Larger changes are needed inP for chest vibration fungus ease cheap fulvicin 250 mg on-line, and there is an increased risk of atelectasis fungal rash on back cheap fulvicin 250mg on-line, collapse and loss of lung recruitment fungus lips purchase discount fulvicin. This has grave clinical consequences and should be avoided under any circumstances fungus simple definition discount fulvicin 250mg without prescription. The patient is spared the deleterious effects of high airway pressures antifungal kill scabies fulvicin 250mg, higher fraction of inspired oxygen (FiO2) antifungal japan 250 mg fulvicin fast delivery, and perfusion impairment fungus gnats tomato seedlings buy generic fulvicin on line, while pathophysiologic processes are allowed to heal antifungal cream for yeast infection order fulvicin with mastercard, either spontaneously or through therapeutic interventions. Simply put, deoxygenated blood is removed from the patient into an external membrane lung where oxygen is diffused into the blood and carbon dioxide is 53 removed. Occasionally, a dialysis filter may also be incorporated into the circuit to address renal injury or failure. Cannulation techniques Cannulation can be performed using cutdown or percutaneous techniques. In neonates, a transverse neck incision is commonly used to access 57 the jugular and carotid vessels. One possible method for cannulation is described [5][see Figure 2]: the infant is positioned with the neck extended with a shoulder roll, facing the left side. Gentle proximal and distal dissection of the vein should be performed; manipulation of the vein should be minimized to avoid induction of venospasm which may preclude placement of a large venous cannula. The common carotid artery lies medial and posterior and may be safely dissected since it has no branches at this level. Ligatures of 2-0 silk are placed proximally and distally around the internal jugular vein and the carotid artery. During a 3 minute period, to allow heparin recirculation, papaverine may be instilled into the wound to enhance dilatation of the vein. The tips of the arterial and venous cannulas will be optimally located at the opening of the right brachiocephalic artery and the inferior aspect of the right atrium, respectively. The cannulas are marked with a suture at the intended extent of insertion (arterial = 2. An obturator is placed into the venous cannula to prevent bleeding via the cannula side holes during insertion. The common carotid artery is ligated distally and an angled ductus clamp is placed proximally. The cannula is anchored in place with two circumferential 2-0 silk ligatures with a small piece of plastic vessel loop inserted between the vein and ligature to prevent vessel injury during incision of the anchoring sutures at the time of decannulation. The marking ligature is tied to the most distal circumferential ligature for extra security and the cannula is debubbled. The vein is then ligated distally and occluded proximally by gently retracting the proximal suture. A venotomy is performed and the cannula is placed into the vein, secured, and debubbled. A chest x-ray is used to confirm position after placement of the cannulas; echocardiography may also be employed to identify the correct position of the cannulas within the great vessels. Care is taken to ensure that hemostasis is obtained and the skin is closed with a continuous 4-0 nylon suture. Percutaneous access to the internal jugular and femoral vein is the preferred approach to cannulation in adults and children over 3 years of age. The cannulas have varied abilities for gas exchange and flow 59 support (see Table 1), although the larger the cannula, the greater the flow that can be achieved. An introducer needle is used to access the vein under ultrasound guidance followed by placement of wire through the needle. The wire can be confirmed by fluoroscopy (the preferred approach at our institution) or echocardiography. Systemic heparin should be administered after placement and confirmation of the guidewire. After incising the skin next to wire, a series of dilators are placed gently over the wire under guidance (fluoro or echo. Generous lubrication is often necessary to place the dilators through the skin and subcutaneous tissues. The ultimate cannula is then placed over the guidewire, with subsequent removal of the wire. Transthoracic cannulation may be appropriate in the post-cardiac surgery patient with cardiac and/or pulmonary dysfunction, or a patient with septic shock to allow for increased blood flow with the larger cannulas that can be placed. The first choice of venous access is the internal jugular vein since it is a large vein which provides easy access to the right atrium via a short cannula. Drainage via the femoral vein is 60 relatively inefficient because of the high resistance associated with the long cannula required to reach the right atrium. A femoral cannula placed into the inferior vena cava does not usually provide adequate extracorporeal blood flow. In children under 5 years of age the femoral vein is too small to function as the primary drainage site; therefore, the iliac vein should be considered the second choice of access in young children. The first choice for placement of a cannula into the arterial circulation is the carotid artery in all age groups since it provides easy access to the aortic arch. Few complications have been associated with carotid artery cannulation and ligation in newborns, children and adults. The second choice for arterial access is the axillary or femoral artery in those patients over 5 years of age who require gas exchange support and the femoral artery in those with isolated cardiac dysfunction. Disadvantages associated with use of the axillary and femoral arterial access sites are that the femoral artery does not provide easy access to the aortic arch 61 while the axillary artery is difficult to dissect and cannulate. In patients under 5 years of age, the femoral and axillary arteries are of insufficient size to provide arterial access: therefore, the iliac artery is the preferred site after the carotid artery. Once on extracorporeal support there typically is rapid cardiopulmonary stabilization. All paralyzing agents, vasoactive drugs, and other infusions are slowly discontinued during use of veno-arterial support, although some vasopressor support may still be necessary when veno-venous bypass is utilized. The mixed venous oxygen saturation (SvO2) is frequently monitored allowing determination of the adequacy of oxygen delivery in relation to oxygen consumption. Pump flow is adjusted to maintain oxygen delivery such that the SvO2 is in the 60-75% range. Heparin and other agents, including nitric-oxide, aprotinin, iloprost, and tranexamic acid, have been used to coat circuits to prevent thrombus formation and continue to be evaluated in laboratory and clinic settings. Chest x-rays are routinely performed to check position of the 63 cannulas and the status of the pulmonary disease. Finally, the sweep gas and flow through the circuit are closely monitored, since increasing sweep gas decreases the arterial carbon dioxide level, while increasing flow provides more oxygenation and blood pressure support. For example, a rated flow of 2 L/min reflects a maximum oxygen delivery of 100 mL O2/min. The sweep gas is usually 100% oxygen, though occasionally carbon dioxide is added at small amounts (5%) due to the efficiency of carbon dioxide 65 transfer compared to oxygen through the membrane lung, creating a potential for hypocarbia. A gas flow rate equal to blood flow rate (1:1) is typically used to begin support, with tailoring further adjustments of the rate to the carbon dioxide level: increasing sweep gas decreases the level and vice versa. Blood flow required for cardiac support is based on the size and age of the patient: 100 ml/kg/min for neonates, 80 ml/kg/min for pediatrics, and 60 ml/kg/min for adults. Normal oxygen delivery rates are also weight and age based: 6 ml/kg/min for neonates, 4-5 ml/kg/min for pediatrics, and 3 ml/kg/min for adults. Inlet pressure refers to the pressure generated in the venous drainage cannula by the pump. With any inlet occlusion, an extreme negative pressure is created that pulls dissolved gases out of the blood, creating a phenomenon called cavitation. Outlet pressure refers to the pressure exiting the pump head, and extremes can lead to loss of integrity between blood tubing connectors. Extreme positive pressure can also lead to heat generation and must be carefully dissipated within the pump. Roller pumps create forward displacement of blood mechanically, and must be constantly monitored and servo-regulated to prevent excess negative inlet pressure. Centrifugal pumps use a series of spinning concentric cones to create centrifugal force to direct forward flow of blood, with a hole in the pumphead to reduce stagnant flow, which acts to decrease hemolysis and heat generation. Centrifugal pumps can be magnetically driven and suspended, and 67 must have outlet pressure carefully monitored. In neonates, centrifugal pumps may also create more hemolysis than traditional roller pumps and patients on these pumps should be carefully monitored for this finding. Indications/Contraindications As with any support technique used in emergent settings, it is critical to continuously review the experience in order to identify those patients who predictably have