointestinal tract (small intestine, large intestine, and anus). Navigational Note: Mucositis oral Asymptomatic or mild Moderate pain or ulcer that Severe pain; interfering with Life-threatening Death symptoms; intervention not does not interfere with oral oral intake consequences; urgent indicated intake; modified diet intervention indicated indicated Definition: A disorder characterized by ulceration or inflammation of the oral mucosal. Navigational Note: Oral cavity fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition: A disorder characterized by an abnormal communication between the oral cavity and another organ or anatomic site. Navigational Note: Oral hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition: A disorder characterized by bleeding from the mouth. Navigational Note: Pancreatic fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition: A disorder characterized by an abnormal communication between the pancreas and another organ or anatomic site. Navigational Note: Pancreatitis Enzyme elevation; radiologic Severe pain; vomiting; Life-threatening Death findings only medical intervention consequences; urgent indicated. Navigational Note: Periodontal disease Gingival recession or Moderate gingival recession Spontaneous bleeding; severe gingivitis; limited bleeding on or gingivitis; multiple sites of bone loss with or without probing; mild local bone loss bleeding on probing; tooth loss; osteonecrosis of moderate bone loss maxilla or mandible Definition: A disorder in the gingival tissue around the teeth. Navigational Note: Rectal fissure Asymptomatic Symptomatic Invasive intervention indicated Definition: A disorder characterized by a tear in the lining of the rectum. Navigational Note: Rectal hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition: A disorder characterized by bleeding from the rectal wall and discharged from the anus. Navigational Note: Rectal perforation Invasive intervention not Invasive intervention Life-threatening Death indicated indicated consequences; urgent operative intervention indicated Definition: A disorder characterized by a rupture in the rectal wall. Navigational Note: Retroperitoneal hemorrhage Self-limited; intervention Transfusion indicated; Life-threatening Death indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition: A disorder characterized by bleeding from the retroperitoneal area. Navigational Note: Salivary duct inflammation Slightly thickened saliva; Thick, ropy, sticky saliva; Acute salivary gland necrosis; Life-threatening Death slightly altered taste. Navigational Note: Salivary gland fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition: A disorder characterized by an abnormal communication between a salivary gland and another organ or anatomic site. Navigational Note: Small intestinal perforation Invasive intervention not Invasive intervention Life-threatening Death indicated indicated consequences; urgent operative intervention indicated Definition: A disorder characterized by a rupture in the small intestine wall. Navigational Note: Tooth discoloration Surface stains Definition: A disorder characterized by a change in tooth hue or tint. Navigational Note: Also report Investigations: Neutrophil count decreased Upper gastrointestinal Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death hemorrhage not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition: A disorder characterized by bleeding from the upper gastrointestinal tract (oral cavity, pharynx, esophagus, and stomach). Navigational Note: Visceral arterial ischemia Brief (<24 hrs) episode of Prolonged (>=24 hrs) or Life-threatening Death ischemia managed medically recurring symptoms and/or consequences; evidence of and without permanent invasive intervention end organ damage; urgent deficit indicated operative intervention indicated Definition: A disorder characterized by a decrease in blood supply due to narrowing or blockage of a visceral (mesenteric) artery. Navigational Note: Death neonatal Neonatal loss of life Definition: Newborn death occurring during the first 28 days after birth. Navigational Note: Synonym: Flu, Influenza Gait disturbance Mild change in gait. Navigational Note: Infusion site extravasation Painless edema Erythema with associated Ulceration or necrosis; severe Life-threatening Death symptoms. Signs and symptoms may include induration, erythema, swelling, burning sensation and marked discomfort at the infusion site. Navigational Note: Injection site reaction Tenderness with or without Pain; lipodystrophy; edema; Ulceration or necrosis; severe Life-threatening Death associated symptoms. Navigational Note: Multi-organ failure Shock with azotemia and Life-threatening Death acid-base disturbances; consequences. Vaccination site Local lymph node Localized ulceration; lymphadenopathy enlargement generalized lymph node enlargement Definition: A disorder characterized by lymph node enlargement after vaccination. Navigational Note: Biliary fistula Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition: A disorder characterized by an abnormal communication between the bile ducts and another organ or anatomic site. Navigational Note: Budd-Chiari syndrome Medical management Severe or medically significant Life-threatening Death indicated but not immediately life consequences; moderate to threatening; hospitalization or severe encephalopathy; coma prolongation of existing hospitalization indicated; asterixis; mild encephalopathy Definition: A disorder characterized by occlusion of the hepatic veins and typically presents with abdominal pain, ascites and hepatomegaly. Navigational Note: Cholecystitis Symptomatic; medical Severe symptoms; invasive Life-threatening Death intervention indicated intervention indicated consequences; urgent operative intervention indicated Definition: A disorder characterized by inflammation involving the gallbladder. Navigational Note: Gallbladder fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition: A disorder characterized by an abnormal communication between the gallbladder and another organ or anatomic site. Navigational Note: Gallbladder necrosis Life-threatening Death consequences; urgent invasive intervention indicated Definition: A disorder characterized by a necrotic process occurring in the gallbladder. Navigational Note: Gallbladder perforation Life-threatening Death consequences; urgent intervention indicated Definition: A disorder characterized by a rupture in the gallbladder wall. Navigational Note: Hepatic hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition: A disorder characterized by bleeding from the liver.

