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By: Bruce Alan Perler, M.B.A., M.D.

  • Vice Chair for Clinical Operations and Financial Affairs
  • Professor of Surgery

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0002711/bruce-perler

In order to cholesterol values normal discount zocor 40mg without a prescription select the best time for a particular patient to cholesterol test without blood cheap 10mg zocor amex receive her scan cholesterol medication generic names buy zocor 10 mg, health care providers must balance the types and accuracy of information to streefwaarde cholesterol ratio cheap zocor 10 mg be gained at different gestational ages with the financial reality of limitations to the number of scans many insurance carriers will pay for. The optimal timing for a single ultrasound examination in the absence of specific indications for first-trimester examinations is at 18–20 weeks of gestation. Each type of ultrasound examination should be performed only when indi cated and should be appropriately documented. A first-trimester ultrasound examination is an ultrasound examination performed before 13 weeks and 6 days of gestation. Scanning in the first trimester can be performed transab dominally or transvaginally. Indications for performing first-trimester ultra sound examinations are listed in Box 5-2. Second-trimester and third-trimester ultrasound examinations include the following three types: 1. Standard––Evaluation of fetal presentation, amniotic fluid volume, cardiac activity, placental position, fetal biometry, and fetal number, plus an anatomic survey. Limited––A limited examination does not replace a standard examina tion and is performed when a specific question, such as fetal presenta tion or amniotic volume assessment, requires investigation. Specialized––A detailed or targeted anatomic examination is performed when an anomaly is suspected on the basis of history, laboratory abnor malities, or the results of either the limited examination or standard examination. Patients with an abnormal fetal ultrasound examination result should be referred for evaluation and management of fetal anomalies to a health care provider who can accurately and thoroughly assess the fetus, communicate the findings to the patient and health care provider, and coordinate further man agement if needed. Some conditions may require the involvement of a maternal–fetal medicine subspe cialist, geneticist, pediatrician, neonatologist, anesthesiologist, or other medical specialist in the evaluation, counseling, and care of the patient. Fetal Magnetic Resonance Imaging If additional imaging modalities are required prenatally, magnetic resonance imaging may be chosen. Indications for First-Trimester Ultrasonography ^ • To confirm the presence of an intrauterine pregnancy • To evaluate a suspected ectopic pregnancy • To evaluate vaginal bleeding • To evaluate pelvic pain • To estimate gestational age • To diagnosis or evaluate multiple gestations • To confirm cardiac activity • As adjunct to chorionic villus sampling, embryo transfer, or localization and removal of an intrauterine device • To assess for certain fetal anomalies, such as anencephaly, in patients at high risk • To evaluate maternal pelvic or adnexal masses or uterine abnormalities • To screen for fetal aneuploidy (nuchal translucency) • To evaluate suspected hydatidiform mole American College of Radiology. The most common use of fetal magnetic resonance imag ing is to further delineate a fetal anomaly or rule out placenta accreta identified or suspected on ultrasound examination results. Although the safety of ultra sonography has been established, comparatively few studies have analyzed the safety of magnetic resonance imaging; however, this technology is being used with increasing frequency in pregnant patients, and there are no known risks. Routine Laboratory Testing in Pregnancy ^174^228^237^415^418^425 Certain laboratory tests should be performed routinely in pregnant women in order to identify conditions that may affect the outcome of the pregnancy for the mother or fetus. The results of these tests should be reviewed in a timely manner, communicated to the patient, and documented in the medical record. Abnormal test results should prompt some action on the part of the health care provider. Other laboratory tests that are routinely performed early in pregnancy are listed in Table 5-3 and Appendix A (College Antepartum Record). Recommended intervals for additional tests that are indicated after the first prenatal visit are detailed in the College Antepartum Record (see also Appendix A). Routine Laboratory Tests Early in Pregnancy ^ Laboratory Test Potential Actions for Abnormal Results Blood type There is no abnormal result here. D (Rh) type Patients who are Rh negative are at risk of developing isoimmu nization to D antigen. Weak rhesus-positive (formerly Du-positive) patients are not at risk of isoimmunization. Antibody screen Any positive antibody test result requires obtaining a titer and further action by the health care provider. Women who are of African descent, Asian, or Mediterranean should have a hemoglobin electrophoresis test performed to rule out thalassemia or sickle cell disease. Further testing may be warranted pending the results of these interventions and tests. False-negative serologic tests results may occur in early primary infection, and infection after the first prenatal visit is possible. Urine screening Obtain baseline screening for urine protein content (dipstick) to