a poor outcome and those who survive with solely conventional modalities. Inclusion criteria are broadly defined to those who fail or are likely to fail conventional therapy for cardiac and pulmonary support. Criteria for high mortality risk among non-neonatal children with respiratory failure and for children of all ages with cardiac failure have been less well- defined. As a result, oxygenation levels are relatively reduced and extracorporeal blood flow rates must be increased approximately 20% to account for this effect. Percutaneously placed cannulas may simply be removed and prolonged pressure applied. The long term follow-up of infants with right common carotid artery reconstruction demonstrated that nearly two-thirds of the anastomoses were occluded or stenotic. At our institution, we do not routine perform reconstruction of the carotid artery. Considerations for discontinuing extracorporeal support at times other than when indicated by improvement of cardiopulmonary function include the presence of irreversible brain damage, other lethal organ failure, and uncontrollable bleeding. Pneumonia secondary to various infectious etiologies is the most common diagnosis with a 61% survival. Intracranial complications were far less frequent in pediatric patients, though survival was much lower when they occurred. There were no differences in survival for a second run, however, among non- survivors, there was a higher rate of renal failure during the first run and there was higher rate of complications during the second run. The overall survival to discharge is about 25%, with non-survivors having a six-fold higher incidence of renal failure. Finally, in patients who underwent multiple runs, neurologic and infectious complications increased the most[4]. Favorable neurologic outcome was noted in about 80-90% of the survivors on short-term 77 follow-up[26]. The most common mechanical problems are clots in the circuit and cannula problems. A dialysis filter added to the circuit can facilitate removal of additional fluid to help pulmonary status and prevent further kidney injury. Hemolysis can occur due to red blood cell trauma during extracorporeal support, which is often 78 related to clot formation within the circuit, overocclusion of the roller pump, or use of a centrifugal pump. If the serum free hemoglobin is noted to be elevated, a change in the circuit could be helpful to stifle this problem. Initial emergent placement of a pleural or pericardial drainage catheter followed by thoracotomy for definitive treatment of a pericardial tamponade may be lifesaving. Bartlett, Extracorporeal membrane oxygenation support in cardiorespiratory failure. Bartlett, Extracorporeal Life Support for Cardiopulmonary Failure, in Pediatric Surgery, A. Bartlett, Extracorporeal Life Support in Cardiopulmonary Failure, in Pediatric Surgery, J. Gross, Subependymal (grade 1) intracranial hemorrhage in neonates on extracorporeal membrane oxygenation. Humphries, Major surgical intervention during extracorporeal membrane oxygenation. Taylor, Lung compliance as a measure of lung function in newborns with respiratory failure requiring extracorporeal membrane oxygenation. Indeed, the original concept of such areas was to be monitored environments where physiologic fluctuations may be tracked and analyzed in real time. Further, monitoring is essential to understand the impact of intensive care unit interventions and to characterize the nature and significance of derangements. Monitoring strategies are designed to follow individual organ function and, to a lesser degree, the interaction between systems. However, monitors are limited in their ability to interrogate tissue health and cellular function. Furthermore, individual monitor values are often insufficient to draw conclusions about global physiology. For example, a normal 83 blood pressure may not be interpreted to signify adequate cardiac output or perfusion just as normal urine output may not equate with normal renal function. The risk of infection (~5%) starts to increase after five days and is not improved with prophylactic antibiotics. The technology makes use of the principle that increase pressure will place greater strain on the diaphragm at the distal tip which can be interpreted as pressure values using experimental norms. Downsides of this catheter include 1) inability to therapeutically drain and 2) measurement drift over time (there is no way to externally re-zero the monitor once it is placed. This drift may begin as soon as 48 hours after catheter placement, though many intensivists argue that the vast majority of intracranial hypertensive issues occur early in patient courses. Therefore, additional monitors of cerebral oxygenation and metabolism are undergoing evaluation. Monitors of Cerebral Perfusion Jugular bulb saturation is a global marker of cerebral perfusion. It is insensitive to small regional abnormalities in brain oxygenation and has largely been abandoned in clinical use. Newer implantable tissue oxygen microsensors (Integras Licox Brain Oxygen Monitoring System) require a catheter be placed into the white matter. Normative values are being developed, with PbtO2 < 10mmHg in adults being considered abnormal. If the catheter is not placed into the area of injury, the data may not correlate with metabolic activity in the zone of injury. Furthermore, it remains unclear whether such monitors should be placed in the area of injury, the penumbra (area around injury at risk for spread of damage), or in a distant site. A microcatheter placed into the brain parenchyma can measure cerebral glucose, lactate, pyruvate, glutamate, aspartate, and glycerol. Differing ratios in measured diasylate concentrations are thought to reflect altered substrate delivery and/or substrate utilization. This methodology again only measures the local effects in the tissue where the catheter is placed. Furthermore, the application of a flank sensor (measuring renal/somatic perfusion) allows comparison of cerebral and somatic perfusion. Surface tonometry can be used in the neonatal population with an open anterior fontanelle. This requires a pressure transducer to be placed on the neonates head directly over the open fontanelle. The measured pressure is influenced by the amount of external pressure, hence making the reported result less valuable than the trend. Other Methodologies for Monitoring Brain Perfusion Transcranial oxygen saturation monitors have been employed in adults to show hemispheric oxygen levels. While the absolute values may be less valuable, trends are potentially useful to evaluate hemispheric oxygenation. However, significant decline in cerebral oxygen saturation may occur once tissue damage from intracranial hemorrhage or embolism/thrombosis is established and, therefore, less likely to be reversible. Using 20 87 electrodes to be placed on the scalp for at least 12 continuous hours, one may detect subclinical seizures. The device utilizes a single sensor placed on the patients forehead and employs complex algorithms to analyze the brain electrical activity to infer the level of consciousness (0=unconscious, 100=fully awake. In adults, values less than 20 are considered excessively deep anesthesia while values greater than 70 may suggest inadequate anesthesia for noxious procedures. Routine use in adults has been shown to decrease intraoperative awareness, but this has not been validated in children. Special Considerations in infants versus older children Many of the monitoring devices discussed above have either not been used in infants or have not been adequately validated to interpret absolute values. Therefore, while the clinician may obtain an ever- expanding data set with regard to neurologic function in the neonate, enthusiasm must be matched with skepticism regarding the validity of any specific values. Pulse oximetry makes use of the principle that hemoglobin saturated with oxygen (or other gases) will exhibit different absorbance and transmittance characteristics for specific wavelengths of light. By testing normal patients in the range of tolerable oxygen saturation (75-100%) and inferring the characteristics at lower saturations, manufacturers built algorithms to report continuous oxygen saturation that approximated arterial blood gas measurements to within 2-5 percent in the higher ranges and 10% at the lower ranges. However, early devices used single wavelengths of light and could only differentiate saturated from unsaturated hemoglobin. The addition of two more wavelengths has resulted in absolute values that reliably lie within 2% of blood gas measurements and can accurately report total hemoglobin, methemoglobin, and carboxyhemoglobin concentrations on a continuous basis. The arterial partial pressure of oxygen (PaO2) may be a more direct measure of the efficiency of gas exchange at the alveolar/capillary junction and is, therefore, an important tool to assess the degree of pulmonary dysfunction. Using the oxygen content equation (shown below), it becomes readily apparent that changes in SaO2 have substantially greater impact on oxygen content. Therefore, there is no mathematical threshold of oxygen saturation that signals patient risk. Many intensivists empirically target 90% or greater as the desirable values though this is neither supported by available data nor by the mathematical principles of the equation.
