Shawn Anderson, PharmD, BCACP
- Clinical Pharmacy Specialist-Cardiology
- NF/SG Veterans Medical Center
- Adjunct Clinical Assistant Professor
- College of Pharmacy University of Florida
A 14-year-old boy is brought to the emergency department after being hit with a baseball bat on the lateral side of his leg immediately below the knee popular erectile dysfunction drugs buy generic super viagra on-line. A 26-year-old woman is brought to the emergency department because of an 8-hour history of severe back and abdominal pain and mild but persistent vaginal bleeding erectile dysfunction treatment old age safe 160mg super viagra. Fluid from this rupture will most likely be found in which of the following locations A 46-year-old woman with active ankylosing spondylitis comes to the office for a follow-up examination erectile dysfunction after 60 discount super viagra 160 mg without a prescription. The use of various conventional nonsteroidal anti-inflammatory drugs has been ineffective erectile dysfunction 20 buy super viagra from india. The most appropriate next step in treatment is administration of a drug that inhibits which of the following A 55-year-old man comes to the physician because of a 2-week history of recurrent erectile dysfunction pills sold at gnc order super viagra 160mg on line, widespread blister formation impotence blood pressure order generic super viagra pills. Physical examination shows lesions that are most numerous in the flexural areas including the axillae and groin. These blisters are most likely the result of adhesion failure involving which of the following A 17-year-old girl is brought to the emergency department 30 minutes after her boyfriend found her unconscious next to an empty bottle of acetaminophen. A 72-year-old woman comes to the physician because of a 3-day history of fever, shortness of breath, difficulty swallowing, chest pain, and cough. A chest x-ray shows an area of opacification in the lower region of the right lung. During the interview, he responds to the questions with a single word and sometimes with sarcastic answers. He does not engage in eye contact, and he frowns as he tells the physician that this is the third time he has been asked these questions. A 54-year-old man comes to the physician because of episodes of fainting for 3 months. She says that she has felt well except for occasional episodes of constipation, abdominal discomfort, and mild fatigue. She was treated for a renal calculus 10 years ago and was told she had a "lazy gallbladder. A 72-year-old woman is brought to the emergency department by her husband because of a 1-hour history of difficulty walking and speaking. The husband says that she was well last night but when she awoke this morning, she had difficulty getting out of bed and her speech was slurred. She has a 20-year history of type 2 diabetes mellitus well controlled with medication and diet. She is alert and oriented and is able to follow commands and respond verbally, but she has impaired speech. Sensation to pinprick and temperature is normal, and proprioception and sensation to light touch are absent over the left upper and lower extremities. Which of the following labeled sites in the photograph of a cross section of a normal brain stem is most likely damaged in this patient A 68-year-old woman with end-stage renal disease comes to the office for a follow-up examination. Initially, she did well, but within the past 3 months, she has been admitted to the hospital for fluid overload because of poor adherence to fluid and salt restrictions. Assuming there were no technical errors, the Southern blot analysis results demonstrate which of the following processes Physical examination shows a normal female body habitus, normal breast development, and normal appearing external genitalia. Which of the following is the most likely explanation for the clinical presentation A 16-year-old boy is brought to the physician because of a 3-day history of abdominal pain and vomiting; he also has had decreased appetite during this period. Examination of peritoneal fluid from this patient will most likely show which of the following organisms A 45-year-old woman comes to the office because of a 6-month history of hot flashes, night sweats, and insomnia. She thinks she is going through menopause and asks the physician if there are any medications that will alleviate her symptoms. The physician explains that hormone therapy likely will help and explains the risks to the patient. A randomized controlled trial is conducted to assess the risk for development of gastrointestinal adverse effects using azithromycin compared with erythromycin in the treatment of pertussis in children. Of the 100 children with pertussis enrolled, 50 receive azithromycin, and 50 receive erythromycin. Results show vomiting among 5 patients in the azithromycin group, compared with 15 patients in the erythromycin group. Which of the following best represents the absolute risk reduction for vomiting among patients in the azithromycin group A 34-year-old woman with a 10-year history of hepatitis C comes