assess renal status. Routine Laboratory Tests Early in Pregnancy (continued) Laboratory Test Potential Actions for Abnormal Results Chlamydia Women found to have chlamydial infection during the first trimester should be retested within approximately 3–6 months, preferably in the third trimester. Gonorrhea Pregnant women found to have gonococcal infection during (when indicated) the first trimester should be retested within approximately 3–6 months, preferably in the third trimester. Uninfected pregnant women who remain at high risk for gonococcal infection also should be retested during the third trimester. Mantoux tuberculin skin Women with a positive or intermediate test result should be test or interferon evaluated with a chest X-ray and review of their pertinent gamma release assay history to determine the need for additional evaluation. Although this practice is recommended in the literature, more data are needed to determine the effectiveness of this strategy. Pregnant women at risk of hepatitis B infec tion also should be vaccinated (see also “Hepatitis B Virus” in Chapter 10). Women who are at high risk of syphilis, live in areas of high syphilis morbidity, or are previously untested should be screened again early in the third trimester (at approx imately 28 weeks of gestation) and at delivery, as well as after exposure to an infected partner. Some states require all women to be screened at Preconception and Antepartum Care 115 delivery. Infants should not be discharged from the hospital unless the syphilis serologic status of the mother has been determined at least one time during pregnancy and preferably again at delivery. Any woman who gives birth to a stillborn fetus should be tested for syphilis (see also “Syphilis” in Chapter 10). Women aged 25 years or younger and those at increased risk of chlamydia (eg, women who have a new sex partner or more than one sex partner) should be retested during the third trimester to prevent maternal postnatal com plications and chlamydial infection in the infant. Women found to have chlamydial infection during the first trimester should be retested within approximately 3–6 months, preferably in the third trimester (see also “Chlamydial Infection” in Chapter 10). Women aged 25 years or younger are at highest risk of gonorrhea infection as are those of black, Hispanic, and American Indian or Alaska Native ethnicity. Pregnant women found to have gonococcal infection during the first trimester should be retested within approximately 3–6 months, preferably in the third trimester. Uninfected pregnant women who remain at high risk of gonorrhea also should be retested during the third trimester (see also “Gonorrhea” in Chapter 10). A positive or intermediate test result should be evaluated by obtaining three induced sputum cultures or with a chest X-ray. These patients also should receive anti-D immune globulin at a dose of 300 micrograms prophylactically at that time. In most women, glucose screening should be performed Preconception and Antepartum Care 117 at 24–28 weeks of gestation and can be done in the fasting state or fed state. A 50-g oral glucose challenge test is given followed in 1 hour by a plasma test for glucose level. Different screening thresholds (ranging from 130 mg/dL to 140 mg/dL) are utilized, and those meeting or exceeding this threshold undergo a 100-g, 3-hour diagnostic oral glucose tolerance test (see also “Gestational Diabetes Mellitus Diagnosis and Management” in Chapter 7). Testing is conducted by obtaining a single swab specimen (not by speculum examination) from the lower vagina (introitus) and rectum (through the anal sphincter), placing the swab in transport media, and using selective broth media. This includes patients expected to have planned cesarean deliveries because onset of labor or rupture of membranes may occur before the recommended administra tion of prophylactic antibiotics. Antepartum Immunizations A routine assessment of each pregnant woman’s immunization status is recom mended, with appropriate immunization if indicated. There is no evidence of risk from vaccinating pregnant women with an inactivated virus or bacterial vaccines or toxoids, and these should be administered if indicated. However, live vaccines do pose a theoretic risk to the fetus and generally should be avoided during pregnancy. The benefits of vaccines outweigh any unproven potential concerns about traces of thimerosal preservative. When deciding whether to immunize a pregnant woman with a vaccine not routinely recommended in pregnancy, the risk of exposure to disease as well as the benefits of vaccination 118 Guidelines for Perinatal Care for reducing the deleterious effects on the woman and the fetus must be balanced against unknown risks of the vaccine. All vaccines administered should be fully documented in the patient’s permanent medical record. Additional information on immunization during pregnancy can be found on the College’s Immunization for Women web site, available at. The influenza vaccine should be recommended to all women who will be pregnant during the influenza season, regardless of their stage of pregnancy. Pregnant women with medical conditions that increase their risk of complica tions from influenza should be offered the vaccine before the influenza season. Administration of the injectable, inactivated influenza vaccine is considered safe at any stage of pregnancy. In contrast, the intranasal influenza vaccine contains a live attenuated virus and should not be used in pregnant women.

