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Nicole C. Pezzino, PharmD

• Assistant Professor of Pharmacy Practice, Wilkes University, School of Pharmacy, Wilkes-Barre
• Clinical Pharmacist in Community/Ambulatory Pharmacy, Nanticoke, Pennsylvania

https://www.wilkes.edu/campus-directory/nicole.pezzino.aspx

Finasteride may not be more efficacious than placebo in patients with prostates < 40 mL [159] cholesterol lowering functional foods cheap rosuvastatin 10mg on-line. Open-label trials have demonstrated relevant changes in urodynamic parameters [167 cholesterol definition wikipedia cheap rosuvastatin online american express, 168] is the cholesterol in shrimp good order rosuvastatin 10 mg online. The incidence of sexual dysfunction and other adverse events is low and even decreased with trial duration is the cholesterol in eggs harmful purchase rosuvastatin in united states online. Due to the slow onset of action cholesterol wiki cheap rosuvastatin 10mg with visa, they are suitable only for long-term treatment (years) cholesterol and foods purchase rosuvastatin with mastercard. Five muscarinic receptor subtypes (M1-M5) have been described, of which M2 and M3 are predominant in the detrusor. M2 are more numerous, but the M3 subtype is functionally more important in bladder contractions in healthy humans [172, 173]. Antimuscarinic effects might also be induced or modulated through other cell types, such as the bladder urothelium or by central nervous system [174, 175]. The following muscarinic receptor antagonists are licensed for treating overactive bladder/storage symptoms (see supplementary online material Table S. Tolterodine can significantly reduce urgency incontinence, daytime or 24-hour frequency, urgency-related voiding, and improve patient perception of treatment benefit. In an open-label study, tolterodine decreased 24-hour micturition, nocturia and American Urological Association Symptom Index scores [183]. Tolerability and safety: Antimuscarinic drug trials generally show approximately 3-10% withdrawals, which is similar to placebo. Drug-related adverse events include dry mouth (up to 16%), constipation (up to 4%), micturition difficulties (up to 2%), nasopharyngitis (up to 3%), and dizziness (up to 5%). These symptoms appeared during the first two weeks of treatment and mainly affected men aged 66 years or older. The urodynamic effects included larger bladder volumes at first detrusor contraction, higher maximum cystometric capacity, and decreased bladder contractility index. Qmax increases in a dose-dependent fashion, but is not significantly different from placebo in most trials. There is limited information about reduction of prostate size and none about disease progression. The most widely used plants are: Cucurbita pepo (pumpkin seeds), Hypoxis rooperi (South African star grass), Pygeum africanum (bark of the African plum tree), Secale cereale (rye pollen), Serenoa repens (syn. Sabal serrulata; berries of the American dwarf palm, saw palmetto) and Urtica dioica (roots of the stinging nettle). Possible relevant compounds include phytosterols, sitosterol, fatty acids, and lectins [206]. In vitro, plant extracts can have anti-inflammatory, anti-androgenic and oestrogenic effects; decrease sexual hormone binding globulin; inhibit aromatase, lipoxygenase, growth factor-stimulated proliferation of prostatic cells, adrenoceptors, 5 reductase, muscarinic cholinoceptors, dihydropyridine receptors and vanilloid receptors; and neutralise free radicals [206-208]. These effects have not been confirmed in vivo, and the precise mechanisms of action of plant extracts remain unclear. Efficacy: the extracts of the same plant produced by different companies do not necessarily have the same biological or clinical effects and so the effects of one brand cannot be extrapolated to others [209]. Batches from the same producer might contain different concentrations of active ingredients [210]. Analysis of each drug class can be found in the supplementary online material (see Tolerability and safety: Side-effects during phytotherapy are generally mild and comparable to placebo. Practical considerations: Phytotherapeutic agents are a heterogeneous group and may contain differing concentrations of the active ingredient(s). Hence, meta-analyses do not seem to be justified and results of any analyses have to be interpreted with caution. It controls urine production through the V2 receptor in the renal collecting ducts. Desmopressin may be used by intravenous infusion, nasal spray, tablet or with melt formulation. Nasally or orally administered desmopressin is rapidly absorbed, and excreted 55% unchanged by the kidneys [222]. Desmopressin has been used for more than 30 years for diabetes insipidus or primary nocturnal enuresis, and it is approved in most European countries for the treatment of nocturia secondary to nocturnal polyuria in adults (see supplementary online material Table S. Efficacy: Desmopressin significantly reduced nocturnal diuresis by approximately 0. Furthermore, desmopressin significantly reduced night-time urine volume, and the percentage of urine volume excreted at night [223-225]. A meta-analysis found that desmopressin significantly reduced the overall number of nocturnal voids and increased hours of undisturbed sleep. The clinical effects of desmopressin were more pronounced in patients with more severe nocturnal polyuria and normal bladder capacity at baseline. The clinical effects were stable over a follow-up period