to the physician because of progressive fatigue during the past month. Which of the following mechanisms is the most likely cause of the ongoing hepatocyte injury in this patient Her blood pressure was 145/100 mm Hg and 145/95 mm Hg, respectively, at two previous visits. Today, her pulse is 75/min, respirations are 15/min, and blood pressure is 150/95 mm Hg. If left untreated, which of the following is most likely to decrease in this patient A 62-year-old man comes to the physician for a follow-up examination after he was diagnosed with chronic inflammatory interstitial pneumonitis. Following pulmonary function testing, a biopsy specimen of the affected area of the lungs is obtained. A 31-year-old woman with type 2 diabetes mellitus comes to the physician because of an oozing, foul-smelling wound on her foot for 2 days. Physical examination shows a 4-cm, necrotizing wound with a purplish black discoloration over the heel. The causal organism most likely produces which of the following virulence factors A 4-month-old boy with severe combined immunodeficiency receives a bone marrow transplant. Six days later, he develops a widespread, erythematous, maculopapular rash over the trunk. Examination of a skin biopsy specimen shows diffuse vacuolar degeneration of basal epidermal cells with a mononuclear inflammatory cell infiltrate. A 37-year-old woman with right lower extremity edema is evaluated because of the sudden onset of shortness of breath and pleuritic chest pain. Which of the following signs, if present on physical examination, would be the most specific indicator of pulmonary arterial hypertension in this patient A 43-year-old woman with type 2 diabetes mellitus is brought to the emergency department because of a 12-hour history of nausea and vomiting. She says that it began after drinking champagne at a birthday party the previous night. Three days ago, she was diagnosed with Trichomonas vaginalis infection, and a 5-day course of metronidazole was initiated. Current medications also include acetaminophen, lisinopril, hydrochlorothiazide, and metformin. A 45-year-old man comes to the physician because of right shoulder pain that began after he chopped wood 2 days ago. Examination of the right upper extremity shows no obvious bone deformities or point tenderness. The pain is reproduced when the patient is asked to externally rotate the shoulder against resistance; there is no weakness. In addition to the teres minor, inflammation of which of the following tendons is most likely in this patient A 44-year-old man comes to the physician because of a 6-week history of progressive numbness of his feet. Two months ago, he completed a course of chemotherapy, including vincristine, for small cell lung carcinoma. Physical examination shows muscle weakness of the distal portion of the feet and absent ankle jerk reflexes. A 10-year-old girl is brought to the office by her mother because her school nurse thinks that she may have Marfan syndrome. Physical examination shows a narrow palate with dental crowding, long slender extremities, and joint laxity. There is no clinical evidence of Marfan syndrome in the mother, but she has the same single nucleotide change as the patient. The same nucleotide change is found in 15 of 200 individuals without Marfan syndrome. Which of the following best describes the single nucleotide change in the patient and her mother A 26-year-old woman comes to a busy emergency department because of a 2-day history of runny nose. She is angry with the staff and says the only reason she had to wait this long is because she does not have insurance. In addition to apologizing to the patient, which of the following is the most appropriate opening remark by the physician A 26-year-old man is brought to the emergency department by ambulance 30 minutes after being shot in the leg. Compared with a healthy adult, which of the following findings is most likely in this patient Arterial Baroreceptor Systemic Vascular Pulmonary Vascular Systemic Capillary Firing Rate Resistance Resistance Fluid Transfer (A) ^ ^ ^ filtration (B) ^ v ^ absorption (C) ^ v v filtration (D) v ^ ^ absorption (E) v ^ v filtration (F) v v v absorption 23 48. A 36-year-old man with profound intellectual disability is brought to the physician by staff at his facility because of increasing abdominal girth during the past 2 weeks. Physical examination shows a protuberant abdomen with a fluid wave and shifting dullness. A new test has been developed to detect the presence of a tumor-specific protein in serum. The initial evaluation of this test shows: Tumor Present Absent Positive 40 20 60 Test Result Negative 10 30 40 50 50 100 Which of the following is the likelihood that a patient with a positive test from this sample has a tumor A 75-year-old woman with type 2 diabetes mellitus and hypertension is brought to the office by her daughter because of a 4-month history of loss of appetite. A certified interpreter is not available at the clinic, but a telephone interpreter service is available. Which of the following is the most appropriate person to