He started his preliminary part at the department of General Surgery at the ‘Onze Lieve Vrouwe Gasthuis’ in Amsterdam cholesterol test manchester purchase 40mg zocor visa, under the supervision of Dr cholesterol in eggs compared to meat buy generic zocor on-line. Extended recovery cholesterol blood test values purchase zocor cheap, limited care accommodation and mobile surgical units are models that will stimulate the further expansion of day surgery cholesterol medication that starts with f zocor 10 mg on-line. Day Surgery Development and Practice Chapter 4 | Day surgery procedures Dick De Jong, Juan Marin, Ricco Rinkel, Paul van Kesteren, Rui Rangel, Saskia Imhof, Ype Henry, Jacques Baart, Arthur de Gast, Seine Ekkelkamp, Chantal van der Horst, Jean de la Rosette and Pilar Laguna. New operative techniques such as endoscopic surgery and other types of minimally invasive surgery have been developed and surgeons have become increasingly aware of important issues such as patient and procedure selection and proper peri-operative care in ambulatory surgery. A knowledge and understanding of the problems and challenges of different procedures in a number of specialties are discussed in order to guarantee success. Selection should be evidence based wherever possible and based on the premise that hospital admission is only justifed where it will simplify management or improve outcome. Various predisposing factors, depending on the patient, the type of anaesthesia and the surgical procedure, have been identifed and will be addressed in this chapter. Day Surgery Development and Practice 11 2 Chapter 12 | Patient outcomes and clinical indicators for ambulatory surgery Paulo Lemos, Ana Margarida Regalado Patient outcome is one of the most important issues related to healthcare. This chapter reviews different perspectives analysing not only the traditional outcomes of mortality and major and minor morbidity, but also aspects that are essential for patient well being, such as functional health status, quality of life, and patient satisfaction. It covers guidelines to be followed in offce-based surgery including physical facilities, minimal standards to be followed and issues of registration and accreditation. The chapter includes specifc requirements for procedures performed under local anaesthesia alone, under local anaesthesia and sedation and under general anaesthesia. Its goals are: To stimulate the formation of National Associations for Ambulatory Surgery. This special occasion seemed an opportune time to produce an international book containing basic and pragmatic recommendations on the practice of ambulatory surgery. They have given freely of their time with the aim of promoting the spread of high quality ambulatory surgery. The initial objectives of this Association were to encourage the development and expansion of high quality day surgery and to promote education and research in the subject. Many of the contributors have frst hand practical knowledge on the subject and they are only too aware of the problems encountered by medical and nursing staff seeking to implement day surgery in their own hospitals. Here is one area of healthcare where people from different professional backgrounds may co-operate to provide a frst class patient service. However, despite its slow development in many European countries the past 20 years has seen day surgery become established practice. In my opinion day surgery should be developed on its own merits and the advantages to be gained include high volume patient throughput, low post operative morbidity and minimal infection rates. Surgical waiting lists may also be reduced and economic benefts may accrue especially if inpatient beds are simultaneously reduced. People are understandably confused by the conficting jargon on this subject and his section seeks to clarify the various terminologies. Briefy there is absolutely no reason why the wheel should be reinvented whether planning a day unit in Australia, Europe or America. The sound advice given in this chapter should smooth any diffculties encountered in establishing the majority of day units elsewhere. Experienced practitioners acknowledge that major and minor complications may arise after ambulatory surgery performed in the best of units. The selection of suitable day procedures is examined by Dr Dick De Jong (Netherlands) et al. Day surgery is not confned to minor procedures and there are now hundreds of operations which lend themselves for treatment on a day basis. Any successful day unit should pay attention to this most important aspect of day care. Day patients clearly require excellent post-operative analgesia and Dr Anil Gupta (Sweden) in Chapter 9 addresses the basis for successful pain management. Over the years early patient discharge from day units has produced relatively minor post-operative morbidity. All these aspects of day surgery should be carefully considered and the guidelines from Professor Chung should be implemented in every ambulatory setting. Chapter 12 written by Dr Paulo Lemos (Portugal) considers aspects of quality assurance. Certainly this publication deserves to be studied by both supporters and non-supporters of day surgery alike. Perhaps 100 years after the introduction of day surgery by Nicoll in Glasgow the subject may now be regarded seriously by all personnel involved in the training of future nurses, doctors and managers. The Association should encourage doctors from every country to improve their effciency and to monitor the outcome of their day programmes. Paulo Lemos is to be congratulated for gathering together such an excellent group of experts in day surgery. Varyingly, they looked at the quality, cost effectiveness and safety of day surgery, standard setting and the organisation and implementation of day surgery. An example of the latter is that in 2003 – 2004 the overall rate for day case inguinal hernia repair in England and Wales was 42% but activity in individual hospitals ranged from 5% to over 90%. Patients operated on in well managed day surgery units (see