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Any external beam modality can be modulated but these generally refer to 45 menstrual cycle order femara without prescription photon or proton beams. If a treatment is described as stereotactic radiotherapy or radiosurgery with online re-optimization/re-planning, then it should be categorized as online re-optimization or re-planning. If a treatment is described as “adaptive” but does not include the descriptor “online,” this code should not be used. Determination of the external beam planning technique may require assistance from the radiation oncologist to ensure consistent coding. Any one of these changes will generally mean that a new radiation plan will be generated in the treatment planning system and should be coded as a new phase of radiation therapy. Note: “Online adaptive therapy” refers to treatment where radiation treatment plans are adapted or updated while a patient is on the treatment table. When treatment plans are adapted, the shape of the target volume may change from day to day but, for registry purposes, the volume that is being targeted will not change. An adapted plan should not be coded as though a new phase of treatment has been initiated unless, as above, the radiation oncologist documents it as a new phase in the radiation treatment summary. Assign code 04 for Conformal or 3-D Conformal Therapy whenever either is explicitly mentioned 3. For the purpose of coding the data item Radiation Sequence with Surgery, ‘Surgery’ is defined as a Surgical Procedure to the Primary Site (codes 10-90) or Scope of Regional Lymph Node Surgery (codes 1-7) or Surgical Procedure of Other Site (codes 1-5). Code Description 0 No radiation and/or surgery as defined above; Unknown if surgery and/or radiation given 2 Radiation before surgery 3 Radiation after surgery 4 Radiation both before and after surgery 5 Intraoperative radiation therapy 6 Intraoperative radiation with other radiation given before and/or after surgery 7 Surgery both before and after radiation (for cases diagnosed 01/01/2012 and later) 9 Sequence unknown, but both surgery and radiation were given Coding Instructions 1. Assign codes 2-9 when first course of therapy includes both cancer-directed surgery and radiation therapy a. Assign code 4 when there are at least two courses, episodes, or fractions of radiation therapy given before and at least two more after surgery to the primary site, scope of regional lymph node surgery, surgery to other regional site(s), distant site(s), or distant lymph node(s) Example 1. Preoperative radiation therapy was administered to shrink a large, bulky lesion 2. Assign code 7 when there are at least two surgeries; radiation was administered between one surgical procedure and a subsequent surgical procedure Example 1 1. Surgery of primary site Code Radiation Sequence with Surgery as 7 (surgery both before and after radiation). Surgery of primary site Code Radiation Sequence with Surgery as 7 (surgery both before and after radiation) because lymph node aspiration is coded in Scope of Regional Lymph Node Surgery. This data item captures the reason the patient did not receive radiation treatment as part of first course of therapy. Code Description 0 Radiation therapy was administered 1 Radiation therapy was not administered because it was not part of the planned first-course treatment. Assign Code 0 if the patient received regional radiation as part of first course of therapy 2. Assign Code 1 if the treatment plan offered multiple alternative treatment options but the patient selected treatment that did not include radiation therapy 3. Assign Code 7 if the patient refused recommended radiation therapy, made a blanket refusal of all recommended treatment, or refused all treatment before any was recommended 4. If it is known that a physician recommended radiation treatment, but no further documentation is available to confirm it was given b. To indicate referral to a radiation oncologist was made and the registry should follow to determine whether radiation was administered c. If follow-up to the specialist or facility determines the patient was never there and no other documentation can be found, assign Code 1 Note: Cases coded 8 should be followed and updated to a more definitive code as appropriate. If the treatment plan offered multiple alternative treatment options, but it is unknown which treatment, if any, was provided b. Record the date of the first/earliest systemic therapy if Chemotherapy, Hormone Therapy, Immunotherapy, or Hematologic Transplant or Endocrine Procedure was recorded as part of the first course of therapy 2. Code Label Definition Blank A valid date value is provided in Date Systemic Therapy Started 10 No information No information whatsoever can be inferred 11 Not applicable No proper value is applicable in this context 12 Unknown A proper value is applicable but not known 15 Planned Treatment planned but not yet started Coding Instructions 1. Leave this item blank if Date Systemic Therapy Started has a full or partial date recorded a. Assign code 11 when no systemic therapy was given during the first course of therapy or initial diagnosis was at autopsy d. Assign code 12 if the Date Systemic Therapy Started cannot be determined, and the patient did receive first course treatment. Assign code 15 if systemic therapy is planned but has not started and date is not available. If systemic therapy was expected to be given or was planned as part of the first course of therapy, but information was not known if the systemic therapy had been started or had not been started at the time of the most recent follow-up, attempt to follow up to assure complete information is collected. Record the date of the first/earliest chemotherapy if chemotherapy was given and recorded as part of the first course of therapy a. Chemotherapy date should be the same as the Date Therapy Initiated when chemotherapy is the only treatment administered 3. Code Label Definition Blank A valid date value is provided in Date Chemotherapy Started 10 No information No information whatsoever can be inferred 11 Not applicable No proper value is applicable in this context 12 Unknown A proper value is applicable but not known 15 Planned Treatment planned but not yet started Coding Instructions 1. Leave this item blank if Date Chemotherapy Started has a full or partial date recorded 2. Assign code 11 when no chemotherapy was given as part of the first course of therapy or initial diagnosis was at autopsy 4. Assign code 12 if the Date Chemotherapy Started cannot be determined, and the patient did receive first course treatment 5. Assign 15 if chemotherapy is planned but has not started and date is not available. If chemotherapy was expected to be given or was planned as part of the first course of therapy, but information was not known if the chemotherapy had been started or had not been started at the time of the most recent follow-up, attempt to follow-up to assure complete information is collected. As information is learned, update this item, Date Chemotherapy Started, and Chemotherapy. Code Description 00 None, chemotherapy was not part of the planned first course of therapy; diagnosed at autopsy 01 Chemotherapy administered as first course therapy, but the type and number of agents is not documented in the patient record 02 Single agent chemotherapy administered as first course therapy 03 Multi-agent chemotherapy administered as first course therapy 82 Chemotherapy was not recommended/administered because it was contraindicated due to patient risk factors (comorbid conditions, advanced age, etc. It was recommended by the patient’s physician but was not administered as part of the first course of therapy. It was recommended by the patient’s physician, but the treatment was refused by the patient, a patient’s family member, or the patient’s guardian. For cases diagnosed prior to January 1, 2013, code these six (6) drugs as chemotherapy. Example 2: Patient diagnosed with breast cancer November 1, 2012, and begins receiving Rituximab January 30, 2013, as part of first course therapy. Code the Rituximab in the chemotherapy data field because the patient was diagnosed prior to January 1, 2013. Definitions Chemotherapy recommended: A consult recommended chemotherapy, or the attending physician documented that chemotherapy was recommended. Multiple agent chemotherapy: Planned first course of therapy included two or more chemotherapeutic agents and those agents were administered. The planned first course of therapy may or may not have included other agents such as hormone therapy, immunotherapy, or other treatment in addition to the chemotherapeutic agents. Single agent chemotherapy: Only one chemotherapeutic agent was administered to destroy cancer tissue during the first course of therapy. The chemotherapeutic agent may or may not have been administered with other drugs classified as immunotherapy, hormone therapy, ancillary, or other treatment. Code the chemotherapeutic agents whose actions are chemotherapeutic only; do not code the method of administration 2. When chemotherapeutic agents are used as radiosensitizers or radioprotectants, they are given at a much lower dosage and do not affect the cancer. Review the radiation-oncology progress notes for information about radiosensitizing chemotherapy. Note: Do not assume that a chemo agent given with radiation therapy is a radiosensitizer. The physician may change a drug during the first course of therapy because the patient cannot tolerate the original agent a. Code as treatment for both primaries when the patient receives chemotherapy for invasive carcinoma in one breast and also has in situ carcinoma in the other breast. The medical record documents chemotherapy was not given, was not recommended, or was not indicated b. If the treatment plan offered multiple treatment options and the patient selected treatment that did not include chemotherapy d.