Endpoints monitored in rats were the same as in hamsters except that total protein and albumin in blood were not determined in rats fungus gnats plants effective fulvicin 250mg. Bone marrow cells were collected for cytogenetic studies from 5 rats/sex/dose after 6 months of exposure fungus yellow toenail fulvicin 250 mg line. The scope of the pathological examinations of the rats was the same as in the hamster study fungus gnats organic buy fulvicin 250 mg otc. No significant exposure-related signs of toxicity were observed in the rats during the th study fungus gnats mosquito bits buy genuine fulvicin online. A significant increase in mortality was seen in high-dose female rats from the 18 to the th 24 month of exposure fungus gnats larvae killer generic fulvicin 250mg without prescription, and this appeared to be exposure-related fungus yard buy discount fulvicin 250mg line. The only exposure-related alterations in organ weights was a significant increase in both absolute and relative liver weight in high-dose males at the 18-month interim kill and a significant increase in relative liver weight in high-dose females also at 18 months antifungal youtube purchase cheap fulvicin. Statistically significant changes in hematologic parameters were restricted to increased mean corpuscular volume and mean corpuscular hemoglobin values at 15 months in males fungus yellow foamy cheap fulvicin 250mg online. Exposure-related, statistically significant increases in incidences of nonneoplastic lesions were restricted to the liver (Table 4-13. The incidences of males or females with hepatocellular vacuolation consistent with fatty change increased as the exposure concentration increased. Hepatocellular necrosis occurred at elevated incidences in male rats exposed to 1,500 or 3,500 ppm compared with controls, but this endpoint was not reported in the female data. There was some evidence that exposure at the two highest levels provided some inhibition of the age-related glomerulonephropathy observed in the control rats at termination. In females, an increasing trend was seen in the incidence of foci or areas of altered hepatocytes. Female rats in all exposed groups showed increased incidence of multinucleated hepatocytes in the centrilobular region compared with controls, but there was no evidence of increasing incidence or severity with increasing exposure level (Table 4-13. The foci and areas were apparent after 12 months, and their number and size increased thereafter, but incidences for neoplastic nodules in the liver or hepatocellular carcinomas were not increased in any exposure group. A statistically significant increased incidence of salivary gland sarcomas was reported for male rats exposed to 3,500 ppm. Incidences of rats with benign mammary gland tumors were not statistically significantly higher in exposed male or female groups compared with controls, and exposed male and female groups showed no significantly increased incidences for malignant mammary gland tumors. The average number of benign mammary tumors per tumor-bearing rat increased with increasing exposure level. Groups of 90 male and 90 female rats were exposed to 0, 50, 200, or 500 ppm dichloromethane (>99. Interim sacrifices were conducted at 6, 12, 15, and 18 months (five rats/sex/interval. An additional group of 30 female rats was exposed to 500 ppm for 12 months and then exposed to room air for up to an additional 12 months, and another group of 30 female rats was exposed to room air for the first 12 months, followed by exposure to 500 ppm for the last 12 months of the study. These latter groups were included to examine temporal relationships between exposure and potential carcinogenic response. All groups of rats were examined daily for signs of toxicity and all rats were examined for palpable masses prior to the initial exposure and at monthly intervals after the first 12 months. Blood samples were collected at interim sacrifices and analyzed for total bilirubin, cholesterol, triglycerides, potassium, estradiol, follicle-stimulating hormone, and luteinizing hormone levels. All rats were subjected to a complete necropsy, and sections from most tissues were processed for microscopic examination. Statistically significantly increased incidences of nonneoplastic liver lesions (hepatic lipid vacuolation consistent with fatty change and multinucleated hepatocytes) occurred only in females in the 500 ppm group (Table 4-14. Male rat incidence for hepatocyte vacuolation was elevated at 500 ppm but not to a statistically significant degree. In the group of female rats exposed for only 12 months to 500 ppm, significantly increased incidences of nonneoplastic lesions compared with controls were restricted to liver cytoplasmic vacuolization (16/25 = 64%) and multinucleated hepatocytes (9/25 = 36%) in rats exposed during the first 12 months of the study; 88 rats exposed only during the last 12 months of the study showed no elevated incidences of the liver lesions. A few fibrosarcomas or undifferentiated sarcomas in the mammary gland were seen in the exposed rats, but these incidences were not statistically significant (Table 4-15. Significantly increased incidences of rats with neoplastic lesions were restricted to benign mammary tumors in female rats exposed for 2 years to 200 ppm compared with controls (61/69 = 87%) (Table 4-15. A slight but statistically significant increase in the number of palpable masses in subcutaneous or mammary regions (at 89 Table 4-15. The numbers of benign mammary tumors per tumor-bearing rat were slightly elevated in the exposed groups compared with control groups, but no statistical analysis of this variable was performed. In female rats exposed to 500 ppm (during the first or second 12 months of the study), slight but statistically significant elevations were found in the number of palpable masses in subcutaneous or mammary regions per tumor-bearing rat; the numbers of benign mammary tumors per tumor- bearing rat were elevated compared with those of the study controls, (and with historical controls), but statistical analysis of this variable was not performed. The authors concluded that there was no distinct exposure-related malignant carcinogenic response in male or female Sprague-Dawley rats exposed (6 hours/day, 5 days/week) to up to 500 ppm dichloromethane for 2 years (Nitschke et al. The exposure period was 4 hours/day, 4 days/week for 7 weeks and then 7 hours/day, 5 days/week for 97 weeks. For each animal sacrificed, histopathologic examinations were performed on the following organs: brain and cerebellum, zymbal glands, interscapular brown fat, salivary glands, tongue, thymus and mediastinal lymph nodes, lungs, liver, kidneys, adrenals, spleen, pancreas, esophagus, stomach, intestine, bladder, uterus, gonads, and any other organs with gross lesions. Dichloromethane exposure was not related to the percentage of rats with benign and malignant tumors, malignant tumors, or the number of total malignant tumors per 100 animals. No statistically significant effects were seen in either protocol, although some evidence of a decrease in fertility index was seen in the 150 and 200 ppm groups (Raje et al. The developmental effects following exposure of Long-Evans rats to 4,500 ppm for 14 days prior to mating and during gestation (or during gestation alone) were decreased offspring weight at birth and changed behavioral habituation of the offspring to novel environments (Bornschein et al. Although few developmental effects were observed at high exposures to dichloromethane (Bornschein et al. The available data identify changes in behavior habituation at 4,500 ppm (Bornschein et al. The behavioral changes observed at 4,500 ppm indicate developmental neurotoxic effects; this is the only dose group used in the Bornschein et al. No other neurological endpoints have been evaluated in the available developmental studies of dichloromethane. The potential for developmental neurotoxicity occurring at lower exposures to dichloromethane represents a data gap. A single 3-hour exposure to 100 ppm dichloromethane significantly increased the susceptibility to respiratory infection and greater mortality following exposure to S. The 3-hour exposure to 100 ppm dichloromethane was associated with a statistically significant (p 0. No difference was seen in either mortality rate or bactericidal activity in experiments using a single 3-hour exposure to 50 ppm or 3-hour exposures to 40 ppm dichloromethane repeated daily for 5 days compared with control animals exposed to filtered air. Perchloroethylene and ethylene trichloride were the only chemicals in this group for which an increased mortality risk from Streptococcal pneumonia was seen (mortality risk 15. Decreased bactericidal activity was also seen with acetaldehyde, acrolein, methyl chloroform, allyl chloride, benzene, benzyl chloride, perchloroethylene, and ethylene trichloride at one or more exposures. Results from several chemicals suggest that 5 days of exposure results in greater decrease in bactericidal activity. Among the controls in the experiments with the 13 chemicals other than dichloromethane, mortality in the Streptococcal infectivity model 4 ranged from 5. The number of bacteria deposited in the lung in an inhalation bacterial infectivity model can show considerable variation. Therefore, concurrent controls are particularly important due to the variation in preparation and aerosol administration of the bacteria in these assays. Groups