Chapters 7 and 11) receive treatment that is better suited to their needs allowing them to return home on the day of surgery and recover in a familiar home environment [22]. They can continue with their routine medication as before surgery, avoiding problems that may arise from prolonged hospitalisation. Readmission rates [20, 25] and contacts with the primary and community healthcare teams [26] are no greater than for the same procedures undertaken as an inpatient. There is less post-operative pain and also a reduction in the risk of thromboembolism associated with early ambulation [12]. The incidence of post-operative wound infection in day surgery patients is generally very low. This is especially true for children who are separated from their parents for as short a time as possible [28]. Apart from less anxiety for patients, there is also less stress for their relatives. For example, parental satisfaction following paediatric day surgery is particularly high [11, 31, 32]. For patients’ relatives, a saving in time, travel and sometimes in accommodation needed to visit a patient in hospital are obvious benefts [12]. Day surgery patients can choose a frm time and date for their operation in the knowledge that it will not be cancelled at the last minute due to unexpected emergency admissions as may happen with inpatient surgery. Advantages for hospitals Because the risk of last minute cancellations is minimal in dedicated day surgery facilities, hospitals can manage elective surgery more effciently. This allows more accurate scheduling than for inpatient work and makes more effective use of staff and facilities alike. In nationalised healthcare systems particularly, this facilitates the implementation of booking systems and greater patient choice [43]. By moving work to a self contained day unit, inpatient beds can be released for new more major surgical cases or other medical usage, or they can be closed with consequent savings [43]. Day surgery is cost effective compared with inpatient surgery as hospitalisation time is reduced, night and weekend staffng is not required, the hotel element of treatment is removed and capital facilities and staff are used more intensively and effectively. In 2005, the Department of Health introduced national tariff rates for procedures which, where relevant, are set between the cost of inpatient and day care treatment [43]. Advances in techniques and methods will allow more surgical conditions to be treated on a day basis in the future. The gynaecologists introduced these to the day unit undertaking frst diagnostic laparoscopy [52] and then other laparoscopic procedures such as tubal ligation, adhesiolysis, salpingostomy, ovarian cystectomy and laser ablation of endometriosis. In general surgery, laparoscopic cholecystectomy is becoming a standard day case procedure [53, 54, 55]. Other day case general surgery endoscopic procedures include hiatus hernia repair [56], inguinal hernia repair [57] and splenectomy [58]. Some totally new approaches to surgical problems have facilitated a move to day treatment. The move from inpatient to day surgery may not require any change in technique but rather a change in attitude of surgeons. The surgical horizons for day procedures are ever widening, but the move from inpatient work to day surgery should not be the only aim.

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The either of the two kinds: investigators for responsibility for the protection of research subjects must always rest clinical trials of medicinal products with the physician or other health regulated by a local or overseas care professional and never the governmental regulatory authority cholesterol levels new zealand purchase cheapest zocor, or for research subjects natural cholesterol lowering foods supplements buy generic zocor pills, even though they other human studies cholesterol stones buy zocor with visa. For clinical trials of medicinal products regulated by a local or overseas government regulatory authority cholesterol levels too high quality 20 mg zocor, a qualified physician entitled to provide health care under the laws of the country/province where the clinical trial site is located must normally act as the investigator. For other clinical trials, the investigator does not always need to be a qualified physician. Financial Conflict of Interest A conflict of interest can be defined as any situation in which an individual or corporation is in a position where personal or corporate interests could interfere with a professional obligation. The existence of a conflict of interest is not evidence of wrongdoing, and for many professionals it is virtually impossible to avoid having conflicts of interest. Someone accused of engaging in a conflict of interest may deny that a conflict exists because he/she did not act improperly. However, a conflict of interest can exist even if there are no improper acts as a result of it. The influence of the pharmaceutical industry on medical research has been a major cause for concern. Conflict of interest examples include but are not limited to: Salary or other payments for services. Financial conflicts of interest that may compromise the truthfulness of research and protection of participants are never welcomed, but they are now and again exposed in media reports. Institutions should have financial conflicts of interest policies and procedures in place to identify, prevent, disclose and manage conflict of interest. A clinical trial investigator is allowed to receive a reasonable financial compensation for the conduct of the trial itself. In General – How to Mitigate Significant Conflicts of Interest: Avoid them entirely or abstain from decisions where such a conflict exists; identify conflicts of interest by disclosing financial information; minimise problems with conflicts of interest through codes of ethics and peer review. Science, Ethics and Quality Assurance of Clinical Trials 81 Clinical Trial Insurance and Indemnity the purpose of an indemnity arrangement is to provide legal Press report, 2009: “A