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By: Curtis L. Smith, PharmD, BCPS

  • Professor of Pharmacy Practice, Ferris State University College of Pharmacy
  • Clinical Pharmacy Specialist, Sparrow Health System, Lansing, Michigan

https://www.ferris.edu/HTMLS/colleges/pharmacy/profiles/pharmacy-practice/curtis-smith.html

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The published scientific evidence consists of 4 case series with no comparison group or comparison only to historical controls. Case series do not provide reliable information regarding efficacy as they are subject to bias because they lack control groups that allow elimination of confounding and selection bias. Publication bias can also influence whether negative results are reported in the literature. The studies reviewed in November 2000 have a number of limitations including a small sample size, potential selection bias, lack of a proper control group, and in one of the studies, the fact that different methods variables were used to compare groups of patients. Given these limitations, there is insufficient evidence to draw conclusions about the efficacy and safety of brachytherapy for patients with glioblastoma. It was noted that glioblastoma has the worst prognosis and shortest survival times of any type of primary brain tumor. All treatments serve only to extend survival, usually by a matter of 2-3 months usually at the cost of significant treatment related morbidity. Recent improvement in imaging techniques and more complete surgical resection makes it impossible to use historical control patients as valid comparisons with respect to clinical outcomes. Two (2) empirically relevant case series were identified (evidence tables attached). Permanent Iodine-125 interstitial implants for the treatment of recurrent glioblastoma multiforme. See Evidence Table J Clin Oncol 1998;16:2202-12 entitled Iodine 131-labeled antitenascin monoclonal antibody 81C6 treatment of patients with recurrent malignant Gliomas: Phase I trial results. Back to Top Date Sent: 4/24/2020 171 these criteria do not imply or guarantee approval. Brachytherapy: Results of two different therapy strategies for patients with primary glioblastoma. See Evidence Table Radioactive Seeds for Treatment of Recurrent Malignant High-Grade Glioblastoma does not meet Kaiser Permanente Medical Technology Assessment Criteria. Back to Top Date Sent: 4/24/2020 172 these criteria do not imply or guarantee approval. For Non-Medicare Members Breast implant removal is covered when All of the following criteria are met: 1. Breast implants were part of a reconstructive procedure meeting criteria for breast reconstructive surgery. Interference with diagnosis and/or treatment of breast cancer Additionally, breast implant removal and subsequent re-implantation may be covered if the implants were placed for a diagnosis of breast cancer or other malignancy involving the breast if criteria are met see Breast Reconstruction or Breast Prostheses following Mastectomy/Lumpectomy. Back to Top Date Sent: 4/24/2020 173 these criteria do not imply or guarantee approval. Criteria | Codes | Revision History Background Breast implant removal is medically necessary under limited circumstances. There is concern and there may be a relationship between silicone breast implants and the development of connective tissue disease, although there is no epidemiological evidence Silicone breast implants can impede early detection of breast cancer in cases of cosmetic breast augmentation, but do not in cases of breast reconstruction following extractive surgery. Articles: Committee reviewed the available data on the safety of silicone breast implants and concluded: There is no evidence linking silicone breast implants to cancer in women, the elective removal of existing implants is not recommended. There is concern and there may be a relationship between silicone breast implants and the development of connective tissue disease, although there is no epidemiological evidence. Silicone breast implants can impede early detection of breast cancer in cases of cosmetic breast augmentation, but do not in cases of breast reconstruction following extractive surgery. Capsular contracture does occur in many patients and patients should be advised, before implantation, that it is a possible side effect that is normal and not harmful to their health. The use of silicone breast implant removal for prevention of breast cancer does not meet the Kaiser Permanente Medical Technology Assessment Criteria. Back to Top Date Sent: 4/24/2020 174 these criteria do not imply or guarantee approval. Back to Top Date Sent: 4/24/2020 175 these criteria do not imply or guarantee approval. Hospital grade breast pump is not considered medically necessary after 12 months of age. Purchase of a basic electric consumer pump (E0603) does not require medical necessity review.

