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Contemporary results of percutaneous biopsy of 100 small renal masses: a single center experience insomnia 55 gaming festival safe sominex 25 mg. Core Needle Biopsy and Fine Needle Aspiration Alone or in Combination: Diagnostic Accuracy and Impact on Management of Renal Masses sleep aid ad order 25mg sominex with mastercard. Systematic Review and Meta-analysis of Diagnostic Accuracy of Percutaneous Renal Tumour Biopsy sleep aid commercials discount 25mg sominex overnight delivery. Imaging guided biopsy of renal masses: indications sleep aid puppy safe 25mg sominex, accuracy and impact on clinical management sleep aid kids sominex 25mg generic. Image-guided biopsy-diagnosed renal cell carcinoma: critical appraisal of technique and long-term follow-up sleep aid recommendations buy 25mg sominex visa. Diagnostic accuracy of computed tomography-guided percutaneous biopsy of renal masses. Multi-Quadrant Biopsy Technique Improves Diagnostic Ability in Large Heterogeneous Renal Masses. Prognostic factors and predictive models in renal cell carcinoma: a contemporary review. Multicenter determination of optimal interobserver agreement using the Fuhrman grading system for renal cell carcinoma: Assessment of 241 patients with > 15-year follow-up. A proposal for reclassification of the Fuhrman grading system in patients with clear cell renal cell carcinoma. Comparisons of outcome and prognostic features among histologic subtypes of renal cell carcinoma. Prognostic value of histologic subtypes in renal cell carcinoma: a multicenter experience. Treatment and overall survival in renal cell carcinoma: a Swedish populationbased study (2000-2008). Survival among patients with advanced renal cell carcinoma in the pretargeted versus targeted therapy eras. Identification of deregulated oncogenic pathways in renal cell carcinoma: an integrated oncogenomic approach based on gene expression profiling. Cachexia-like symptoms predict a worse prognosis in localized t1 renal cell carcinoma. Prognostic significance of modified Glasgow Prognostic Score in patients with nonmetastatic clear cell renal cell carcinoma. Serum vascular endothelial growth factor and fibronectin predict clinical response to high-dose interleukin-2 therapy. Serum carbonic anhydrase 9 level is associated with postoperative recurrence of conventional renal cell cancer. A 16-gene assay to predict recurrence after surgery in localised renal cell carcinoma: development and validation studies. Specific genomic aberrations predict survival, but low mutation rate in cancer hot spots, in clear cell renal cell carcinoma. A CpG-methylation-based assay to predict survival in clear cell renal cell carcinoma. A postoperative prognostic nomogram predicting recurrence for patients with conventional clear cell renal cell carcinoma. Use of the University of California Los Angeles integrated staging system to predict survival in renal cell carcinoma: an international multicenter study. A preoperative prognostic model for patients treated with nephrectomy for renal cell carcinoma. Systematic review of oncological outcomes following surgical management of localised renal cancer. Management of small unilateral renal cell carcinomas: radical versus nephronsparing surgery. Elective conservative surgery for renal carcinoma versus radical nephrectomy: a prospective study. Comparison of the surgical outcome and renal function between radical and nephron-sparing surgery for renal cell carcinomas. Partial nephrectomy versus radical nephrectomy in patients with small renal tumors-is there a difference in mortality and cardiovascular outcomes? Increased risk of overall and cardiovascular mortality after radical nephrectomy for renal cell carcinoma 2 cm or less. Management of localized kidney cancer: calculating cancer-specific mortality and competing risks of death for surgery and nonsurgical management. Comparison of partial vs radical nephrectomy with regard to other-cause mortality in T1 renal cell carcinoma among patients aged >/=75 years with multiple comorbidities. Nephrectomy induced chronic renal insufficiency is associated with increased risk of cardiovascular death and death from any cause in patients with localized cT1b renal masses. Elective partial nephrectomy is equivalent to radical nephrectomy in patients with clinical T1 renal cell carcinoma: results of a retrospective, comparative, multi-institutional study. Quality of life after surgery for localized renal cell carcinoma: comparison between radical nephrectomy and nephron-sparing surgery. Comparison of costs and complications of radical and partial nephrectomy for treatment of localized renal cell carcinoma. Systematic review of adrenalectomy and lymph node dissection in locally advanced renal cell carcinoma. What are the benefits of extended dissection of the regional renal lymph nodes in the therapy of renal cell carcinoma. The relationship of lymph node dissection with recurrence and survival for patients treated with nephrectomy for high-risk renal cell carcinoma. Reassessment of renal cell carcinoma lymph node staging: analysis of patterns of progression. Intraoperative sentinel node identification and sampling in clinically node-negative renal cell carcinoma: initial experience in 20 patients. Pre-operative renal arterial embolisation does not provide survival benefit in patients with radical nephrectomy for renal cell carcinoma. Utility of preoperative renal artery embolization for management of renal tumors with inferior vena caval thrombi. Management of renal masses in patients medically unsuitable for nephrectomynatural history, complications, and outcome. Laparoscopic versus open radical nephrectomy for large renal tumors: a longterm prospective comparison. Perioperative and renal function outcomes of minimally invasive partial nephrectomy for T1b and T2a kidney tumors. Evaluation of perioperative complications in open and laparoscopic surgery for renal cell cancer with tumor thrombus involvement using the Clavien-Dindo classification. Matched pair analysis of laparoscopic versus open radical nephrectomy for the treatment of T3 renal cell carcinoma. Comparison of laparoscopic versus open radical nephrectomy for large renal tumors: a retrospective analysis of multi-center results. Prospective randomized comparison of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy. Prospective, randomized controlled study: transperitoneal laparoscopic versus retroperitoneoscopic radical nephrectomy. A prospective study of laparoscopic radical nephrectomy for T1 tumors-is transperitoneal, retroperitoneal or hand assisted the best approach? A prospective comparison of laparoscopic and robotic radical nephrectomy for T1-2N0M0 renal cell carcinoma. Comparison of radical nephrectomy techniques in one center: minimal incision portless endoscopic surgery versus laparoscopic surgery. Laparoendoscopic single-site radical nephrectomy for localized renal cell carcinoma: comparison with conventional laparoscopic surgery. Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. Comparison of laparoscopic and open partial nephrectomy in clinical T1a renal tumors. Laparoscopic and open partial nephrectomy: a matched-pair comparison of 200 patients. Prognostic Factors Influencing Postoperative Development of Chronic Kidney Disease in Patients with Small Renal Tumors who Underwent Partial Nephrectomy. Transperitoneal versus retroperitoneal laparoscopic partial nephrectomy: initial experience. Simple enucleation versus radical nephrectomy in the treatment of pT1a and pT1b renal cell carcinoma. Hand-assisted laparoscopic versus open partial nephrectomy in patients with T1 renal tumor: Comparative perioperative, functional and oncological outcome. Off-clamp versus complete hilar control laparoscopic partial nephrectomy: comparison by clinical stage. Comparison of laparoendoscopic single-site and multiport laparoscopic radical and partial nephrectomy: a prospective, nonrandomized study. A prospective comparison of the pathologic and surgical outcomes obtained after elective treatment of renal cell carcinoma by open or robot-assisted partial nephrectomy. Comparison of perioperative outcomes between robotic and laparoscopic partial nephrectomy: a systematic review and meta-analysis. Variation in Surgical Margin Status by Surgical Approach among Patients Undergoing Partial Nephrectomy for Small Renal Masses. Positive surgical margins in nephron-sparing surgery: risk factors and therapeutic consequences. Local Tumor Bed Recurrence Following Partial Nephrectomy in Patients with Small Renal Masses. Positive surgical margin appears to have negligible impact on survival of renal cell carcinomas treated by nephron-sparing surgery. Oncological outcomes and prognostic factors after nephron-sparing surgery in renal cell carcinoma. Positive Surgical Margins Increase Risk of Recurrence after Partial Nephrectomy for High Risk Renal Tumors. Positive margin during partial nephrectomy: does cancer remain in the renal remnant? Partial nephrectomy for renal tumors: lack of correlation between margin status and local recurrence. Surveillance for the management of small renal masses: outcomes in a population-based cohort. Non-surgical management for small renal massess: a population-based comparison of disease-specific and overall survival. Five-year survival after surgical treatment for kidney cancer: a populationbased competing risk analysis. Small renal masses progressing to metastases under active surveillance: a systematic review and pooled analysis. Active surveillance of small renal masses offers short-term oncological efficacy equivalent to radical and partial nephrectomy. Active surveillance for selected patients with renal masses: updated results with long-term follow-up. Single-center comparative oncologic outcomes of surgical and percutaneous cryoablation for treatment of renal tumors. Cryoablation for Small Renal Masses: Selection Criteria, Complications, and Functional and Oncologic Results. A matched-cohort comparison of laparoscopic cryoablation and laparoscopic partial nephrectomy for treating renal masses. A matched-cohort comparison of laparoscopic renal cryoablation using ultra-thin cryoprobes with open partial nephrectomy for the treatment of small renal cell carcinoma. Laparoscopic partial nephrectomy versus laparoscopic cryoablation for the small renal tumor. Tumour in solitary kidney: laparoscopic partial nephrectomy vs laparoscopic cryoablation. Robotic partial nephrectomy versus laparoscopic cryoablation for the small renal mass. Perioperative, oncologic, and functional outcomes of laparoscopic renal cryoablation and open partial nephrectomy: a matched pair analysis. Single-center comparison of complications in laparoscopic and percutaneous radiofrequency ablation with ultrasound guidance for renal tumors. Comparison of safety, renal function outcomes and efficacy of laparoscopic and percutaneous radio frequency ablation of renal masses. Radiofrequency ablation of renal tumors: four-year follow-up results in 47 patients. Comparison of Postoperative Complications and Mortality Between Laparoscopic and Percutaneous Local Tumor Ablation for T1a Renal Cell Carcinoma: A Population-based Study. Midterm results of radiofrequency ablation versus nephrectomy for T1a renal cell carcinoma. Radiofrequency ablation versus partial nephrectomy in patients with solitary clinical T1a renal cell carcinoma: comparable oncologic outcomes at a minimum of 5 years of follow-up. Radiofrequency ablation versus partial nephrectomy for treatment of renal masses: A systematic review and meta-analysis. Percutaneous radiofrequency ablation versus percutaneous cryoablation: long-term outcomes following ablation for renal cell carcinoma. Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus. Renal cell carcinoma with tumor thrombus extension into the vena cava: prospective long-term followup.
When assessing risk sleep aid juice purchase sominex 25 mg with mastercard, it is important to know which agent the patient is taking sleep aid in elderly sominex 25 mg, since the risk of sulphonylurea induced hypoglycaemia appears to be greater for some agents than others sleep aid vitamin shoppe sominex 25mg with mastercard. Taking the incidence of hypoglycaemia among patients treated with chlorpropamide as 100 insomnia in pregnancy buy sominex 25mg with visa, the standardized incidence ratios are 111 for glibenclamide insomnia used in a sentence order sominex 25 mg with mastercard, 46 for glipizide and 21 for tolbutamide (Berger et al insomnia 411 25 mg sominex free shipping. There is no mathematical formula, neither simple nor complex, which predicts with certainty hypoglycaemia in sulphonylurea treated patients. The risk factors for sulphonylurea induced hypoglycaemia are primarily: a) b) c) d) age over 60; impaired renal function; poor nutrition; and, often forgotten, multi-drug therapy. Its mechanism of action does not involve the stimulation of insulin secretion and it does not cause hypoglycaemia. The mortality risk from metformin-induced lactic acidosis has been estimated to be not significantly different from that of sulphonylurea-induced hypoglycaemia (Berger, 1986). It is likely, however, that a highly selected pilot group with Type 2 diabetes will lie at the lower end of the range of hypoglycaemia i. On the other hand, the biguanide metformin does not cause hypoglycaemia, and it carries an extremely low risk of metabolic acidosis which is acceptable in appropriately selected pilots (see below). The main area of concern is the vascular tree, for the reasons previously discussed. If the diet controlled diabetic is to be returned to flying, and his fitness status maintained, a screening for coronary disease is important. The gold standard for diagnosing coronary artery disease is coronary angiography; this method, however, is not without risk and cannot be repeated on a regular basis. It is not of value as a routine method for general screening, as the prevalence of coronary artery disease in the pilot population overall is low. However, those pilots treated with metformin tend to be overweight and do carry a small albeit acceptable