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Using the 2-to-1 rule of thumb breast cancer uk purchase femara online now, doing 150 minutes of vigorous intensity aerobic activity a week provides about the same benefts as 300 minutes of moderate-intensity activity. Adults are encouraged to do a variety of activities to reduce the risk of injury often caused by doing too much of one kind of activity (this is called an overuse injury). Highly Active Adults Adults who are highly active—doing more than the equivalent of 300 minutes of moderate-intensity physical activity and at least 2 days of muscle-strengthening activity each week—should maintain or continue to increase their activity level. Special Considerations Maintaining a Healthy Body Weight the health benefts of physical activity are generally independent of body weight. The good news for people needing to lose weight is that regular physical activity provides major health benefts, no matter how their weight changes over time. Physical activity, along with appropriate dietary intake, is an important part of maintaining a healthy weight because it helps in preventing weight gain, losing weight, and keeping extra weight off once it has been lost. Physical activity also helps reduce abdominal fat and preserve muscle during weight loss. The amount of physical activity necessary to achieve this weight varies greatly from person to person. Active Adults 63 the frst step in achieving or maintaining a healthy weight is to meet the minimum level of physical activity in the Guidelines. Learn More For some people this will result in a stable and healthy body See the Dietary Guidelines for weight, but for many it may not. Americans for additional information on weight management and how to People who are at a healthy body weight, but slowly gaining determine a healthy weight. That is, by regularly checking body weight, people can fnd the amount of physical activity that works for them. Many adults will need to do more than the 150 minutes a week of moderate-intensity aerobic physical activity to lose weight or keep it off. These adults should do more physical activity and/or further reduce their caloric intake. Some people will need to do the equivalent of 300 or more minutes of moderate-intensity physical activity a week to meet their body-weight goals. In addition to restricting caloric intake, these adults should gradually increase minutes or the intensity of aerobic physical activity, to the point at which the physical activity is effective in achieving a healthy weight. It is important to remember that all activities, whether light, moderate, or vigorous intensity, “count” for energy balance. Active choices, such as taking the stairs rather than the elevator or adding short episodes of walking to the day, are examples of activities that can be helpful in weight control. Getting and Staying Active: Real-Life Examples Adults can meet the key guidelines in all sorts of ways and with many types of physical activity. The choices of types and amounts of physical activity depend upon personal health and ftness goals. Here are a few examples: Madison: A 20-Year-Old Woman Madison is an active 20-year-old who lives on campus at a small university. At the end of her frst year, she realized she had become quite sedentary and had gained weight. She found that physical activity helped her feel less anxious and study more productively, so she made the commitment to build regular physical activity into her week. Now at the end of her second year, Madison does the equivalent of at least 420 minutes of moderate-intensity aerobic activity each week, plus muscle strengthening activities 2 days a week. Walking provides at least 30 minutes of moderate-intensity activity each day (150 minutes a week). The 45-minute class is mostly vigorous-intensity activity (equivalent of 180 minutes of moderate-intensity activity a week) and incorporates dance, calisthenics. They use dumbbells, weight machines, suspension trainers, and kettlebells to target all of their major muscle groups. Miguel: A 40-Year-Old Man With Young Children Between a demanding job, caring for his two children ages 5 and 7, and spending time with his wife and extended family, Miguel does not have much time to spare. But physical activity helps Miguel deal with the stress of his hectic life, and he squeezes it in wherever he can. Adding it up, he does the equivalent of 95 minutes a week of moderate-intensity physical activity and 1 day of muscle-strengthening activity each week. The leisurely walk counts as light-intensity activity, but Miguel typically spends at least 15 minutes running around and playing with the kids each time they visit the park. While at the park, Miguel and his wife take turns doing body-weight exercises like squats, push-ups, and crunches while the other parent keeps an eye on the kids. Miguel knows he has not quite met the key guidelines, so he plans to add another park outing each week this summer. He plans to start walking briskly up or down the stairs in his offce rather than taking the elevator to attend various meetings to accumulate at least 10 minutes of moderate-to-vigorous physical activity each day. Once he makes these changes, he will be getting the equivalent of 160 minutes of moderate-intensity activity and 2 days of muscle-strengthening activity each week. Active Older Adults the benefts of regular physical activity occur throughout life and are essential for healthy aging. Adults ages 65 years and older gain substantial health benefts from regular physical activity. Being physically active makes it easier to perform activities of daily living, including eating, bathing, toileting, dressing, getting into or out of a bed or chair, and moving around the house or neighborhood. Physically active older adults are less likely to experience falls, and if they do fall, they are less likely to be seriously injured. Physical activity can also preserve physical function and mobility, which may help maintain independence longer and delay the onset of major disability. Research shows that physical activity can improve physical function in adults of any age, adults with overweight or obesity, and even those who are frail. Promoting physical activity and reducing sedentary behavior for older adults is especially important because this population is the least physically active of any age group, and most older adults spend a signifcant proportion of their day being sedentary. Most, but not all, have one or more chronic conditions, such as type 2 diabetes, Learn More cardiovascular disease, osteoarthritis, or cancer, and these See Chapter 6. Nevertheless, being Considerations for Some Adults for a physically active has signifcant benefts for all older adults. Other benefts include a lower risk of dementia, better perceived quality of life, and reduced symptoms of anxiety and depression. Additionally, doing physical activity with others can provide opportunities for social engagement and interaction. All older adults experience a loss of physical ftness and function with age, but some experience this more than others. This diversity means that some older adults can run several miles, while others struggle to walk a few blocks. This chapter provides guidance about physical activity for adults ages 65 years and older. The Guidelines seeks to help older adults select the types and amounts of physical activity appropriate for their own abilities. For adults ages 65 years and older who have good ftness and no chronic conditions, the guidance in this chapter is essentially the same as that provided in Chapter 4. Active Older Adults 67 Key Guidelines for Older Adults these guidelines are the same for adults and older adults: Adults should move more and sit less throughout the day. Additional health benefts are gained by engaging in physical activity beyond the equivalent of 300 minutes (5 hours) of moderate-intensity physical activity a week. Guidelines just for older adults: As part of their weekly physical activity, older adults should do multicomponent physical activity that includes balance training as well as aerobic and muscle-strengthening activities. Older adults should determine their level of effort for physical activity relative to their level of ftness. Older adults with chronic conditions should understand whether and how their conditions affect their ability to do regular physical activity safely. When older adults cannot do 150 minutes of moderate-intensity aerobic activity a week because of chronic conditions, they should be as physically active as their abilities and conditions allow. In addition, these key guidelines discuss the importance of multicomponent physical activity, which includes balance training along with aerobic and muscle-strengthening activity. Each provides important health benefts, especially to improve physical function, as explained in Chapter 2. Aerobic Activity Aerobic activities, also called endurance or cardio activities, are physical activities in which people move their large muscles in a rhythmic manner for a sustained period of time. Brisk walking, jogging, biking, dancing, and swimming are all examples of aerobic activities.

