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Continent Ileostomy (or Kock Pouch): the surgical creation of an ileal pouch inside the lower abdomen to collect waste after a colectomy for ulcerative colitis. The pouch is emptied regularly with a small tube inserted through an opening in the abdomen no external bag is required. Diverticulitis: inflammation of the diverticula (little sacs on the colon); can cause abscess, scarring with stricture or perforation of the colon with peritonitis in severe cases. Enzyme: substance formed in animal and plant cells that start or speeds up specific chemical reactions. This is a different condition from merely the presence of a small number of polyps in the colon. Familial polyposis requires regular medical supervision of all members of the family because of serious complications and strong tendency to malignancy. Fistula: an abnormal passage between two internal organs or from an internal organ to the surface of the body. Hernia (abdominal): the protrusion of an internal organ through the abdominal musculature; can occur around stomas. Also referred to as intestinal contents, discharge, drainage, body waste, stool, feces. Ileostomy: an opening of the ileum in which the end of the small intestine (ileum) is brought out surgically through an opening in the abdomen. J-Pouch: a reservoir created out of small intestine after removal of the colon and portions of the rectum. This internal pouch holds fecal matter (stool) before elimination through the anus. Obstruction: blockage of ileostomy indicated by partial or complete stoppage of ileal flow. Ostomy: surgically created opening through the abdominal wall for the elimination of body waste. Ostomy Visitor: person with an ostomy, member of United Ostomy Associations of America, with special training to visit people before or shortly after ostomy surgery. Peristalsis: progressive waves of motion which occur without voluntary control to push waste material through the intestine. Revision: construction of a new stoma when the original one does not function well. Stoma (opening): an end of the ileum or colon which is brought through the skin as a site for stool or urine to exit the body. Stomas do not include nerves sensitive to pain, so it is possible to cut or burn a stoma without feeling anything. Ulcerative Colitis: one form of inflammatory bowel disease in which ulcers form in the intestinal lining of the colon and rectum. Severe, often bloody, diarrhea is the primary symptom of the disease, which occurs most often in young adults. Emptying your ostomy pouch A common guideline is to empty your pouch when it is 1/3 to 1 In this article: full, or more often if you desire. Emptying and changing cause the adhesive backing on your barrier to loosen from your ostomy pouch your skin. But the frequency will depend on your body, your activity level, and the type of barrier you use. The best time of day to change Ileostomy: Self-Care and Dietary Guidelines Helpful tips. You can empty your pouch while either surgery, the size of your stoma will gradually sitting or standing over the toilet. During this time, it is very important to measure your stoma every time you change your. Always remember to securely close the Showering and bathing will not hurt your stoma or end of the pouch your pouching system. Some people prefer to shower without their pouching system on the days they change their pouch and barrier. You can your pouching system may be frst thing in the decide what works best for you. These products may If there is burning or itching under the barrier, make it harder for the barrier to stick to your skin. Have all of your materials ready before you bathe, Burning and itching could indicate leakage, and so your pouching system can be easily applied possible damage to the skin around the stoma. At times your skin may look your stoma pink or red after removing the adhesive, but this. You don?t need to use soap, cleansers, or moistened wipes as they may cause skin problems and keep the barrier from sticking. Wellness Education Dietary Guidelines Important: Confusion, dizziness and shriveled skin can be signs of extreme dehydration. If you notice Below are some general dietary guidelines that are these symptoms of extreme dehydration, go to the helpful for people with an ileostomy. Fluid intake With an ileostomy you may still get diarrhea or even looser, watery stools from time to time. Since Drink 10 to 12 glasses of fuid every day unless your pouch may fll more quickly than normal, you your doctor tells you otherwise. Pretzels or crackers Ilelostomy: Self-Care and Dietary Guidelines Foods to avoid How to manage odor Before your surgery, large particles of food passed the only time you or anyone else should notice an through your large bowel. Now, however, large odor is when you are emptying your ileostomy food particles can easily get caught where your pouch. The released in spurts, as your intestines try to get the next time you empty your pouch, the drops should waste past the blockage. For the frst six to eight weeks after your surgery, avoid high-fber foods that absorb water?foods Some people prefer to carry bathroom deodorizer such as oats, citrus fruits, apples and beans. This can be helpful when using a these high-fber foods can cause a food blockage restroom in a public place. Foods like apples that have fbrous peels with certain coated pills (called enteric-coated pills). You can also help avoid a food blockage by eating slowly, chewing your food thoroughly and drinking. Rather, consult with your and you have some output from your stoma, try to pharmacist. This could cause severe take a hot shower and run water on your back to dehydration. Important: If you have no output from your stoma Some fnal comments and you are vomiting, do not drink any liquids. Feeling comfortable with your body is important, especially after this type of surgery. If you have any questions regarding stoma care, product usage and availability please contact your Coloplast Consumer Care Advisor at 1-877-858-2656. It is not intended to substitute for professional medical advice and should not be interpreted to contain treatment recommendations. You should rely on the healthcare professional who knows your individual history for personal medical advice and diagnosis. Call your healthcare provider if you have any medical concerns about managing your ostomy. You may also contact your Coloplast Consumer Care Advisor for product usage and availability questions at 1-877-858-2656. Before disposable ostomy pouches, people used metal or glass capsules, fabric belts or rubber bags. Since then, Coloplast has expanded to include wound, skin, continence and interventional urology divisions. While many changes have occurred over the years, we continue to conduct business in the same spirit as Elise and our founders: we listen, we learn and we respond. This booklet was designed to do so by answering some of the most frequently asked questions you may have regarding your ostomy care.