risk of lactic acidosis; their overall risk is slightly greater than the diet-only patient. In combination with metformin and/or sulphonylureas hypoglycaemia is common, and this regime is not normally acceptable for certification. If used in combination with sulphonylureas they may potentiate hypoglycaemia and are not usually acceptable. All policies for certification should be audited regularly in the light of developments in the world literature and modified accordingly. Introduction the methods used to treat diabetic patients have improved over recent decades and individuals that require insulin to mantain satisfactory blood glucose levels may apply, or re-apply, for a licence to fly or to undertake air traffic control work. Since the risk to flight safety is greater in Type 1 than in Type 2 insulin-treated diabetic patients, Type 1 applicants should, with currently available treatments and level of knowledge, be precluded from obtaining a Medical Assessment. The key areas of concern in certificating flight crew members with insulin treated diabetes mellitus are hypoglycaemia and the enhanced risks of micro- and macrovascular disease. In the paragraphs that follow, the focus will be on the risks of hypoglycaemia and the protocol at the end of the Appendix will include an assessment of cardiovascular risk. Also required is the application of sound clinical judgement as to whether one can extrapolate population data to individual cases. It is proposed to discuss the rate of hypoglycaemia in Type 1 diabetes and then review the differing rates in Type 2 diabetes. It is very difficult to assess the frequency of hypoglycaemia in insulin-treated diabetic populations because of the wide variation of severity and outcome. As examples can be mentioned the common occurrence of asymptomatic biochemical hypoglycaemia, which is only evident if blood glucose is measured frequently, and the failure to recognize or record many mild episodes including those occurring during sleep. However, a critical review of the medical literature on the subject provides some data on which to base a risk assessment. However, this study showed an approximate three-fold increase in prevalence of severe hypoglycaemia in the intensively treated group compared to that of the conventionally treated (0. An analysis of the cumulative incidence of successive episodes indicated that intensive treatment was also associated with an increased risk of multiple episodes within the same patient. Several sub-groups defined by baseline characteristics, including males, adolescents and subjects with no C-peptide or with a prior history of hypoglycaemia, had a particularly high risk of severe hypoglycaemia in both treatment groups. Ward and colleagues (1990) found in an out-patient study of 158 patients in Auckland that almost all, 98 per cent, had experienced hypoglycaemic episodes and for 30 per cent these were a major problem. In theory this may be modulated by good hypoglycaemic awareness and adequate early correction. The adverse effects of hypoglycaemia on cognitive function, in Type 1 diabetes, have been studied by Holmes (1983, 1986), Herold (1985) and Pramming (1986). In practice, therefore, it would be unacceptable for a pilot who has lack of hypoglycaemic awareness to fly as this would present a risk to the safety of the flight. Further work by Cox (2003), comparing Type 1 and Type 2 diabetic individuals and the relationship to driving mishaps, found that Type 1 diabetic drivers were at increased risk for driving mishaps but Type 2 diabetic drivers, even on insulin, appeared not to be at higher risk than non-diabetic individuals. This study adds further weight to the evidence showing a lower risk of hypoglycaemia in Type 2 diabetic individuals, even those taking insulin. The risk of severe hypoglycaemia with intensive insulin therapy was further explored in a study by Bott et al. The incidence of severe hypoglycaemia among participants in the study varied between 0. In particular, the authors sought to find a level of haemoglobin A1 that could predict severe hypoglycaemia but there was no linear or exponential relationship. Having accepted that there is evidence in the literature that intensive insulin regimens increase the rate of hypoglycaemia, it is logical to postulate that one might predict the frequency of such hypoglycaemic episodes and perhaps prevent them. Over the following six-month period these subjects recorded their severe hypoglycaemic episodes (stupor or unconsciousness). There was no difference in the number of severe hypoglycaemic episodes between the subjects in good versus poor metabolic control. The higher frequency of severe hypoglycaemia during the subsequent six months of follow-up was predicted by frequent and extremely low self-monitoring blood glucose readings and the variability in the day-to-day readings of the blood glucose. Regression analysis indicated that 44 per cent of the variance in severe hypoglycaemic episodes could be accounted for by initial measures of blood glucose variance and the extent of low blood glucose readings. Individuals who had lower haemoglobin A1 levels were not at a higher risk of severe hypoglycaemic episodes and thus blood glucose variability and low blood glucose readings were good predictors of severe hypoglycaemia. Casparie (1985) found that one of the causes of hypoglycaemia in a study of 32 severe hypoglycaemic episodes in 26 patients (a patient per year incidence of 8 per cent) was often a lack of alertness or carelessness in calculating the insulin dose. The author felt that by teaching patients to respond more adequately to changing circumstances in daily life and to react to warning signs by appropriate action would also reduce the incidence of hypoglycaemia. The difficulty in predicting hypoglycaemic episodes in an individual patient was highlighted by Goldgewitch et al. The clinical characteristics which predisposed to hypoglycaemic coma were the presence of neuropathy, coincident treatment with beta blocking agents and the use of alcohol. These three observations were controlled to adjust for duration of diabetes, which is also a significant predictor of hypoglycaemia. However, Pramming (1991) studied the frequency of the symptomatic hypoglycaemic episodes in 411 randomly selected Type 1 diabetic outpatients. From questionnaire analysis the retrospective frequencies of mild and severe hypoglycaemia were 1. From the patient diaries prospective frequencies of mild and severe hypoglycaemic episodes were 1. Interestingly, symptomatic hypoglycaemia was more frequent on working days than during weekends (1. Importantly, the symptoms of hypoglycaemia were somewhat non-specific, heterogeneous, and weakened with increasing duration of diabetes. These data are congruent with other data in the literature suggesting that hypoglycaemic unawareness increases with duration of diabetes and, of course, the duration of diabetes is also a predictor of hypoglycaemia. The basic pathology in Type 1 diabetes is islet cell failure while that of Type 2 diabetes is abnormal insulin resistance. It