of 10-12 months and returned to baseline values after cessation of the trial [223]. Tolerability and safety: the most frequent adverse events in short-term (up to three weeks) and long term studies (12 months) were headache, nausea, diarrhoea, abdominal pain, dizziness, dry mouth and hyponatraemia (serum sodium concentration of <130 mmol/L). Peripheral oedema (2%) and hypertension (5%) were reported in the long-term treatment trial [223]. The risk of developing hyponatraemia significantly increases with age (odds ratio 1. The risk of hyponatraemia in patients < 65 years is < 1%; for older patients with normal sodium concentration it is 8%, but it is up to 75% in old patients with low sodium concentration at baseline [235]. A recent subanalysis suggests that oral doses of 50-100 g desmopressin (melt) are safe in men [237]. At the time of treatment initiation or dose change, older men with normal values of serum sodium should be monitored by Na+ measurement at day three and day seven of treatment, and one month later. If serum sodium concentration has remained normal and no dose adjustment is intended, Na+ should be monitored every three to six months thereafter [238]. Patients should be informed about the symptoms of hyponatraemia, (headache, nausea or insomnia). Because the optimal dose differs between patients, desmopressin treatment should be initiated at a low dose (0. Patients should avoid drinking fluids at least one hour before and for eight hours after dosing. In men aged 65 years or older, desmopressin should not be used if the serum sodium concentration is below normal. Tolerability and safety: the most common treatment-related adverse events in the mirabegron groups were hypertension, urinary tract infection, headache and nasopharyngitis [239-242]. Finasteride has been tested in clinical trials with alfuzosin, doxazosin or terazosin, and dutasteride with tamsulosin. Initial studies with follow-up periods of 6-12 months demonstrated that the 1-blocker was superior to finasteride in symptom reduction, whereas combination was not superior to 1-blocker alone [151, 152, 162]. In studies with a placebo arm, the 1-blocker was consistently more effective than placebo, but finasteride was not. The first trial evaluated the combination of tamsulosin with dutasteride and the impact of tamsulosin discontinuation after six months [244], with almost three-quarters of patients reporting no worsening of symptoms. A more recently published trial evaluated the symptomatic outcome of finasteride monotherapy at three and nine months after discontinuation of nine-month combination therapy [245]. However, the main limitations of the studies include the short duration and the short follow-up period after discontinuation. Tolerability and safety: Adverse events for both drug classes have been reported with combination treatment [49, 124, 125]. Combination therapy should only be used when long-term treatment (more than 12 months) is intended; this issue should be discussed with the patient before treatment. One trial used the 1-blocker naftopidil (not registered in most European countries) with and without antimuscarinics [254]. Two systematic reviews of the efficacy and safety of antimuscarinics in men suggested that combination treatment provides significant benefit [255, 256]. The combination therapy was not inferior to placebo for the primary urodynamic variables; Qmax was increased versus placebo [257]. Practical considerations: Class effects are likely to underlie efficacy and QoL using an 1-blocker and antimuscarinic. One study with a mean follow-up of 13 years reported a significant and sustained decrease in most symptoms and improvement in urodynamic parameters. In this meta-analysis, an upper limit of prostate size was reported as an entry criterion for eight studies with five < 30 ml and three < 60 ml. Tolerability and safety: Peri-operative mortality and morbidity have decreased over time, but the latter remains considerable (0. The possibility of increased long-term mortality compared to open surgery [271] has not been verified [272-274]. No studies on the optimal cut-off value exist but the complication rates increase with prostate size [270]. Bipolar circuitry is completed locally; energy is confined between an active (resection loop) and a passive pole situated on the resectosope tip (true bipolar systems) or the sheath (quasi bipolar systems). Energy from the loop is transmitted to the saline solution, resulting in excitation of sodium ions to form a plasma; molecules are then easily cleaved under relatively low voltage enabling resection. During coagulation, heat dissipates within vessel walls, creating a sealing coagulum and collagen shrinkage. The various bipolar devices available differ in the way in which current flow is delivered [276, 277]. Subsequent meta-analyses supported these conclusions [258, 279], though trial quality was generally poor. Obstructive adenomas are enucleated using the index finger, approaching from within the bladder (Freyer procedure) or through the anterior prostatic capsule (Millin procedure). Tolerability and safety: Mortality has decreased significantly during the past two decades (< 0. The heat may also cause apoptosis and denervation of receptors, thereby decreasing the smooth muscle tone of the prostatic urethra. Efficacy: A systematic review assessed therapeutic efficacy in different devices/software, including Prostatron (Prostatsoft 2. In a study with a longer follow-up, treatment failure was 