serve as an interpreter for this patient encounter During a study of renal glomeruli, a healthy animal kidney is kept in a vascular bath preparation at a constant afferent arterial pressure of 100 mm Hg. If the efferent arteriole is constricted with a vascular clamp, which of the following Starling forces is most likely to change in the glomeruli His birth weight was 3500 g (7 lb 11 oz), and Apgar scores were 8 and 10 at 1 and 5 minutes, respectively. At the age of 15 months, physical examination showed no abnormalities, but he was not yet talking. Both of his parents had learning difficulties in school, and his mother stopped attending after the 10th grade. He is at the 25th percentile for height, 15th percentile for weight, and 90th percentile for head circumference. He appears irritable, he resists making eye contact, and he is flapping his hands. During the operation, moderate hemorrhaging requires ligation of several vessels in the left side of the neck. A 46-year-old woman comes to the physician because of a 2-month history of fatigue and muscle weakness. Her pulse is 90/min, and blood pressure is 105/60 mm Hg while seated; pulse is 95/min, and blood pressure is 99/59 mm Hg while standing. A 55-year-old man who is a business executive is admitted to the hospital for evaluation of abdominal pain. The patient says with disgust that the missing child is and always has been worthless. A study is designed to evaluate the feasibility of acupuncture in children with chronic headaches. In addition to their usual therapy, all children are treated with acupuncture three times a week for 2 months. A 6-year-old girl is admitted to the hospital because of a 1-week history of constant increasingly severe neck pain and a 2-month history of severe headaches that occur three to four times weekly and last for 1 hour. She also has had four episodes of otitis media and three urinary tract infections during the past 4 years. Examination of the neck shows no palpable masses, but there is generalized hyperreflexia and Babinski sign is present. Examination of a biopsy specimen of the retropharyngeal area shows aggregates of segmented neutrophils as well as evidence of Candida albicans.
Bascombe erectile dysfunction after stopping zoloft buy super viagra 160mg low price, Ravi Maharaj erectile dysfunction causes heart disease order super viagra 160mg, Marjorie Lamont-Greene erectile dysfunction treatment austin tx purchase super viagra paypal, Allana Roach impotence use it or lose it super viagra 160 mg amex, Melissa Bondy erectile dysfunction oil treatment order super viagra 160mg line, 11 12 3 13 erectile dysfunction and injections cheap 160 mg super viagra visa,14 14 Matthew J. Methods: Cancer surveillance data on 29,512 incident cancer cases reported to the Dr. Age-standardized rates, overall and by sex, ancestry, and geography, were reported. Results: the highest incidence and mortality rates were observed for cancers related to reproductive organs in women, namely, breast, cervical, and uterine cancers, and prostate, lung and colorectal cancers among men. Nationals of African ancestry exhibited the highest rates of cancer incidence (243 per 100,000) and mortality (156 per 100,000) compared to their counterparts who were of East Indian (incidence, 125 per 100,000; mortality, 66 per 100,000) or mixed ancestry (incidence, 119 per 100,000; mortality, 66 per 100,000). Conclusions: Our findings highlight the need for national investment to improve the understanding of the epidemiology of cancer in Trinidad and Tobago, and to ultimately guide much needed cancer prevention and control initiatives in the near future. Keywords: Trinidad and Tobago, Caribbean, Cancer incidence, Cancer mortality, Cancer surveillance, Cancer in populations of African ancestry, Cancer in populations of Indian ancestry Background cancer mortality will increase by 67% during this period, Cancer is the second leading cause of death in the from 52,282 to 87,430 deaths [2]. Aging of the popula Caribbean and has created tremendous challenges for tion, improvements in healthcare and economic devel healthcare services and expenditures throughout the opment has led to a higher prevalence of lifestyle-related region [1]. These English-speaking islands analytic dataset consisted of the 29,512 incident cancers are unique in terms of their economy and ancestry. The source of the registry records was previously one of the richest countries by gross domestic product described [18]. Self-identification, medical records, and underwent a transition marked by a declining fertility to a lesser extent, imputation by binary logistic regres rate, a decrease in the < 15 years age-group, and a doub sion were used to determine ancestry [18]. While the Trinidad Death certification and population data were obtained population consists of diverse ancestral groups (includ from the Trinidad and Tobago Central Statistical Office ing African (31. These demographic patterns have resulted in several population measures including age (single year of customs and traditions that have marked the sociocul age, 