is, therefore, inappropriate to transpose hypoglycaemic frequency data from Type 1 to Type 2 individuals. The literature review above for Type 1 does not support the certification of Type 1 diabetic-treated applicants. The next paragraphs consider the risk of hypocyglycaemia in Type 2 insulin-treated diabetics. The frequency of severe hypoglycaemia in Type 1 diabetics was more than double that in Type 2 diabetics being treated with insulin (1. This finding of a lower average rate of hypoglycaemia in Type 2 diabetes was noted by Wright et al. Cryer (2002) in a review of the literature also suggested that the risk of serious hypoglycaemia is much less in Type 2 diabetes, even in patients treated intensively as judged by HbA1c levels. Estimation of incapacitation risk Based on the data from this literature review, the rate of severe hypoglycaemia, i. These data, however, come from hospital populations; the pilot group are highly selected, well motivated and usually meticulous in managing their diabetes. If only those Type 2 diabetics are selected who have a low risk of hypoglycaemia, the figure is likely to be less. Using this extrapolation, one may estimate the annual rate to be between one and two per cent. Risk of subtle impairment of performance Data to estimate this prevalence are rather difficult to obtain and frequently not robust, but from the study of Pramming (1991), one may postulate, using the work of McLeod (1993), that the rate of mild hypoglycaemia may be 50 per cent less in Type 2 diabetics than Type 1. The lower rate of hypoglycaemia in Type 2 diabetes has been confirmed by Holman et al. This differing rate of hypoglycaemia between Type 1 and Type 2 diabetes may be due in part to the preservation of the glucose counter regulation mechanism which protects against progression to severe hypoglycaemia. In contrast to Type 1 diabetes, the rate of substantive hypoglycaemia in Type 2 diabetes is lower, ranging from 2. As mentioned, these data are from hospital populations and in the pilot population, highly committed and well educated in diabetes, it is likely, using careful selection criteria, that the rate may be lower. Selection criteria On the basis of the literature review it would be appropriate to consider only Type 2 insulin-treated diabetes with its lower prevalence of hypoglycaemia. The following selection criteria are based on criteria used by one Contracting State: · · No hypoglycaemic episodes requiring the intervention of another party during the previous 12 months. Stability of blood glucose control in the year prior to certification as measured by glycosylated (glycated) haemoglobin which should be less than twice the upper limit of normal for the laboratory assay. The individual should have good diabetic education and be well motivated to achieve good control. There should be no evidence of hypoglycaemic unawareness and the individual should fall into the "low risk group of hypoglycaemia" shown in Table 1. In addition the individual should be regularly monitored by a diabetologist to exclude any complications. Pilots in this age group usually have extensive flying experience and are likely to exhibit more mature judgement skills than their more junior colleagues. By selecting Type 2 diabetics and returning them to the flight deck with a multi-crew limitation, the risk is further reduced due to the incapacitation training that commercial pilots are required to undergo when operating on multi-crew flight decks. This risk can be further mitigated by a stipulation that the pilot must inform his colleagues on the flight deck of the nature of his multi-crew endorsement and instruct them in actions should mild or severe hypoglycaemic events occur. In any long-haul operation there is ample time to check blood sugar levels at regular intervals and the availability of carbohydrate is not a problem. In a short-haul operation it is unlikely that the blood sugar will change dramatically over a one-to-two-hour period but at the midpoint of the flight, monitoring should be carried out. Provided these interventions are given adequate attention, this approach has potential benefit to the aviation industry as well as to the pilots concerned. It is, however, clear that any licence holder who requres insulin for treatment must be carefully assessed and those who are believed to be at low risk of complications must agree to cooperate fully with the Licensing Authority. The Authority must be confident that all relevant reports will be supplied to it in a timely manner. Monitoring procedures It is essential that individuals who are accepted for this approach use a glucometer which is regularly calibrated and has a memory chip. The pilot must carry a supply of 10 g portions of readily absorbable carbohydrate to cover the duration of the flight. During the flight the blood glucose should be monitored every 30-60 minutes, and if it falls below 6. If, for operational reasons, the inflight blood glucose measurement cannot be done, then 10 g of carbohydrate should be ingested. The frequency of monitoring during flights/duty periods over two hours may be reduced depending on individual circumstances, in consultation with the diabetologist and an aviation medicine specialist. Blood glucose should be measured approximately 30-45 minutes prior to landing and if the blood glucose has fallen below 6. With modern diabetic management involving prandial bolus injections of insulin, it is reasonable on long-haul flights to have the diabetic pilot inject at appropriate times. In flights over eight hours it is likely that the aircraft will carry "heavy crew" (one or more pilots in addition to the minimum required to operate the aircraft) and thus this should not present a significant problem. If, despite this approach, the blood glucose exceeds 15 mmol/L, medical advice should be sought in order that corrective therapeutic measures may be taken. A standard operating procedure needs to be in place to deal with the situation when medical advice. End points this approach balances risk and benefit, but should event rates exceed those experienced in the literature and stated above, consideration should be given to discontinuing any programme that permits certification of Type 2 diabetic insulin-treated applicants. In the United Kingdom approximately 1-2 professional pilots/20 000 per annum show failure of treatment with oral hypoglycaemic agents and require insulin, and it is likely that similar numbers may occur within the jurisdiction of other Authorities. Several factors may explain why patients with Type 2 diabetes are less prone to severe hypoglycaemia. Normally, as plasma glucose concentrations fall, there is a hierarchy of defence responses. The first is an increase in the release of counter-regulatory hormones as plasma glucose falls to approximately 3. The second is an awareness of warning symptoms, predominantly autonomic (sweating, hunger, anxiety, tachycardia, etc. In patients well educated in diabetic management, such symptoms will prompt preventive steps, i.