38% in the retention group, with a cumulative risk of 59% at 5 years [306]. Most durability studies have a high attrition rate; in this study, less than half of the patients were analysed at 4-5 years. In addition, patients who remained in the study were likely to represent the best data (responders). A study with 5 years follow-up demonstrated symptomatic improvement in 58% and improved flow in 41%. Tolerability and safety: Post-operative urinary retention with a mean duration of 1-3 days is seen in 13-42% of patients; within 1 week, 90-95% of patients are catheter-free [320]. Tissue coagulation and necrosis are limited to 3-4 mm, which is enough to obtain adequate haemostasis [322]. Tolerability and safety: Dysuria is the most common post-operative complication [322, 325]. In a study of 83 patients, blood transfusion was required in seven patients (8%) [335]. No transfusions were required and bleeding complication rates were not significantly different [334]. Practical considerations: Holmium laser operations are surgical procedures that require experience and relevant endoscopic skills. The experience of the surgeon was the most important factor affecting the overall occurrence of complications [333, 339]. They differ in maximum power output, fibre design, and maximum energy application. Another case series of 500 patients treated with the 80-W system with a mean follow-up of 30. Significant improvements in voiding parameters at a follow-up of 12 months were demonstrated urodynamically [346]. A multicentre case series of the 180-W laser demonstrated comparable safety and symptom improvement compared with the former Greenlight laser systems [349]. No difference was noted in post-operative urinary retention, infection, meatal stenosis, urethral stricture, or bladder neck stenosis [340]. The Greenlight laser appears to be safe in high-risk patients under anticoagulation treatment [350 354]. In one study, anticoagulated patients had significantly higher rate of bladder irrigation (17. Safety in patients with urinary retention, or prostates > 80 mL was shown in various prospective non-randomised trials [354-356]. Practical considerations: the evolution of the Greenlight laser from 80-W to 120-W and then to 180-W resulted in a wide variation in the degree of maturity of each laser therapy. Tolerability and safety: Two studies (980 nm) indicate high intraoperative safety, since no bleeding was reported, although anticoagulants or platelet aggregation inhibitors were taken in 24% and 52% [362, 363]. In summary, high re-operation rates (20-33%) and persisting stress urinary incontinence (9. Maximum follow-up of 4 years (case control study) with cumulative re-operation rates of 6% reported [371]. In summary, studies show comparable improvement of symptoms and voiding parameters. Recently a large series of complications after vapoenucleation reported adverse events in 31% of cases, with 6. Table 15: Efficacy of different lasers for the treatment based on the highest-quality study for each of the treatment options. Prostatic stents were primarily designed as an alternative to an indwelling catheter but have also been assessed as a primary treatment option in patients without significant comorbidities [384, 385].

Syndromes

• Antifreeze
• Take other medicines, especially blood thinners such as warfarin or clopidgrel.
• Sunscreen, hat, and sunglasses
• Allow the child to help around the house and participate in the daily family responsibilities.
• Permanent skin damage and scarring (very rare)
• Swelling of in the armpit (next to the breast with cancer)
• Pancreatitis

Long-term clinical outcome of large volume paracentesis with intravenous albumin in patients with 107 cholesterol levels in different meats generic rosuvastatin 10mg mastercard. Percutaneous Transjugular intrahepatic portosystemic shunt for refractory peritoneovenous shunt creation for the treatment of benign ascites: a meta-analysis of individual patient data cholesterol test fasting australia purchase rosuvastatin 10mg with amex. Evidence of functional and infusions to achieve diuresis in patients with ascites structural cardiac abnormalities in cirrhotic patients with who are not candidates for transjugular intrahepatic and without ascites cholesterol in eggs organic buy rosuvastatin american express. Comparative pilot study of repeated large volume patients treated for complications of portal hypertension cholesterol levels that are dangerous buy rosuvastatin 10 mg line. Transjugular intrahepatic portosystemic shunt for cirrhosis and ascites: efects in patients with organic or 122 cholesterol lowering foods and supplements buy 10 mg rosuvastatin free shipping. Yang Y-Y cholesterol test perth buy rosuvastatin 10mg without prescription, Lin H-C, Lin M-W, Chu C-j, Lee F-Y, Hou M-C, outcome using polytetrafuoroethylene coated stents for Lee S-D, et al. Gastroenterology with poor long-term clinical outcomes: a 1-year follow-up 2004;126:469-475. Angermayr B, Cejna M, Koenig F, Karnel F, Hackl F, Gangl A, Peck Radosavljevic M, et al. Hepatology 2010;51;1-16 insensitive and nonspecifc tests in detecting ascitic fuid 117. Spontaneous bacterial of albumin as compared with peritoneovenous shunting in peritonitis. Angeli P, Guarda S, Fasolato S, Miola E, Craighhero R, Del a variant of spontaneous bacterial peritonitis. Sort P, Navasa M, Arroyo V, Aldeguer X, Planas R, Ruiz del-Arbol L, Castells L, et al. N Engl J Med efcacy and nephrotoxicity of ampicillin plus tobramycin 1999;341:403-409. Short-course