of rats (8/sex/dose level) were exposed to 0 or 5,000 ppm dichloromethane 6 hours/day, 5 days/week for 28 days. Five days before sacrifice (day 23 of exposure) all rats were injected with sheep red blood cells. IgM levels in response to the sheep red blood cells were comparable between dichloromethane-exposed and air-exposed rats, indicating that dichloromethane did not produce immunosuppression in the animals under these exposure conditions. Cyclophosphamide-treated animals had significantly lower levels of IgM in the blood serum, indicating immunosuppression. Rats exposed to dichloromethane showed reduced response to sound, piloerection, and hunched posture during exposures. Relative and absolute liver weights were significantly increased in females but not in males. Relative spleen weight was reduced in females, and no significant changes were seen in the weight of the thymus and lungs. Exposure to 5,000 ppm dichloromethane did not affect antibody production to the challenge with sheep red blood cells. In contrast, in a functional immune assay of systemic immunosuppression conducted in rats, Warbrick et al. Histopathologic analyses of immune system organs in chronic exposure studies for B6C3F1 mice and F344 rats (Nitschke et al. These two studies for dichloromethane do not suggest systemic immunosuppression, but the Aranyi et al. Overall, there are decreased motor activity, impaired memory, and changes in responses to sensory stimuli. An overview of these types of studies and a summary of the results seen in these studies are provided below; a detailed description of individual studies is provided in Appendix E, Section E. Learning and memory changes with dichloromethane were studied by using a passive avoidance task. The oral and inhalation studies that examined neurobehavioral endpoints are summarized in Table 4-17. Neurophysiological studies with dichloromethane exposure consisted of measuring evoked responses in response to sensory stimuli. In these studies, animals were implanted with electrodes over the brain region that responds to the particular stimuli. For example, an electrode would be implanted over the visual cortex in an animal presented with a visual stimulus. Once the stimulus is presented to the animal, an evoked response is elicited from the brain region and transmitted to the implanted electrode. During administration of a chemical, if there is a significant change in the magnitude, shape, and latency (among other measures) in the evoked response, then the chemical is considered to produce neurological effects. A summary of studies examining dichloromethane exposure and neurophysiological changes is shown in Table 4-18. Additionally, dopamine and serotonin levels, which are associated with addiction and mood, were also measured. Measurement of neurochemical changes provides mechanistic information, and neurobehavioral and neurophysiological effects can be correlated to these results. Three studies evaluated the neurotoxic potential of dichloromethane by either administering the solvent orally or by injection; two of these studies (Herr and Boyes, 1997; Kanada et al. Observed neurological effects included decreased spontaneous activity (Moser et al. The database pertaining to neurotoxic effects from inhalation exposure to dichloromethane is considerably larger than the oral exposure database. Higher (5,000 ppm) acute and short-term exposures resulted in decreased spontaneous activity and lethargy (Weinstein et al. Longer-term exposures (up to 14 weeks) produced decreased motor activity and lethargy in several animals at 1,000 and 5,000 ppm (Haun et al. As a result, it is difficult to ascertain if tolerance is developed to dichloromethane-mediated changes in sensory potentials seen during an acute exposure, or if these effects are still maintained during repeated exposure, since measurements were not taken during the subchronic exposure. Altered learning and memory abilities were demonstrated in young (3-, 5-, and 8-week-old) male Swiss-Webster mice exposed to 168 mg/L (~47,000 ppm) dichloromethane for approximately 20 seconds (until there was a loss of the righting reflex) (Alexeeff and Kilgore, 1983. Studies of neurochemical changes from dichloromethane, by route of exposure a Species and sex Exposure Duration Regions Effect Reference Oral exposure Sprague-Dawley rat, 534 mg/kg Acute, single dose; Hippocampus, ^ acetylcholine in hippocampus Kanada et male evaluated 2 hrs after dosed medulla, midbrain, ^ dopamine and serotonin in medulla al. Genotoxicity Studies the application of genotoxicity data to predict potential carcinogenicity is based on the principle that genetic alterations are found in all cancers. Genotoxicity assays that indicate mutagenicity are those that provide evidence of the ability of a chemical to alter the amount or structure of genetic material in a manner that permits changes to be transmitted during cell division. Certain genetic alterations, including gene mutations and chromosomal aberrations, are considered mutational events that can occur through a variety of mechanisms; evidence of mutagenesis provides mechanistic support for the inference of potential for carcinogenicity in humans. Evaluation of genotoxicity data entails a weight of evidence approach that includes consideration of the various types of genetic damage that can occur. The following section summarizes available data on genotoxicity for dichloromethane by genotoxic endpoint and organism. Numerous in vitro studies have demonstrated the mutagenic potential of dichloromethane in bacterial, yeast, and fungal mutagenesis assays. These effects were not markedly influenced by the addition of exogenous mammalian liver fractions, suggesting that endogenous metabolism in these strains was sufficient to activate dichloromethane (Green, 1983; Jongen et al. A 60-fold higher concentration of dichloromethane was needed to induce a response. This study also included several trihalomethanes; dichloromethane was several-fold less genotoxic than dibromochloromethane or bromoform, but was similar in potency to bromodichloromethane (Demarini et al. The mutagenic effects of dichloromethane have also been examined in fungi and yeast with both systems reporting positive results. Fungal assays were positive for mitotic segregation in Aspergillus nidulans (Crebelli et al. A yeast assay was positive for gene conversion and recombination in Saccharomyces cerevisiae for concentrations up to 209 mM (Callen et al. These results are consistent with the evidence that exposure to dichloromethane results specifically in lung and liver tumors. Results from in vitro genotoxicity assays of dichloromethane with mammalian systems, by type of test Assay Test system Concentrations Results Reference Forward mutation (hgprt Chinese hamster epithelial 10,000, 20,000, Negative Jongen et al. Sister chromatid Chinese hamster V79 cells 10,000, 20,000, Weak positive with or without rat-liver microsomal system Jongen et al. Sister chromatid Primary human peripheral 0, 15, 30, 60, 125, Sister chromatid exchanges significantly increased at Olvera-Bello et al. This study found that all three enzymes yielded a similar pattern of adduct formation, forming primarily with guanine and to a lesser extent with cytosine, adenine, and thymine (two- to threefold less than guanine), consistent with the results reported by Kayser and Vuilleumier (2001. High levels of guanosine-specific adducts were also seen with S-(1-acetoxymethyl)glutathione, a compound that is structurally similar but more stable than S-(chloromethyl)glutathione (Marsch et al. In studies with human cell lines or isolated cells, positive results were reported for chromosomal mutation assays (chromosomal aberrations and micronucleus test) (Olvera-Bello et al. Similar results are seen in analyses using categorical data: for dichloromethane, values of 9. The cultured cells were exposed to dichloromethane (15, 30, 60, 125, 250, or 500 ppm) for 72 hours and sister chromatid exchanges were evaluated as a measure of genotoxicity. Frequency of sister chromatid exchanges significantly increased beginning at 125 ppm. Indices of cytoxicity (mitotic index) and cytostaticity (cell proliferation kinetics) were also examined. The mitotic index was approximately 50% lower in the highest activity group compared to the medium and low activity groups at all concentrations. This provided further evidence that the S-(chloromethyl)glutathione intermediate may be primarily responsible for dichloromethane genotoxicity. In Vivo Genotoxicity Assays Genotoxicity findings in Drosophila melanogaster assays are mixed (Table 4-22. An additional feeding study (Rodriguez- + Arnaiz, 1998) reported a positive response in the somatic w/w assay. Results from in vivo genotoxicity assays of dichloromethane in insects Assay Test system Doses Result Reference Gene mutation (sex- Drosophila 125, 620 mM Positive (feeding Gocke et al. It is generally recognized that this assay is not sensitive for detecting genotoxic chemicals (Eastmond et al. Results from in vivo genotoxicity assays of dichloromethane in mice Assay Test system Route and dose Duration Results Reference Kras and Hras oncogenes Mouse liver and lung 0, 2,000 ppm Up to 104 wks No difference in mutation profile Devereux et al. Increased chromosomal aberrations in lung and bone marrow cells and increased micronuclei in peripheral red blood cells were found in mice exposed by inhalation for 2 weeks to 8,000 ppm or for 12 weeks to 2,000 ppm (Allen et al. Under the same exposure conditions, increased sister chromatid exchanges were also found in lung cells and peripheral lymphocytes (Allen et al. Animals were administered 5 mg/kg intraperitoneally of radiolabeled dichloromethane and sacrificed at 1 or 8 hours after administration. Fifty dichloromethane- induced and 49 spontaneous liver tumors were screened for H-ras mutations. There was a relatively high frequency of activated H-ras among the nonexposed B6C3F1 mice: 67% of the spontaneous tumors and 76% of the dichloromethane-induced tumors contained mutations in the H-ras gene. Overall, the mutation profile of the dichloromethane-induced tumors did not significantly differ from the spontaneous tumors. In the analysis of K-ras mutations in 54 dichloromethane-induced and 17 spontaneous lung tumors reported by Devereux et al.