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Proteinuria is an important risk factor for both chronic kidney disease (1,2) and cardiovascular morbidity and mortality (3). However, early renal disease may be reflected by lesser degrees of proteinuria, and particularly by increased albuminuria. The normal rate of albumin excretion is <10 mg per day in healthy young adults and increases with age and with increased body weight. Persistent albumin excretion between 30 and 300 mg/day is termed moderately increased albuminuria (formerly known as "microalbuminuria") and in non-diabetic patients is associated with an increased risk of cardiovascular disease (3). An albumin excretion >300 mg/day is considered overt proteinuria or severely increased albuminuria (formerly known as "macroalbuminuria"), and is the level at which the standard urine dipstick becomes positive. It should be noted that the standard urine dipstick primarily detects albumin and is relatively insensitive to non-albumin proteins. Furthermore, the dipstick is insensitive to low levels of albumin excretion with a lower limit of detection of approximately 10-20 mg/dL. Thus patients with moderately increased albuminuria or low molecular weight proteinuria may be missed if this is the sole method of detection. The gold standard for measurement of protein excretion is a 24-hour urine collection, but this is cumbersome for patients and often collected inaccurately. In 2005 the Amsterdam Forum concluded by consensus that a 24-hour urinary protein excretion of >300 mg is a contraindication to donation (8). Orthostatic proteinuria should not be considered as a contraindication to donation. There are few studies examining either the renal or cardiovascular outcome for living kidney donors who have donated despite pre-existing low level proteinuria. In one study, five donors with low-grade proteinuria (mean 210 mg in a 24 hr urine collection) were more likely to have significant proteinuria 20 years or more after donation (>800 mg/day), although without significant loss of kidney function (17). Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis. A report of the Amsterdam Forum on the care of the live kidney donor: data and medical guidelines. Lower estimated glomerular filtration rate and higher albuminuria are associated with all cause and cardiovascular mortality. Fixed and reproducible orthostatic proteinuria: results of a 20-year follow-up study. No evidence of accelerated loss of kidney function in living kidney donors: results from a cross-sectional follow-up. Proteinuria and reduced kidney function in living kidney donors: a systematic review, meta-analysis and meta-regression. Long-term consequences of live kidney donation follow-up in 93% of living kidney donors in a single transplant center. Non-visible haematuria is a common finding in the general population, may indicate either urological or renal parenchymal disease, and must be carefully evaluated in prospective living kidney donors. Potential living donors must have reagent strip urinalysis performed on at least two occasions not related to fever, menstruation or exercise. If two out of three consecutive tests are positive then the donor is considered to have persistent non-visible haematuria. Non-visible haematuria is present in 1-21% of the general population, the prevalence increasing with age (3-7). Most patients are asymptomatic with no urologic symptoms, no proteinuria and normal renal function. Such transient haematuria is generally considered insignificant, although with little supporting evidence from longitudinal studies. In one report including 432 patients with normal urological investigation who were followed for 5. In a smaller study of 49 patients investigated for non-visible haematuria, those in whom haematuria disappeared all had a normal kidney biopsy (9). Malignant disease of the urinary tract, present in 3 5% of patients overall (13,14), is rare under the age of 40 but diagnosed in up to 10% of those aged >60.