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Rightmire and Campbell examined 35 pregnancies at more than 42 weeks of gestation and reported that impedance to flow in the uterine and umbilical arteries did not change with gestation, but impedance in the umbilical artery was higher in fetuses with a worse clinical outcome 16. Blood flow velocity in the fetal descending aorta decreased with gestation and velocity was lower in fetuses who passed meconium before delivery. It was suggested that fetal compromise in prolonged pregnancy is more a fetal?placental problem than a uteroplacental problem 16. Pregnancies that subsequently developed signs of fetal distress during labor had increased impedance in the umbilical artery, decreased impedance in the fetal middle cerebral artery, and decreased time averaged velocity in the fetal aorta. It was concluded that, in uncomplicated post-term pregnancies, those with abnormal Doppler results are prone to need intervention following fetal distress in labor 17. Further evidence for centralization of the fetal circulation was provided by the study of Devine et al. In contrast, the sensitivities of oligohydramnios (amniotic fluid index of less than 5 cm), non-reactive fetal heart rate pattern, and a biophysical profile score equal to or less than 6, had sensitivities equal to or less than 40%18. In this group, compared to those with normal amniotic fluid and reactive fetal heart rate pattern, there was no significant difference in impedance to flow in the umbilical and uterine arteries, but impedance in the fetal internal cerebral artery was significantly lower 19. Normal placental and fetal Doppler Some studies suggested that the pathophysiology of placental insufficiency in post-term pregnancies differs from that observed in cases of fetal growth restriction at earlier gestational ages, because, in post-term pregnancies, both placental and fetal Doppler indices are normal. The majority of Doppler measurements in pregnancies with subsequent asphyxia or otherwise complicated fetal outcome were within the 95% prediction interval for patients with normal fetal outcome. This study also reported that, in the prediction of asphyxia, the sensitivity for oligohydramnios and antepartum cardiotocography was less than 20%. They measured impedance to flow in the umbilical arteries and the fetal middle cerebral and renal arteries. In 15 pregnancies, there was oligohydramnios and, although in this group the mean birth weight was significantly lower than in the 42 pregnancies with normal amniotic fluid, there were no significant differences between the groups in the Doppler indices. It was concluded that, in post-term pregnancies, oligohydramnios is not associated with a major redistribution in the fetal circulation. Prolonged pregnancy: evaluating gestation-specific risks of fetal and infant mortality. The role of ultrasound assessment of amniotic fluid volume in the management of the postdate pregnancy. Central and peripheral haemodynamic changes in post-term fetuses: correlation with oligohydramnios and abnormal fetal heart rate pattern. Histologic placenta findings in prolonged pregnancy: correlation of placental retarded maturation, fetal outcome and Doppler sonographic findings in the umbilical artery. Fetal and uteroplacental circulatory changes in pregnancies proceeding beyond 43 weeks. Association between a low umbilical artery pulsatility index and fetal distress in labor in very prolonged pregnancies. Doppler assessment of fetal blood flow velocity waveforms during acute maternal oxygen administration as predictor of fetal outcome in post-term pregnancy. Doppler evaluation of umbilical and uterinearcuate arteries in the postdates pregnancy. Doppler sonography of the umbilical artery, mode of delivery and perinatal morbidity in prolonged pregnancy. Post-term pregnancies with normal cardiotocographs and amniotic fluid columns: the role of Doppler evaluation in predicting perinatal outcome. Cerebral, umbilical, and uterine resistance using Doppler velocimetry in postterm pregnancy. Doppler flow velocimetry of the umbilical artery, uteroplacental arteries and fetal middle cerebral artery in prolonged pregnancy. In monozygotic pregnancies, splitting of the single embryonic mass into two within 3 days of fertilization, which occurs in one-third of cases, results in dichorionic twins. When embryonic splitting occurs after the 3rd day following fertilization, there are vascular communications within the two placental circulations (monochorionic). Embryonic splitting after the 9th day following fertilization results in monoamniotic monochorionic twins, and splitting after the 12th day results in conjoined twins. Determination of chorionicity can be performed reliably by ultrasound examination at 11?14 weeks of gestation (Figure 1); in dichorionic twins, there is an extension of placental tissue into the base of the intertwin membrane (lambda sign) 1,2. Figure 1: Ultrasound appearance of monochorionic (left) and dichorionic (right) twin pregnancies at 12 weeks of gestation. In both types, there appears to be a single placental mass but, in the dichorionic type, there is an extension of placental tissue into the base of the intertwin membrane, forming the lambda sign. This increased loss in monochorionic pregnancies is likely to be the consequence of severe early-onset twin-to-twin transfusion syndrome. The perinatal mortality rate in twins is around six times higher than in singletons, and is about three to four times higher in monochorionic compared to dichorionic twins, regardless of zygosity 4,5. In monochorionic twins, the incidence is about 9% and in dichorionic twins it is about 5% 3. In monochorionic twins, an additional complication to prematurity is twin-to-twin transfusion syndrome. In twin pregnancies, the risk of delivering growth-restricted babies is about ten times higher than in singleton pregnancies 6. In a study of 467 twin pregnancies, the chance of growth restriction (birth weight below the 5th centile for gestation in singletons) of at least one of the fetuses was 34% for monochorionic and 23% for dichorionic twins 3. Furthermore, the chance of growth restriction of both twins was about four times as high in monochorionic (7. In monochorionic twins, a disparity in size between the fetuses may be a consequence of the degree of imbalance in fetal nutrition as a result of chronic twin-to-twin transfusion syndrome. In dichorionic twins, disparity in size may also be due to differences in fetal nutrition, but in this case such differences may be a consequence of discordancy in the effectiveness of trophoblastic invasion of the maternal spiral arteries and therefore placental function. Twin-to-twin transfusion syndrome In monochorionic twin pregnancies, there are placental vascular anastamoses which allow communication of the two fetoplacental circulations 7. In about 25% of pregnancies, imbalance in the net flow of blood across the placental vascular arteriovenous communications from one fetus, the donor, to the other, the recipient, results in twin-to-twin transfusion syndrome; in about half of these cases, there is severe twin-to-twin transfusion syndrome presenting as acute polyhydramnios in the second trimester. The pathognomonic features of severe twin-to-twin transfusion syndrome by ultrasonographic examination are the presence of a large bladder in the polyuric recipient fetus in the polyhydramniotic sac and absent bladder in the anuric donor, that is found to be stuck and immobile at the edge of the placenta or the uterine wall, where it is held fixed by the collapsed membranes of the anhydramniotic sac (Figure 2) 8. Other sonographic findings that may prove to be of prognostic significance include the presence of a hypertrophic, dilated and dyskinetic heart, with absence or reversal of flow in the ductus venosus during atrial contraction (Figure 3) 9. In the donor, the heart may be dilated, the bowel is hyperechogenic, and there is absent end-diastolic flow in the umbilical artery; these features are commonly seen in hypoxemic fetuses in pregnancies with severe uteroplacental insufficiency. In severe twin-to-twin transfusion syndrome, survival with expectant management is less than 10% 8. In the polyuric recipient, there is a large bladder and polyhydramnios (left) and the anuric donor is held fixed to the placenta by the collapsed membranes of the anhydramniotic sac (right). Figure 3: Abnormal waveform of the ductus venosus with reversal of flow during atrial contraction in the recipient fetus of a pregnancy with twin-to-twin transfusion syndrome. The precise underlying mechanisms by which a select population of those monochorionic pregnancies with vascular communications go on to develop twin-to-twin transfusion syndrome is not fully understood. However, it has been hypothesized that primary maldevelopment of the placenta of the donor twin may cause increased peripheral resistance in the placental circulation, which promotes shunting of blood to the recipient; the donor therefore suffers from both hypovolemia due to blood loss and hypoxia due to placental insufficiency8. The recipient fetus compensates for its expanded blood volume with polyuria 10, but, since protein and cellular components remain in its circulation, the consequent increase in colloid oncotic pressure draws water from the maternal compartment across the placenta. A vicious cycle of hypervolemia, polyuria, hyperosmolality is established, leading to high-output heart failure and polyhydramnios. Monoamniotic twins Splitting of the embryonic mass after day 9 of fertilization results in monoamniotic twins. In these cases, there is a single amniotic cavity with a single placenta and the two umbilical cords insert close to each other. In monoamniotic twins, found in about 1% of all twins or about 5% of monochorionic twins, the fetal loss rate is about 50?75%, due to fetal malformations, preterm delivery and complications arising from the close proximity of the two umbilical cords. Cord entanglement is generally thought to be the underlying mechanism for the majority of fetal losses. However, cord entanglement is found in most cases of monoamniotic twins and this is usually present from the first trimester of pregnancy 11?13. Therefore, a more likely cause of fetal death in monoamniotic twins, which occurs suddenly and unpredictably, is acute twin-to-twin transfusion syndrome, rather than cord entanglement per se. The close insertion of the umbilical cords into the placenta is associated with large-caliber anastamoses between the two fetal circulations13,14.