Consistent with other research in the field fungus journal fulvicin 250 mg amex, the results of their study suggest that children with cerebral palsy experience reduced frequency of participation in a variety of activities when compared to typically developing peers fungus gnats walls order fulvicin in united states online. Rationale To date fungal rash on neck buy 250 mg fulvicin free shipping, much research has focused upon the important issue of functional ability fungus gnats killer buy fulvicin 250 mg line, however with advances in medical technology and children now being expected to reach adulthood fungus in throat order fulvicin american express, the focus of research has shifted to that of the experience of parenting and parental quality of life (Aran et al fungus virus purchase generic fulvicin on line. Such research findings are varied antifungal otc oral cheap 250mg fulvicin with amex, with some evidence of the experience being stressful (Brinchmann vinegar for fungus gnats purchase generic fulvicin canada, 1999), and others suggesting that it can have a positive affect on the lives of parents (Davis et al. Moving from the perspective of the parent to that of the child, Mitchell and Sloper (2001) reported that there was a paucity of studies investigating the views of children with learning disabilities. In recent years there has been some research focusing on the perceptions of children and young people. Their findings suggest that a majority (67%) of the sample (N=118) had quality of life scores less than would be expected for typically developing children. Considering such inconsistency in findings, it may be argued that Dickinson et als results are more representative of the population of children with cerebral palsy than those of Maher et al. In comparison, Maher et als sample was smaller, it spanned a larger age range and all children lived in South Australia. Studies employed different measures in assessing quality of life and clearly each represents a different age group within different populations of children with cerebral palsy and as such this may account partly for the difference in findings. Their results highlighted a variety of themes that appear to affect quality of life, including physical health and acceptance of disability. It seems that with the recognition of the importance of childrens views, combined with the finding that parent and self-report data demonstrate low levels of correlation (Livingston et al. The discrepancy between self and proxy reports is recognised within quality of life literature (Verrips et al. Much research employing childrens own views have been concerned with quality of life (Dickinson et al. However, such designs do not capture the personal view or subjective experience of living with cerebral palsy and as such these studies are restrictive in terms of the data they collate. With quality of life and more specifically psychological well being in mind, the proposed study aims to investigate what it is like to be a child living with cerebral palsy. Existing research documents that children with cerebral palsy are at increased 150 risk for psychological difficulties, however, such research has failed to identify why this may be the case. There is a dearth of studies that focus upon the experience of children with cerebral palsy, with the majority of research focussing upon the experience of the parents. This is the first study, as far as is known, to adopt a qualitative approach to examine the experience of living with cerebral palsy from the perspective of the child. Such an approach will allow children to guide the conversation with issues that are important to them. Previous research has found that employing standardised measures has not addressed all areas that impact on quality of life (Davis et al. Therefore, it is proposed that adopting a semi-structured interview will allow more flexible communication of what is considered to be important to the child, rather than what is deemed important by the researcher. It is argued that the view of the child is important, and that the results of the study may provide rich data that will enable a more holistic view of children with cerebral palsy. Moreover, the data may identify issues that are indicative of why children with cerebral palsy are at increased risk for psychological difficulties. Aims and Hypotheses Aims the study aims to explore young peoples experience of living with cerebral palsy. To explore young peoples experiences of living with cerebral palsy, what it means to the individual, how it affects their life in general, and how they think it impacts upon their relationship with family and peers. To contribute to the emerging evidence base detailing the view of the child as opposed to the parent or caregiver. Plan of Investigation Participants Participants will be children (8-12 years) with a diagnosis of cerebral palsy who are listed on the support needs register within Ayrshire and Arran. From the group of children identified, only those who attend mainstream school will be invited to take part. To aid the identification of common themes within the collected data, purposive sampling will be employed and participants will all be functioning cognitively at a level which allows attendance at mainstream school. Inclusion and Exclusion Criteria Inclusion/Exclusion Children attending mainstream school, aged 8-12 years with a diagnosis of cerebral palsy will be included. Justification of Sample Size and Age As the study will employ qualitative methods and an idiographic mode of investigation, a small sample size is generally deemed as acceptable. Smith and Osborn (2003) propose that sample size, should be concerned with providing 152 sufficient data to explore any differences and similarities between accounts, while at the same time not producing an excessive and unmanageable amount of data. The study will target children aged 8 to 12 years as it has been suggested that difficulties can be exacerbated during this pre-adolescence phase when typical developmental shifts with regards to decision making tend to happen (Holmbeck et al. Recruitment Procedures Participants will be recruited via the support needs register which contains details of children within Ayrshire with cerebral palsy. If insufficient numbers are identified with Ayrshire, then we will access the registers held within other health boards. It is anticipated that the sample size should be achievable, as within Ayrshire and Arran there are a pool of approximately 15 children. Guardians of identified children will be approached and informed of the study by a health professional with whom they are already involved. Invitations will be followed up with a phone call from the researcher asking whether or not they wish to participate. If they do wish to participate, then the researcher will arrange to meet with the parent and child in order to build rapport, clarify the procedure and answer any questions they may have. They will be informed that the interview will be recorded and transcribed for the purpose of later analyses, and that their identifiable information will be removed from the written transcription. It will be explained that the transcription will be read by the researcher and supervisors and that the interviews and transcription data will be stored securely for a period of five years to allow analysis and replication by others, following which it will be destroyed. If consent and assent are achieved then a suitable appointment will be arranged for the interview. If the parent is not sitting in on the interview then they will be asked to remain within the waiting area; if the child becomes distressed at any point, then their parent will be available to them. The child will then be reminded of the purpose of the interview and will be told that they can stop for a break or stop completely at any point if they decide they do not want to carry on. Interviews will last for approximately an hour, and they will begin when the child informs the researcher that they are ready. Bruce (2007) employed a poster icebreaker that involved the child filling in a poster with details regarding their family, hobbies, school and friends with the researcher. Since the current study will enquire about such topics, it will adopt this as an icebreaker; however a choice of games will be offered to play initially as a means of engagement for children who appear to require it. Interviews will employ a semi-structured approach with an interview schedule acting