Know that obesity increases the risk of Blount disease and of slipped capital femoral epiphyses i hiv infection rates europe symmetrel 100mg sale. Know that obesity increases the risk of non-alcoholic steatohepatitis (non-alcoholic fatty liver disease) 4 antiviral quotes buy cheap symmetrel 100 mg on-line. Understand the role of leptin in the control of pubertal onset in boys and girls 5 hiv infection control buy symmetrel with paypal. Understand the role of the regional distribution of body fat on serum leptin concentration b stages of hiv infection medscape buy symmetrel 100mg online. Know that ghrelin stimulates the hypothalamus to direct an increase in energy production. Know the role of melanocortin receptor mutations in the pathogenesis of severe obesity F. Recognize that anorexia nervosa is considered to be primarily a psychiatric disease with serious endocrine and metabolic consequences and approximately 15% mortality b. Know the sequence of endocrine changes that result from weight regain in anorexia nervosa. Know that treatment of anorexia nervosa is primarily psychologic counseling and behavioral modification coupled with nutritional rehabilitation f. Know the appropriate therapy of the decreased bone mineral concentration associated with anorexia nervosa h. Know that ballet dancers, wrestlers, and long distance runners are at increased risk for eating disorders j. Know the components, diagnostic criteria, and treatment of the female athlete triad 2. Be familiar with the pathophysiology of bulimia and the effects of laxatives and diuretics in these patients b. Know that bulimia nervosa is commonly associated with impaired growth and undermineralization of bone in adolescents 7. Understand the mechanism and genetic regulation of the differentiation and growth of external genitalia in the fetus including the tissues of origin 2. Know the role(s) of key genes on the X and Y chromosomes for gonadal differentiation 5. Know the gene maps of the X and Y chromosomes and relationships between genes on the respective chromosome 6. Understand that germ cells migrate to the urogenital ridge to form the undifferentiated gonad b. Know the relationship of egg meiotic phases to ovulation and the developmental stages at which the phases are reached b. Know that two X-chromosomes are necessary for maintenance of primordial follicle c. Know the changes in the number, size, and composition of ovarian follicles with age d. Know the hormonal determinants of antral follicle formation and follicular growth. Know the determinants of spermatogenesis and the developmental stages at which various phases are reached b. Know the hormonal regulation of Leydig cell steroidogenesis and the rate limiting steps d. Know the steps of testicular differentiation and the developmental ages at which they are reached 4. Know the pros and cons of chorionic gonadotropin or gonadotropin analog treatment of cryptorchidism and the age at which it may be indicated d. Know the pros and cons of surgical treatment of cryptorchidism and the age at which it is indicated. Know the role of measuring testicular products in the diagnosis of cryptorchidism versus anorchia g. Know that the contralateral testis in a patient with an undescended testis might itself be abnormal h. Recognize how compensatory hypertrophy in a testis relates to the function of the other testis i. Know that cryptorchidism may lead to testicular carcinoma, the relative incidence of such carcinoma, and recommend monitoring c. Know that the Mullerian duct differentiates to the uterus, fallopian tubes, and upper vagina 3. Understand the paracrine actions of anti-Mullerian hormone during male reproductive development and the time at which it occurs d. Know the paracrine role of testosterone in normal and abnormal Wolffian duct differentiation b. Know that the Wolffian ducts differentiate into the rete testis, efferent ducts, epididymis, vas deferens, and seminal vesicle 2. Know the role of testosterone and dihydrotestosterone in pubertal development of the Wolffian derivatives. Know the embryonic precursors of the male and female external genitalia and the mechanism and timing of their differentiation 2. Know the role of dihydrotestosterone in the differentiation of male external genitalia f. Know the effects of androgens on the pilosebaceous unit on the scalp versus in the pubic and axillary area 2. Understand the physiologic and clinical importance of free (unbound) sex steroid hormone concentrations b. Know the organs that produce testosterone in men and women and the relative proportion secreted by each organ 2. Know the relative roles of secretion and peripheral metabolism in the production of testosterone in men and women 3. Know the structure and function of the androgen receptor and the steroids to which they respond 9. Know patterns of fetal concentrations of estrogens, progestins, androgens, and gonadotropins b. Know the organs that secrete