lawyer who helped protection for the participants in the win a multimillion settlement from a event of an unforeseen adverse university after the death of a study participant has since been known as an circumstance arising during the expert on how clinical trials go wrong; the course of a clinical trial. Among them was a case against a university on behalf of a as a result of providing woman that suffered temporary liver indemnification, the indemnifier can toxicity in a trial; a lawsuit against a obtain clinical trial insurance. It is cancer research center for allegedly important that clinical trial harming subjects in a study aimed at participants are insured to provide making bone-marrow transplantation safer; against a university on behalf of a treatment for adverse events linked to patient and her husband who claim they participation in a clinical trial (see text were harmed by an experimental box). Often health plan policies define medication to aid nerve regeneration; a clinical trials as experimental or suit against four university scientists that investigational. Under this scenario, alleges participants were harmed in a melanoma cancer vaccine trial; and a suit normal health insurance may not against a university for a schizophrenic cover the costs of what is actually patient who committed suicide after routine care, i. Clinical trials insurance should cover the following liabilities: Professional negligence in the course of conducting clinical trials. For non-industry-sponsored clinical trials, the institution or any other non-profit sponsor is responsible for the insurance coverage or indemnification. Injuries caused by the misconduct of the institutions may not be covered by the insurance or sponsor’s guarantee. However, there are 82 Reviewing Clinical Trials: A Guide for the Ethics Committee exceptions when non-industry sponsors are unwilling to take up the indemnity responsibility, which must be addressed in the informed consent. In some regions such as the European Union and Australia there is a basic requirement that no clinical trial may be held without providing both insurance and indemnification to cover the liability of the investigator and the sponsor. The basic principle is that clinical trial insurance/indemnity should be in place whether there is an industry or non-industry sponsor, but there are large geographic and local variations in liability/insurance policies, laws and requirements. Essential Clinical Trial Documents Essential documents are those enabling evaluation of the conduct of a trial and quality of the data. Filing essential documents at the investigative sites and sponsor sites also enables successful management of a trial. They are also those usually audited by the sponsor and inspected by the regulatory authority(ies). Science, Ethics and Quality Assurance of Clinical Trials 83 Interim or progress reports. Clinical Trial Registration Some countries and institutions have mandatory rules enforcing the registration of clinical research projects/clinical trials in a publicly available trials registry prior to the initiation of a trial. For instance, free web-based access to information about ongoing clinical trials is regarded as important for the public. It also provides a complete picture of past research, whether negative or successful. The past decade witnessed a clear trend that called for clinical trials to be registered. Two different organisations have enforced this development: regulatory authorities and scientific journals. Regulatory Authorities and Trial Registration: Since the late 1990s, drug regulatory authorities have put more emphasis on the need to publish essential information about ongoing clinical trials on publicly searchable trial registries. Each trial must be registered before its onset, and there is a penalty system in place for non-compliance. The policy became mandatory in July 2005, 84 Reviewing Clinical Trials: A Guide for the Ethics Committee and the registration must take place before the onset of patient enrollment. The main reason for introducing this policy is related to the so-called publication bias phenomenon; successful trials have a much higher likelihood to be published in a scientific journal than unsuccessful trials. The impact of publication bias is that the scientific literature is over-represented by “success stories” providing a distorted picture. Trial registries therefore allow identification of all trials, including those never published. The consequence of this trial registry publication policy is that an investigator may have a manuscript rejected on the grounds that it has not been properly registered before the initiation of the trial. It is the investigator’s prime responsibility to adhere to the publication policy. Investigator-initiated clinical trials – with the prime sponsor being a non-profit organisation – exceed the number of industry-sponsored trials. Many countries/regions have established their own trial registries, which may be preferred by some investigators. For instance, there are local trial registries in China, Australia and New Zealand, Germany, Hong Kong, the Netherlands, Iran, Japan, Pan Africa and Sri Lanka. Dissemination of Trial Results the sponsor, investigator and institution have an ethical responsibility to make reasonable efforts to publicly disseminate the results of clinical research in a timely manner. However, it has to be accepted that negative research results are less often submitted and accepted for publication in international medical journals. Proper dissemination of the trial be paid to trials that may include results is, in the first instance, an vulnerable subjects. Some further general details document(s) adequately addresses relevant ethical concerns and are provided on the following pages. Payments to a subject should be prorated and not wholly contingent on completion of the trial by the subject. However, the interpretation and implementation of those and other guidelines are highly dependent on local laws and guidance. A balanced ethics review approach