Although the prospect of labour in these circumstances is especially daunting sleep aids over the counter sominex 25mg with mastercard, some women gain some satisfaction from having given birth and have welcomed the chance to see and hold their baby sleep aid mouth guard order sominex 25 mg with visa. Pre-termination discussions will include how and where the procedure will be managed alteril sleep aid 60-count box safe sominex 25mg, the options regarding pain relief and whether the woman might want to see the baby and have mementos such as photographs and hand and footprints insomnia articles sominex 25mg for sale. She will also need information about the postnatal period insomnia vs sleep apnea 25mg sominex visa, including physical implications for her and the possibility of a postmortem examination being performed insomnia 3 am meme purchase 25mg sominex mastercard. She will need to be made aware of information from a postmortem that may be relevant for a subsequent pregnancy. These discussions are likely to be distressing for the woman and her partner so they should be handled by a suitably skilled and trained member of staff. Wherever the termination is to take place, the woman should be given a private room with facilities for her partner to stay. Women who decide to have a surgical procedure will need to be prepared for the possibility that this may be performed on a gynaecological ward or at a day clinic, where they will be alongside women undergoing other types of procedures, including termination of pregnancies for non-medical reasons. If it is considered likely, on the basis of the non-lethal nature of the anomaly and the gestational age, that feticide is appropriate, a referral to a fetal medicine specialist or subspecialist with competence in feticide will be required. However, because not all units will be able to undertake feticide, some women will have to travel a considerable distance for this to be performed and make the return journey after the procedure. Staff should be aware of the emotional distress this can cause and should ensure that support is available and that travel arrangements are practical. Anecdotal feedback from Antenatal Results and Choices indicates that this is an area of care that some women find lacking. At the post-termination follow-up appointment with the obstetrician the autopsy findings will be discussed and the risk of recurrence clarified. An appointment to discuss postmortem results needs to be arranged as soon as possible and any unavoidable delays should be explained to women and their partners and the stress this causes acknowledged. Many women will be very anxious about this appointment because of the implications it may have for subsequent pregnancies. The drawing up of a provisional plan for prenatal diagnosis in a subsequent pregnancy should be envisaged. Subsequent pregnancy will be anxiety laden for most women and will require sensitive management, with a care plan agreed as early in the pregnancy as possible. When termination is not offered There may be a situation when an abnormality is diagnosed and the clinician does not consider that termination would meet the criteria of the law but the woman requests it. If the diagnosis is made before 24 weeks, the woman may be entitled to a termination under an alternative Ground in the Abortion Act and if the attending clinician feels unable to support this for reasons of personal conviction, she must be offered a referral to a colleague or another centre as quickly as possible for assessment as to whether termination meets the legal requirements. If the diagnosis is made after 24 weeks, the woman should be given access to a second opinion and if she is still not offered a termination she should be offered counselling. The importance of continuity of care Optimal care for women after a diagnosis of fetal abnormality relies on a multidisciplinary approach. All involved in the process should be clear on their role and make sure that the women and her partner are carefully guided along a planned care pathway by fully briefed and supportive staff. This is particularly important when care is divided between local and tertiary units and clear lines of communication must always be in place. Standard antenatal care is often not suitable for women with a diagnosis of fetal anomaly. G Although the majority of fetal abnormalities are identified through fetal anomaly screening, some are detected during the course of an ultrasound examination for other reasons. No matter how the abnormality is detected, there must be a robust pathway in place to ensure that appropriate information and support are available. G All practitioners performing fetal anomaly ultrasound screening should be trained to impart information about abnormal findings to women and a health professional should be available to provide immediate support to the woman and her partner. G Optimal care for women after a diagnosis of fetal abnormality relies on a multidisciplinary approach. Those involved should be clear about their own roles and should sure that the woman is carefully guided along a planned care pathway by fully briefed and supportive staff. G All staff involved in the care of a woman or couple facing a possible termination of pregnancy must adopt a non-directive, non-judgemental and supportive approach. G It should not be assumed that, even in the presence of an obviously fatal fetal condition such as anencephaly, a woman will choose to have a termination. G After a termination for fetal abnormality, well-organised follow-up care is essential. Methods of termination of pregnancy Termination of pregnancy can be performed surgically before 15 weeks of pregnancy, when uterine evacuation can usually be achieved by vacuum aspiration with an appropriate-sized curette after cervical preparation with misoprostol or gemeprost. After this gestational age, fetal size precludes complete aspiration and dilatation and evacuation (D&E) becomes necessary. Risks of termination increase with gestational age, particularly with medical termination; complication rates (haemorrhage, uterine perforation and/or sepsis up to the time of discharge from the place of termination) increase from 5/1000 medical procedures at 1012 weeks to 16/1000 at 20 weeks of gestation and over. The situation is very different when only terminations performed under Ground E are considered (Figure 3). This may reflect the value placed on having an intact fetus to perform postmortem examination, especially in euploid cases. Almost all second-trimester abortions in Scotland, for whatever reason, are carried out medically rather than surgically. This may be critically important where the finding of unrecognised structural anomalies may amend the prenatal diagnosis and alter recurrence risk. Feticide When undertaking a termination of pregnancy, the intention is that the fetus should not survive and that the process of abortion should achieve this. Death may also occur after birth either because of the severity of the abnormality for which termination was performed or because of extreme prematurity (or both). In the Epicure study, 11% of 2122 fetuses believed to be 2022 