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They searched Medline, Embase and the Cochrane Library, and identified 1,415 publications. The study quality was assessed and data were extracted independently by at least 2 authors. However, whether progesterone supplementation in the first trimester of pregnancy would increase the rate of live births among women with a history of unexplained recurrent miscarriages is uncertain. These researchers conducted a multi-center, double-blind, placebo-controlled, randomized trial to examine if treatment with progesterone would increase the rates of live births and newborn survival among women with unexplained recurrent miscarriage. They randomly assigned women with recurrent miscarriages to receive twice-daily vaginal suppositories containing either 400 mg of micronized progesterone or matched placebo from a time soon after a positive urinary pregnancy test (and no later than 6 weeks of gestation) through 12 weeks of gestation. A total of 1,568 women were assessed for eligibility, and 836 of these women who conceived naturally within 1 year and remained willing to participate in the trial were randomly assigned to receive either progesterone (404 women) or placebo (432 women). There were no significant between-group differences in the rate of adverse events. The authors concluded that progesterone therapy in the first trimester of pregnancy did not result in a significantly higher rate of live births among women with a history of unexplained recurrent miscarriages. The numbers of each -137G/C and 607C/A genotype in the case and control groups were extracted. For the -607C/A mutation, these researchers failed to find any association under any genetic models. Meta-analysis was performed on 12 of the polymorphisms, and a review included the others. An extensive eligible literature search for relevant studies was conducted on PubMed, Embase, and the Cochrane Library from their inceptions to May 12, 2015. It was critical that larger and well-designed studies should be performed to re-evaluate the association precisely. This defect of the mitochondrial respiratory chain is recognized as a major cause of human disease. Overall, 7 variations in mitochondrial complex I genes were found (T4216C, A5153G, C10142T, C12062T, A12662G, G14179A and T14263C) using direct sequencing technique. Genotyping for prolactin receptor gene intron C/T polymorphism was performed using a TaqMan assay. When the analysis was restricted to patients with 3 or more consecutive spontaneous miscarriages or patients without prior live-birth, there were also no differences in the genotype distribution between these subgroups and controls. Recently, 1 study examined if genetic polymorphisms involved in the regulation of the hypothalamic-pituitary-ovarian axis would be associated with recurrent miscarriage. Among 35 polymorphisms in 20 candidate genes, genotype distribution with regard to the prolactin receptor gene intron C/T polymorphism (rs37389) differed between the recurrent miscarriage and the control groups. Since this study reporting the candidate association between the prolactin receptor gene and recurrent miscarriage, no replication study has been performed. The genotype distribution of the prolactin receptor gene C/T polymorphism in the recurrent miscarriage group did not differ from that in the control group. The authors stated that the findings of this study may be useful in that it is the first replication study since the initial report of the association of prolactin receptor gene polymorphism with recurrent miscarriage. They noted that although no association was found, the potential role of prolactin in pregnancy loss needs to be further investigated because prolactin and its receptor have been postulated to play an important role in the maintenance of normal pregnancy. When comparing women with an "unembryonic" to those with an "embryonic" most recent miscarriage, there was no difference in median age (36. However, these investigators stated that they could not provide reliable data on these issue in the present study because of its retrospective design and the small sample size (n = 79) that must be considered general study limitations. The primary outcomes were live-birth rate and miscarriage rate; secondary outcome was clinical pregnancy rate. Of the 7,226 publications identified, 53 were selected during the initial screening; 30 satisfied the selection criteria and were included in this review. The authors concluded that available evidence showed controversial results regarding the role of immunotherapy when used for improving reproductive outcomes. These researchers stated that currently, immunotherapy should be used in the context of research and should not be used in routine clinical practice to improve reproductive outcomes. All of the included studies demonstrated some risk of bias due to uncertain external validity (representativeness) and some studies demonstrated a risk of confounding, in particular. With clinical management, 24 live-birth outcomes were observed, with an incidence of 1 birth in 4. A comprehensive search of common databases was conducted, which yielded 20 studies. Major histocompatibility complex antigens, maternal and paternal immune responses, and chronic habitual abortions in humans. The rationale for leukocyte immunization in women with recurrent spontaneous abortion: Fact or fiction? Controlled trial of treatment of recurrent spontaneous abortion by immunization with paternal cells. Treatment of recurrent spontaneous abortion with paternal lymphocytes: Results of a controlled trial. Immunization as therapy for recurrent spontaneous abortion: A review and meta-analysis. The role of blocking factors and antipaternal lymphocytotoxic antibodies in the success of pregnancy in patients with recurrent spontaneous abortion. Placebo-controlled trial of active immunization with third party leukocytes in recurrent miscarriage. Worldwide collaborative observational study and meta analysis on allogeneic leukocyte immunotherapy for recurrent spontaneous abortion. The effectiveness of allogeneic leukocyte immunization in unexplained primary recurrent spontaneous abortion. Reproductive outcome in women with recurrent spontaneous abortions of alloimmune and autoimmune etiologies; pre vs. Successful treatment in two women with antiphospholipid antibodies and refractory pregnancy losses with intravenous immunoglobulin infusions. Intravenous immunoglobulin treatment of pregnant patients with recurrent pregnancy loss caused by antiphospholipid antibodies and Rh immunization. Intravenous immunoglobulin infusion therapy in women with recurrent spontaneous abortions of immune etiologies. Mononuclear-cell immunisation in prevention of recurrent miscarriages: A randomised trial. Randomized study of subcutaneous low molecular weight heparin plus aspirin versus intravenous immunoglobulin in the treatment of recurrent fetal loss associated with antiphospholipid antibodies. Sera from women with unexplained infertility inhibit both mouse and human embryo growth in vitro. Similar embryotoxic effects of sera from infertile patients and exogenous interferon-gamma on long-term in vitro development of mouse embryos. Prevalence of embryotoxic factor in sera from women with unexplained recurrent abortion. The use of whole rat embryo culture as a technique for investigating potential serum toxicity in recurrent miscarriage patients. Recurrent pregnancy loss with antiphospholipid antibody: A systematic review of therapeutic trials. Diagnosis and treatment of recurrent miscarriage associated with immunologic disorders: Is paternal lymphocyte immunization a relic of the past? Phosphatidylserine dependent antiprothrombin antibodies are not useful markers for high risk women with recurrent miscarriages. Prevention of recurrent miscarriage for women with antiphospholipid antibody or lupus anticoagulant. Aspirin or anticoagulants for the treatment of recurrent pregnancy loss in women without antiphospholipid syndrome. Preliminary prospective study of the endocrinology of conception cycles and early pregnancy in women with antiphospholipid syndrome treated with low molecular weight heparin. Thrombophilias and recurrent pregnancy loss: A critical appraisal of the literature.