vs long-course antibiotic treatment of spontaneous bacterial peritonitis: 143. Restricted use of albumin for spontaneous bacterial Gastroenterology 1991;100:1737-1742. Fernandez J, Monteagudo J, Bargallo X, Jimenez W, Bosch and serum cefotaxime and desacetyl cefotaxime levels J, Arroyo V, Navasa M. Dig Dis Sci study comparing albumin versus hydroxyethyl starch in 1991;36:1782-1786. Soriano G, Castellote J, Alvarez C, Girbau A, Gordillo J, negative neutrocytic ascites in cirrhotic patients. Prevalence and risk factors of infections by resistant bacteria in cirrhosis: a 146. Risk factors for resistance to ceftriaxone and its impact on mortality in community, 147. Bert F, Larroque B, Paugam-Burtz C, Janny S, Durand is predisposed to spontaneous bacterial peritonitis. Randomized, comparative study of oral ofoxacin versus intravenous cefotaxime in spontaneous bacterial peritonitis. Norfoxacin prevents spontaneous bacterial prophylaxis reduces spontaneous bacterial peritonitis peritonitis recurrence in cirrhosis: results of a double-blind, occurrence and improves short-term survival in cirrhosis: a placebo-controlled trial. Norfoxacin prevents bacterial fuoroquinolones in the primary prophylaxis of spontaneous infection in cirrhotics with gastrointestinal hemorrhage. Improved survival after variceal bleeding bacterial infection in cirrhotic patients with gastrointestinal in patients with cirrhosis over the past two decades. Rolando N, Gimson A, Philpott-Howard J, Sahathevan M, Recurrence of spontaneous bacteria peritonitis in cirrhosis: Casewell M, Fagan E, Westaby D, et al. Rolachon A, Cordier L, Bacq Y, Nousbaum J-B, Franza role of antibiotic prophylaxis. A prospective controlled prevention of spontaneous bacterial peritonitis: results of study of the risk of bacteremia in emergency sclerotherapy a prospective controlled trial. Efect of oral ciprofoxacin on aerobic prevention and treatment of the hepatorenal syndrome gram-negative fora of cirrhotic patients: results of short in cirrhosis: a consensus workshop of the international and long term administration with variable does [abstract]. Antibiotic prophylaxis for the prevention of syndrome as defned by the International Ascites Club bacterial infections in cirrhotic patients with gastrointestinal by albumin and furosemide infusion according to the bleeding: a meta-analysis. Fernandez J, Navasa M, Planas R, Montoliu S, Monfort Gastroenterol 2005;100:2702-2707. Martin-Llahi M, Guevara M, Torre A, Fagundes C, Restuccia spontaneous bacterial peritonitis delays hepatorenal T, Gilabert R, Sola E, et al. Fagundes C, Pepin M-N, Guevara M, Barreto R, Casals in the treatment of hepatorenal syndrome: a retrospective G, Sola E, Pereira G, et al. Prevention of hepatorenal syndrome in patients with prospective, randomized, unblended, pilot study. J Hepatol cirrhosis and ascites: a pilot randomized control trial 2007;47:499-505. Terlipressin and albumin vs albumin in patients with cirrhosis and hepatorenal 178. Witzke O, Baumann M, Patschan D, Patschan S, Mitchell syndrome: a randomized study. Angeli P, Volpin R, Gerunda G, Craighero R, Roner P, portosystemic shunt in hepatorenal syndrome: efects Merenda R, Amodio P, et al. Octreotide/ midodrine therapy signifcantly improves terlipressin in clinical approach to hepatorenal syndrome renal function and 30-day survival in patients with type 1 type 2. Surgical repair of umbilical hernias in cirrhosis with syndrome and refractory ascites: role of transjugular ascites. Systemic in the absence of clinical ascites: diagnosis and review of randomized trials of vasoconstrictor drugs for management. Xiol X, Castellote J, Cortes-Beut J, Delgado M, Guardiola J, syndrome after orthotopic liver transplantation. Proceedings of consensus conference on patients with chronic liver disease and ascites. Abdominal wall hernias in the setting is a relative contraindication to chest tube insertion. Outcomes of patients with chest tube umbilical hernia in cirrhotics patients with ascites. Cellulitis in patients with following transjugular intrahepatic portosystemic shunt for cirrhosis and edema: an under-recognized complication treatment of ascites. Gastrointestinal Endoscopy to treat ruptures umbilical hernias in patients with liver 2010;72:1072-1075. Minimally invasive repair of practice guideline for gastrointestinal access for enteral recurrent strangulated umbilical hernia in cirrhotic patient nutrition and decompression from the Society of with refractory ascites. Guidelines are a work in progress that may be redefned as often as new signifcant data become available. The those sufering from pancreatitis and pancreatic cancer guidelines provide comprehensive explanations of the through funding cutting edge research, advocating for disease, stages, and treatments options in language new and better therapies, and providing support and patients can understand. The small intestine is wrapped along the wide the pancreas is a large gland found in your end of the pancreas. If you have diabetes, it might Wide end called the head (includes neck make it worse. Removing part of Narrow end called the tail the pancreas can decrease the amount of these enzymes. This can cause oily the pancreas does 2 things: diarrhea (watery stool), stools that foat, abdominal pain, bloating, gas, and weight It makes hormones (insulin and glucagon) loss. It also makes proteins, called enzymes, which Cancer is a disease that starts in the cells of help to digest food. Pancreatic cancer starts