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The author stumbled upon its efficacy for joint pain when she began taking it at her Naturopathic Oncologist’s suggestion in order to women's health clinic calgary ne femara 2.5 mg mastercard bolster her immune system. Coincidentally, she was suffering from a painful episode of bursitis at the time and noticed that by the evening of the first dose her bursitis felt less acute. Surprised and pleased, she researched the mixture and found it is purported to have anti-inflammatory properties, which evidently worked in her situation. Since inflammation may be associated with joint pain, adding turmeric (mixed with freshly ground black pepper and olive oil for bioavailability) to foods or taking supplements may help relieve symptoms. Exercise consisted of 150 minutes per week of aerobic exercise, and twice-weekly supervised strength training. The researchers found that, at 12 months, the worst joint pain scores decreased by 29% in the exercise group. Some people swear that over-the-counter dietary supplements called glucosamine and chondroitin ease arthritis pain, reduce stiffness, and protect joints from further damage, although others say they didn’t help as much as they’d hoped. One small controlled pilot study found that Reiki was linked with reduced pain in patients with advanced cancer. Letrozole) may have some different ingredients called “fillers” than the name brand of the drug. So, switching to the name brand name drug or to another generic form of it may sometimes help (one lady indicated that switched from Anastrozole to brand-name Arimidex and experienced profound relief). If switching to the brand-name drug is not possible due to insurance related issues, then trying a different manufacturer of the generic drug may help. In the study, 21 patients received acupuncture therapy according to classical Chinese Medicine while 26 patients received the best medical care but no specific neuropathy treatment. Sixteen patients (76%) in the acupuncture group improved symptomatically and objectively, while only four patients in the control group (15%) did so. In a study of neuropathic pain caused by diabetes, it was concluded that alpha lipoic acid leads to a significant and clinically relevant reduction in neuropathic pain. Scrambler therapy, on the other hand, is proposed to provide normal-self, non-pain electrical information via nerves that have been transmitting chronic pain information. Through a process termed plasticity, this is able to retrain the brain so that it does not ascribe pain to the chronic pain area. To reduce this side effect, patients are encouraged to discuss exercise with their doctor because a recent study comparing neuropathy symptoms in exercisers (those who undertook walking and gentle resistance-band workouts) vs. One woman wrote that she started experiencing extreme pain in her liver, sometimes crying when a Percocet wore off. Initially, she tried it on her back for intense pain from bone metastases and reported that her back pain almost completely subsided. I am not into this kind of stuff, but I have to say it has helped my neuropathy and other aches and pain. She wrote that she learned it is called "intestinal neuropathy" and is a rare, but very real side effect of Navelbine. Note: Stomach (abdominal) pain may be caused by many different reasons, so it is very important for patients with abdominal pain to contact their doctor. The terms “anxiety” and “depression” are frequently used interchangeably, yet they are a bit different: People suffering from anxiety have a sense of doubt and vulnerability about future events. The attention of anxious people is focused on their prospects, along with fear that those future prospects will be bad. Patients suffering from depression may think they already know what will happen and believe it will be bad. Some key symptoms include: Feeling sad and/or hopeless Lack of interest and enjoyment in activities that used to be fun and interesting A feeling of psychological “numbness” Physical aches and pains without apparent cause Lack of energy Restlessness and/or irritability Difficulty concentrating, remembering, and/or making decisions Changes in appetite and weight Unwelcome changes in usual sleep patterns Social withdrawal In extreme cases, thoughts of death and suicide Patients with anxiety and/or depression are encouraged to consult with their doctor about possible ways to decrease these unwelcome feelings. One study found that Electroacupuncture—in which a mild electric current is transmitted through tiny needles inserted into the skin —was just as effective as Prozac in reducing symptoms of depression. Even is relatively simple companion such as a goldfish may provide patients with relaxation and enjoyment. Some patients who were getting cancer treatment have reported an increased sense of well-being after Reiki sessions. While their effect on mood is not completely clear, doctors recognize that modulating these brain chemicals may help with depression. Physicians prescribing antidepressants must also be made fully aware of all other medications the patient is taking (see Warning about Tamoxifen Interactions below). The three main chemical messengers (neurotransmitters) involved in depression are: 1. Patients taking Tamoxifen should preferably not be given the following drugs or supplements for depression unless a viable reason is provided by their doctor. Remeron (mirtazapine) – There may be a slight risk of interaction with Tamoxifen, although it has not been well-studied. They include Trazodone (Oleptro), Mirtazapine (Remeron) and Vortioxetine (Brintellix). A newer medication called Vilazodone (Viibryd) is thought to have a low risk of sexual side effects. Benzodiazepines such as Xanax (Alprazolam), Clonazepam, (Klonopin) Valium (Diazepam), and Ativan (Lorazepam) can be effective in promoting relaxation and reducing physical symptoms of anxiety. Instead, it belongs to a group of anti-anxiety drugs called anxiolytics, but it seems to work somewhat differently than other drugs in that class. Esketamine, which acts somewhat as a Dopamine Reuptake Inhibitor, is specifically intended for people with major depressive disorder who have tried at least two antidepressants and haven’t responded to treatment (known as treatment-resistant depression). Changing the balance of serotonin seems to help brain cells send and receive chemical messages, which in turn boosts mood. Therefore, medications in this group of antidepressants are sometimes called “dual-action” antidepressants. These drugs, such as Imipramine (Tofranil), Nortriptyline (Pamelor), Amitriptyline, Doxepin, Trimipramine (Surmontil), Desipramine (Norpramin) and Protriptyline (Vivactil) — tend to cause more side effects than newer antidepressants. I noticed how much the stimulant had enhanced the effect of the antidepressant when I allowed the prescription to run out. I let it go for a few weeks, and was really stunned by the comparative achiness, deep fatigue and loss of pleasure I felt. I got back on the Dextroamphetamine stimulant and felt increased well-being, much less fatigue, and a normal level of interest in life. For many people living with cancer, everyday activities – talking on the phone, shopping for groceries, even lifting a fork to eat – can be overwhelming tasks. Additionally, many patients also experience insomnia, which is the inability to fall asleep within a reasonable amount of time and to remain asleep adequately through the night. Both issues can be caused by cancer treatment, stress, pain, anxiety and/or depression, and even perhaps by the cancer itself. For people undergoing chemotherapy in cycles, fatigue often becomes worse for the first few days and then gets better until the next treatment, when the pattern begins again. Left untreated, cancer-related fatigue can upset the patient’s quality of life by adversely affecting daily routines, self-care, recreation, relationships, and general well-being. Thinning of the tissues of the vagina, bladder and urethra, as well as change in the vaginal environment after menopause, may make these areas less resistant to bacteria and cause more frequent urinary tract infections. Patients are encouraged to speak with their doctor about these concerns, and to discuss Palliative Care (please refer to the Palliative Care section for additional information). It involves inserting thin sterile needles into different points on the body by a skilled practitioner. Based upon a study of 246 patients with breast cancer, acupuncture improved their general fatigue, physical fatigue, mental fatigue, anxiety and depression, and quality of life. She takes one 650mg capsule of Sona Korean Ginseng daily with breakfast, with two months on and one month off, and has experienced a profound difference in energy. One study found that music therapy daily greatly increased relaxation sensations and significantly decreased fatigue sensation in treated cancer survivors. Some patients who were getting cancer treatment have reported an increased sense of well-being, with less pain, nausea, and vomiting after Reiki sessions. Because tai chi promotes robust improvements in sleep health in breast cancer survivors with insomnia, it offers the additional benefits of improving depressive symptoms and fatigue.