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In health, 40% of albumin is in the intravascular space and leaks through the capillary pores at a rate of 5%/h, being returned to the circulation via the lymphatic system. This flux increases in inflammatory conditions including sepsis and surgery which, together with the cost, has led to a decreased use of albumin as a volume expander for resuscitation. Hydroxyethyl starch preparations have widely differing properties depending on their average molecular weight, the degree of hydroxyethyl group substitution of the starch polymer and the C2 to C6 substitution ratio. There are well recognized and documented differences in the pharmacokinetic properties of 88 these colloids. Because the choice of colloid is controversial, where recommendation is made in these guidelines for a suitable colloid, the choice is left to the practitioner based on their own judgement and experience. However, it must be emphasized that because of the widely differing properties of colloids, care must be taken to ensure that sufficient water is given to avoid hyperoncotic states which may lead to acute 42 kidney injury. No intravenous solution is without risk, and it is essential that the practitioner reads and follows the product instructions carefully and understands its limitations. As can be seen in Table 1, with the exception of 5% dextrose solutions, almost all intravenous solutions contain sodium and chloride some in near physiological concentrations of 140 mmol/L for sodium and 95 mmol/L for chloride, and others in 15 supranormal amounts. Several studies have demonstrated that, in comparison with more physiological solutions such as Hartmann?s, even healthy subjects find it difficult to excrete solutions with a high chloride content such as 0. Following surgery, even when the serum osmolarity is reduced by administration of hypotonic fluid, the ability to excrete free water is 92,93 limited because the capacity of the kidney to dilute, as well as to concentrate the urine, is impaired (see below). In more seriously ill surgical catabolic patients with significant co-morbidities and increased urea production, there is a reduced ability to concentrate 95 urine. As a consequence it requires two or more times the normal volume of urine to excrete a sodium and chloride load given in the perioperative period. Sodium and chloride excretion competes with excretion of nitrogen mobilized by the inflammatory response to surgery; a large proportion of the administered sodium, chloride and water is therefore retained as interstitial 96 oedema. Acute kidney injury may occur due to abdominal compartment syndrome 98-100 compressing the kidney externally and increased intra-capsular 101 pressure due to oedematous renal tissue. A sustained increase in systemic capillary permeability allows albumin and its attendant fluid (18 ml for every gram of albumin) to leak into the 77,102,103 interstitial space into the interstitial space, thereby worsening interstitial oedema. In postoperative adults 10 hyponatraemia can still occur when near-isotonic solutions are used. In the absence of complications, oliguria occurring soon after operation is usually a normal physiological response to surgery. However, at the bedside a falling urine output is commonly interpreted as indicating hypovolaemia and prompts infusion of yet more sodium-containing fluids. This not only expands the blood volume (often unnecessarily) but also over-expands the interstitial fluid volume, causing oedema and weight gain, as well as causing haemodilution, resulting in reduced serum 2,63,82 albumin concentration and reduced haematocrit. Confusion may also arise in the common context of dilutional hypoalbuminaemia and dilutional or euvolaemic hyponatraemia, both of which are erroneously taken as indications for more saline. The key question is whether or not the oliguric patient has significant intravascular hypovolaemia which needs treatment. That can usually be decided on clinical grounds, but in more severe cases, and particularly intra-operatively, it may necessitate more invasive monitoring (see below section 4). Clinical signs reflecting intravascular volume include capillary refill, jugular (central) venous pressure, and the trend in pulse and blood pressure. Urine output should be interpreted in the light of these clinical signs, bearing in mind the normal short term physiological effects of surgery on urine output. Recommendation 1 Because of the risk of inducing hyperchloraemic acidosis in routine practice, when crystalloid resuscitation or replacement is indicated, balanced salt solutions. These solutions are not appropriate for resuscitation or replacement therapy except in conditions of significant free water deficit. For many surgical procedures, the assessment of fluid requirements will be straightforward, relying on the usual clinical parameters. Although the gold standard for volume replacement is invasive cardiac monitoring (see below), especially in high dependency patients, in most cases fluid requirements have to be assessed and monitored using the usual clinical approach of history, clinical 114 examination and investigations (Table 2). No symptom or sign is pathognomonic in isolation so that a proper assessment can only be made using a combination of different variables interpreted in the light of an understanding of the underlying pathophysiology. Changes over time in any variable or the response to an appropriate fluid challenge are usually more significant than any isolated measurement. Before any intravenous fluid is prescribed, whether for resuscitation, replacement of ongoing losses, or just maintenance, the following should be considered: a. The appropriate rate of fluid administration guided by clinical assessment and safety limits. Flow guided fluid therapy Historically, intravenous fluid administration to treat hypovolaemia has been guided by measurements of pulse rate, arterial pressure and central venous pressure. However, this approach seems to lack sensitivity and specificity in identifying volume deficit, leading to both inadequate and excessive fluid administration (See section 6). Thus while the pattern of change in heart rate, arterial pressure and central venous pressure remain helpful markers of the effects of fluid administration on vascular filling they are influenced by other factors and do not have a linear relationship with cardiac output or tissue perfusion. The absolute values of these parameters may therefore fail to provide a reliable indication of the need for intravenous fluid administration. Because of the Frank-Starling relationship between cardiac filling pressure and stroke volume, the latter more reliably reflects vascular filling and hence fluid requirement. With the availability of minimally invasive techniques for measurement of stroke volume and cardiac output, using trans-oesophageal 18 Doppler or pulse contour analysis, it has been possible to tailor fluid requirements more precisely to the needs of the individual patient. Clinical trials have demonstrated that fluid therapy guided by measurements of stroke volume and cardiac index result in significantly better clinical outcomes than those associated with traditional intraoperative monitoring. The beneficial effect is likely to relate to the early tailoring of fluid administration to the requirements of the individual patient rather than the blanket administration of extra fluid. Recommendation 3 To meet maintenance requirements, patients should receive sodium 50-100 mmol/day, potassium 40-80 mmol/day in 1. Careful monitoring should be undertaken using clinical examination, fluid balance charts and regular weighing, when possible. Judgements in practice will be based on clinical parameters such as, jugular (central) venous pressure, pulse, blood pressure, capillary refill, the presence of oedema and on fluid balance charting. It is important that, where possible, patients are brought to theatre in a state of normal and stable fluid and electrolyte balance. Where appropriate and possible, fluid retention caused by cardiac, renal or hepatocellular disease should be corrected prior to surgery. Patients should be screened nutritionally preoperatively and if malnourished consideration should be given to perioperative nutritional support (see page 29). These guidelines have since been supported by a 13 Cochrane collaboration review reporting the results of 22 trials in which a relaxation of the period of preoperative fasting, as indicated above, failed to alter significantly the volume or pH of gastric secretions (although aspiration and regurgitation were seldom reported and studies excluded patients at particular risk of morbidity related to aspiration). Recommendation 4 In patients without disorders of gastric emptying undergoing elective surgery clear non-particulate oral fluids should not be withheld for more than two hours prior to the induction of anaesthesia. Preoperative oral administration of solutions of carbohydrate oligomers has been shown in several trials to attenuate preoperative thirst, anxiety and postoperative nausea and vomiting. It also substantially reduces postoperative insulin resistance, thereby 15-19 improving the efficacy of postoperative nutritional support. It should be considered in the routine preoperative preparation for elective surgery. Although mechanical bowel preparation was previously 20 considered the cornerstone of safe colorectal surgery, the use of powerful laxative agents to empty the colon has significant adverse effects on perioperative 115 fluid balance and the benefits may be less clear than previously thought. Unless corrected preoperatively, these fluid and electrolyte derangements may complicate intra and postoperative fluid management. This may exacerbate hypovolaemia after induction of anaesthesia, necessitating intraoperative over-replacement and causing retention of fluid in the extravascular space and postoperative oedema. Since mechanical bowel preparation may actually increase anastomotic leak rates and has failed to show 21 any benefit in terms of reducing postoperative complication rates, consideration should be given to avoiding mechanical bowel preparation in routine colorectal surgery. In those cases in which mechanical bowel preparation is deemed appropriate, simultaneous intravenous fluid therapy should be administered to minimize the resulting fluid and electrolyte derangement. Recommendation 6 Routine use of preoperative mechanical bowel preparation is not beneficial and may complicate intra and postoperative management of fluid and electrolyte balance. Evidence level 5 e) Replacement of Fluid Losses Fluid replacement should be appropriate to the fluid deficit. Increased evaporation, for example from hyperventilation, non-humidified face masks, open wounds or excessive sweating, results in proportionately greater need for free water replacement. It is sometimes forgotten that, in the presence of hypovolaemia, the efficient mechanism for maintaining serum osmolality in normal subjects is superseded by the need to preserve volume, so that the kidney retains whatever volume or 93 composition of fluid is infused.