Endocrine cells of the pancreas make in exocrine or endocrine cells of the pancreas. These are released directly into the Cancer that forms in the ampulla of Vater (ducts bloodstream. Guidelines for Patients: Neuroendocrine Tumors, the pancreas lies behind the stomach and available at across the spine. Bile is a An exocrine cell makes or secretes an enzyme fuid that helps to digest food. The common bile Sometimes, pancreatic cancer is also called duct carries bile from the liver into the main exocrine cancer. From the main pancreatic duct, cancers start in exocrine cells that line small bile and enzymes empty into the duodenum. These the duodenum is the frst part of the small ducts carry fuid that contain enzymes into the intestine, which absorbs nutrients from food you main pancreatic duct and then into the small eat. An adenocarcinoma is Depending on the size of the tumor and its cancer in the cells that secrete fuids or other location, surgery can be very difcult. Genetic means that it is passed down Anything that increases your chances of from parent to child through genes. In be activities that people do, things you have a process called mutation something goes contact with in the environment, or traits passed wrong in the genetic code. Share what you know Risk factors for pancreatic cancer about your family history with your doctor. Periodontal disease A genetic counselor will speak to you about the Family history of pancreatitis results. It is important to tell your health care and form tumors in other parts of the body. Locally advanced pancreatic cancer means the cancer has spread to nearby blood vessels and it may be in nearby lymph nodes. Symptoms Cancer can spread to distant sites through Symptoms of pancreatic cancer blood. Pancreatic cancer can travel through these Nausea blood vessels and metastasize in the liver, Vomiting spleen, stomach, lungs, and other structures. Jaundice (yellowing of the skin and eyes) Cancer can also spread through the lymphatic system. The lymphatic system has a clear fuid Indigestion (eg, heartburn, pain, fullness in belly) called lymph. Lymph vessels and Trouble controlling diabetes nodes are found everywhere in the body. Physical exam Testing is used to confrm (diagnose) A physical exam is a study of your body. This chapter outlines Doctors should perform a thorough physical tests used to diagnose and treat exam along with a complete health history. A health care provider may: General health tests Check your temperature, blood pressure, pulse, and breathing rate Medical history Weigh you Before and after cancer treatment, your doctor Listen to your lungs and heart will look at your medical history. A medical history is a record of your past and current Look in your eyes, ears, nose, and throat medical problems and treatments. Your doctor Feel and apply pressure to parts of your will ask about all health issues and treatments body to see if organs are of normal size, you have had in your life. Be prepared to list are soft or hard, or cause pain when any illness or injury and when it happened. Bring a list of old and new medicines and any Feel for enlarged lymph nodes in your over-the-counter medicines, herbs, or other neck, underarm, and groin. Tell your doctor about if you have felt any lumps or have any any symptoms you have. Jaundice is a yellowing of the skin and eyes Family history due to a buildup of bilirubin in the body. Bilirubin Some cancers and other diseases can run in is a yellow-brown substance in bile that is families. Your doctor will ask about the health formed when red blood cells are broken down. A tumor their health issues like heart disease, cancer, in the pancreas can cause jaundice by blocking and diabetes, and at what age they were the main bile duct. Images Imaging tests take pictures (images) of the can be made with scanning machines or inside of your body. The images may show if there is the diagnosis and follow-up after treatment of a tumor in your pancreas as well as the tumor cancer. The types of imaging scans recommended for Imaging tests are used to fnd and confrm pancreatic cancer are described next. A radiologist, who is an expert that looks at patients images, will review your images and Your medical records write a report. Feel free to ask as many 3 Your doctors will order tests and questions as you like. Common imaging tests: 3 It is helpful to keep track of your test results at all times. Ask your doctors X-rays use low-dose radiation to take one questions about the results. A tracer is a substance put in your body to see how cancer is growing and where it is in the body. A protocol is a detailed plan many angles to create real-looking images of a medical study, treatment, or procedure. Tell a contrast material is often used to make the your doctors if you have had bad reactions to pictures clearer. The scope is guided into the body through a natural opening, such as the mouth or nose. The type of scope often used because bile and other fuids act as their own for pancreatic cancer is called an endoscope. The endoscope is Laparoscopy inserted through your mouth and guided down this test is a type of surgery that allows your your throat and stomach to the frst part of the doctors to see organs in your abdomen. The ultrasound a tool like an endoscope called a laparoscope probe bounces sound waves of your pancreas to look for metastases. For this test, the and other organs to make pictures of the inside laparoscope will be inserted through a tiny of your body.