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Patients receiving radiotherapy with curative intent should be part of a national quality assurance programme menstruation after miscarriage order femara paypal. Ensure all patients potentially suitable for multimodality treatment (surgery, radiotherapy and chemotherapy in any combination) are assessed by a thoracic oncologist and by a thoracic surgeon. Timing of radiotherapy Radiotherapy to start 4 weeks from time of decision to treat. Information for patients Thoracic radiotherapy information leaflets to be given to patient in lung clinic 9. Radiotherapy treatment planning for external beam: radical with curative intent 9. Positioning / immobilisation  Patients should be supine with arms above head  Imobilisation using chest board and fixed arm position  the patient should be breathing normally 9. Not more than 12 cm of oesophagus (any part of the circumference) should lie within the 95% isodose. Maximum radiation dose to 10 cm spinal cord should not exceed 44 Gy in 2 Gy per fraction or 36Gy in 2. The pericardium will act as the boundary axially from the superior to the inferior border. The superior aspect will begin at the level where the pulmonary trunk and pulmonary arteries are first seen as separate structures. The inferior aspect will be from the inferior wall of the left ventricle which it is indistinguishable from the liver. Treatment verification  the volume to be treated should be verified according to local practice. It is recommended that treatment verifications should be taken for the first three fractions, then weekly to correct any systematic errors. On Treatment Review Clinics and Schedule Gap Category for Management of Unscheduled Interruptions  Weekly review by On-Treatment Review Specialist for assessment of toxicity. If weekend treatment is not possible, then missed treatments should be added to the end of the treatment schedule. Thoracic radiation specific toxicities Acute radiation oesophagitis : management  Ensure that the patient maintains adequate fluid intake  Access to dietitian  Ant-acid mucilage ie Oxetacaine or similar  Simple analgesics, escalating strength as necessary  Proton pump inhibitors  Treat for oesophageal candidiasis Radiation induced pneumonitis : management 28  Collaborate with chest physician  Patients should not be smoking  Early treatment with corticosteroids ie prednisolone 40 mg daily, or equivalent, for 2-4 weeks then reduce. Diagram of exclusion zone: Tumour within red line considered too close to critical structures 9. Tumour Dose schedules  18 Gy x 3 fractions  12 Gy x 5 fraction  11 Gy x 5 fraction  2-4 days between each fraction 9. Radiotherapy Dose Schedules  Dose: 55 Gy in 20 F over 4 weeks  Or Dose : 64-66 Gy in 32-33 F over 6 ½ weeks. After 4 week following last radiotherapy fraction, consider further 2 cycles Cisplatin iv 75mg /m2 day 1, Vinorelbine iv 30mg/m2 days 1,8 q=21 days. Indications  the main purpose is to palliate symptoms, although in some patients of good performance status, higher doses of radiotherapy have been shown to result in a modest improvement in survival. Several studies have shown no apparent benefit in survival in the use of immediate radiotherapy versus delayed radiotherapy and no difference in symptom control or quality of life. Therefore, in this group, there should be a discussion with the Clinical Oncologist regarding the options of using palliative radiotherapy upfront or withholding radiotherapy until symptoms arise. Symptomatic chest disease Patients with symptoms such as haemoptysis, cough, pain, dysphagia and breathlessness should receive palliative thoracic radiotherapy when appropriate according to their performance status. Consideration should be given to the spinal cord dose with isodose intervention and cord shielding as appropriate. It is then imperative to reduce the dose with a view to discontinuation as quickly as symptoms allow. Surgical resection followed by whole brain radiotherapy may be an option or whole brain radiotherapy followed by stereotactic boost. Follow-up of patients after treatment with palliative intent Follow-up should be individualised to anticipate treatment-related toxicity and potential changes in symptoms or quality of life. Essential Investigations and Information required  Referral Form indicating diagnosis, stage and intent. Position / Immobilisation 34  Head Rest, Knee fix, Vacbag  Supine  the patient must be able to lie flat for a period of at least 20 minutes for accurate radiotherapy planning to take place 9. Planning Technique  A parallel opposed field technique, using Megavoltage photons from linear accelerator. Side effects of treatment and management  Immediate: 6-12 hours: nausea, vomiting and chest discomfort occasionally seen, particularly after larger radiotherapy fractions. This may be alleviated with Paracetamol, Domperidone/Metoclopramide and Dexamethasone tablets 4mg bd x 1 day. Occasionally, candidiasis may be responsible and treated using Fluconazole tabs 50mg x 7 days or equivalent. Definition of staging  Limited stage: No universally accepted definition of this term is available. Timing of Thoracic Radical Radiotherapy (consolidation)  Several metanalyses have indicated superior survival rates when radical radiotherapy is used early on, within 1st or 2nd chemotherapy cycles4. Further analysis suggests that the overall duration of the radiotherapy (to be completed within 4 weeks) has advantage over longer duration radiotherapy. Cancer has spread outside of the lung to other tissues in the chest or to other parts of the body (metastasized). Current disease status Treatment regimen A Previously  Limited disease Radical Chemoradiotherapy untreated amenable to radical Fractionated Cisplatin & Etoposide thoracic irradiation. Monitoring investigations required at each visit: physical examination, chest x-ray and tests as indicated. Follow-up: Patients will be seen 6 weeks after completion of treatment with subsequent follow up as per local policy. Patients with sensitivity or susceptibility to carboplatin side effects may occasionally be considered. Follow-up: Patients will be seen 6 weeks after completion of treatment and subsequently according to local protocol. Occasionally the Irinotecan dose can be 100 mg/m2 at cycle one; the Irinotecan dose may also be increased to 100 mg/m2 pending toxicity (discuss with consultant). If response seen at 4 cycles a further 2 may be given at discretion of treating physician (Mitomycin is omitted after 4 cycles completed). Follow-up: Patients will be seen 6 weeks after completion of treatment then according to local follow up protocols. Intravenous Topotecan is not recommended for people with relapsed small-cell lung cancer. It may be appropriate to start with 3 consecutive days’ therapy initially, increasing to the full 5 days subsequently. Follow-up: Patients should be reviewed every 3 weeks, as this is palliative treatment. Consider relevant clinical trial E Other protocols/drugs Protocols including vinorelbine with or without cisplatin and gemcitabine with or without carboplatin, may be appropriate on occasion. Palliative Paclitaxel and Carboplatin weekly regimen or 3 weekly regimen Elisabeth Quoix, Gérard Zalcman, Jean-Philippe Oster et al. Treatment: Erlotinib 150mg once daily orally until disease progression or emergence of intolerable toxicities. N Engl J Med 361:947-957, 2009 Treatment: Gefitinib 250mg once daily orally until disease progression or emergence of intolerable toxicities. Follow-up: Monthly until disease stabilisation or response established, then consider two monthly 10. Prospective randomised trial of docetaxel versus best supportive care in patients with non-small cell lung cancer previously treated with platinum based chermotherapy. People who have received Pemetrexed in combination with cisplatin as first-line chemotherapy cannot receive Pemetrexed maintenance treatment. People currently receiving treatment with Erlotinib, but for whom treatment would not be recommended according to section 1. Common symptoms of lung cancer Common symptoms of lung cancer include fatigue, loss of appetite, weight loss, breathlessness, cough, haemoptysis, hoarseness, chest pain, bone pain, spinal cord compression, brain metastases and superior vena caval obstruction. Thoracic symptoms have been subdivided into dyspnoea (breathlessness), including malignant pleural effusion, non-obstructive airway symptoms (cough, haemoptysis, hoarseness and chest pain) and superior vena caval obstruction. Neurological symptoms include those arising from brain metastases and spinal cord compression. The treatment of bone pain and pathological fractures is covered under a section on bone metastases. No specific evidence on the treatment of pain has been reviewed as this is a general symptom of cancer and not specific to lung cancer which is outside the scope of this chapter.

Syndromes

  • Diabetes
  • Health screening - women - over 65
  • Rapid heart rate
  • Knee appears to be deformed
  • Washing of the skin (irrigation) -- perhaps every few hours for several days
  • Infection (rare)
  • Blocked glands in the anal area
  • Short bowel syndrome (e.g., from surgery or an inherited problem)