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Diseases

  • Mitochondrial myopathy-encephalopathy-lactic acidosis
  • Gaucher-like disease
  • Miller Dieker syndrome
  • Caregiver syndrome
  • Malignant germ cell tumor
  • Protein R deficiency
  • Paruresis
  • Guibaud Vainsel syndrome
  • Macular degeneration, polymorphic

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If appropriate care measures are not taken, heat cramps can turn into heat exhaustion or heat stroke. To care for heat cramps, help the person move to a cool place to rest, and have him or her sip a drink containing electrolytes and carbohydrates (such as a commercial sports drink, coconut water or milk). If a drink containing electrolytes and carbohydrates is not available, have the person drink water. When the cramps stop, the person usually can resume his or her activity as long as there are no other signs or symptoms of illness. Encourage the person to keep drinking plenty of fluids, and watch the person carefully for additional signs or symptoms of heat-related illness. Myth: When a person has heat cramps, you should give the person salt tablets to replenish lost sodium. Heat Exhaustion Heat exhaustion occurs when fluids lost through sweating are not replaced. If a person does not take in enough fluids, the body does not have what it needs to make adequate amounts of sweat. Humid environments and environments without good air circulation can make it difficult for the sweat to evaporate. If the person is responsive and able to swallow, have the person drink a cool electrolyte and carbohydrate-containing fluid (such as a commercial sports drink, coconut water or milk). Encourage the person to rest in a comfortable position, and watch carefully for changes in his or her condition. The person should wait for several hours after he or she is no longer having signs and symptoms to resume activity. Signs and Symptoms of Heat Stroke the person will have mental status changes (such as confusion or loss of consciousness) and may have trouble seeing or a seizure. First Aid Care for Heat Stroke Send someone to call 9-1-1 or the designated emergency number immediately. The preferred way of doing this is to immerse the person up to his or her neck in cold water, if you can do this safely. Cold-Related Illnesses and Injuries Exposure illnesses and injuries can also result from exposure to cold temperatures (Box 7-1). Hypothermia In hypothermia, the body loses heat faster than it can produce heat, causing the core body temperature to fall below 95 F (35 C). Just as with heat-related illnesses, the air or water temperature does not have to be extreme. Prolonged exposure to cold, wet or windy conditions and wet clothing increase risk for hypothermia, even at moderate environmental temperatures. As with heat-related illnesses, children and older adults are especially susceptible to hypothermia. Signs and Symptoms of Hypothermia A person who has hypothermia may seem indifferent, disoriented or confused. Initially, the person may shiver, but as the hypothermia progresses, the shivering may stop. In advanced cases of hypothermia, the person may become unresponsive, and his or her breathing may slow or stop. Rapid rewarming (for example, by immersing the person in a hot bath or shower) can lead to dangerous heart rhythms and should be avoided. Remove any wet clothing, dry the person, and help the person to put on dry clothing (including a hat, gloves and socks). Then wrap the person in dry blankets and plastic sheeting, if available, to hold in body heat. If you are far from medical care, position the person near a heat source or apply heating pads or hot water bottles filled with warm water to the body. If you have positioned the person near a heat source, carefully monitor the heat source to avoid burning the person. If the person is alert and able to swallow, you can give the person small sips of a warm, non-caffeinated liquid such as broth or warm water. Myth: Giving a person with hypothermia an alcoholic drink can help the person to warm up. Although alcohol may temporarily make the person feel warmer, it actually increases loss of body heat. You should also avoid giving a person who has hypothermia beverages containing caffeine, because caffeine promotes fluid loss and can lead to dehydration. Frostbite Frostbite is an injury caused by freezing of the skin and underlying tissues as a result of prolonged exposure to freezing or subfreezing temperatures. Signs and Symptoms of Frostbite the frostbitten area is numb, and the skin is cold to the touch and appears waxy. First Aid Care for Frostbite If the frostbite is severe or the person is also showing signs and symptoms of hypothermia, call 9-1-1 or the designated emergency number. Never rub the frostbitten area, because this can cause additional damage to the tissue. Remove wet clothing and jewelry (if possible) from the affected area and care for hypothermia, if necessary. Do not attempt to rewarm the frostbitten area if there is a chance that the body part could refreeze before the person receives medical attention. Once the rewarming process is started, the tissue cannot be allowed to refreeze because refreezing can lead to tissue necrosis (death). Skin-to-skin contact (for example, cupping the affected area in your hands) may be sufficient to rewarm the frostbitten body part if the frostbite is mild. Alternatively, you can rewarm the affected body part by soaking it in warm water until normal color and warmth returns (about 20 to 30 minutes). If the fingers or toes were affected, place cotton or gauze between them before bandaging the area (Figure 7-1). To care for frostbite, rewarm the body part by immersing it in warm water (A) and then loosely bandage it (B). Poisoning A poison is any substance that causes injury, illness or death if it enters the body. Poisons can be ingested (swallowed), inhaled, absorbed through the skin or eyes, or injected. Practically anything can be a poison if it is not meant to be taken into the body. Even some substances that are meant to be taken into the body, such as medications, can be poisonous if they are taken by the wrong person, or if the person takes too much. Children younger than 5 years, especially toddlers, are at the highest risk for poisoning. Children may be attracted to pretty liquids in bottles, sweet-smelling powders, berries on plants that look like they are edible, or medications or vitamins that look like candy. Additionally, very young children explore their world by touching and tasting things around them, so even substances that do not look or smell attractive are poisoning hazards among this age group. Older adults who have medical conditions that cause confusion (such as dementia) or who have impaired vision are also at high risk for unintentional poisoning. Box 7-2 lists common household poisons, and Box 7-3 describes strategies for reducing the risk for unintentional poisoning at home. Common causes of death as a result of poisoning include drug overdose (of over-the counter, prescription and illicit or street drugs), alcohol poisoning and carbon monoxide poisoning (Box 7-4). The person may experience: Gastrointestinal signs and symptoms, such as abdominal pain, nausea, vomiting or diarrhea. If you think that a person has been poisoned, try to find out: the type of poison. First Aid Care for Poisoning If the person is showing signs and symptoms of a life-threatening condition (for example, loss of consciousness, difficulty breathing) or if multiple people are affected, call 9-1-1 or the designated emergency number. If the person is responsive and alert, call the national Poison Help hotline at 1-800-222-1222. When you dial this number, your call is routed to the regional poison control center that serves your area, based on the area code and exchange of the phone number you are calling from (Box 7-5). General first aid care steps for poisoning include the following: Remove the source of the poison if you can do If you do not know what the poison was so without endangering yourself. Myth: If a person has been poisoned, you should make the person vomit to get rid of the poison. Inducing vomiting in a person who has been poisoned often causes additional harm and is not recommended.