starts with assessment Approval Time of the risk of harm and potential benefits associated with the research (see illustration). An expedited review is by definition completed more rapidly than a full board review, since the type of review the concept of “minimal risk” provides selected is related to the anticipated risks of harm for the the foundation for a balanced review, and participants. Parts of the magnitude of harm or discomfort text are included as they are related to anticipated in the research are not greater clinical trials on drugs and devices. However, it required to be included in the does specify that each protocol must be continuing progress report. A scientific review judges the who completed the trial; number of importance of the research question and withdrawals from trial to date, due validity of the methodology; this can only to (a) withdrawal of consent, (b) be assessed by those familiar with the loss to follow-up, (c) death; total disciplines and methods of the proposed study withdrawals; number of treatment failures to date, due to (a) research. If yes, give trials overseen by regulatory authorities details; do you plan to increase the planned recruitment of participants will have already been subject to scientific into the study Any protocol raising many minor concerns or a few major concerns should either be Serious breaches of the protocol or Good Clinical Practice: Have any rejected or subject to revision and serious breaches of the protocol or subsequently re-assessed. Are there any ethical issues on Such trials could also put participants at which further advice is required

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There was a weak link ossification cholesterol lowering medication over the counter proven 40mg zocor, omarthritis cholesterol test price buy zocor 10 mg low cost, gonarthrosis qrisk cholesterol ratio discount zocor 40 mg with visa, heel spurs and for non-Hodgkin lymphoma among men although hidradenitis suppurativa cholesterol never sleeps buy 10mg zocor visa. However, often the numbers showed linear dose–response curves even up to 60 involved are large, making estimates somewhat Gy; the only exception was thyroid cancer, which more reliable. They also confirmed bomb form a very large group, which has been that the risk varied according to the tissue of origin of continuously monitored within the lifespan study the second cancer. This persisted beyond 40 years of follow Tissue-specifc cancer risks following up and was modified by age at treatment. However, since some childhood cancers have an underlying germline mutation, this may also contribute to the observed increase in the previous section has discussed the variety of susceptibility to second malignancies. However, there is still considerable the number of malignant melanomas was unaffected. Overall the authors considered the excess risk of There are many limitations inherent in these malignant skin cancers to be very small. However, there was only one exposed to multiple fluoroscopies, have not shown any death in this group and it has been advised that with significant increase in skin cancer risk. A nested case treatment, although the trends were only marginally 31 control study of secondary sarcomas (105 cases, 422 significant. The secondary sarcomas therefore it was advised that it should be treated with occurred at a median of 11. Five 100 centimetres (cm) skin area treated to a mean excess cases have been documented after a mean dose of 3 Gy have indicated a lifetime risk of local 33 total-body dose of 0. In skin fields not exposed to sunlight, the risk In a key study published in 1965, the cause of death would be smaller by about one order of magnitude. There were 40 leukaemia deaths, which was they presented at a younger age, compared to 70% greater than expected. The incidence of radiation-induced commonly reported tumour type although the risk is astrocytoma was slightly lower than in a control small. The overall incidence was not 15 years’ follow-up, and 56, 788 patient-years of data. For adults >40 years, there is no evidence However, in these situations it has been suggested that of an increase in risk. Most studies show that for women, exposure to breast Although the mean follow-up was 12. Nevertheless, following exposure to higher therapeutic doses Further analysis of this cohort suggested that the (such as those for thyroid eye disease, pituitary mechanism underlying the risk may relate to genomic instability at an early stage of tumour development. The risk factor for breast cancer needs to be assessed for women exposed in specific circumstances Thyroid cancer where the breast is directly affected; the effective dose concept which applies to a general population the thyroid of young children is the most 10 is unhelpful in this situation. Several estimates of the radiosensitive organ with regard to radiation risk versus benefit of mammography screening are carcinogenesis; a risk that falls rapidly with increasing available, however, these are very dependent on the age. It has been also been found to show a small but measureable estimated that after a mean lung dose of 1 Gy the increase. Sadetzki S, Chetrit A, Freedman L, Stovall M, unique human population: lessons learned from Modan B, Novikov I. Long-term follow-up for the atomic bomb survivors of Hiroshima and brain tumor development after childhood Nagasaki. Disaster Med Public Health Prep 2011; exposure to ionizing radiation for tinea capitis. Sadetzki S, Chetrit A, Lubina A, Stovall M, of leukaemia, lymphoma and multiple myeloma Novikov I. Solid cancer incidence in atomic bomb A reanalysis of curvature in the dose response for survivors exposed in utero or as young children. Second malignant neoplasms following Int J Radiat Oncol Biol Phys 2013; 85(2): 451–459. Berrington de Gonzalez A, Gilbert E, Curtis R considering radiation effects in the cell and et al. Second solid cancers after radiation therapy: possible implications for cancer therapy: a a systematic review of the epidemiologic studies collection of papers