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Clinical nodal category cN0 may be Note: the (m) suffx applies to women's heart health tips buy 2.5 mg femara with visa assigned based solely on physical examination. It is not Imaging to assess regional lymph nodes is not applicable to multiple foci of in situ required to assign clinical stage. Example: Direct extension into the Example: Bone and soft tissue sarcoma may liver from a primary colon cancer use cN0 to assign the clinical stage group, would be in the T category and not in that is, cT1 cN0 cM0. Microscopic Microscopic examination of regional nodes Microscopic assessment of If microscopic assessment of the assessment for cN during the diagnostic workup is included in the highest T category primary site or regional tissue clinical classifcation as cN. Example: Sentinel node biopsy performed Unknown primary or no If there is no evidence of a primary before neoadjuvant therapy in breast cancer is evidence of primary tumor tumor, or the site of the primary designated as clinical (cN). In some circumstances, this In situ neoplasia identifed during the diagnostic workup on a core or the managing physician also may label incisional biopsy is assigned cTis. Any T Any T includes all T categories except Nodes that do not concentrate colloidal material Tis. Their resection is not coded as a separate nodal procedure or a lymph node dissection. The cM0(i+) category denotes the uncertain Clinical evidence of cM1 prognostic signifcance of these fndings. Examination methods confrm distant not confrm metastatic cancer, M is include: metastatic disease categorized as clinically M0 (cM0) or. Use of pM1 for pM1 Direct extension into Direct extension from the primary tumor or multiple distant In patients who have distant metastases in an organ not M lymph nodes into a contiguous or adjacent metastases multiple sites and have a cancer type for category organ is not included in the M category but which M subcategories distinguish between is used in the T and N category assignments one or more metastatic sites, microscopic as noted earlier. Pathological T (pT) the purpose of pathological classifcation is to provide the pathological assessment of the primary tumor generally additional precise and objective data: is based on resection of the primary tumor. Component of pT Description Tumor size and Primarily based on size and local extension of extent the resected specimen the pathologist provides information to assign Criteria for assigning pathological stage the pT category based on the specimen Component of received, but this may not be the fnal pT used pathological staging Details for staging assignment. Final pThis assigned by Assignment of Pathological stage is based on a the managing physician and also may include pathological stage by synthesis of clinical and pathological clinical stage information and operative managing physician fndings and is assigned only by the fndings. The extent of assignment specifc disease site, and primary tumor surgical resection ranges. If resected and highest T assigned without tumor resection if: in several partial specimens at the same or category. Other criteria, such as microscopic the estimate of multiple specimens may be confrmation of the highest pN, must be met in based on the best combination of gross and order to assign pathological staging. Protocols for tumor-specifc Unknown primary If there is no evidence of a primary tumor, or recommendations. The rules for staging cancers categorized assigned based on fndings in the resection as T0 are specifed in the relevant disease site specimen and at operation. In situations in which the surgeon has left Examples of exception: the T0 category is not behind grossly identifed tumor in performing used for head and neck squamous cancer sites, a noncurative resection, the T category should as such patients with an involved lymph node be based on all available clinical and are staged as unknown primary cancers using the pathological information. It may be assigned when relevant acceptable alternative is: specimens are not available for examination by. It may also be assigned by the N0 M0 pathologist for a subsequent resection or Note: the (m) suffx applies to multiple multiple partial resections when tumor invasive cancers. It is not applicable for fragmentation precludes assessment of the pT multiple foci of in situ cancer, or for a mixed category. Tumor nodule in Rounded tumor nodules with smooth node area not contoured capsules in the regional nodal considered in T drainage area generally represent lymph category nodes completely replaced with cancer and Pathological N (pN) are classifed as lymph nodes, unless there is Pathological assessment of regional node involvement (pN) clear evidence of residual blood vessel wall is necessary. They are not considered in the confrm the status of the highest N category to T category. If pThis available (resection), Sentinel node or Microscopic examination of regional nodes then any microscopic evaluation of nodes is regional node without resection of the primary site (during classifed as pN. For example, assessment of excision the diagnostic workup) is included in the the axillary nodes is suffcient to assign pN for clinical classifcation as cN. For some disease sites, the size of tumor Nodes that do not concentrate colloidal metastasis within the regional lymph node is material and are resected along with other a criterion for the N category. If the size of sentinel nodes are nonsentinel nodes, and are the tumor in the regional nodal metastasis is considered part of the sentinel node unknown, the size of the involved lymph procedure. These recommendations are offered as the concepts regarding this staging rule metrics for evaluation of quality review of continue to evolve, and further study is the extent of surgical resection and warranted. These rule serves as a guideline for uniformity minimum benchmarks should not be and consistency in practice in recording construed as unique indicators for information, and clinical judgment by the additional surgical resection or adjuvant managing physician prevails. The concepts regarding this staging rule Node status not For some cancer sites in which lymph node continue to evolve, and further study is required in rare involvement is rare, patients whose nodal warranted. The assignment of cN0 will ensure it is not these usually are classifed as clinically node confused with a case in which the nodes were negative and identifed with the (mol+) microscopically proven to not contain tumor, designator: for example, cN0(mol+). The concepts regarding this staging rule Examples: For bone and soft tissue sarcoma, continue to evolve, and further study is cN0 may be used to assign the pathological warranted. Micro-metastases: Lymph node micro-metastases are defned as For melanoma, cN0 may be used to assign a use of mi designator tumor deposits >0. Regional nodes when In the rare occurrence in which a tumor the concepts regarding this staging rule a tumor involves involves more than one organ or structure, continue to evolve, and further study is more than one organ the regional nodes include those of all warranted. It is sometimes also termed nodes would be considered regional for the extranodal spread, extracapsular extension, transverse colon, even if the colon regional or extracapsular spread. The concepts regarding this staging Clinical evidence of distant cM1 rule continue to evolve, and further metastasis Patients with clinical evidence of study is warranted. Examination M0 (cM0) or clinically M1 (cM1) methods include: based on the evaluation of other. Note: pM0 is not a valid category Microscopic evidence of pM1 If clinical evidence of distant distant metastasis Patients in whom there is microscopic metastasis remains in other areas that evidence confrming distant metastatic are not or cannot be microscopically disease are categorized as confrmed, cM1 is assigned. Use of pM1 if there are pM1 No direct extension in M Direct extension from the primary multiple distant metastases In patients who have distant metastases category tumor or lymph nodes into a contiguous in multiple sites, and have a cancer or adjacent organ is not included in the type for which M subcategories M category but is used in the T and N distinguish between one or more category assignments as noted earlier. The c/pM category may include category for post neoadjuvant therapy classifcation remains cM0, cM1, or pM1. Time frame: the yp classifcation is used when staging Radiologists may provide T, N, and M information based on imaging studies to assist after neoadjuvant therapy and planned post neoadjuvant the managing physician in assigning the fnal therapy surgery. Examples of treatments that satisfy the defnition of neo Examples: adjuvant therapy for a disease site may be found in sources. Note: Once distant metastasis is identifed, that Recurrence/retreatment staging assessment criteria M category designation always remains, even Component of if there no longer is evidence of the metastasis recurrence/ after neoadjuvant therapy. In this situation, the retreatment staging Details yc and yp stages always maintain the M1 Stage at initial the initially assigned clinical and category. Note: this situation is not classifed as Stage Information included: r All information available at the time of 0, because such a designation would denote classifcation recurrence or retreatment should be used to in situ neoplasia. Important: Biopsy confrmation is not the complete pathological response also may required but is encouraged if clinically be documented by using the response feasible. Response to It is important to record the response to rc neoadjuvant therapy neoadjuvant therapy. Consult disease site the r-clinical (rc) classifcation is based on: chapters for specifc systems. The r-pathological (rp) classifcation is Mucin pools, Histologic confrmation of residual cancer based on: necrosis, and other requires identifcation of non-necrotic tumor. Mucin pools and necrotic cells currently play no role in assigning the ypT and ypN. Time frame: From identifcation of recurrence or pro Component of autopsy gression until treatment is initiated for rc, and from identif staging Details cation of recurrence or progression through surgical resection Diagnosis at autopsy Cancer must be diagnosed at autopsy. Criteria: Disease recurrence after disease-free interval, Information included All clinical and pathological information or disease progression is included. Clinical and pathological Assigning stage with A presumptive stage to facilitate patient stage groups are defned for each case as appropriate. These incomplete management may be used by the treating disease-specifc groups are composed of the following information physician/management team. This approach commonly is used for cancer conferences (tumor boards) and other medical conversations. Once the fnal clinical stage is determined, these Rules for assigning prognostic stage groups (stage groups) preliminary stages no longer are used and are Component of replaced by the clinical stage.