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Thyroid status affects number and localization of thyroid hormone receptor expressing mast cells in bone marrow. Chronic urticaria and angioedema associated with thyroid autoimmunity: review and therapeutic implications. Mast cells squeeze the heart and stretch the gird: their role in atherosclerosis and obesity. Different roles of mast cells in obesity and diabetes: lessons from experimental animals and humans. The peroxisome proliferator activated receptor-gamma is a negative regulator of macrophage activation. Bone marrow biopsies for the diagnosis of systemic mastocytosis: is one biopsy sufficient? Systemic mastocytosis in adults: 2011 update on diagnosis, risk stratification, and management. Immunophenotypic characterization of bone marrow mast cells in mastocytosis and other mast cell disorders. Establishment of a simple test for iron absorption from the gastrointestinal tract. Variable hematological presentation of autoimmune gastritis: age-related progression from iron deficiency to cobalamin depletion. Gastrointestinal causes of refractory iron deficiency anemia in patients without gastrointestinal symptoms. Proton pump inhibitors suppress absorption of dietary non-haem iron in hereditary hemochromatosis. Denture cream: an unusual source of excess zinc, leading to hypocupremia and neurologic disease. A comparison of two intensities of warfarin for the prevention of recurrent thrombosis in patients with the antiphospholipid antibody syndrome. Antiphospholipid thrombosis: clinical course after the first thrombotic event in 70 patients. Mast cells in tumor growth: angiogenesis, tissue remodeling and immune-modulation. Cognitive load theory in health professional education: design principles and strategies. Greater neural pattern similarity across repetitions is associated with better memory. So much to do, so little time: care for the socially disadvantaged and the 15-minute visit. Will generalist physician supply meet demands of an increasing and aging population? Regulation of tryptase from human lung mast cells by heparin: stabilization of the active tetramer. Serum gastrin and chromogranin A during medium and long-term acid suppressive therapy: a case-control study. Serum chromogranin A as a screening test for gastric enterochromaffin-like cell hyperplasia during acid-suppressive therapy. Significant histamine formation in tuna (Thunnus albacares) at 2 C effect of vacuum and modified atmosphere-package on psychro tolerant bacteria. Biochemical markers of anaphylactoid reactions to drugs: comparison of plasma histamine and tryptase. Plasma N-methylhistamine concentration as an indicator of histamine release by intravenous d-tubocurarine in humans: preliminary study in five patients by radioimmunoassay kits. Radioimmunoassay for plasma histamine: a study of false positive and false negative values. Nicotinic acid induces secretion of prostaglandin D2 in human macrophages: an in vitro model of the niacin flush. Identification of prostaglandin D2 as the major eicosanoid from liver endothelial and Kupffer cells. Cutting edge: differential production of prostaglandin D2 by human helper T cell subsets. Improved diagnosis of mastocytosis by measurement of the major urinary metabolite of prostaglandin D2. Development of a radioimmunoassay for prostaglandin D2 using an antiserum against 11-methoxime prostaglandin D2. Release of prostaglandin D2 by murine mast cells: importance of metabolite formation for antiproliferative activity. Immunohistochemical characterization of human cutaneous mast cells in urticaria pigmentosa (cutaneous mastocytosis). The measurement of leukotrienes in urine as diagnostic option for systemic mastocytosis. High dose of inhaled fluticasone reduces high levels of urinary leukotriene E4 in the early morning in mild and moderate nocturnal asthma. Allergic mastocytic gastroenteritis and colitis: an unexplained etiology in chronic abdominal pain and gastrointestinal dysmotility. Gastro-oesophageal reflux disease in primary care: an international study of different treatment strategies with omeprazole. How satisfied are chronic heartburn sufferers with their prescription medications? Stem cell factor expressed in human gastric mucosa in relation to mast cell increase in Helicobacter pylori-infected gastritis. Gastric mucosal mast cells are increased in Helicobacter pylori-negative functional dyspepsia. Systemic mast cell disease with gastrointestinal symptoms a diagnostic questionnaire. Tobacco smoke releases preformed mediators from canine mast cells and modulates prostaglandin production. Exposure to tobacco-derived materials induces overproduction of secreted proteinases in mast cells. Inhibition of mouse mast cell proliferation and proinflammatory mediator release by benzodiazepines. Die systemische Mastozytose Standortbestimmung einer internistischen Erkrankung. Investigation on the molecular mechanisms mediating the inhibitory effect of benzodiazepines on mast cells. Evidence for the involvement of peripheral-type benzodiazepine receptors in the inhibitory effcet of diazepam, flunitrazepam and 4-chlorodiazepam on the interleukin-8 production in human mast cells. Molecular-genetic investigations on the mechanisms mediating the inhibitory effect of benzodiazepines on mast cells. Aspirin idiosyncrasy in systemic mast cell disease: a new look at mediator release during aspirin desensitization. Cardiovascular risk associated with celecoxib in a clinical trial for colorectal adenoma prevention. G-protein coupled receptor 35 is a target of the asthma drugs cromolyn disodium and nedocromil sodium. Effects of daily oral administration of quercetin chalcone and modified citrus pectin on implanted colon-25 tumor growth in Balb-c mice. Phase I clinical trial of the flavonoid quercetin: pharmacokinetics and evidence for in vivo tyrosine kinase inhibition. Omalizumab treatment of systemic mast cell activation disease: experiences from four cases. Prevention of anaphylaxis related to mast cell activation syndrome with omalizumab. Interferon alpha and pamidronate in osteoporosis with fracture secondary to mastocytosis. Cytoreductive therapy in 108 adults with systemic mastocytosis: outcome analysis and response prediction during treatment with interferon-alpha, imatinib mesylate or 2-chlorodeoxyadenosine.

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Grade of In patients with symptomatic stable angina (fast-acting recommendation I, Level of evidence B. Symptom class of drugs whose pharmacological effects include smooth relief is a result of venodilation, afterload reduction, muscle relaxation, afterload reduction, negative inotropic and coronary dilation. Fast-acting, short-duration effects (in some formulations), and decreased oxygen nitrates remain the treatment of choice for angina consumption. When crises occur, the patient should rest in a sitting position, considering the risk of hypotension amlodipine, among others), benzodiazepines (diltiazem), and/or syncope during orthostasis, and the increased and phenylalkylamines (verapamil) are the three major venous return and cardiac output in the lying position. Alternatively, fast effects distinguish these three subgroups regarding acting nitrates can be used prophylactically, before their vasodilating properties, their ability to decrease conditions known to cause angina occur, including both myocardial contractility and the speed of impulse sexual intercourse and emotional stress, among conduction in the atrioventricular node. Grade consequently increasing coronary flow and decreasing of recommendation I, Level of evidence B. Long-acting nitrates: the continued use of long-acting muscle, have no effects on the speed of atrioventricular nitrates induces drug tolerance, which can supposedly conduction, and increase heart rate by reflex mechanisms. Although widely myocardial depression, which is less intense in this used, a worsening of endothelial dysfunction has been benzodiazepine subgroup. Therefore, the observed when these drugs are used in combination with common practice of the routine use of long-acting nitrates beta-blockers216,219. The short-duration pharmaceutical as first-line agents should be reconsidered because of preparations have been proscribed for treating stable the current availability of other options221. Unless otherwise specified, the indications below long-acting nitrates should be restricted to patients with are valid not only for long-acting dihydropyridines but angina that cannot be controlled with other antianginal also for diltiazem and verapamil. For the treatment of patients with vasospastic verapamil associated with beta-blockers should be avoided angina, nitrates can be associated with calcium-channel because of the risk of severe bradycardia and considering blockers for the symptomatic control, if necessary. A recent meta-analysis241 reported the decreased number As third-line agents in patients with stable angina who are symptomatic even after the associated use of other of hospitalizations for cardiovascular causes in patients antianginal agents. Furthermore, a South Korean