as a guide. This method of data collection is often chosen when employing qualitative research (Reid et al. A non-directive approach will be adopted, thus allowing the interview to be directed by the participant (Smith & Eatough, 2007) who can highlight areas they think are important to them. Prompts such as can you tell me more about will be used to encourage elaboration on topics. As there may be difficulty achieving the sample, the interview will be piloted with seven year-old children. It is estimated that transcription and analysis will take approximately 7 hours per interview (Smith & Eatough, 2007) therefore total transcription and analyses will take approximately 56 hours. This screening tool provides an indication of the childs social functioning and targets areas such as conduct, hyperactivity and emotional difficulties. Settings and Equipment Data collection will take place in a clinic room with the researcher. Necessary equipment will include coloured pens and paper, a digital voice recorder, transcription equipment and possible computer software for analysis. In anticipation of difficulties in engaging children, a range of warm-up activities and games will be available for children to play with until they appear to be comfortable and ready to begin the interview. Similar to grounded theory, this approach is not theory driven, but adopts a bottom-up approach, meaning that the data are analysed without attempts to mould it into pre-existing theoretical paradigms. However, it also recognises that achieving an insider perspective (Conrad, 1987) is somewhat impossible, as the process of obtaining this is dependent on the researchers interpretation of the data they receive. Health and Safety Issues Researcher safety issues Data collection will only occur during working hours when there are other staff members in the building. Participant safety issues Participants will be in child-friendly areas of the building. Questionnaires will be completed by parents in a clinic room and they will be accompanied by the researcher. Should a parent or child become upset or show signs of distress at any point during the study they will be reminded of their right to discontinue participation and they will be offered an appointment with a suitable professional. Ethical Issues Permission to conduct the study will be sought from the West of Scotland Ethics committee and research practice will adhere to the British Psychological Society (2009) code of ethics and conduct. Children and their parent will receive information detailing the nature and purpose of the study, this information will be provided in a child-friendly format therefore facilitating understanding. The researcher will discuss the nature of the study, the procedures involved and how the interview data will be stored, analysed and destroyed. The researcher will check with children and their parent/guardian that they fully understand what will happen within the interview and then with the information they provide. If they do understand then this will be taken as being informed and they will be asked to sign consent/assent forms. All demographic information will be stored in a locked filing cabinet with access limited to the researcher. While all recordings will be transferred onto a computer that will be password protected. All transcripts will be anonymised and stored on the computer or in the locked filing cabinet separate from the demographic information. Timetable Below is an estimation of when each stage of the research will take place. Moreover, regardless of whether any such indications are achieved, the results of the study will provide an understanding of what it is like to live with a condition such as cerebral palsy. To date there has been much research concerning the quality of life of those caring for individuals with cerebral palsy, but as far as we are aware, there exists no qualitative investigation into the experience of children suffering from this condition. Insight into the experience will provide information that can be used to inform clinical practice in terms of what matters to children with cerebral palsy, such information can provide the grounds for further research, clinical intervention and policy provision. Quality of life of adolescents with cerebral palsy: perspectives of adolescents and parents. Observed and perceived parental overprotection in relation to psychosocial adjustment in preadolescents with a physical disability: the mediational role of behavioural autonomy. Quality of life among adolescents with cerebral palsy: what does the literature tell us Psychological problems in children with cerebral palsy: a cross-sectional European study. To what extent do children with cerebral palsy participate in everyday life situations Children with cerebral palsy assess their parents influence on the quality of their lives: Implications for intervention. Measuring health-related quality of life in adolescents: agreement between raters and between methods of administration. It was developed by the Early Support programme in partnership with Scope, in response to requests from families, professional agencies and voluntary organisations for better standard information. Families were consulted about the content and the text reflects what parents who have been there before say they would have liked to have known in the early days of finding out about their childs situation. Where a word or phrase appears in colour, like this, it means you can look them up in the Glossary at the back of the booklet, that the contact details for the organisation or agency identified are listed in the Useful contacts and organisations section or that you can find out more in the Who can help Information for parents Cerebral palsy Contents Introduction What is cerebral palsy Its a complex condition that can be very mild or severe, with no two people being affected in quite the same way. This booklet has been written in partnership with parents of children with cerebral palsy to provide general information for families and carers. It aims to answer some of the questions you may have in the early days and to explain where you can get more information and help. If you feel you dont want to read all the information now, thats fine - come back to it later when you have particular questions in mind or want to check up on things as your child develops. Everybody reacts differently to the news that their child has a problem that they were not expecting. Most people feel anxious about what it will mean and how they will cope when they first discover that their child has cerebral palsy. Dont be afraid to ask as many questions as you like - no matter how simple or trivial they may seem. It helps if you understand more, and realise that there are positive things you can do to help your child develop. Cerebral palsy is an umbrella term for a non-progressive condition within the brain that affects movement, posture and co-ordination. Problems may be noticed around the time of birth or may not become obvious until later. Its a wide-ranging condition and no two children with cerebral palsy will be affected in the same way. If a person has cerebral palsy it means that the part of the brain that controls muscles and movement has been affected or damaged. Sometimes other areas of the brain are involved, affecting vision, communication and learning. Cerebral palsy is sometimes referred to as a developmental condition because damage can occur during the prenatal, natal or postnatal periods - that is, before birth, at birth or after birth. However, the effects on the body may become more (or less) obvious as time goes by. Cerebral palsy, therefore, is a general term for a wide range of non- progressive cerebral (brain) disorders, which result in some sort of movement impairment, that become apparent during early childhood. It is important to remember that no two people with cerebral palsy are affected in the same way. It is often not possible for doctors to explain exactly why part of a babys brain has been injured or has failed to develop, as there may be no obvious or single reason. Cerebral palsy can be caused by multiple and complex factors and the cause of about 40% of cases is unknown. Pre-term babies are extremely vulnerable and at risk of haemorrhage, infection and oxygen deprivation to the brain. The effects of cerebral palsy vary enormously from one person to another, with some people experiencing a combination of two or more types. This form of cerebral palsy causes the muscles to stiffen and decreases the range of movement in the joints. It is the most common form of cerebral palsy and occurs in three-quarters of people affected. Spasticity can affect different areas of the body and may have an effect on how clearly children can speak. If only one side of their body is affected, the term used to describe this is hemiplegia. Their speech can be hard to understand as they may have difficulty controlling their tongue, breathing and using their vocal cords. A child with athetoid cerebral palsy is rarely still - they have too much movement. As soon as they try to initiate a movement or thought, their body will start to move. Ataxic cerebral palsy Children with ataxic cerebral palsy find it very difficult to balance. They may also have poor spatial awareness, which means its difficult for them to judge their body position relative to the things around them. Mixed the descriptions above dont always describe individual children with cerebral palsy. People often experience a mix - for example athetosis with ataxia, athetosis with spasticity etc. Another way of describing cerebral palsy - the limbs affected Cerebral palsy is sometimes grouped and described according to the area of the body or the number of limbs involved. Monoplegia means only one limb (arm or leg) on one side of the body is affected - this is very rare. Children with diplegia may also have subtle or mild muscle tone problems in the upper part of their body, but they have sufficient control for most daily activities. Childhood hemiplegia is a relatively common condition, affecting up to one child in 1,000. They dont tell you anything about how severely different parts of your childs body are affected. Hemiplegia Hemiplegia is a condition affecting one side of the body - its often referred to as right or left sided depending on the side of the body thats affected.