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Treatment of enterobiosis includes hygienic measures and prescribing of medicines. Hygienic measures to prevent autoinvasion: daily toilet of perionale region, sleep in pants with elastic round the legs, daily change of under wear and linen with following washing and ironing, soda purifaing clysma before sleep. The more effective medicines are mebendazol (0,1 gr one time), pirantel (10mg/kg of 10 the body massa, one time), albendazol (400 mg, one time). It is necessary to keep body clean, clean dwelling, working places especially childrens institutions. The discharge of helminth eggs with feces begins in 1-1,5 month after contamination and leasts for 3-6 years. The disease begins at the use in food only mature eggs, that`s why it isn`t dangerous to have direct contact with ill man. When mature (invasion) eggs get into the large intestine the larva leaves it and invades in villus. The main place of helminth inhabitancy is cecal intestine, sometimes vermiform process rarely other parts of large intestine and lower parts of thin intestine. At this time hairy-like part of Trichuris trichiura body is in mucous, submucous and even muscular layer, the posterior thickened part hangs down in the intestine lumen. Such arrangement of Trichuris trichiura is connected with peculiarities of feeding. In the place of Trichuris trichiura invasion and fixation in mucous layer of thin intestine, edema and infiltration are developed, sometimes hemorrhage. The important meaning in trichicephalios pathogenesis is the sensabilization of organism with parasite metabolites. At serious invasion the main symptoms are: nausea, sometimes vomiting, appetite lowering, sialorrhea, stomacache localizing in right iliac region, meteorism. The patients often notice irritability, insomnia, sometimes intestine headache may appear. At trichcephaliosis instable stool or moderate diarrhea often appears, which is stupulated with disorder of water absorption in thick intestine as the result of the damage of mucous tunic and interoreceptors irritation. Use of the methods of enrichment essentially improve the effectiveness of parasitologic examinations, which must be done some times in succession. It is preferably to prescribe mebendazol (0,1gr one time after meal), medamin(10 mg/kg during 3 days), albendazol (0,4 gr one time). So as Trichuris trichiura become accustomed to live in anaerobic conditions, the high content of oxygen is dangerous for them. That`s why it is necessary to use moistened oxygen which is prescribed per rectum during 5-7 days. Timely discovery and treatment of infected people, protection of environment from fecal contamination, observance of the rules of personal hygiene, necessary to wash vegetables and fruits. Ancylostomidoses unite two helminthoses similar in epidemiologic and clinical manifestations. The agent of ancilostomosis is Ancylostoma duodenale, necatoriasis agent is Necator americanus. The agent of infection is ill man, excreted in environment immature eggs of helminths. The infection with ancylostomosis often takes place through contaminated hands, vegetables, fruits, greenery. Ancylostoma and nekator are localized in thin intestine, mainly in duodenum and jejunal intestine. The larvas of ancylostoma get into organism per os and develop in intestine without migration. Necator larvas usually invade activly through cutis, penetrate into the bloody capillaries, migrate along large and small circle of blood circulation.

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Disadvantage the suturing is difficult Shearing of the tissue occurs the repaired wound tends to be pucked. Disadvantages Bartholins duct may be served the levatorani muscle is weakened Bleeding is more profuse Suturing is more difficult the woman experiences subsequent discomfort Local analgesia for Episotomy Lignocaine /lidocaine/ 0. The head should be well down on the perineum, low enough to keep it stretched and thinned 2. The two extent of the laceration is determined Controlling methods of bleeding after episiotomy 1. The first stitch inserted at the apex of the incision the most commonly used suturing material is 2/0 chromic catgut. Defintion Puerperium is period from the expulsion of the placenta to the time the reproductive organs returns to pregravid state lasts 6 weeks. Other physiological changes occurred during pregnancy are reversed (Involution) 3. Recuperation of the mother from the stress of pregnancy and delivery and assumes responsibility for the care & nurture of her infant. The care which required during the puerperium should be based up on 3 main principles 1. Encouraging sound methods of infant feeding and promoting the developmenof good maternal and child relationship. Physiology of Puerperium Involution of the uterus Definition: the uterus returns to its normal site, tone & position of non pregnant state Mechanism: 1. Ischemia: After the birth of the baby & placenta, the uterine muscle & blood vessels contracts so the blood circulation decreases. Autolysis: muscle fibers are digested by proteolytic enzyme, waste product then pass in to the blood stream and are eliminated by the kidneys. Lining of the uterus is cast off and is replaced first by granular tissue and then by endometrium. Progress of change in the uterus after delivery Weight of uterus Diameter of placental site Cervix End of labour 900Gms 12. Alimentary canal: Heart burn improves due to hormonal fall and released pressure on the sphincter. Circulatory system: blood volume decreases to pregravid level & blood regains its normal viscosity. Muscle tone of 123 blood vessel improves cardiac out put returns to normal and blood pressure returns to its usual level. Respiratory system full ventilation because lungs are no longer compressed by the enlarged uterus. It continuous to act upon uterine muscle fibers that maintaining their contractions reducing the placental site & presenting hemorrhage. In women who choose to breast feed their babies, the sucking of the infant stimulates further secretion of oxytocin and this aids the continuing involution of the uterus and expulsion of milk.