weeks of gestation were born alive, of which two (0. For those born at 23 weeks, live birth and survival rates increased to 39% and 4%, respectively. The number and proportion of live births at or over 22 weeks decreased over the period of study from 10% to 16% in 19951997 to 2% in 2004. Livebirth rates after termination of pregnancy for fetal abnormality in West Midlands, 19952004 Gestation (weeks) 20 21 22 23 Live births (n) 404 429 235 154 (%) 3. The proportion of abortions performed under Ground E preceded by feticide for the years 2005 2008 is shown in Table 8. From this it can be seen that feticide is undertaken for a significant number of abortions before 22 weeks of gestation. It is not known whether this relates to a decision not to offer the procedure on the part of the clinician or whether the procedure was offered but declined by the woman. While many professionals will find the procedure stressful, most agree that feticide will prevent parents and labour ward staff from facing the agony of neonatal distress and pain. However, both studies identified specialists who were more flexible about offering feticide after 21+6 weeks of gestation where the anomaly was considered to be incompatible with survival. Feticide should be performed by an appropriately trained practitioner (and always under consultant supervision) under aseptic conditions and continuous ultrasound guidance. A repeat injection may be required if asystole has not occurred after 3060 seconds. Asystole should be documented for at least 2 minutes and a scan repeated after 3060 minutes to ensure fetal demise. In a series of 239 cases of feticide using this technique, between 20+5 and 37+5 weeks of gestation, there were no failures (live births);40 asystole was confirmed in all cases within 2 minutes of the initial injection, with no woman requiring a second needle insertion and no maternal complications. In addition, acute haemorrhage of the survivor into the dead co-twin can result in death or neurological injury. To avoid these complications, selective feticide of the affected twin should be performed by a vascular occlusion procedure such as radiofrequency ablation, bipolar cord coagulation, laser cord coagulation or cord ligation. The optimal surgical approach remains undetermined and is dependent upon gestational age and available expertise (occlusion is available in a limited number of fetal medicine centres). Nevertheless, women and their partners should be counselled about this unlikely possibility and staff should be trained to deal with this eventuality. G Instances of recorded live birth and survival increase as gestation at birth extends from 22 weeks. Where the fetal abnormality is not compatible with survival, termination of pregnancy without prior feticide may be preferred by some women. In such cases, delivery management should be discussed and planned with the parents and all health professionals involved and a written care plan agreed before termination takes place. G Where the fetal abnormality is not lethal and termination of pregnancy is being undertaken after 22 weeks of gestation, failure to perform feticide could result in live birth and survival, an outcome that contradicts the intention of the abortion. The management of babies born extremely preterm at less than 26 weeks of gestation. Withholding or Withdrawing Life Sustaining Treatment in Children: A Framework for Practice. Evaluation of two-dimensional versus three-dimensional ultrasound in obstetric diagnostics: a prospective study. Prenatal diagnosis, prediction of outcome and in utero therapy of isolated congenital diaphragmatic hernia. Continuing with pregnancy after a diagnosis of lethal abnormality: experience of five couples and recommendations for management. Further issues relating to late abortion, fetal viability and registration of births and deaths. Termination of pregnancy for fetal anomaly: a population-based study 1995 to 2004. Disclosure Review for Health Statistics 1st Report Guidance for Abortion Statistics [ Feticide during second- and third-trimester termination of pregnancy: opinions of health care professionals. Late termination of pregnancy: law, policy and decision making in four English fetal medicine units. Induction of fetal demise in advanced pregnancy terminations: report on a funic potassium chloride protocol. Effectiveness and safety of digoxin to induce fetal demise prior to second-trimester abortion. Digoxin to facilitate late second-trimester abortion: a randomized, masked, placebo-controlled trial. Transfusional fetal compliations after single intrauterine death in monochorionic multiple pregnancy are reduced but not prevented by vascular occlusion. FiFth Edition Handbook of Dialysis FiFth Edition Handbook of Dialysis Edited by Clinical Professor of Medicine University of Illinois at Chicago Chicago, Illinois Professor of Medicine Western University London, Ontario, Canada John t. Library of Congress Cataloging-in-Publication Data Handbook of dialysis / [edited by] John T. However, the author(s), editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The author(s), editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. Louis, Missouri Assistant Professor of Medicine Icahn School of Medicine at Mount Sinai New York, New York Sevag demirjian, Md olof heimbьrger, Md, Phd Assistant Professor of Medicine Cleveland Clinic Lerner College of Medicine Cleveland, Ohio Department of Clinical Science, Intervention, and Technology Karolinska Institute Stockholm, Sweden Peter B. Leehey, Md Professor of Medicine Loyola University Chicago Maywood, Illinois Clinical Education Specialist Department of Critical Care NxStage Medical, Inc. It has been 7 years since the Fourth Edition; the long interval reflects the relatively slow, incremental nature of improvements that have occurred in dialysis therapy during that period. The chapter on online hemodiafiltration, a therapy still not available in the United States, has been maintained and updated. The hemodialysis vascular access section, which grew from one to two chapters between the third and fourth editions, has now expanded to four chapters, testifying to the importance of vascular access to overall hemodialysis patient care. In the peritoneal dialysis section, the access chapter was completely rewritten by a general surgeon with long experience and dedication in this area. For both peritoneal dialysis and hemodialysis adequacy, fewer equations are used and, instead, analogies help explain key concepts. More emphasis is placed on dialysis time, frequency, ultrafiltration rate, and other supplementary metrics of adequacy, including doing dialysis the "European way. As in previous editions, we have tried to maintain the unique character of the Handbook of Dialysis, aiming for a resource that will be useful to both new and experienced nephrology care providers to help them in their difficult job of assuring the best treatment for our patients. The time demands on clinical nephrologists and other care providers continue to increase, and we greatly appreciate the willingness of our chapter