estradiol in males and females and the relative proportion secreted by each organ 3. Know the role of secretion relative to peripheral metabolism in production of estradiol in men and women 4. Know the intracellular signaling pathway of estrogen action within target cells 7. Know the relationship of progesterone secretion to granulosa cell luteinization 2. Know the relative androgenicity of the synthetic progestins used in oral contraceptives d. Know the secretion of androstenedione relative to testosterone by the interstitial cells of ovaries and testes 2. Know the relative contribution of the peripheral metabolism of androstenedione to the synthesis of testosterone and estrone. Know the control of anti-Mullerian hormone and changes in concentrations throughout development c. Know the control of inhibin/activin secretion and changes in concentration throughout development c. Know that genetic determinants for stature and ovarian development are coded by different genes on the X-chromosome 2. Know the different karyotypes that can lead to Turner syndrome and the resulting clinical features 4. Know the risk of malignant degeneration of gonads in patients with gonadal dysgenesis and Y chromosomal material and the methods of identifying Y material 5. Know the pattern of gonadotropin secretion in gonadal dysgenesis as a function of age in girls and the reason that it differs from a normal girl c. Know the time course of changes in ovarian morphology in the development of ovarian failure, including the decline in ovum at various stages 2.
Medical insurance system in Japan (universal health insurance system) Midori Tsuneishi Japan Dental Association Research Institute Year and Month of Medicine Dentistry Revision 1961 4 Establishment of the public health insurance for the whole nation system 7 12 hiv infection onset buy symmetrel 100 mg mastercard. The dentistry0 Hospitalization-related medical fee items including the nursing specific technical fees are increased hiv infection process buy symmetrel 100 mg cheap. Medical insurance system in Japan (universal health insurance system) Year and Month of Medicine Dentistry Revision 0 the first-visit fee kleenex anti viral walmart purchase symmetrel 100mg without a prescription, the after-hours premium fee highest hiv infection rates world cheap symmetrel 100 mg otc, the X-ray diagnosis fee, and the charge for injections, etc. Meanwhile, the medical fees for mentally and physically disabled for artificial kidneys are specified separately for materials or implants and persons for whom dental care would techniques. The fees for items related to rehabilitation are substantially be very difficult is established in increased, resulting in an approximately 80% increase in the charge for order to secure dental care for these physical therapy. The age of infants subject the instruction fee for chronic diseases, the charge for cooperative to an additional medical fee is raised instruction by research hospitals, and other management charges from less than 4 years old to less than are significantly increased to enrich the primary care experience. Dental fees are revised injured individuals are established in order to reduce copayment, thereby in accordance with the revisions in dealing with the amenity bed issue and the issue of private nursing care. The medical management restoration and dental prostheses is fee during hospitalization and hospitalization costs are increased. An evaluation for glazing and hardening material for is conducted on diseases subject to the instruction fee for chronic diseases resin surfaces are first established. New medical technologies such as digital angiography (computed angiography system) are introduced. The charge for instruction for 4 to 5 hours are increased, while the points for 5 hours or more are on/management of pyorrhea and decreased. The fees for multiple-item examinations which can be performed automatically are decreased. Emphasis is placed on the evaluation of fees for inpatient care at hospitals and outpatient care at clinics. The fee for provision of patient medical information is introduced and the term is changed from "the fee for introducing hospitalized/ discharged patients" in order to develop a community healthcare plan to form functional partnerships between hospitals (for hospitalization) and clinics (for non-hospitalization care). A medical management fee for hospitalization in designated geriatriccare hospitals is established as a part of the medical fee for the elders. Efforts including the appropriate evaluation of basic nursing are made to ensure stable and effective provision of nursing services. In addition, efforts are made to rationalize medical fees and drug costs by promoting proper use of drugs and appropriate separation of dispensaries from medical practices; the method for determining drug prices is reviewed. Medical fees for the areas with the highest needs, including acutephase