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For inhaled antibiotics (nebulised and dry powder) and hypertonic saline the child must st always have a drug response assessment to detect any bronchoconstriction when the 1 dose is given. This should be done in hospital and requires the patient to perform pre and post dose spirometry. If the patient already always takes an inhaled bronchodilator before physiotherapy, then this should be taken before the baseline lung function. If the patient fails the challenge, we will repeat it at a later date giving an inhaled short-acting bronchodilator with the inhaled antibiotic. If the child cannot perform spirometry then they should be observed having their first dose. They will personally deliver the device, teach the patient how to best use it for efficient nebulisation delivery, and provide details of cleaning instructions and the online download application. This enables the patient to download their I-neb regularly to view treatment times. These devices may not be suitable for all patients so it is important to get advice from the physiotherapist. If nebulised antibiotics are required in a child under 5 years of age then we recommend wherever possible using a faster nebuliser device (such as the Pari eFlow Rapid). Nebulisers in this age group should be introduced carefully and a staged approach may be useful to reduce anxiety and ensure they are well tolerated in the long run (see appendix 8). This table can be used when switching nebulised colistin from use via a conventional compressor to the I-Neb. Tobramycin 300mg/4 or 5 mLs and hypertonic saline 7%/4mLs can be nebulised through the I-neb. In-Patients: All children admitted will be assessed and physiotherapy requirements established. Children will also be seen pre and post-general anaesthesia to ensure they can clear sputum effectively. Children will also be seen by the Therapy Assistant for regular exercise sessions on and off the ward. Prior to discharge, the home regimen will be reviewed; as well as exercise and progression of treatment where appropriate. They should be given an appointment for a Drug Response Assessment (see section 6. Doses are ideally taken 12 hours apart, but definitely not closer than 6 hours apart. As with most inhaled antibiotics it is recommended they are taken after chest physiotherapy. The blister packs are split up into weekly boxes (4 boxes for a 28 day supply), and each box comes with its own Podhaler and storage device. The child is instructed to perform at least 2 separate inhalations per capsule and following this, it is important to inspect the used capsule to ensure it is empty. The first dose should be trialled in hospital to assess for tolerability, bronchoconstriction (see section 6. The dose for adults and children over 6 years is one capsule inhaled twice daily, ideally 12 hours apart and following chest physiotherapy. The hard capsules are stored in blister packs containing 14 capsules per strip (1 week supply). Each pack contains 4 strips of 14 capsules and 1 turbospin powder inhaler device (28 day supply). It is recommended that when inserting the capsules into the device, the fat end goes in first, as there have been reports of the capsule breaking thus delivering all the powder in one go; also press the plunger slowly. The child is instructed to perform 2-3 separate inhalations for the one capsule, and following this it is important to inspect the used capsule to ensure it is empty. If it is not, it should be replaced in the device 109 Clinical guidelines for the care of children with cystic fibrosis 2017 Cough and bronchospasm may occur on inhalation but theses reactions usually diminish with continued use. Most commonly reported adverse reactions include unpleasant taste, cough, throat irritation, dyspnoea, dysphonia and altered taste.

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There it develops into Cysticercus bovis in about 12 weeks and re mains viable for about one year. In muscles, cysticerci become sur rounded by fibrous capsules formed by the host, which may be cal cified later on. Male genitals: 3 testes, one on the side of the genital pore and two on the aporal side. The onchosphere liberates in the intestine of the insect, penetrates into the body cavity where it deve lops into a cysticercoid. The cysticercoid persists through the meta morphosis of the larva into adult flea. When such flea is ingested with food the cysticercoid is liberated and develops into adult. Treatment is prolonged or re peated in 3 weeks to kill worms that emerge from cysticercoids in the submucosa. This is irregular and has the tendency to multiply by budding giving lateral branches. Egg: similar to Taenia Hydatid cyst: a complex cyst composed of daughter and even grand daughter cysts inside and may be outside the mother cyst and contains several scolices. Other types of hydatid cyst: (a) Sterile cyst or acephalocyst: the germinal layer fails to produce scolices, brood capsules or daughter cysts. The liver is the commonest organ affected followed by the lungs and then the brain and other organs.