authors to allocate precious time to share their insights and expertise. We would also like to recognize Aleksandra Godlevska for her beautiful modern artinspired cover design. Daugirdas 4 Hemodialysis Apparatus Suhail Ahmad, Madhukar Misra, Nicholas Hoenich, and John T. Vachharajani, Steven Wu, Deborah Brouwer-Maier, and Arif Asif 7 Venous Catheter Access: the Basics Michael Allon and Arif Asif 121 8 Arteriovenous Vascular Access Monitoring and Complications Alexander Yevzlin, Anil K. Agarwal, Loay Salman, and Arif Asif 137 xv xvi Contents 9 Venous Catheter Infections and Other Complications 155 Loay Salman, Arif Asif, and Michael Allon 10 Acute Hemodialysis Prescription Edward A. DeOreo 14 Anticoagulation Andrew Davenport, Kar Neng Lai, Joachim Hertel, and Ralph J. Messer, Horng Ruey Chua, Priscilla How, and Sevag Demirjian 268 16 Home and Intensive Hemodialysis Gihad E. Lindsay, and Andreas Pierratos 305 17 Hemodiafiltration Bernard Canaud, Sudhir Bowry, and Stefano Stuard 321 333 360 18 Therapeutic Apheresis Dobri D. Kiprov, Amber Sanchez, and Charles Pusey 19 the Relevance of Sorbent Technology Today Jose A. Bentley 20 Use of Dialysis and Hemoperfusion in the Treatment of Poisoning James F. Daugirdas 391 392 408 22 Apparatus for Peritoneal Dialysis Olof Heimbьrger and Peter G. Crabtree and Arsh Jain 425 24 Peritoneal Dialysis for the Treatment of Acute Kidney Injury Daniela Ponce, Andrй Luis Balbi, and Fredric O. Finkelstein 451 25 Adequacy of Peritoneal Dialysis and Chronic Peritoneal Dialysis Prescription Peter G.
Syndromes
These species should be maintained only where natural-type foods are available year round sleep aid using pumpkin seeds order 25 mg sominex amex. In captivity they should be provided soft green plants sleep aid for teenager generic sominex 25 mg amex, fruits and berries and no grains insomnia 2nd ave order sominex 25 mg visa. Spinach sleep aids over the counter purchase 25mg sominex with mastercard, romaine lettuce and fresh sleep aid herbal remedies buy cheap sominex 25mg online, frozen vegetables can be substituted in the winter months insomnia quitting drinking purchase 25mg sominex mastercard. Free-ranging Blood Pheasants feed on mosses, lichen, ferns, grass tips and conifer needle-buds. Tragopans consume oak trees, bamboo sprouts, grasses, mosses, oaknuts, berries and a few insects. In captivity, tragopans can be fed lucerne, grasses, cucumbers, apples and different kinds of berries. In the winter, most grouse species are restricted to consuming one or a few plant species. During the winter season, the Spruce Grouse, capercaillies and other grouse species feed almost exclusively on conifer needles, the Black Grouse on birch buds, and ptarmigans on buds from different deciduous trees (birch, alder, willow). Captive grouse should receive natural foods or at least large amounts of leaves, grass and berries supplemented with a limited quantity of pellets and grain. Halofuginone is toxic for the Common Pheasant, guineafowl and the Common Partridge. The presence of antimicrobial agents can be life-threatening in species that depend on a functional cecal flora and fauna (eg, grouse) for proper digestion. In general, the effects of coccidiostats and other medical feed supplements on gallinaceous birds have not been sufficiently studied. The grit container should be emptied and refilled regularly because birds select only stones that are suitable for their body mass. Chicks During their first few weeks of life, free-ranging gallinaceous chicks feed mainly on live invertebrates like insects, larvae of insects, worms and snails in order to obtain the protein levels needed to sustain rapid growth. Starting at five to six weeks of age, the protein requirements begin to decrease, and the intake of carbohydrates increases to meet energy requirements. By six months of age, most young gallinaceous birds have reached a mass equivalent to that of adults. The quantity of carbohydrates in the diet must then be reduced to prevent obesity. Feed should be provided to newly hatched chicks on a large flat plate on which they can move around and practice picking. The change from the plate to larger containers should occur by offering feed in both containers at the same time. Chicks of unpretentious species (Common Pheasant, peafowl, guineafowl) are initially fed a starter diet like turkey starter (28% crude protein) and are transferred to a lower protein diet (18% to 20% crude protein) from the eighth to eighteenth week of age. It is best to provide these birds with foods that are similar to those eaten by their free-ranging conspecifics. A diet composed of turkey starter mixed with mealworms, ant cocoons, chopped hard-cooked eggs, diced romaine lettuce, spinach, dandelion and other green plants is a viable substitute. In several species (some grouse), chicks obtain food by picking at the ground and by cutting off parts of plants with the bill. In these species, it is important that chicks be provided intact plants that are placed in the ground or tied in bundles to facilitate natural food-gathering behavior. Perhaps chicks are imprinted with food shapes and colors, or at the least, they learn what foods to consume from the hen. The chicks of some gallinaceous birds will not pick downwards in the first days of life. This is because peacock pheasants, Crested Argus, Great Argus and some other gallinaceous hens feed their chicks for several days after hatching. Breeding failures are an indication that the birds are not happy or healthy, and that the natural conditions of the bird are not being sufficiently simulated. Some pheasant and quail species are approaching a level of domestication that is advantageous for both the captive animal and the breeder. Comparatively, "semi-domesticated" animals are of no value if offspring are to be released to the wild with the intent of reintroducing genetic diversity into dwindling populations. Genetic selection and breeding to achieve color variants increase the expression of genetic abnormalities, semilethal factors and susceptibility to disease. The clutch size and incubation times for commonly maintained gallinaceous birds are listed in Table 45. General Considerations Gallinaceous birds to be used for breeding purposes should be introduced to each other before the breeding season in surroundings that are novel to all the candidates concerned. In some species, it is possible to keep several males together if there are no females present. If females are present, only one male should be housed in an aviary or in one compartment. Males of some species are very aggressive, and during the breeding season may attack other males, other bird species or even the keeper. Pursuit by the male and mock escape by the female is normal behavior in some species like eared pheasants and francolins. If there is insufficient space for the hen to escape, she may be injured or killed by the cock. Lophophorinae Pucrasiinae Ithagininae Gallinae Tragopaninae Galloperdicinae Ptilopachinae Lophophorus spp. Densely planted aviaries that provide a hen with areas to hide may still have inherent