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The use of radiation is reported historically as beneficial women's health center vidalia ga 2.5mg femara visa, but with little evidence. Amyloidosis There is only an occasional case report of the use of ionizing radiation therapy in the treatment of amyloidosis. Aneurysmal bone cyst these are relatively rare and benign osteolytic lesions of bone usually occurring in children or young adults. Radiation therapy is medically necessary only if accompanied by documentation that its use is considered essential by a multi-disciplinary team. Angiofibroma of nasopharynx (juvenile nasopharyngeal angiofibroma) While optimum management is controversial, there is general agreement that surgery is preferred if considered safe, as in cases when there is no extension into the orbital apex or base of skull. When radiation is used, the radiation dose is lower than in malignant tumors of the same location. Policy: Radiation therapy is medically necessary in those cases with extension into the orbital apex or base of skull. Angiomatosis retinae (von Hippel Lindau syndrome) Capillary hemangiomas associated with von Hippel Lindau syndrome may be single or multiple, and can severely affect vision. Ankylosing spondylitis the use of radiation therapy in the treatment of ankylosing spondylitis is of historical interest. The risk of radiation-induced cancer and other morbidity contraindicates its use and is often cited as a common example of radiation carcinogenesis in radiobiological studies. Arachnoiditis In the pre-antibiotic era the beneficial use of radiation for the treatment of arachnoiditis was described. Resolution is slow and may take years, during which the risk of hemorrhage is not eliminated. Arthritis (see total lymphoid irradiation for radioimmunosuppression) (see rheumatoid arthritis) (see osteoarthritis) N. Basalioma this synonym for basal cell carcinoma of the skin is sometimes included in lists of "benign" disorders of skin suitable for treatment with radiation therapy. It can be mistaken for other disorders because of the features it shares with psoriasis and eczema. Bronchial adenoma this term in the past has lumped together a variety of tumors arising from the mucous glands of the tracheobronchial tree including carcinoid, cylindroma, and mucoepidermoid carcinoma. Surgical resection has historically been the treatment of choice with radiation reserved for technically or medically inoperable cases. Precise histologic classification may help discriminate those truly benign lesions that would not be expected to benefit from radiation therapy from lesions that would be best treated as invasive carcinomas. Bursitis, synovitis, and tendinitis Randomized studies in 1952, 1970, and 1975 cited in the Order and Donaldson review claimed "no benefit" to the use of radiation therapy for any of these, and the authors of the review recommend against its use. Department of Health, Education, and Welfare survey report of 1977 reporting the results of a survey of American radiation oncologists included these diagnoses as acceptable for treatment, as did the German survey of 2008. The relationship to subsequent malignant lymphoma is unclear, with malignant lymphoma reported in as many as 30% of cases. Synonyms include giant follicular lymph node hyperplasia, follicular lymphoreticuloma, angiomatous lymphoid hamartoma, and giant benign lymphoma. Low dose radiation therapy has been reported as effective in refractory or relapsed cases if further use of steroids is contraindicated. Surveys reported by Order and Donaldson (1998) indicated 75% of surveyed radiation oncologists would use radiation for this purpose with the appropriate indication. Department of Health, Education, and Welfare survey report of 1977 included castration as an acceptable indication. Chemodectoma (carotid body, glomus jugulare, aortic body, glomus vagale, glomus tympanicum) (chromaffin negative) Chemodectoma is a general term that includes many specific types based on the location of the body in which they arise. These are chromaffin-negative, benign tumors that can arise in the chemoreceptor system, such as the aortic body; carotid body; glomus jugulare; and tympanic body. These tumors of notochord origin can be benign or malignant, but all tend to be locally invasive and tend to recur locally, some with the potential to metastasize. Surgery is the primary approach, but is often inadequate to control the primary tumor. Choroidal Hemangioma these are rare vascular tumors and may be circumscribed or diffuse, the latter associated with Sturge-Weber syndrome. Typically, radiation therapy is given using complex or three dimensional conformal external photon beam technique, or using low dose rate brachytherapy plaque. Corneal Vascularization Radiation therapy is not indicated in the treatment of corneal neovascularization. Corneal xanthogranuloma Corneal xanthogranulomas may develop in association with generalized juvenile xanthogranuloma and generalized histiocytosis. Craniopharyngioma Most often radiation therapy is used as an adjuvant after maximal safe resection. Dermatitis Skin inflammation from a variety of etiologies (both known and unknown) has been treated in the past by using low dose, very superficial radiation or Grenz rays. The use of radiation for this purpose is reserved for cases refractory to non-radiation measures. Desmoid Tumor Also known as aggressive fibromatosis or deep musculoapeuronotic fibromatosis, a desmoid tumor is a histologically benign connective tissue tumor with a high recurrence rate after resection. Surgical resection with negative surgical microscopic margins in the treatment of choice for most. Fractionated radiation therapy in excess of 50 Gy is needed for control, which may preclude its use in those of intra-abdominal location. Dupuytren’s Contracture (fibromatosis) this may develop in the hand (Morbus Dupuytren) or foot (Morbus Ledderhose) and is a connective tissue disorder of the palmar or plantar fascia. Typical treatment is with photon beam therapy using, at most, complex treatment planning, or with electron beam therapy in ten or fewer fractions. Eczema There is little support in the recent American literature for the use of ionizing radiation in the treatment of eczema. Erythroplasia of Queyrat this in situ form of epidermoid carcinoma involves the mucosal or mucoepidermoid areas of the prepuce or glans penis. Exophthalmos Refer to specific etiology section (Graves’s ophthalmopathy, Langerhans cell histiocytosis, etc. Extramammary Paget’s disease (adenocarcinoma of the skin) When it occurs, adenocarcinoma of the skin usually arises in areas of abundant apocrine glands. The entity is discussed in the non-cancer policy due to historical references to its being a benign condition. Radiation therapy is necessary in those cases in which medical management is ineffective or otherwise contraindicated. Fibrosclerosis (sclerosing disorders) Unifocal and multifocal episodes of sclerosis have been treated in the past using radiation therapy. Sites reported include retroperitoneum, mediastinum, bile ducts, thyroid, meninges, orbits and others. While anecdotal reports of improvement have been reported, radiation therapy is generally regarded as ineffective and should not be used. Fungal infections (see Infections, fungal) In the 1940s and 1950s xrays were not infrequently used to treat tinea capitis and other skin fungal infections. Graves’ Ophthalmopathy this is an autoimmune disorder associated with hyperthyroidism that affects the eye musculature and retrobulbar tissues causing proptosis and visual impairment. Gynecomastia In the older era of orchiectomy or the use of diethylstilbestrol for the treatment of metastatic or locally advanced prostate cancer, it was commonplace to irradiate Page 162 of 263 the breasts on a prophylactic basis to prevent uncomfortable gynecomastia. Typically the radiation is given with electron beam therapy in five or fewer fractions. Herpes Zoster Presented here only for historical perspective, the use of radiation to treat the nerve roots associated with cutaneous eruption of zoster was once employed, and even said to be sometimes acceptable in the 1977 survey of the U. Heterotopic Ossification (before or after surgery) Radiation is known to prevent the heterotopic bone formation often seen in association with trauma or joint replacement in high risk patients. A radiation dose of 7 Gy to 8 Gy in a single fraction of complex planned therapy is typical. Hypersalivation (of amyotrophic lateral sclerosis) It is well known that radiation will decrease saliva production as a consequence of treating head and neck cancer.