medical care, pediatric care, psychiatric care, and treatment for periodontal diseases, etc. Because patients in Japan stay in hospital longer than those in foreign countries, efforts are made to reduce long-term hospitalization and to enrich services for acute-phase short-term hospitalization. In addition, medical technologies are evaluated to make medical services more efficient and a trial implementation of the fixed medical fee payment system for hospitalization is initiated in national hospitals in an attempt to review and modify the medical fee system. Long-term hospitalization practices are evaluated and examinations and imaging diagnoses are rationalized to save financial resources, evaluate acutephase medical services, and promote provision of medical information to patients. Various practices are evaluated and reviewed, including: (1) Evaluation based on the degree of difficulty, time required, technical performance, etc. Adjustments are made to evaluate and appropriately reflect the costs borne by medical institutions, including: (1) Evaluation depending on characteristics of diseases, etc. Medical insurance system in Japan (universal health insurance system) Year and Month of Medicine Dentistry Revision degression, and limited calculation, is conducted as a first step toward For some dental practices, the simplifying and rationalizing the system. Other rationalizations are made for specific areas of interest, including reviewing the medical fee system in establishing the special provisions on oxygen price and the additional fee consideration of the specific needs of for hospitalization on remote islands. Viewpoints for exploring ideal methods of evaluation in specific medical areas that warrant a stronger focus in the future in Japan: (1) Evaluation of pediatric care and pediatric emergency care; (2) Evaluation of obstetric care; (3) Evaluation of anesthesia; (4) Evaluation of pathological examinations; (5) Evaluation of acute-phase medical care during hospitalization; (6) Evaluation of the introduction of information technology for medical care; (7) Evaluation of medical care safety measures; and (8) Evaluation of medical techniques. Viewpoints for promoting division/cooperation of medical care functions to help provide efficient, high-quality medical care: (1) Promotion of efficient, high-quality medical care during hospitalization; (2) Exploring a method for evaluating medical service quality; (3) Evaluation based on medical care needs; (4) Promotion of home medical care; (5) Support of home healthcare for mentally disabled individuals; (6) Enrichment of dental care; (7) Review of the dispensing fee. Viewpoints for exploring ideal methods for evaluation in fields for which the allocated medical cost can be streamlined: (1) Updating practices with the use of new techniques; (2) Promotion of the use of generics, etc. Medical fee adjustments for late-life older patients: (1) Medical care during hospitalization; (2) Home medical care; (3) Outpatient medical care; and (4) Terminal medical care. Abolishment of the medical fee system with a particular focus on those 75 and older. Better evaluation of emergency medical care: (1) Enrichment of emergency medical care during hospitalization; and (2) Evaluation of emergency care in cooperation with the community. Medical insurance system in Japan (universal health insurance system) Year and Month of Medicine Dentistry Revision 2. Better evaluation of obstetric/pediatric care: (1) Better management of high-risk pregnant and parturient women; (2) Evaluation of intensive care for newborns; and (3) Enrichment of pediatric care during hospitalization. Reduction of burden on hospital doctors: (1) Reduction of burden on hospital doctors; (2) Evaluation of medical care during hospitalization under a careful nursing system with a sufficient number of staff members; and (3) Evaluation of team medical care provided by various professionals. Appropriate evaluation of operation fees: (1) Increase in operation fees utilizing the draft proposal of "Gaihoren" (Association of Surgical Specialties Social Insurance Committees); (2) Increase in the fees for pediatric operations; and (3) Introduction of novel medical techniques into the health insurance system. Promotion of bill issuance: (1) Promotion of bill issuance; and (2) Support with medical fees related to bill issuance. Reduction of burden on heavily burdened medical workers: (1) (4) Promotion of team medical care Promotion of emergency/perinatal stage medical care; (2) Measures to involving hospital pharmacists and improve the working environment for hospital workers; (3) Division dentists. Division of functions of medical care and nursing care and cooperation between these functions; enrichment of home care: (1) Promotion of division of functions of medical institutions responsible for home care and cooperation among them; (2) Enrichment of overall medical care including terminal