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The rules for selection will be followed in determining the underlying cause cholesterol levels of athletes rosuvastatin 10mg with amex, with no special preference given to conditions which are not qualified by these expressions cholesterol lowering foods in hindi order rosuvastatin with mastercard. When two conditions are reported on one line and both are preceded by one of these doubtful expressions cholesterol ratio target order rosuvastatin discount, consider as a statement of either/or cholesterol test at home order 10 mg rosuvastatin fast delivery. Codes for Record I (a) Hemorrhage of stomach K922 (b) Probable ulcers of the stomach K259 Code to ulcer of stomach with hemorrhage (K254) boost good cholesterol foods buy cheap rosuvastatin on line. Code for Record I (a) Cancer of kidney or bladder C689 Code to malignant neoplasm of unspecified urinary organs (C689) cholesterol test during menstruation purchase rosuvastatin without a prescription. Code for Record I (a) Cancer of adrenal or kidney C80 Code to malignant neoplasm without specification of site (C80) since adrenal and kidney are in different anatomical systems. Code for Record I (a) Tuberculosis or cancer of lung J9840 Code to disease of lung (J984). Code for Record I (a) Stroke or heart attack I99 Code to disease, circulatory system (I99). Code for Record I (a) Cardiac thrombosis vs pulmonary embolism I749 Code to I749, clot (blood). When different diseases or conditions are classifiable to the same three character category with different fourth characters, assign to the three character category with fourth character 9. When different diseases or conditions are classifiable to different three character categories and Volume 1 provides a residual category for the disease in general, assign the residual category. When different diseases or conditions involving different anatomical systems are qualified by either. Code for Record I (a) Gallbladder colic or R688 (b) coronary thrombosis Code to other specified general symptoms and signs (R688). Code for Record I (a) Coronary occlusion or R99 (b) war injuries Code to other ill-defined and unspecified causes of mortality (R99). Interpretation of nonmedical connecting terms used in reporting the following connecting terms should be interpreted as meaning due to , or as a consequence of when the entity immediately preceding and following these terms is a disease condition, nature of injury or an external cause: after induced by arising in or during occurred after as (a) complication of occurred during as a result of occurred in because of occurred when caused by occurred while complication(s) of origin during received from etiology received in following resulting from for resulting when from secondary to (2) in subsequent to incident to sustained as incurred after sustained by incurred during sustained during incurred in sustained in incurred when sustained when sustained while the following terms are interpreted to mean that the condition following the term was due to the condition that preceded it: as a cause of led to cause of manifested by caused producing causing resulted in followed by resulting in induced underlying leading to with resultant with resulting the following terms are interpreted to mean or: and/or versus the following terms imply that the conditions are meant to remain on the same line. They are separated by and or by another connecting term that does not imply a due to relationship: and with accompanied by precipitated by also predisposing (to) associated with superimposed on complicated by complicating consistent with Q. Deletion of due to on the death certificate When the certifier has indicated conditions in Part I were not causally related by marking through items I(a), I(b), I(c) and/or I(d), or through the printed due to , or as a consequence of which appears below items I(a), I(b), and I(c) on the death certificate, proceed as follows: 1. If the deletion(s) indicates none of the conditions in Part I were causally related, consider as though all of the conditions had been reported on the uppermost used line. If only item, I(c) or the printed due to , or as a consequence of (which appears below line I(b)) is marked through, consider the condition(s) reported on line I(c) as though reported as the last entry (or entries) on the preceding line. If only one item, for example, I(b) or the printed due to , or as a consequence of (which appears below line I(a)) is marked through, consider the condition(s) reported on line I(b) as though reported as the last entry (or entries) on the preceding line. Codes for Record I (a) Cardiac arrest I469 K746 (b) Cirrhosis of liver (c) Alcoholism F102 Code to alcoholic cirrhosis of liver (K703). If the due to , or as a consequence of is partially deleted, consider as if completely deleted. Codes for Record I (a) Cardiorespiratory failure R092 Due to , or as a consequence of (b) Infarction of brain I639 I251 Due to or, as a consequence of (c) Coronary arteriosclerosis Code to infarction of brain (I639) by applying Rule 1. Numbering of causes reported in Part I Where the certifier has numbered all causes or lines in Part I, that is, 1, 2, 3, etc. This provision applies whether or not the due to on lines I(b), I(c), and/or I(d) are marked through. Where part of the causes in Part I are numbered, the interpretation is made on an individual basis. Terms that stop the sequence Includes: Cause not found Immediate cause unknown Cause unknown No specific etiology identified Cause undetermined No specific known causes Could not be determined Nonspecific causes Etiology never determined Not known Etiology not defined Obscure etiology Etiology uncertain Undetermined Etiology unexplained Uncertain Etiology unknown Unclear Etiology undetermined Unexplained cause Etiology unspecified Unknown Final event undetermined Etiology determined Codes for Record I (a) Cardiac arrest I469 (b) Stroke I64 (c) Cause unknown (d) Diabetes E149 Code to stroke (I64) using Rule 1. Codes for Record I (a) Pneumonia J189 (b) Intestinal obstruction K566 (c) Undetermined (d) Ulcerative colitis K519 Code to ulcerative colitis (K519). Codes for Record I (a) Gastric ulcer, cause unknown K259 (b) Rheumatoid arthritis (c) M069 Code to gastric ulcer (K259). Querying cause of death Because the selection of the underlying cause of death is based on how the physician reports causes of death as well as what he reports, State and local vital statistics offices should query certifying physicians where there is doubt that the manner of reporting reflects the true underlying cause of death. Querying is most valuable when carried out by persons who are thoroughly familiar with mortality medical classifi-cation. It is possible to choose a presumptive underlying cause for any cause-of-death certification no matter how poorly reported. However, selecting the cause by arbitrary rules (Rules 1-3) is not only difficult and time consuming, but the end results often are not satisfactory. Querying can be used to great advantage to inform physicians of the proper method of reporting causes of death. It is hoped that intensive querying and other educational efforts will reduce the necessity of resorting to arbitrary rules, and at the same time improve the quality and completeness of the reporting. When a certifier is queried about a particular cause or for inadequate or missing information he may or may not have at hand, the query should be specific. When the queries are sufficiently specific to elicit specific replies, the final coding should reflect this additional information from the certifier. The additional information cannot be used to replace the reported underlying cause. If one of these conditions (see Appendix A) is reported as a cause of death, the diagnosis should have been confirmed by the certifier or the State Health Officer when it was first reported. Coding Specific Categories the following are the international linkages and notes with expansions and additions concerning the selection and modification of conditions classifiable to certain categories. Therefore, reference should be made to the category or code within parentheses before making the final code assignment. The following notes often indicate that if the provisionally selected code, as indicated in the left-hand column, is present with one of the conditions listed below it, the code to be used is the one shown in bold type. There are two types of combination: with mention of means that the other condition may appear anywhere on the certificate; when reported as the originating antecedent cause of means that the other condition must appear in a correct causal relationship or be otherwise indicated as being due to the originating antecedent cause. Specific disease conditions indicated to have been bacterial in origin are classified to the specified disease rather than to A49. B16 Acute hepatitis B B17 Other acute viral hepatitis when reported as the originating antecedent cause of: K72. Conditions classifiable to two or more subcategories of the same category should be coded to the. Specific disease conditions indicated to have been viral in origin are classified to the specific disease rather than to B34. Examples: adenovirus enteritis is classified to A082, and acute viral bronchitis is classified to J208. B95-B97 Bacterial, viral and other infectious agents Not to be used for underlying cause mortality coding. C00-D48 Neoplasms Separate categories are provided for coding malignant primary and secondary neoplasms (C00-C96), Malignant neoplasms of independent (primary) multiple sites (C97), carcinoma in situ (D00-D09), benign neoplasms (D10-D36), and neoplasms of uncertain or unknown behavior (D37-D48). Categories and subcategories within these groups identify sites and/or morphological types. Morphology describes the type and structure of cells or tissues (histology) as seen under the microscope and the behavior of neoplasms. They are also described in Volume 3 (the Alphabetical Index) with their morphology code and with an indication as to the coding by site. The morphological code numbers consist of five characters: the first four identify the histological type of the neoplasm and the fifth, following a slash, indicates its behavior. The following terms describe the behavior of neoplasms: Malignant, primary site (capable of rapid growth C00-C76, and of spreading to nearby and distant sites) C80-C97 Malignant secondary (spread from another C77-C79 site; metastasis) In-situ (confined to one site) D00-D09 Benign (non-malignant) D10-D36 Uncertain or unknown behavior D37-D48 (undetermined whether benign or malignant) Morphology, behavior, and site must all be considered when coding neoplasms. Always look up the morphological type in the Alphabetical Index before referring to the listing under Neoplasm for the site. This may take the form of a reference to the appropriate column in the Neoplasm listing in the Index when the morphological type could occur in several organs. For example: Adenoma, villous (M8261/1) see Neoplasm, uncertain behavior Or to a particular part of that listing when the morphological type originates in a particular type of tissue. The Index may give the code for the site assumed to be most likely when no site is reported in a morphological type. For example: Adenocarcinoma pseudomucinous (M8470/3) specified site see Neoplasm, malignant unspecified site C56 Or the Index may give a code to be used regardless of the reported site when the vast majority of neoplasms of that particular morphological type occur in a particular site. For example: Nephroma (M8960/3) C64 Unless it is specifically indexed, code a morphological term ending in osis in the same way as the tumor name to which osis has been added is coded. However, do not code hemangiomatosis which is specifically indexed to a different category in the same way as hemangioma. All combinations of the order of prefixes in compound morphological terms are not indexed. For example, the term chondrofibrosarcoma does not appear in the Index, but fibrochondrosarcoma does. Since the two terms have the same prefixes (in a different order), code the chondrofibrosarcoma