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This deficit was similar in magnitude for a hemifield stimuli was significantly improved by the presence variety of stimulus manipulations women's health clinic bendigo discount 2.5mg femara with amex. In contrast, more recent studies from three split between the hemispheres is a right-hemisphere specialization brain patients (L. All these studies employed similar a square frame that contained a small icon in one corner. In the other and the detection of sequentiality was obtained within a single condition (the ‘spatial’ condition), the task was to judge patient (L. There was a suggestion in the data that the left perception of sequentiality is performed better by the left hemisphere may perform the identity task better than the hemisphere, but that apparent motion, i. Although this difference should not be over has special processes devoted to the efficient detection of interpreted, it is consistent with the idea that the evolution upright faces (Gazzaniga, 1989). Although the left hemisphere of language in the left hemisphere has resulted in the loss of can also perceive and recognize faces and can reveal superior some visuospatial abilities it once possessed. This pattern of There are hemispheric differences in the asymmetry has also been shown for the rhesus monkey (Hamilton and Vermiere, 1988). This phenomenon is studies have shown, however, that while both hemispheres known as apparent motion. Whether apparent motion is can generate spontaneous facial expressions, only the perceived depends critically on the timing of the stimulus dominant left hemisphere can generate voluntary facial presentations. For example, Kolers has reported that the expressions (Gazzaniga and Smylie, 1990). Nevertheless, subjects are typically able to fact that the callosum is involved in the execution of voluntary discriminate which of two flashes occurs first at much lower facial commands. Thus, the perception of apparent motion can be dissociated from the ability to discriminate sequentiality from simultaneity. Recent findings suggest that the neural representations of these Hemispheric specialization for sensory–motor processes may also be dissociable. Rorden and colleagues tasks have reported that parietal lesions that disrupt the judgement There are some tests that bring out hemispheric superiorities of successiveness can leave motion perception unimpaired in some of the patients. In two recent papers, Corballis and Wechsler Adult Intelligence Scale is one such test. A command to the left hemisphere of a split-brain patient to ‘smile’ results in an asymmetrical response, the right side of the face smiling and the left side remaining neutral (left panel). The right hemisphere is apparently unable to carry out commands to smile or to frown (adapted from Gazzaniga and Smylie, 1990). An such as the nonsense wire figure test (Milner and Taylor, anorthoscopic display presents an image by moving it past a 1972). The ability underlying these tests frequently seems to viewing slit that is too narrow to permit identification. When the capacity right viewing conditions, a figure percept occurs and the happens to be lateralized in this way, it should be easier to viewer suddenly perceives a coherent moving image (Parks, analyse than when the processes involved are shared between 1965; Rock, 1981). Since the right hemisphere is the components of the block design task have not yet specialized for spatial processing, one might expect been identified. We do know that a patient who demonstrates anorthoscopic percepts to be right-hemisphere-mediated. The stimuli consisted of 56 complex 4° 4° Lissajous hemisphere, each can easily find the match from a series of figures (Fig. And since each hand is demonstrably dexterous, the forth across a 15 slit at 4°/s (Fendrich et al. The right for writing and the left for this kind of task, the crucial medial edge of the slit was 1. It remains for future research to and eliminate retinal painting, the Purkinje image eyetracker understand this superiority in performance when it is seen in was used to retinally stabilize the slit on the horizontal axis. Surgical patients where callosal section is either limited or where there is inadvertent sparing of a part of the callosum enable one to examine functions of the callosum by region. For example, when the splenial region (posterior area of the callosum that interconnects the occipital lobe) is spared, there is normal transfer of visual information between the two cerebral hemispheres (Fig. In such instances, pattern, colour, and linguistic information presented anywhere in either visual field can be matched with information presented to the other half-brain. Yet such patients do not transfer stereognostic information, and they also display a left ear suppression to dichotically presented auditory stimuli. Such observations are consistent with other human and animal data which reveal that the callosum’s major subdivisions are organized in functional zones where the posterior regions are more concerned with visual information; the anterior regions Fig. When the posterior of correct choices and the time required to attain correct half of the callosum is sectioned, the transfer of visual, figure percepts was recorded. The result was that both tactile and auditory information is severely disrupted, but the hemispheres could generate anorthoscopic percepts, the right remaining intact anterior callosum can transfer higher-order hemisphere having only a minimal advantage. In one study the corpus callosum was sectioned synthesis of anorthoscopic figures occurs at a low level in in two stages (Sidtis et al. After the first stage of the cortical visual processing hierarchy, where the processing sectioning the posterior callosum, the patient was unable to of visual information does not depend on lateralized name stimuli presented to the right hemisphere. Upon close inspection of this capacity it was discovered that the right hemisphere was transmitting to the left hemisphere Partial callosal section reveals specificity of gnostic cues about the stimulus but not the actual stimulus commissure function (Fig. In short, the anterior callosum transfers gnostic In animal studies, sectioning the entire corpus callosum and representations of the stimulus rather than the real stimulus. Partial sectioning of the commissures could also prevent some functions transferring across the callosum (Black and Myers, Callosal specificity for orthographic transfer 1966; Sullivan and Hamilton, 1973; Hamilton and Vermeire, Patient V. In humans, comparable studies were not possible until fibres in the splenium and rostrum. They When the corpus callosum is fully sectioned, there is little speculate that transfer of word information is supported by or no perceptual or cognitive interaction between the fibres in the ventroposterior region of the splenium, which Callosum and cerebral specialization 1309 Fig. This suggests that the neural fibres involved in transmitting the motor information to the opposite hemisphere were sectioned for only one direction of transfer. She is able to transfer some information about visually presented words from one hemisphere to the other, but otherwise appears fully split. For example, she is able to determine whether bilaterally presented words rhyme only if the two words look and sound alike (R L), but performs at chance level for all other conditions. At a remarkable functional specificity resides within the corpus superficial level of observation, separating half of the callosum. Yet standardized memory tests administered Memory studies after cerebral disconnection postoperatively hint at an impairment of short-term memory the most powerful impression one has when observing (Zaidel and Sperry, 1974). Recent studies have extended patients who have had their hemispheres divided is how these observations. Following posterior callosotomy, he was unable to read these words but could transfer semantic information about them (centre panel). After complete callosotomy, he was no longer able to transfer any information about the words (right panel). These results are consistent with the notion that anterior regions of the callosum are involved in the transfer of higher-order information (adapted from Sidtis et al. Free recall but not recognition memory is as procedural memory and perceptual priming, and short impaired in each cerebral hemisphere term ones such as working memory. Yet the widely studied We have recently looked into information-processing cap distinction between episodic and semantic memory (Tulving, acities and sometimes have been able to compare 1986) has been debated. Some argue that semantic memory postoperative performance with preoperative capacity. In is only a subsystem of a broader declarative memory system these new tests, an interesting picture emerges: (Squire and Knowlton, 1995; Squire and Zola, 1998). Free recall requires a subject, with no cueing, to recall of brain-damaged patients, who show a dissociation between prior information such as a previously studied word list. There are many reports Recognition tasks merely require a subject to judge whether in the literature of patients who have virtually no episodic a stimulus such as a printed word has been seen before on a memory but do have intact semantic memory (Tulving et al. It is as if the resources for encoding a stimulus that exhibit the reverse pattern of memory deficit, such as patients contributes to free recall are less available after disconnection with damaged anterior sections of the temporal lobe and involving the hippocampal commissure. These patients often have difficulty understanding the meaning of common words or the properties of common There are multiple memory systems objects. The dominant theme in the cognitive neuroscience of memory Hence, the patients have impaired semantic memory yet is that memory is not a unitary system but is rather composed intact episodic memory. Researchers generally agree on the Split-brain patients offer the opportunity to see a double existence of many of these systems, including explicit ones dissociation within one brain. Many semantic and linguistic such as episodic or declarative memory, implicit ones such processes are known to be lateralized to the left hemisphere Callosum and cerebral specialization 1311 Fig.

References:

  • https://www.cfsph.iastate.edu/Factsheets/pdfs/brucellosis.pdf
  • https://www.health.state.mn.us/communities/practice/research/phncouncil/docs/PHInterventions.pdf
  • https://www.pearson.com/content/dam/one-dot-com/one-dot-com/us/en/higher-ed/en/products-services/course-products/belk-biology-5e-info/pdf/belk-chapter6.pdf
  • https://www.uiltexas.org/files/academics/WordPower_2017-18.pdf
  • http://swimed.org/wp-content/uploads/2016/05/ACGGuideline-Liver-Disease-and-Pregnancy-2016-1.pdf