study reported decreased cardiovascular events (including death in patients after For the symptomatic relief of patients with vasospastic acute coronary events) in patients on trimetazidine angina after the use of calcium-channel blockers. Furthermore, the dinitrate, reported that significant endothelial dysfunction, use of trimetazidine as a therapy adjunctive to standard and the stimulation of both the renin?angiotensin treatment during myocardial revascularization procedures aldosterone and the sympathetic nervous systems, which (percutaneous or surgical) led to decreased release of trigger the release of vasopressors, challenge the prolonged markers of myocardial necrosis, decreased oxidative stress, use of long-acting nitrates to treat patients with angina225-230. These studies demonstrate that the rapid tolerance In patients with symptomatic stable angina on beta acquired with the prolonged use of these drugs is associated blockers alone or in combination with other antianginal with such changes. Therefore, decreases the heart rate without affecting blood pressure, considering the existing evidence, this is the most robust myocardial contractility, intracardiac conduction, and evidence for precluding the long-term use of nitrates in ventricular repolarization. In noninferiority studies, its d) Trimetazidine: It is a drug with metabolic and anti antianginal efficacy was similar to that of atenolol and amlodipine250,251. However, in the overall study calcium overload233, accumulation of ischemia-induced free population, including individuals with resting heart rate of radicals234, and (3) preservation of cellular membranes235. Ivabradine can be activity and can be used as monotherapy236,237 or in used as an alternative in patients who do not tolerate beta combination with other drugs. Several studies showed blockers and in patients with diabetes because it does not that combination therapy with beta-blockers or calcium interfere with glucose metabolism, and also concomitantly channel blockers can decrease angina and exercise-induced with beta-blockers. The effects of this combination were superior known as phosphenes, which correspond to a bright glare to those of monotherapy. Trimetazidine can also be used sensation, particularly when moving from a dark to a light alone, and its beneficial effects were similar to those of environment. However, this effect is reversible over time monotherapy with beta-blockers or calcium-channel in most cases or after discontinuing drug use. In patients with symptomatic stable angina on beta A recent retrospective and observational study showed blockers, either alone or in combination with other that the use of trimetazidine associated with optimized antianginal agents, and heart rate > 60 bpm. This current is activated during ischemia, leading to intracellular calcium f) Allopurinol: It is a xanthine oxidase inhibitor that overload in the ischemic tissue and, consequently, decreases uric acid levels in subjects with gout and has increased ventricular wall stiffness, decreased compliance, antianginal properties. Its antianginal efficacy was In symptomatic patients with stable angina subjected to demonstrated using monotherapy and in combination with antianginal therapy that is maximally tolerated. In addition, this diltiazem, and verapamil, among others, should be used drug decreases the afterload and stimulates the expression with caution. Similar to trimetazidine, ranolazine does not decrease major cardiovascular complications256. Pharmacological Treatment of Stable Angina to Relieve Symptoms and Improve Quality of Life Control of the factors that Fast-acting nitrates aggravate/precipitate angina 1st line Beta-blockers Calcium-channel blockers ndt Calcium-channel blockers 2 line (in association with beta blockers and/or alone) Trimetazidine Ivabradine 3rd line Long-acting nitrates 4th line Allopurinol Figure 1 Algorithm for use of antianginal medications to relieve symptoms and improve quality of life. Coronary artery by-pass surgery However, the long-term mortality rates among the three groups the direct myocardial revascularization using grafts for the were statistically similar. After a 5-year using the same experimental design and used stents in most follow up, no difference was observed in the overall mortality patients with lesions > 70% in the treatment arm subjected to (13. The arterial pattern should include patients referred to both revascularization techniques. The mean Syntax score of the study population was 26, indicating moderate difficulty to treatment 2. Transmyocardial laser revascularization surgery a) Use of laser in cardiac muscle. With regard to exercise tolerance, despite the overall improvement at 12 months, no significant differences were observed between the two treatments. Most patients with extensive coronary atherosclerosis and persistence patients in both treatments experienced improved myocardial of symptoms despite drug therapy is not eligible for percutaneous perfusion during recovery, but this improvement did not differ or surgical revascularization. However, was performed after lateral anterior thoracotomy without hospital mortality assessed at 30 days was significantly higher in extracorporeal circulation. At first, the needed to avoid evaluation biases in the perception of angina mechanism proposed was that these microchannels would be in the clinical group. In contrast, the myocardial 263 patients and indicated no significant differences in the relief perfusion imaging results during patient recovery are conflicting. After a 5-year follow-up period, although both groups had improved angina relief compared with baseline values, the 1. The survival after 5 years was similar between the two of the Cochrane database reviewed these studies, which groups (76% vs. This review indicated that none of the studies met all the established quality criteria primarily because they were open studies with great potential for bias 1. Several clinical, anatomical, technical, and difference was observed in any of the clinical outcomes environmental factors should be considered and discussed by the evaluated289,290. Although they noted some improvement in refractory to optimized pharmacological treatment. However, more qualified, patients with angina, with or without documented myocardial 26 Arq Bras Cardiol. Many clinical, anatomical, technical, beneficial for identifying hemodynamically or functionally and environmental factors should be considered and discussed significant stenoses that are inducers of ischemia, which can before the benefit of revascularization is anticipated (Chart justify the indication for revascularization291-293. The heterogeneity of these factors makes Previous studies with conventional stent demonstrated absolute recommendations unfeasible for the management that medical treatment provides better results than immediate of each clinical condition. Similarly, the use of covered those of patients with multivessel diseases of heterogeneous stents did not have any advantage over conventional stents presentation. However, a comorbidities, unfavorable anatomy, or symptomatic patients substudy indicated that patients with ischemia > 10% on without extensive induced ischemia. In and prolonged hospitalization and rehabilitation after contrast, approximately 30% of the patients with a positive myocardial revascularization. Despite statistical adjustment, this large record could and complementary treatment at some point in disease not eliminate confounding factors, in addition to the fact progression. In contrast, several the indiscriminate and improper use of percutaneous records matched by propensity scores have consistently interventions. The risk of thrombosis show the algorithms recommended to simplify the decision dramatically increases in patients who prematurely interrupt making process. An overall assessment of comorbidities, surgical risk, ischemia, and coronary anatomy of comorbidities, surgical risk, ischemia, and coronary anatomy is important when choosing the most appropriate method of is important when deciding on the most appropriate method revascularization for each patient. Furthermore, improved survival compared with regarding when the indication for a procedure is appropriate optimized drug therapy has not been demonstrated in patients or questionable352,353. Similarly, improve survival: indication for revascularization is considered inappropriate when the procedure probably will not improve patient outcome and/or increase patient survival299,329. Therefore, stricter guidelines with appropriate indication criteria for intervention Grade of recommendation I, Level of evidence C. In anatomically and functionally insignificant lesions 18% were questionable, and 14% were inappropriate. With regard that are amenable to treatment and to patients with refractory to the Heart Team, the revascularization strategy was decided angina, despite optimized drug therapy. The adherence to the Heart Team concept, required for each type of implanted stent, regardless of the detailed clinical evaluation, evaluation of the experience of number of affected arteries.