presented at the of the radiation dose–response relationship. Radiother Oncol breast tumors after radiotherapy for a first cancer 2005; 76(3): 270–277. An international collaboration among Second primary neoplasms in patients with cancer registries. Incidence of malignant factors associated with secondary sarcomas in skin tumours in 14, 140 patients after grenz-ray childhood cancer survivors: a report from the treatment for benign skin disorders. Mortality from cancer and A report of a Task Group of Committee 1 of the other causes after radiotherapy for ankylosing International Commission of Radiological spondylitis. Tumours and other diseases following childhood X-ray treatment for ringworm of the scalp (Tinea capitis). Malignant of intracranial meningiomas in Nagasaki atomic transformation of a vestibular schwannoma after bomb survivors. Minim Invasive Neurosurg 2005; 48(6): the influence of pretreatment characteristics 334–339. Int J Radiat Oncol Biol Phys 2009; after exposure to external radiation: a pooled 75(5): 1408–1414. Dose and time-response for breast cancer risk J Natl Cancer Inst 2006; 98(21): 1528–1537. Breast cancer risk after radiation treatment at infancy: potential consequences of 51. Rowe J, Grainger A, Walton L, Silcocks P, Radatz radiation-induced genomic instability. Otolaryngol Clin North Am 2009; Malignant neoplasms after radiation therapy 42(4): 717–729. Long-term safety and efficacy of Radiation and smoking effects on lung cancer stereotactic radiosurgery for vestibular incidence among atomic bomb survivors. Head and neck Head and neck Watch and wait paraganglioma One series documents the outcomes of expectant management with a long follow-up. Local control rate was blood vessel involvement, and a propensity for skull 87% with a high rate of reported complications of 46%. The excellent results reported in external beam and radiosurgery series has challenged this approach. The mean Radiosurgery is an appealing treatment modality for the duration of follow-up was 113 months. Most series reported single including sensorineural hearing loss and institution studies with limited numbers and follow-up. Although variably reported, documented Stereotactic radiosurgery: the review identified complications appeared infrequent. The total number of cranial nerve palsies pre and post radiosurgery was 306 and 279 respectively. Comparison of surgery, Ivan et al published a meta-analysis of tumour control external beam radiation therapy rates and treatment-related morbidity for glomus and radiosurgery jugulare tumours with 869 patients meeting the inclusion criteria. The majority of reports are single centre subtotal resection in addition to postoperative retrospective series with variable follow-up. In addition, radiosurgery in 97 patients and radiosurgery alone comparison between surgically and non-surgically in 339 patients. Tumour control rates were 86%, 69%, treated patients is difficult as historically, non-surgical 71% and 95% respectively. The meta-analysis also approaches were considered for advanced lesions, examined the rates of cranial neuropathy following recurrent disease or poor surgical candidates. Tumour control was achieved in surgery have advanced rapidly and older series are 78% of patients. Oncologic outcome in as the primary treatment for new and recurrent surgical management of jugular paraganglioma paragangliomas: is open surgical resection still and factors influencing outcomes. A meta-analysis of tumor control rates and Which paragangliomas of the head and neck have treatment-related morbidity for patients with a higher rate of malignancy Clin Otolaryngol 2007; Irradiated paragangliomas of the head and neck: 32(1): 7–11. Does catecholamine secretion from and neck paragangliomas influences the head and neck paragangliomas respond to treatment proposal. Radiosurgery Does intervention improve the natural course of of glomus jugulare tumors: a meta-analysis.

Again Prof Seegenschmiedt found that the results with the shorter interval were not so good as with the 12 weeks plus or minus 2 weeks cholesterol medication in pregnancy generic 40 mg zocor amex. He does schedule a longer interval in some cases when a patient cannot return in 3 months cholesterol ratio the lower the better order zocor without prescription. Splitting the responsibility between clinics cannot work too well if there are questions that need to cholesterol medication heartburn purchase zocor 10 mg on-line be asked later on cholesterol and vitamin d order zocor 20mg on line. To expect that all the nodules, cords and pits in the hand will totally disappear with radiation therapy is a mistake. I did however as a "bonus" get improved flexibility in my right little finger as shown in the photos. The nodules on my right hand seem flatter and smaller and less visible but are still there. It’s important to make accurate records of the disease when first detected, before treatment, and on a quarterly basis. The first thing Prof Seegenschmiedt will ask is what date/year did you first see the nodules/cords Miami Conference 2010 Prof Seegenschmiedt Presentation 15 To me seeing Prof Seegenschmiedt give a lecture to a conference on Dupuytren’s is very informative and also gives a lot of confidence in his first-hand knowledge. By sending Prof Seegenschmiedt photos of your hands and also your situation he will give you an opinion based on what he can tell from the information you give. In February 2014 it was mentioned on the forum that that Prof S had not responded for 3 weeks. This turned out to be because he had been away on business and replied on his return. Sometimes the radiation technicians came across as more focused on getting the procedure going and pressing the button than getting the hand position right. I even went to the extent of having Staples (positioned halfway along the walk) print out both the photos of the hand mark ups and also the hand under the lead cut out for reference during the week. Eaton has presented a range of photos of later stage Dupuytren’s (way beyond the stage in which