care; (3) Enrichment of home dentistry and home (3) Enrichment of home dentistry medication management; and (4) Enrichment of home-visit nursing care and home medication management; and smooth cooperation between medical care functions and nursing care functions. Lying down can make your sinuses feel more stopped-up, so try lying on the side that lets you breathe the Current health concerns best. Illnesses for which another healthcare professional is treating or has treated me Sip hot liquids and drink plenty of fluids. Apply moist heat by holding a warm, wet Current medications and supplements towel against your face or breathing in steam through a cloth or towel. The best way to take my medications Don’t use a nasal spray with a decongesHow my diet may affect my medications tant in it for more than 3 days. Avoid alcohol, which can worsen swelling Changes in my diet It is a common condition with more than 24 million in the sinuses. Some people have Treatment for sinusitis growths called polyps (say: “pawl-ips”) that block depends on the cause. Various Over-TheCounter medications may When sinusitis is caused by a bacterial or viral help relieve your symptoms. You can use a saline nasal spray, which will the cold virus attacks the lining of your sinuses, clean out your nasal passages and help clear causing them to swell and become narrow. Your doctor may recommend a prebody responds to the virus by producing more scription nasal spray that helps treat inflammamucus, but it gets blocked in your swollen sition. The bacteria can cause a sinus Saline sinus rinses often bring relief to patients infection. Decongestants Sinuses are the air chambers in the bone beare generally only recommended for short-term hind your cheeks, eyebrows and jaw. Tiny Over-the-counter pain relievers such as acetahairs called cilia (“sill-ee-ah”) sweep mucus minophen. Advil, out of your sinuses so it can drain out through What are the symptoms of sinusitisfi The symptoms include: If your case of sinusitis is very severe and your What is sinusitisfi You may take an nose and between the eyes Sinusitis (“sine-you-site-iss”) is the name antibiotic for 10 to 14 days, but you will usually Headache start feeling better a couple of days after you for a condition in which the lining of your Fever start taking it. Nasal congestion exactly as your doctor tells you and to continue taking it until it is completely gone, even after What causes sinusitisfi Cough, which may be worse at night Anything that causes swelling in your siBad breath (called halitosis) If allergies are causing your sinusitis, your doctor nuses or keeps the cilia from moving mumay treat the allergy. Pediatric Emergency Medicine Each Pediatric Emergency Medicine exam is built to the same specifications, also known as the blueprint. This blueprint is used to ensure that, for the initial certification and in-training exams, each exam measures the same depth and breadth of content knowledge. Emergencies Treated Medically 17% 17% Emergencies Treated Surgically or Requiring 4. Know the use of pharmacologic agents in the management of patients in respiratory failure c. Know the use of basic airway management techniques in patients with respiratory failure. Know the use of advanced airway management techniques in patients with respiratory failure f. Know the applications, indications, and complications of invasive monitoring in shock d.
Generic symmetrel 100mg with visa. Bacteriophage and HIV.
Yoong W hiv infection woman to man generic symmetrel 100mg on line, Ridout A hiv infection rates by county buy symmetrel line, Memtsa M antiviral herpes medication cheap symmetrel 100mg visa, Stavroulis A hiv infection in zimbabwe buy 100mg symmetrel fast delivery, placenta-prevalence, risk factors and antenatal suspicion: Aref-Adib M, Ramsay-Marcelle Z, et al. Application of results from a large population-based pregnancy cohort uterine compression suture in association with intrauterstudy in the Nordic countries. The Netherlands: a nationwide population-based cohort Obstet Gynecol 1985;66:353–6. J Perinat Med dosis, hypocalcemia, anemia, and hypothermia on func2014;42:745–53. Role of Hayman technique and its modiTransfusion-related adverse reactions: From institutional fication in recurrent puerperal uterine inversion. Acta Anaesthesiol Scand life-threatening primary postpartum hemorrhage with a 2007;51:929–36. In situ simulation: idenrous sulfate for antenatal and postpartum iron deficiency tification of systems issues. American College setting for acute obstetric emergencies: a systematic of Obstetricians and Gynecologists. Preventive Services Task Force: I Evidence obtained from at least one properly designed randomized controlled trial. Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories: Level A—Recommendations are based on good and consis tent sci en tif ic evidence. Level B—Recommendations are based on limited or inconsistent scientific evidence. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. Separated from whole blood and frozen at 20 to 30 within 6-8 hours of collection! Provides: plasma, albumin, all coagulation factors (labile, Vit K dept), alpha-macroglobulins! Hemolytic reactions: Fever, tachycardia, weakness, muscle tremors, vomiting, collapse, hemoglobinemia, hemoglobinuria! Dark brown to black supernatant plasma: digested hemoglobin from bacterial growth! What s in it: Plasma, albumin, all coagulation factors (Vit K dependent factors, labile coagulation factors), and alpha-macroglobulins! Infections Prophylaxis, Pre-emptive Therapy, and Intravenous Immunoglobulin 10-22 A. General Guidelines for Prevention of Osteoporosis including during treatment with corticosteroids 52-57 A. Voriconazole, posaconazole and the other azoles should be used with caution during treatment with sirolimus. Fasting lipids profile is recommended periodically due to increased risk of cardiovascular disease and increased risk of metabolic syndrome in transplant survivors. In patients receiving sirolimus, tacrolimus or cyclosporine, monthly fasting lipids profile is recommended until acceptable values are achieved, thereafter, monitoring may be decreased to every 3 to 6 months, or more often if clinically indicated. Testing should include evaluation of morphology and immunophenotyping, cytogenetics and molecular testing as applicable. Bacterial, fungal and viral infections occur most frequently during this time interval. If desensitization is not feasible, Dapsone should be administered at a dose of 50 mg p. Atovaquone: Dosing Adults and pediatric patients > 50 kg: 1500 mg oral suspension, once daily, to be taken with a meal. Pediatric patients less than or equal to 50 kg: 30 mg/kg, once daily, to be taken with a meal. Acyclovir should be administered according to the following regimen (assuming adequate renal function): fi Weight > 40 kg, receiving < 0. For patients < 40 kg, 2 the dose of acyclovir should be 300 mg/m (maximum 400 mg) P. Long-term chemoprophylaxis is recommended in this setting due to unpredictable protection provided by vaccination, 11 which is also recommended after transplant. Studies have shown that 11% to 50% of postsplenectomy patients remain unaware of their increased risk for serious infection or the appropriate health precautions that should be undertaken. The use of prophylactic or preemptive measures should never be allowed to engender a false sense of security. Preemptive therapy for the post-splenectomy patient with fever and rigors Another strategy that has been advocated is the provision of "standby" antipneumococcal antibiotics; this strategy may be particularly relevant for patients who are not receiving prophylaxis. For patients who are > 150% ideal body weight, the weight used should be capped at 150% of ideal body weight. This strategy has been shown to reduce the incidence of candidemia and candidiasis-related mortality. Continue for 10 months after transplant prior to anticipated start of routine vaccinations. All patients with absent pre-transplant serum IgA levels should be evaluated for the presence of anti-IgA antibodies. The following evaluation should be instituted promptly in all patients with fever. Empiric treatment with antibiotics may be indicated after cultures have been obtained. To minimize the risk of bleeding, avoid biopsies of the duodenum unless this is the only site of abnormalities. Nonetheless, vaccine-preventable diseases continue to pose risks to the population. The vaccination recommendations shown in the following schema were formulated based on review of the approaches taken by these organizations. The earliest time to start vaccinations is 6 months post transplant in Non-Primary Immune Deficiency patients and should be considered in conjunction with factors that significantly delay immune reconstitution. P 2:P ediatric V accination S ch em a: Ifpatientnotvaccinated before 12 m onth s 1,8 M inim alTim e Interval Vaccine >12m >14m >16m >18m >22m >24m >25m B etweenVaccinations Influenz ae (inactivated) < 9 years F lu F lu 1 month (September–M arch) > 9 years F lu H. Isolation is necessary if live (oral) polio vaccine is administered to family members or other persons in close contact with the patient during the first year after the transplant or at any time during treatment with immunosuppressive medications. Smallpox vaccine should not be administered to any family members or other persons who share living space with the patient during the first year after transplant and beyond one year if the patient continues on treatment with immunosuppressive medications. Evaluate for upper respiratory infection or other etiologies of airflow decline i. If alternative diagnosis is made, repeat spirometry monthly for at least 3 months i. Bronchoscopy is indicated when there are signs and symptoms of potential infection. If a reversible etiology is not identified, stop the taper