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Initially, there is extrarenal hydronephrosis characterised by dilatation of renal pelvis medially in the Hydronephrosis is the term used for dilatation of renal pelvis form of a sac (Fig. The kidney is there is progressive dilatation of pelvis and calyces and enlarged and heavy. On cut section, the renal pelvis and calyces are dilated and cystic and contain a large stone in the pelvis of the kidney pressure atrophy of renal parenchyma. The cystic change is seen to extend into renal p arenchyma, dilated pelvi-calyceal system extends deep into the renal compressing the cortex as a thin rim at the periphery. Unlike polycystic cortex so that a thin rim of renal cortex is stretched over kidney, however, these cysts are communicating with the pelvi-calyceal the dilated calyces and the external surface assumes system. These may arise from renal tubules is the direct continuity of dilated cystic spaces. There is progressive atrophy of these tumours, the kidney may be the site of the secondary tubules and glomeruli alongwith interstitial fibrosis. Cortical Adenoma Cortical tubular adenomas are more common than other benign renal neoplasms. They are frequently multiple and associated with chronic pyelonephritis or benign nephrosclerosis. Microscopically, they are composed of tubular cords or papillary structures projecting into cystic space. The cells of the adenoma are usually uniform, cuboidal with no atypicality or mitosis. Transitional cell papilloma Transitional cell carcinoma Others (squamous cell carcinoma, Medullary interstitial cell tumour is a tiny nodule in the adenocarcinoma of renal pelvis, medulla composed of fibroblast-like cells in hyalinised undifferentiated carcinoma of stroma. These tumours used to be called renal fibromas but renal pelvis) electron microscopy has revealed that the tumour cells are not fibrocytes but are medullary interstitial cells. A third Juxtaglomerular cell malignant renal tumour is urothelial carcinoma occurring more tumour (Reninoma) commonly in the renal pelvis is described in the next section F. Adenocarcinoma of Kidney (Synonyms: Renal cell Oncocytoma carcinoma, Hypernephroma, Grawitz tumour) Oncocytoma is a benign epithelial tumour arising from Hypernephroma is an old misnomer under the mistaken collecting ducts. This cancer comprises 70 to 80% of all renal cancers and Microscopically, the tumour cells are plump with occurs most commonly in 50 to 70 years of age with male abundant, finely granular, acidophilic cytoplasm and preponderance (2:1). These cases have following associations: Mesoblastic nephroma is a congenital benign tumour. Granular cell type 8% Sporadic and familial Abundant acidophilic cytoplasm, marked atypia 4. Chromophobe type 5% Multiple chromosome losses, Mixture of pale clear cells with hypodiploidy perinuclear halo and granular cells 5. The clear cytoplasm of tumour cells is due to form of multiple losses of whole chromosomes i. Both hereditary and patterns: solid, trabecular and tubular, separated by acquired cystic diseases of the kidney have increased risk of delicate vasculature. Adult polycystic kidney disease and multicystic ged in papillary pattern over the fibrovascular stalks. The nephroma is associated with higher occurrence of papillary tumour cells are cuboidal with small round nuclei. These tumours have i) Exposure to asbestos, heavy metals and petrochemical more marked nuclear pleomorphism, hyperchromatism products. The tumour is papillary, granular cell, chromophobe, sarcomatoid and characterised by whorls of atypical spindle tumour cells. It is composed of a single layer of arises from the poles of the kidney as a solitary and cuboidal tumour cells arranged in tubular and papillary unilateral tumour, more often in the upper pole. Cut slow-growing tumour and the tumour may have been section of the tumour commonly shows large areas of present for years before it is detected. The upper pole of the kidney shows a large and tan mass while rest of the kidney has reniform contour. Sectioned surface shows irregular, circumscribed, yellowish mass with areas of haemorrhages and necrosis. The residual kidney is compressed on one side and shows obliterated calyces and renal pelvis.

References:

  • https://www.sprc.org/sites/default/files/resource-program/SPRC_MiMYReportFinal_0.pdf
  • https://etha.eu/wp-content/uploads/2018/03/vwd_in_brief.pdf
  • https://mchb.hrsa.gov/sites/default/files/mchb/MaternalChildHealthTopics/maternal-womens-health/depression_during_and_after_pregnancy_en.pdf
  • http://med-mu.com/wp-content/uploads/2018/08/Kaplan-Pathology.pdf