Radiotherapy would be used). After visiting Prof S I then went to my physiotherapist and showed him an invisible area near the base of my thumb which Prof S had pointed out. There is a possibility that the "drawing on the hands ceremony" actually undermines and unnecessarily reduces the result of the treatment given. This information is misleading giving the impression it is a brand new experimental treatment and that there is no long term data. Professor Seegenschmiedt and other German doctors have been treating with radiation and publishing documents in relation to early stage Dupuytren’s for over 25 years. Also the patient will be told to wait until deformation has reached 20-30 degrees which is the wrong answer! They have provided incorrect information on their website, in stating only one phase of treatment is necessary in most cases. The view held by the International Dupuytren’s Society is that there has never been a documented case of cancer following this treatment. As Prof Seegenschmiedt describes this as a "theoretical risk" and one which must be stated up front, prior to treatment and signing treatment consent. Beyond Radiation Treatment As patients, our mission should be to do our own research relevant to our own particular case, knowing that a mix of different treatments might even be necessary over the long term. It might be that Radiation Therapy is not for you or that you are at a later stage. There is a spirit of friendliness and good will and the patients say "hello" when a new face arrives in the waiting room. On each visit to the Strahlenzentrum it is important to "check in" at reception otherwise you will never be called. Once called there is no hurry because as soon as you have got down the stairs you are either shown a seat to sit on, or in the case of my first visit a cubicle to sit in. Some of the other patients are not at all well and they would probably need a fair bit of that 5 minutes to get down to the treatment area. On the first treatment they take a photo of the hand position under the lead cut out. Prof S provides a photo of the hands marked up at consultation time but if you want a picture of the hand under the lead cut out bring your own camera. Once the photos were taken the technician left the room and then pressed the button to start the radiation. The technicians are getting a continuous flow of Dupuytren’s patients throughout the year and it comes across that they do a lot of hands, so they are very familiar with the set up and the procedure. Having said that there is a note below about double checking the hand position yourself, which only takes a few seconds. In the past apparently there have been enough Dupuytren’s patients for a "group photo". I found it helpful talking face to face with other patients as it gave further insights into the disease. The idea of putting this link in is just to show the building and Prof Seegenschmiedt. The reception area shown 17 seconds into the video is where I checked in each day. The consulting room shown 33 seconds into the video is where I had my meetings with Prof Seegenschmiedt. One of the technicians who treated me on my visits makes an appearance 45 seconds into the video. Although Prof Seegenschmiedt speaks German in this video, his English is fluent as shown in the Dupuytren’s 2010 Symposium conference video. Hotels Near to the Strahlenzentrum, Maps, and Arriving from the Airport the next section discusses the various hotels and their position relative to the Strahlenzentrum. Also the maps give an idea as to where the hotels are relative to the airport and the Strahlenzentrum. Mercure Hamburg Airport Hotel (after April 1st 2014 "Leonardo Hotel Hamburg Airport") Hotel Address: Langenhorner Chaussee 183, Hamburg. A recent visitor has noted that that the name of this hotel will change after 1st April 2014 to: "Leonardo Hotel Hamburg Airport". The Mercure Hamburg Airport Hotel was suggested by previous travelers due to it being the closest hotel to the Strahlenzentrum. The walk from outside the Mercure Hotel to the Strahlenzentrum usually took me 17 minutes. When I arrived at the Mercure I was allowed to book into the room at 11am, although booking. I asked the Mercure receptionist to re-confirm my appointment time by ringing the Strahlenzentrum and I think this helped them locate me on their system. On the second week of treatment on the Monday I did the same thing asking reception to ring the Strahlenzentrum to confirm the appointment time which was just as well as the appointment time was 5:50pm. On the second time around I was given the option of the same room on the floor above reception. The arrow (on the pavement/sidewalk) in the picture above shows the direction for the Strahlenzentrum which is on the same side of the road as the Mercure Hotel. There are two menus for evening meals and you can eat in the restaurant, the bar or on the patio outside if the weather is ok. In the evening I ate up by the bar where it was quite sociable and the barman Saks from Thailand is friendly and will take your food order from either menu. There is a free wireless internet connection in the lounge area near to the reception. Although other reports said there is a pool, it actually closed down a few years back. The courtesy bus runs all day; however, it services several hotels and has only a small Mercure sticker on the right (passenger) side of the bus and works on a booking system. If you do use this service, book with reception for the set time and then wait outside looking for the bus with the stickers on the side. To book the Mercure courtesy bus from the airport after arriving, go to the airport information on the upper level (departures). There is a free phone at information where the hotel number is stored in the phone. Arriving at the airport I booked this service but never saw the bus, so after a wait took a taxi from the upper level instead. The "Airport Plaza" sign on the departures level (upper level) is the standard meeting place for courtesy buses.

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