and resume all components. In hematopoietic transplant recipients, other factors that may contribute to osteoporosis include electrolyte imbalances, inactivity, significant weight loss, and endocrine deficiencies. Osteopenia is defined as bone mineral density less than 1 standard deviation but above –2. It measures urinary excretion of the cross-linked N-telopeptide of type I collagen which is a marker of bone resorption. Elemental Calcium requirement between diet and supplement the Medical Nutrition Therapy staff educates patients to consume the following amounts of calcium during steroid therapy: Age 7-12 months 600 mg/day Age 1-3 years: 1000 mg/day Age 4-8 years: 1200 mg/day Age > 9 years: 1500 mg/day the nutritionist recommends appropriate levels of calcium supplementation for patients unable to meet daily requirements with diet. Normal serum magnesium levels are necessary to prevent osteopenia and bone fragility. Exercise A combination of weight bearing and resistive exercise is recommended for 30-60 minutes daily to promote cardiovascular function, minimize bone loss, strengthen skeletal muscles and improve balance, helping to prevent falls. Appropriate forms of exercise include swimming, biking (on a stationary bike if the patient has poor balance), Nordic tracking, rowing, low impact aerobic dancing. Testosterone replacement should be given to men if the serum testosterone level is low, unless contraindicated. Anti-resorptive therapy can be considered in patients who are at high risk for subsequent fractures.
Two –year follow-up results a multi-center trial of intra-operative electronic brachytherapy during breast conservation surgery for early stage breast cancer hiv infection medicine purchase symmetrel 100mg line. Planning comparison of intensity modulated radiation therapy delivered with 2 tangential fields versus 3-dimensional conformal radiotherapy for cardiac sparing in women with left-sided breast cancer hiv infection rates in los angeles order symmetrel 100mg visa. Limitations of the American Society of Therapeutic Radiology and Oncology consensus panel guidelines on the use of accelerated partial breast irradiation hiv infection rates city buy generic symmetrel pills. Technological Updates on Targeting Partial Breast Dose via Non-Invasive Brachytherapy hiv infection no ejaculation generic 100 mg symmetrel visa. Invasive carcinoma diagnosed only by microscopy without evidence of a gross lesion; microscopic lesions with stromal invasion 3. Definitive treatment when additional brachytherapy cannot be performed and the individual is inoperable 3. As postoperative treatment for positive surgical margins, positive pelvic nodes, vaginal margins less than 0. All clinically visible lesions confined to the cervix with or without extension to the parametria, pelvic sidewall(s), lower third of vagina, or causing hydronephrosis or nonfunctioning kidney 4. Tumor invading the mucosa of the bladder or rectum, and/or extending beyond the true pelvis Page 98 of 272 5. In the non-curative setting and where symptoms are present, palliative external beam photon radiation therapy may be medically necessary. Key Clinical Points Within the United States in 2018, 13,240 new cases of cervical cancer are projected resulting in approximately 4,170 deaths. The prognosis of an individual with cervical cancer is markedly affected by the extent of disease at the time of diagnosis. Brachytherapy (internal radiation) Brachytherapy is an important component of the radiation therapy regimen in the curative treatment of cervical cancer. Dose recommendations are available in the literature of the American Brachytherapy Society. It is recognized that disease presentations and anatomic deformity may result in less than optimal dosimetry using conventional radiation applicators, and that supplementary interstitial brachytherapy may be required on an individual basis to achieve optimal therapeutic effect. Page 99 of 272 the type of implant may include tandem and ovoids, tandem alone, ovoids only, interstitial, or vaginal cylinder only. Surgical findings of clinical relevance include the size of the primary tumor, depth of stromal invasion, and presence of lymphovascular invasion. Positive pelvic and/or para-aortic nodes, surgical margins, and involvement of the parametrium are also important. When indicated, postoperative radiation therapy typically is delivered using up to 30 fractions. An intracavitary boost may be clinically appropriate in the setting of positive surgical findings. Management of the para-aortic nodes the treatment of para-aortic nodal regions may be indicated in the following clinical situations: A. Positive para-aortic lymph nodes on surgical staging if lymph nodes are less than 2 cm and are below L3 B. Positive para-aortic lymph nodes on surgical staging and all macroscopic paraaortic nodes are removed C. For concurrent treatment, up to 6 gantry angles are approved, and a conedown (additional phase) may be appropriate. For Page 100 of 272 sequential treatment, up to 6 gantry angles, 1 conedown, and up to 28 additional fractions may be appropriate. Devices for the immobilization of the cervix are considered experimental at this time. There were only 2 locoregional failures, 1 vaginal and 1 pelvic (Folkert Page 101 of 272 et al. Palliative therapy In the non-curative setting and where symptoms are present, palliative external beam photon radiation therapy may be medically necessary. Chemotherapy Randomized trials have shown an overall survival advantage for cisplatin-based therapy given concurrently with radiation therapy, while one trial examining this regimen demonstrated no benefit. Although the positive trials vary in terms of the stage of disease and incorporate varying radiation treatment regimens with chemotherapy schedules of cisplatin alone or combined with fluorouracil, the trials demonstrate significant survival benefit for this combined approach. Based on these results, strong consideration should be given to the incorporation of concurrent chemotherapy with radiation therapy in women who require radiation therapy for the treatment of cervical cancer. Page 102 of 272 References 1. Cervix moves significantly more than previously thought during radiation for cancer. Impact of improved irradiation technique, age, and lymph node sampling on the severe complication rate of surgically staged endometrial cancer patients: a multivariate analysis. Prospective clinical trial of positron emission tomography/computed tomography image-guided intensity-modulated radiation therapy for cervical carcinoma with positive para-aortic lymph nodes. Clinical outcomes of definitive intensity-modulated radiation therapy with fluorodeoxyglucose-positron emission tomography simulation in patients with locally advanced cervical cancer. Consensus guidelines for delineation of clinical target volume for intensity-modulated pelvic radiotherapy for the definitive treatment of cervix cancer. Pelvic radiotherapy for cancer of the cervix: is what you plan actually what you deliverfi Cervical carcinoma: postoperative radiotherapy: fifteen-year experience in a Norwegian health region. Combined intensity-modulated radiation therapy and brachytherapy in the treatment of cervical cancer. Long-term follow-up of a randomized trial comparing concurrent single agent cisplatin, cisplatin-based combination chemotherapy, or hydroxyurea during pelvic irradiation for locally advanced cervical cancer: a Gynecologic Oncology Group Study. Preliminary outcome and toxicity report of extended-field, intensity modulated radiation therapy for gynecologic malignancies. Consensus guidelines for delineation of clinical target volume for intensity-modulated pelvic radiotherapy in postoperative treatment of endometrial and cervical cancer. Effect of intensity-modulated pelvic radiotherapy on second cancer risk in the postoperative treatment of endometrial and cervical cancer. Postoperative brachytherapy (alone) is considered medically necessary for any of the following: A. Pelvic external beam photon radiation therapy (alone) is considered medically necessary for either of the following: A. Postoperative pelvic external beam photon radiation therapy and brachytherapy are considered medically necessary for any of the following: A. Para-aortic lymph node radiation treatment with pelvic external beam photon radiation therapy with or without brachytherapy is considered medically necessary for either of the following: A. Tumor directed radiation therapy is considered medically necessary for any of the following: A. Electronic/kilovoltage brachytherapy is considered medically necessary when utilizing a vaginal cylinder B. Endometriod (tumors resembling the lining of the uterus; adenocarcinomas) are the most prevalent subtype. Adverse risk factors include advancing age, lymphovascular extension, tumor size, lower uterine involvement classified as cervical glandular involvement (newly classified as Stage I). For cases that are not completely surgically staged, radiologic imaging plays an important role in selecting a treatment strategy. Should treatment rather than observation be decided upon for these same groups, radiation techniques are stratified in the preceding guideline statements. With more advanced clinical state and/or radiological presentations, more extended external beam photon radiation fields with or without brachytherapy may be medically necessary. In advanced disease, the increased utilization of adjuvant chemotherapy has called into question the magnitude of the added benefit of adjuvant radiation therapy. We are awaiting the results of some recent trials that may help to answer some of these questions. Patients younger than age 60 who received external beam treatment did not have a survival benefit but did suffer an increased risk of secondary cancers with subsequent increased mortality.