the same as fibrochondrosarcoma. Malignant neoplasms When a malignant neoplasm is considered to be the underlying cause of death, it is most important to determine the primary site. Cancer is a generic term and may be used for any morphological group, although it is rarely applied to malignant neoplasms of lymphatic, hematopoietic and related tissues. Some death certificates may be ambiguous if there was doubt about the primary site or imprecision in drafting the certificate. In these circumstances, if possible, the certifier should be asked to give clarification. The categories that have been provided for the classification of malignant neoplasms distinguish between those that are stated or presumed to be primary (originate in) of the particular site or types of tissue involved, those that are stated or presumed to be secondary (deposits, metastasis, or spread from a primary elsewhere) of specified sites, and malignant neoplasms without specification of site. These categories are the following: C00-C75 Malignant neoplasms, stated or presumed to be primary, of specified sites and different types of tissue, except lymphoid, hematopoietic, and related tissue C76 Malignant neoplasms of other and ill-defined sites C77-C79 Malignant secondary neoplasm, stated or presumed to be spread from another site, metastases of sites, regardless of morphological type of neoplasm C80 Malignant neoplasm of unspecified site (primary) (secondary) C81-C96 Malignant neoplasms, stated or presumed to be primary, of lymphoid, hematopoietic, and related tissue C97 Malignant neoplasms of independent (primary) multiple sites In order to determine the appropriate code for each reported neoplasm, a number of factors must be taken into account including the morphological type of neoplasm and qualifying terms. Assign malignant neoplasms to the appropriate category for the morphological type of neoplasm. Morphological types of neoplasm include categories C40-C41, C43, C44, C45, C46, C47, C49, C70-C72, and C80. Specific morphological types include: C40-C41 Malignant neoplasm of bone and articular cartilage of other and unspecified sites Osteosarcoma Osteochondrosarcoma Osteofibrosarcoma Any neoplasm cross-referenced as See also Neoplasm, bone, malignant Code for Record I (a) Osteosarcoma of leg C402 Code to osteosarcoma leg (C402). C43 Malignant melanoma of skin Melanosarcoma Melanoblastoma Any neoplasm cross-referenced as See also Melanoma Code for Record I (a) Melanoma C439 Code to melanoma, (C439) unspecified site as indexed. Code for Record I (a) Melanoma of arm C436 Code to melanoma of arm (C436) as indexed under site classification. Code for Record I (a) Melanoma of stomach C169 Code to melanoma of stomach (C169). Since stomach is not found under Melanoma in the Index, the term should be coded by site under Neoplasm, malignant, stomach. C44 Other malignant neoplasm of skin Basal cell carcinoma Sebaceous cell carcinoma Any neoplasm cross-referenced as See also Neoplasm, skin, malignant Code for Record I (a) Sebaceous cell carcinoma nose C443 Code to sebaceous cell carcinoma nose (C443). Code the morphological type Sebaceous cell carcinoma to Neoplasm, skin, malignant. C49 Malignant neoplasm of other connective and soft tissue Liposarcoma Rhabdomyosarcoma Any neoplasm cross-referenced as See also Neoplasm, connective tissue, malignant Code for Record I (a) Rhabdomyosarcoma abdomen C494 Code to rhabdomyosarcoma abdomen (C494). Code the morphological type Rhabdomyosarcoma to Neoplasm, connective tissue, malignant. Refer to the Note under Neoplasm, connective tissue, malignant, concerning sites which do not appear on this list. Code for Record I (a) Angiosarcoma of liver C223 Code angiosarcoma of liver as indexed. Code for Record I (a) Kaposi sarcoma of lung C467 Code Kaposi sarcoma of lung to Kaposis, sarcoma, specified site (C467). C80 Malignant neoplasm without specification of site Cancer Carcinoma Malignancy Malignant tumor or neoplasm Any neoplasm cross-referenced as See also Neoplasm, malignant Code for Record I (a) Carcinoma of stomach C169 Code to carcinoma of stomach (C169) as indexed. Neoplasm stated to be secondary Categories C77-C79 include secondary neoplasms of specified sites regardless of the morphological type of the neoplasm. The Index contains a listing of secondary neoplasms of specified sites under Neoplasm. Code for Record I (a) Secondary carcinoma of intestine C785 Code to secondary carcinoma of intestine (C785). Codes for Record I (a) Secondary melanoma of lung C439 C780 Code to melanoma of unspecified site (C439). If a morphological type implies a primary site, such as hepatoma, consider this as if the word primary had been included. Codes for Record I (a) Metastatic carcinoma C80 (b) Pseudomucinous adenocarcinoma C56 Code to malignant neoplasm of ovary (C56), since pseudomucinous adenocarcinoma of unspecified site is assigned to the ovary in the Alphabetical Index. If two or more primary sites or morphologies are indicated, these should be coded according to Sections D, E and G. If two or more sites mentioned in Part I are in the same organ system, see Section E. If the sites are not in the same organ system and there is no indication that any is primary or secondary, code to malignant neoplasms of independent (primary) multiple sites (C97), unless all are classifiable to C81-C96, or one of the sites mentioned is a common site of metastases or the lung (see Section G). Codes for Record I (a) Cancer of stomach 3 months C169 (b) Cancer of breast 1 year C509 Code to malignant neoplasms of independent (primary) multiple sites (C97), since two different anatomical sites are mentioned and it is unlikely that one primary malignant neoplasm would be due to another. Codes for Record I (a) Hodgkin disease C819 (b) Carcinoma of bladder C679 Code to malignant neoplasms of independent (primary) multiple sites (C97), since two distinct morphological types are mentioned.

Diseases

• Lipomucopolysaccharidosis
• Mediastinal endodermal sinus tumors
• Non-small cell lung cancer
• Aniridia cerebellar ataxia mental deficiency
• Oliver syndrome
• Kathisophobia