This item in combination with Date Radiation Ended [3220] allows the duration of treatment to be calculated antifungal pills buy generic fulvicin 250mg. Both dates can be used to describe lag time between diagnosis and initialization of specific aspects of treatment antifungal shampoo cvs purchase fulvicin 250 mg with amex. Location of Radiation Treatment [1550] can be used to assess where therapy was provided fungus under nail fulvicin 250 mg free shipping. This item allows for the distinction between summary treatment and treatment given at the accessioning facility fungus gnats boiling water generic 250 mg fulvicin amex. Codes are provided that allow the description of where regional and boost dose therapy were provided antifungal body lotion cheap fulvicin generic, whether all the therapy was provided at the accessioning facility or if all or some of the radiation therapy was referred out to another treatment location antifungal for jock itch purchase cheap fulvicin. The treatment volume may be the same as the primary site of disease; however fungus under my toenail purchase fulvicin 250 mg online, the available code values provide descriptions of anatomic regions that may extend beyond the primary site of disease and may be used to describe the treatment of metastatic disease fungus medical definition order fulvicin 250 mg free shipping. If two distinct volumes are radiated, and one of those includes the primary site, record the radiation involving the primary site in all radiation fields. In addition to knowing the duration of treatment and the modalities and doses involved, it is critical to know the number of treatments to be able to gauge the intensity of the dose delivered to the patient. Two items augment the information recorded in the radiation modality, dose, volume, and number of treatment items. Radiation therapy can precede the surgical resection of a tumor and then be continued after the patients surgery, or radiation can be administered intraoperatively. Systemic Therapy Systemic therapy encompasses the treatment modalities captured by the items chemotherapy, hormone therapy, and immunotherapy. Hormone Cancer therapy that achieves its antitumor effect through changes in hormonal balance. This therapy type of therapy includes the administration of hormones, agents acting via hormonal mechanisms, antihormones, and steroids. Immunotherapy Cancer therapy that achieves its antitumor effect by altering the immune system or changing the hosts response to the tumor cells. Endocrine Cancer therapy that achieves its antitumor effect through the use of radiation or surgical therapy procedures that suppress the naturally occurring hormonal activity of the patient (when the cancer occurs at another site) and, therefore, alter or affect the long-term control of the cancers growth. Hematologic Bone marrow or stem cell transplants performed to protect patients from myelosuppression or transplants bone marrow ablation associated with the administration of high-dose chemotherapy or radiation therapy. For cases diagnosed prior to January 1, 2013, registrars have been instructed to continue coding these drugs as Chemotherapy. If a patient has an adverse reaction, the managing physician may change one of the agents in a combination regimen. If the replacement agent belongs to the same group as the original agent, there is no change in the regimen. However, if the replacement agent is of a different group than the original agent, the new regimen represents the start of subsequent therapy, only the original agent or regimen is recorded as first course therapy. Pleural/pericardial Injected directly into pleural or pericardial space to control malignant effusions. Hepatic artery Injected into a catheter inserted into the artery that supplies blood to the liver. Relationships among Systemic Therapy Items the data item Date Systemic Therapy Started describes the first date on which any first course systemic treatment was administered to the patient. Nine out of 10 patients treated with systemic therapy receive only a single class of drugs (chemotherapy, hormone therapy, or immunotherapy. Of the remaining patients who receive a combined regimen of systemic therapies, two-thirds begin these combined regimens simultaneously. For the purposes of clinical surveillance, the collection of multiple dates to describe the sequence of systemic therapy administration is not necessary. In the case of chemotherapy, additional distinction is allowed for instances where single or multiagent regimens were administered. Each of these three items includes code values that describe the reason a particular class of drugs is not administered to the patient and distinguishes a physicians not recommending systemic therapy due to contraindicating conditions from a patients refusal of a recommended treatment plan. Hematologic Transplant and Endocrine Procedures captures those infrequent instances in which a medical, surgical, or radiation procedure is performed on a patient that has an effect on the hormonal or immunologic balance of the patient. Hematologic procedures, such as bone marrow transplants or stem cell harvests, are typically employed in conjunction with administration of systemic agent(s), usually chemotherapy. The use of code 40 in response to this data item should be reviewed and confirmed with the managing physician(s. Other Treatment Other Treatment encompasses first course treatment that cannot be described as surgery, radiation, or systemic therapy according to the defined data items found in this manual. Consult the most recent version of the Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding Manual for instructions for coding care of specific hematopoietic neoplasms in this item. Palliative care provided to relieve symptoms may include surgery, radiation therapy, systemic therapy (chemotherapy, hormone therapy, or other systemic drugs), and/or other pain management therapy. The following items apply to all palliative care provided at this facility and at other facilities: Palliative Care [3270] Palliative Care at this Facility [3280] Any surgical procedure, radiation therapy, and/or systemic therapy that is provided to modify, control, remove, or destroy primary or metastatic cancer tissue, is coded in the respective first course of treatment fields and also identified in the Palliative Care items. Refer to the preceding discussion of the surgery, radiation and systemic therapy data items for specific coding guidelines. Because these treatments are less aggressive when given for palliation than for treatment, the treatment plan or treatment notes will indicate when they are performed for palliative purposes. For example, a patient with metastatic prostate cancer may receive an orchiectomy and systemic hormone therapy in combination with palliative radiation for bone metastasis. Treatment, Palliative, and Prophylactic Care Any first course radiation or systemic treatment that acts to kill cancer cells is to be reported as treatment. Second, it contributes to the patients treatment by destroying cancer cells in the bone marrow, though its use alone would generally not be sufficient to produce a cure. The situation is analogous to the use of breast-conserving surgery and adjuvant radiation when the surgery or radiation alone may not be sufficient to produce a cure, though together they are more effective. When first course surgery, systemic treatment, or radiation is undertaken to reduce the patients symptoms, that treatment should be coded as palliative care. An example is radiation to bone metastases for prostate cancer to reduce bone pain, which is palliative when there is no expectation that the radiation will effectively reduce the cancer burden. This treatment qualifies the patient as analytic if it is given as part of planned first course treatment. An action taken to prevent cancer from developing (such as a double mastectomy for a healthy woman who has several relatives diagnosed with breast cancer when they were young) is not reportable; there is no cancer to report. Embolization the term embolization refers to the intentional blocking of an artery or vein. The mechanism and the reason for embolization determine how and whether it is to be recorded. Chemoembolization is a procedure in which the blood supply to the tumor is blocked surgically or mechanically and anticancer drugs are administered directly into the tumor. This procedure permits a higher concentration