problems. Fiberglass panels leaned against the wall or concrete tubes provide similar protection and are easy to clean. Small holes, just big enough for the hen, are used to connect adjacent enclosures. In some species, the visual or acoustic presence of other males is necessary to stimulate display and mating behavior. Most gallinaceous birds incubate eggs on the ground and should be provided with flat trays containing moss, foliage or hay for nesting material. A box placed approximately 150 cm from the ground and filled with hay and foliage can be used as an artificial nest. Nests of ground- and tree-nesting birds should be inconspicuous to provide the pair with visual security but should be placed such that the birds can easily look out. Because gallinaceous chicks are nidifuguous, the family can stay together only if all the chicks hatch at the same time. Synchronization of the hatch dates can occur by two mechanisms: 1) the hen does not incubate the clutch until the last egg has been laid, allowing the eggs to cool (which slows the process of embryogenesis); or 2) the chicks in a clutch synchronize hatching through audible signals. When no sounds are heard from other eggs, the most developed chicks reduce their speed of hatching. The exception is the megapode chick, which is independent immediately after hatching. Cracid, Common Pheasant and nearly all species of New World quail hens are unamenable brooders in captivity. Domestic turkey hens can be used to incubate the eggs of larger gallinaceous birds. Small and fragile eggs should be placed under Golden Pheasant hens, which are cautious brooders and excellent care-providers. During the last week of incubation, the eggs of tropical birds being raised in dry climates should be moistened with a clean mister once a day. After hatching, the hen and chicks can be placed in a small enclosure that is movable, and can be placed on fresh grassy areas on a daily basis. Chicks are prone to chilling the first few days post-hatching and must have supplemental body heat from the attending hen. Infanticide and disease transmission can be reduced by placing the eggs in an incubator for the last third of the incubation period (this method is often used for grouse). Generally, chicks that are to be released into the wild should be reared by a hen of the same species. Specific Reproductive Characteristics Megapodes Megapode eggs differ from those of other gallinaceous birds, owing to the uncommon brooding biology of these birds. The eggs are not incubated by the parents but by solar heat, fermentation heat or geothermal energy. Cocks or both sexes begin constructing an induction mound out of foliage and earth when the air temperature and atmospheric humidity reach a certain level. The hens lay their eggs every two to three days in previously prepared holes, which are quickly covered after oviposition. Eggs are deposited in a mound with the pointed pole downwards, and they are not turned during incubation. The birds may determine the temperature of the mound, and perhaps other parameters, with the bill or tongue. The incubation period varies from 45 to 90 days, depending on the temperature in the mound. The chicks join their brothers and sisters who have hatched at around the same time. Cracids Cracids are Central and South American species that are considered monogamous. Most nests are well hidden in a fork or branch of a tree, but some species are ground-nesters. A clutch consists of two to three eggs, which are rough-shelled with wide pores and a uniform white color. Behavior of free-ranging birds is dramatically different from that of domesticated breeds. The brain volume of domesticated turkeys is 35% smaller than that of their wild-type conspecifics. The nest is formed of a flat depression in the soil and may be padded with leaves, grass or twigs. Several hens, together with their offspring, typically associate in a flock in winter. Outside the breeding season, the gregarious New World quail live together in large family groups (coveys). At the beginning of the breeding season, the older cocks become very aggressive toward young cocks. Captive Bobwhite Quail have become polygamous and it is possible to keep one cock with two hens, indicating the effects of domestication. The cocks, which are housed in different compartments of an aviary, may see and hear each other if there are enough hiding places for the hens. The chicks of different species can be distinguished by the varying color patterns on the head and back plumage. Similarities in the appearance and display behavior of hens seem to induce cocks to crossbreed. Hens will choose cocks of another species if a representative of their own species is not available. Hens reach sexual maturity in the second year and cocks in the third year of life. The Green Peafowl is more aggressive than the Indian Peafowl, but has a more pleasant call. They tend to be indiscriminant in the placement of eggs and will not incubate the eggs. Free-ranging Golden Pheasants are monogamous, but in captivity one cock can be kept with three to four hens. Young Golden Pheasant hens are sexually mature within one year, cocks within two years. Both male and female argus pheasants, peacock pheasants and the Copper Pheasant establish and defend their own territories. Males should be introduced to females only for a short time during the breeding season to prevent aggressive behavior and traumatic injuries from both genders. The hens can breed year-round, but the main breeding season is from February to May in the northern hemisphere. The young birds are independent at an age of four months, and sexually mature after the first year. Many domestic fowl breeds have lost their brooding behavior, and eggs must be artificially incubated. The size (height and width), the body mass (weight), the color of the plumage, the shape of certain feathers, the presence of spurs and the length and color of the tail feathers assist in gender determination between adults of some species (Table 45. In some breeds of domestic fowl, fertile cocks may have plumage that resembles that of hens. Gender can be determined by highly skilled individuals by examining the cloaca in one-day-old chicks or adults. The cloacal examination in newly hatched chicks of small bird species must be done carefully (see Chapter 46). Restraint of a chick for gender determination should start by gently pressing on the abdomen from both sides distal to the keel bone to stimulate defecation. The procedure is then similar to that described for Anseriformes (see Chapter 46). Behavioral clues like dominance and certain mating rituals may suggest a gender, but are not always indicative. Under certain conditions the hens of some gallinaceous birds behave like, and can have plumage like, the males. Artificial Insemination Artificial insemination is of economic importance in the domestic turkey and domestic guineafowl. Domestic turkey cocks, like domestic fowl cocks, are fertile year-round, except during periods of extreme heat or during the molt period.
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