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Advise females of reproductive potential to use effective contraception during treatment with Herceptin and for 7 months following the last dose of Herceptin [see Use in Specific Populations (8. The risk of cardiac dysfunction was increased in geriatric patients as compared to younger patients in both those receiving treatment for metastatic disease in Studies 5 and 6, or adjuvant therapy in Studies 1 and 2. Limitations in data collection and differences in study design of the 4 studies of Herceptin in adjuvant treatment of breast cancer preclude a determination of whether the toxicity profile of Herceptin in older patients is different from younger patients. In Study 7 (metastatic gastric cancer), of the 294 patients treated with Herceptin, 108 (37%) were 65 years of age or older, while 13 (4. Herceptin (trastuzumab) for injection is a sterile, white to pale yellow, preservative-free lyophilized powder with a cake-like appearance, for intravenous administration. Total trastuzumab clearance increases with decreasing concentrations due to parallel linear and non-linear elimination pathways. Although the average trastuzumab exposure was higher following the first cycle in breast cancer patients receiving the three-weekly schedule compared to the weekly schedule of Herceptin, the average steady-state exposure was essentially the same at both dosages. The pharmacokinetics of trastuzumab in patients with severe renal impairment, end-stage renal disease with or without hemodialysis, or hepatic impairment is unknown. Drug Interaction Studies There have been no formal drug interaction studies performed with Herceptin in humans. Clinically significant interactions between Herceptin and concomitant medications used in clinical trials have not been observed. Paclitaxel and doxorubicin: Concentrations of paclitaxel and doxorubicin and their major metabolites. Docetaxel and carboplatin: When Herceptin was administered in combination with docetaxel or carboplatin, neither the plasma concentrations of docetaxel or carboplatin nor the plasma concentrations of trastuzumab were altered. Cisplatin and capecitabine: In a drug interaction substudy conducted in patients in Study 7, the pharmacokinetics of cisplatin, capecitabine and their metabolites were not altered when administered in combination with Herceptin. No evidence of mutagenic activity was observed when trastuzumab was tested in the standard Ames bacterial and human peripheral blood lymphocyte mutagenicity assays at concentrations of up to 5000 mcg/mL. In an in vivo micronucleus assay, no evidence of chromosomal damage to mouse bone marrow cells was observed following bolus intravenous doses of up to 118 mg/kg of trastuzumab. Patients with a history of active cardiac disease based on symptoms, abnormal electrocardiographic, radiologic, or left ventricular ejection fraction findings or uncontrolled hypertension (diastolic > 100 mm Hg or systolic > 200 mm Hg) were not eligible. Paclitaxel was administered either weekly (80 mg/m) or every 3 weeks (175 mg/m) for a total of 12 weeks in Study 1; paclitaxel was administered only by the weekly schedule in Study 2. Herceptin was administered at 4 mg/kg on the day of initiation of paclitaxel and then at a dose of 2 mg/kg weekly for a total of 52 weeks. Radiation therapy, if administered, was initiated after the completion of chemotherapy. The data from both arms in Study 1 and two of the three study arms in Study 2 were pooled for efficacy analyses. Similar demographic and baseline characteristics were reported for the efficacy evaluable population, after 8. Patients were randomized (1:1:1) upon completion of definitive surgery, and at least four cycles of chemotherapy to receive no additional treatment, or one year of Herceptin treatment or two years of Herceptin treatment. Herceptin was administered with an initial dose of 8 mg/kg followed by subsequent doses of 6 mg/kg once every three weeks. A protocol specified interim efficacy analysis comparing one-year Herceptin treatment to observation was performed at a median follow-up duration of 12. Among the 3386 patients randomized to the observation (n = 1693) and Herceptin one-year (n = 1693) treatment arms, the median age was 49 years (range 21? Prior to randomization, 94% of patients had received anthracycline-based chemotherapy regimens. Radiation therapy, if administered, was initiated after completion of chemotherapy. Definitive conclusions cannot be drawn regarding efficacy within other subgroups due to the small number of events. Patients were eligible if they had 2 or 3 levels of overexpression (based on a 0 to 3 scale) by immunohistochemical assessment of tumor tissue performed by a central testing lab. Previously Untreated Metastatic Breast Cancer (Study 5) Study 5 was a multicenter, randomized, open-label clinical trial conducted in 469 women with metastatic breast cancer who had not been previously treated with chemotherapy for metastatic disease. Only patients with 2+ or 3+ positive tumors were eligible (about 33% of those screened). Patients were randomized to receive chemotherapy alone or in combination with Herceptin given intravenously as a 4 mg/kg loading dose followed by weekly doses of Herceptin at 2 mg/kg. Sixty-five percent of patients randomized to 32 receive chemotherapy alone in this study received Herceptin at the time of disease progression as part of a separate extension study. Patients randomized to Herceptin and chemotherapy also had a longer median survival (see Table 11). Of 222 patients enrolled, 66% had received prior adjuvant chemotherapy, 68% had received two prior chemotherapy regimens for metastatic disease, and 25% had received prior myeloablative treatment with hematopoietic rescue. Complete responses were observed only in patients with disease limited to skin and lymph nodes. On both study arms, capecitabine was administered at 1000 mg/m dose orally twice daily 2 (total daily dose 2000 mg/m) for 14 days of each 21 day cycle for 6 cycles. Of these patients, 23% had undergone prior gastrectomy, 7% had received prior neoadjuvant and/or adjuvant therapy, and 2% had received prior radiotherapy. The efficacy results of both the final and the updated analyses are summarized in Table 13 and Figure 7. Advise pregnant women and females of reproductive potential that Herceptin exposure during pregnancy or within 7 months prior to conception can result in fetal harm. Advise female patients to contact their healthcare provider with a known or suspected pregnancy [see Use in Specific Populations (8. Encourage these patients to report their pregnancy to Genentech [see Use in Specific Populations (8. These guidelines are not intended to define standard of care, and are revised at regular intervals as new information, devices, medications, and techniques become available. Age: no specific age contraindication but consider increasing risk with increasing age C. Idiopathic fibrosis, sickle cell crisis, primary pulmonary hypertension Chest trauma, post pneumonectomy Posttransplant: acute, chronic (Bronchiolitis obliterans) Chronic respiratory failure bridging to transplant 2. The circuit is planned to be capable of total support for the patient involved, unless the intent is specifically partial support. The circuit components are selected to support blood flow 3 2 L/m /min (neonates 100 cc/kg/min; pediatrics 80 cc/kg/min; adults 60 cc/kg/min. Achieving a desired flow is determined by vascular access, drainage tubing resistance, and pump properties. Oxygen delivery capability is determined by blood flow, hemoglobin concentration, inlet hemoglobin saturation, and membrane lung properties. Carbon dioxide removal always exceeds oxygen delivery when the circuit is planned for full support. Circuit components the basic circuit includes a blood pump, a membrane lung, and conduit tubing. Depending on the application, additional components may include a heat exchanger, monitors, and alarms. Pump the pump should be able to provide full blood flow for the patient, as defined above. Any pump which meets the specifications can be used (modified roller with inlet pressure control; centrifugal or axial rotary pump with inlet pressure control; peristaltic pump). Inlet (suction) pressure With the inlet line occluded the suction pressure should not exceed minus 300 mmHg. The inlet pressure can be very low (minus 300 mmHg) when the venous drainage is occluded (chattering) which causes hemolysis. Inlet pressure in excess of minus 300 mmHg can be avoided by inherent pump design or through a servocontrolled pressure sensor on the pump inlet side. Outlet pressure With the outlet line occluded the outlet pressure should not exceed 400 mm/Hg (inherent in the pump design or by a servocontrolled system). Power failure the pump should have a battery capable of at least one hour operation, and a system to hand crank the pump in the event of power failure. Hemolysis the plasma hemoglobin should be less than 10 mg/dl under most conditions. Membrane surface area and mixing in the blood path determine the maximum oxygenation capacity (the rated flow).

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