of drug to be in contact with the tumor for a longer period of time. Code chemoembolization as Chemotherapy when the embolizing agent(s) is a chemotherapeutic drug(s) or when the term chemoembolization is used with no reference to the agent. Also code as Chemotherapy when the patient has primary or metastatic cancer in the liver and the only information about embolization is a statement that the patient had chemoembolization, tumor embolization or embolization of the tumor in the liver. However, if alcohol is specified as the embolizing agent, even in the liver, code the treatment as Other Therapy. Radioembolization is embolization combined with injection of small radioactive beads or coils into an organ or tumor. Code Radiation Modality as brachytherapy when tumor embolization is performed using a radioactive agent or radioactive seeds. Do not code presurgical embolization of hypervascular tumors with particles, coils or alcohol. These presurgical embolizations are typically performed to make the resection of the primary tumor easier. Examples where presurgical embolization is used include meningiomas, hemangioblastomas, paragangliomas, and renal cell metastases in the brain. Outcomes the outcomes data items describe the known clinical and vital status of the patient. Follow-up information is obtained at least annually for all living Class of Case 10-22 patients included in a cancer registrys database. Recorded follow-up data should reflect the most recent information available to the registry that originates from reported patient hospitalizations, known patient readmissions, contact with the patients physician, and/or direct contact with the patient. The paragraphs below describe the range of follow-up information that should be obtained. Therefore, it is important to continue follow-up efforts to be certain the necessary treatment information is collected. If the Type of First Recurrence [1880] is coded 70 (never cancer free), when the patient was last seen, but treatment was still underway, then check at follow-up to see whether the patient subsequently became cancer-free. Occasionally, if first course treatment ends due to disease progression, it may be the second course or subsequent treatment that results in a cancer-free status. If the Type of First Recurrence is coded 00 (became cancer-free and has had no recurrence), then continue to follow for recurrence and record the type and date when it occurs. In order to facilitate research on cancer recurrence, two new follow-up data items have been added for 2018 that allow for the recording of the last date on which the patients cancer status has been updated. Class of Case 00 patients that are not followed will have the most recent information as of the Date of Last Contact or Death [1750]. Once the patients death has been recorded and all care given prior to death is recorded, no further follow-up is performed. Case Administration Correct and timely management of case records in a registry data set are necessary to describe the nature of the data in the cancer record and to facilitate meaningful analysis of data, and it is necessary to understand each items respective purpose to ensure their accuracy and how to use them in facility analysis. In a registry with more than one abstractor or serving more than one facility, it will ordinarily be necessary to enter these three numbers only when they change. For these edits, an override flag can be set if, upon review, the unusual combination is verified as being correct. If correction of data entry errors resolves the problem, do not make an override entry. If no comment regarding the unusual circumstances can be found in the record, it may be necessary to check with the managing physician or pathologist to determine whether it is appropriate to override the edit. Because registries cover many years of cases, registry data will be recorded according to many different coding systems. These items are necessary for the analysis of registry data and for further conversions, so it is important that they be maintained accurately. Registry software operations differ, but typically the registrar will need to update the version of CoC codes, race coding system, site coding system, and morphology coding system whenever it changes. For newly abstracted cases, code version information will be applied both as the current and original code versions. When registry data are converted to an updated version for a coding system, the code for the current version should be updated automatically by the conversion. The registrar should ascertain that the correct version number is recorded for autocoding. If the results of either conversion were verified by review for some cases, the conversion flag will need to be updated to indicate that the case was reviewed. Rationale this data item protects the identity of the patient and allows cases to be identified on a local, state and national level. Code Definition (fill spaces) Nine-digit number used to identify the year in which the patient was first seen at the reporting facility for the diagnosis and/or treatment of cancer. Examples Code Reason 200300033 Patient enters the hospital in 2003, and is diagnosed with breast cancer. Rationale this data item is used to distinguish among cases having the same accession numbers, to select patients with only one malignant primary tumor for certain follow-up studies, and to analyze factors involved in the development of multiple tumors. If the patient develops a subsequent invasive or in situ primary tumor, change the code for the first tumor from 00 to 01, and number subsequent tumors sequentially. If the patient develops a subsequent non-malignant primary, change the code for the first tumor from 60 to 61, and assign codes to subsequent non-malignant primaries sequentially. However, do not reassign sequence numbers if one of those tumors becomes non-reportable later. The sequence number is changed when the patient with an in situ breast carcinoma 01 diagnosed June 13, 2003, is diagnosed with a subsequent melanoma on August 30, 2003. Sequence number assigned to the melanoma diagnosed on August 30, 2003, following a 02 breast cancer in situ diagnosis on June 13, 2003 A nursing home patient is admitted to the hospital for first course surgery for a colon adenocarcinoma. The patient has a prior history of three malignant cancers of the type 04 the registry is required to accession, though the patient was not seen for these cancers at the hospital. The sequence number assigned to a benign brain tumor diagnosed on November 1, 60 2005, following a breast carcinoma diagnosed on June 13, 2003, and a melanoma on August 30, 2003. Myeloproliferative disease (9975/1) is diagnosed by the facility in 2003 and accessioned as Sequence 60. A benign brain tumor was diagnosed and treated elsewhere in 2002; 63 the patient comes to the facility with a second independent benign brain tumor in 2004. Unaccessioned earlier brain tumor is counted as Sequence 61, myeloproliferative disease is resequenced to 62, and second benign brain tumor is Sequence 63. It can be used to reference a patient record and it helps to identify multiple reports on the same patient. The patient receives benefits under the spouses number and this is the spouses Social Security number. Rationale this data item is used by hospitals to differentiate between patients with the same last names. Examples Code Reason Michael Patients name is Michael David Hogan (leave blank) If patients first name is not known, do not fill in the space. Rationale this data item helps distinguish between patients with identical first and last names. Examples Code Reason David Patients name is Michael David Hogan D Patients name is Michael D. Hogan (leave blank) If patients middle name is not known or there is none, do not fill in the space. Rationale the address is part of the patients demographic data and has multiple uses. Rationale the city or town is part of the patients demographic data and has multiple uses. It indicates referral patterns and allows for the analysis of cancer clusters or environmental studies. Rationale the state of residence is part of the patients demographic data and has multiple uses. Rationale the postal code is part of the patients demographic data and has multiple uses. It will provide a referral pattern report and allow analysis of cancer clusters or environmental studies. Rationale the country code is part of the patients demographic data and has multiple uses. Patients with more than one tumor may have different countries at diagnosis, however. This publication is available in a reference library or can be accessed on the Internet through the U. Use of the pound sign (#) to designate address units should be avoided whenever possible. Rationale A registry may receive the name of a facility instead of a proper street address containing the street number, name, direction, and other elements necessary to locate an address on a street file for the purpose of geocoding. Rationale this data item provides a current city or town used for follow-up purposes. Rationale this item provides a current state of residence used for follow-up purposes. Rationale this data item provides a current postal code for follow-up purposes and should be updated. M6G2S8 the patients six-character Canadian postal code left justified, followed by three blanks.
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