5 and 10-year age groups), ethnicity, and sex. However, a comprehensive analysis of cancer incidence period by the number of incident cases and then multi and mortality has never been reported. N = 10,087) was calculated by taking the average of the time from incidence to date of last contact. Several basic metrics of the highest overall age-standardized cancer incidence data quality from the registry are provided (Add (238 per 100,000) and mortality (151 per 100,000). Simi cancers with the highest incidence and mortality (pros larly, the cancers with the highest mortality rates among tate, colon, hematologic and stomach cancers) were ob men were prostate (37. The most commonly diagnosed cancers among corpus uteri incidence, while colon cancer and ovarian women were breast (46. The cancers with 64 years, while the highest mortality rates for colon and the highest mortality were breast (18. Stage distribution of selected cancers Cancer incidence and mortality rates by geography Figure 5 shows the distribution of stage at diagnosis among the geographical area of residence corresponded with the leading cancers by sex and ancestry. Information refering to major organ systems are bolded aAnus, anal canal, bile tract, esophagus, gall bladder, gastrointestinal, rectosigmoid junction, small intestine bMyeloma, lymphoma, leukemia cAccessory sinus, ear/nose, heart, pleura, respiratory tract, thymus, trachea dExcludes genital cancer Warner et al. Data for persons under 24 are presented in Additional file 2: Table S2 Warner et al. Stage categories may not sum to 100% because of rounding attributable to preventable lifestyle factors. Tobacco use, obesity, pathogens, physical studies reporting that members of the African diaspora inactivity, diet, and alcohol are among the known life suffer a disproportionate cancer burden compared to style factors associated with increased cancer incidence other groups [37, 38]. This and support cancer prevention and control initiatives study found that Caribbean-born men were diagnosed at [44]. This gap could women, and prostate, lung and colorectal cancers among be due to the intersection of screening, health literacy, men, with differences observed by geography and ances tumor biology, genomics, and patterns of care issues [42]. For ex need for national investment to improve the understand ample, large proportions of data on cancer stage were ing of the epidemiology of cancer in Trinidad and Tobago, missing and molecular subtype for breast cancer, for ex and to ultimately guide much needed cancer prevention ample was not reported, which precludes interpretation and control initiatives in the near future. There are issues related tion efforts should be strategically increased, particularly to the data validity that can be addressed by an increase among those cancers that are attributable to lifestyle in the quality of the data collected and improved steps choices. The high proportion of cancers diagnosed at dis to have its data included in Cancer Incidence in Five tant and unknown stages, also highlights the need for im Continents. Another limitation was the inability to access lar subtyping of tumors) is essential for improved cancer and examine cancer screening data, which would be an surveillance. This will undoubtedly improve the quality of important consideration in terms of the mortality dispar data available for future research and will play an instru ities reported herein. Another limitation was the lack of information on where patients sought cancer care. Acknowledgements 14Division of Public Health Sciences, Department of Surgery, Washington the authors would like to acknowledge Stephan Samuell (Central Statistical University School of Medicine, St. The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official References views of the funding sources. All authors Prevalence of cancer-associated viral infections in healthy afro-Caribbean assisted with the drafting the manuscript, revising the manuscript critically populations: a review of the literature. All authors also agree to be accountable for all aspects of the tt/downloads/DownloadDetails. Trinidad & Tobago 2011 Consent for publication Housing and Population Census, vol. Trinidad and Tobago 2011 Population and Competing interests Housing Census Demographic Report. A perfect storm: how tumor biology, genomics, and International classification of diseases for oncology. Geneva: World health care delivery patterns collide to create a racial survival disparity in Health Organization; 2000. Cancer mortality for selected sites in 24 countries (1966 Gombe Mbalawa C, Kohler B, Pineros M, Steliarova-Foucher E, Swaminathan 1967) vol. In: the 5th Annual Glob cancer: diagnosis and management of lung cancer, 3rd ed: American Health and Infectious Disease Conference, Science to Solutions: 2017. Adiposity and cancer at major anatomical sites: umbrella review of the literature. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the global burden of disease study 2010. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990 2013: a systematic analysis for the global burden of disease study 2013. Comparative Quantification of Health Risks: Global and Regional Burden of Diseases Attributable to Selected Major Risk Factors. Prostate cancer disparities in black men of African descent: a comparative literature review of prostate cancer burden among black men in the United States, Caribbean, United Kingdom, and West Africa. High prevalence of screening-detected prostate cancer among afro-Caribbeans: the Tobago prostate Cancer survey. Global patterns of prostate cancer incidence, aggressiveness, and mortality in men of african descent. Cell Differentiation Cell differentiation: selective activation of genes that synthesize proteins not found in other cell types. Adult Bone Marrow Embryonic Stem Cells Embryonic stem cells are pluripotent, meaning that can differentiate into any cell type. Cell Proliferation & Death Cell proliferation & cell death (apoptosis) occur throughout life. Basal cells divide faster than needed to replenish the cells being shed, and with each division both of the two newly formed cells will often retain the capacity to divide, leading to an increased number of dividing cells. Rx: salicylic acid: First pare the wart with a blade, pumice stone, or emory board. Soak it in warm water to increase uptake of salicylic acid, apply the acid, & let it dry, and cover. Cancers can spread by: Metastasis (travel via blood, lymph) to establish colonies in distant tissues. Cancer Grading Aggressive tumors might be described by a pathologist as poorly differentiated; in contrast, a well-differentiated adenocarcinoma of the colon would be less aggressive. Cancer Grading the microscopic appearance a cancer indicates its likely behavior and its responsiveness to treatment. Types of Cancer Carcinomas, the most common types of cancer, arise from the cells that cover external and internal body surfaces. Lung, breast, and colon are the most frequent cancers of this type in the United States. The activated transcription factors turn on genes required for cell growth and proliferation. Individuals with familial retinoblastoma are born with one defective copy of the tumor suppressor gene Rb. One particular tumor suppressor gene codes for a protein called "p53" that can trigger cell suicide (apoptosis). Summary: Control Of Cell Division Oncogenes: variants (mutants) of proto-oncogenes that provide a continual signal to divide. Cancer Cell: A Failure of Cell Regulation A cancer cell has multiple defects: Increased division due to oncogenes. Examples: cervical cancer, liver cancer, and certain lymphomas, leukemias, and sarcomas. The risk of cervical cancer is increased in women with multiple sexual partners (& very high in women who marry men whose previous wives had it). Human Papilloma Virus Papilloma viruses were recognized years ago as the cause of warts on the hands and feet or condyloma accuminata on the pubic area (penis and urethra in males or vulva and vagina in females). For years, warts were considered just an ugly nuisance, rather than a forerunner of cancer. Warts on fingers and toes usually are not dangerous, but virus types that target the face can make skin cancer more likely. Instead, the immune deficiency makes people more susceptible to other viral infections. In turn, the resulting free radicals damage other molecules by stealing their electrons. Free Radicals: Chemicals with Unpaired Electrons Free radicals seek electrons to complete their unpaired electrons. Lipid peroxidation: A free radical can pull off a hydrogen atom (with its only electron) from polyunsaturated fatty acids, so the fatty acid has an unpaired electron and becomes a peroxyl radical, which can attack another fatty acid setting off a chain reaction. It only penetrates single celled organisms and the superficial cell layers of multicellular organisms. Industrial Pollutants & Cancer The fact that many environmental chemicals can cause cancer has fostered the idea that industrial pollution is a frequent cause of cancer. Diet and Cancer Diet may also play a role in determining cancer risk, but unlike tobacco and sunlight, the exact dietary components that influence cancer risk are unclear. The responsible components remain unknown, but many recommend at least 5 servings/day. Correlation Between Meat Consumption & Colon Cancer Average Meat consumption (in many people) Helicobacter pylori & Stomach Cancer the bacterium H. Tumor formation may result from excessive hormonal stimulation of cells whose normal growth and function are under endocrine control. NormalHyperplasia Neoplasia Intraductal Intraductal Intraductal Invasive hyperplasia Normal duct hyperplasia carcinoma in situ ductal cancer with atypia Cumulative exposure of breast tissue to estrogen may increase risk of breast cancer by accelerating progression from normal to hyperplasia to cancer. The Breast Cancer Prevention Trial studied effect of Tamoxifen for 5 years in a large group of women at increased risk. As the embryo develops, cells develop different morphologies and functions as a result of selective activation of certain groups of genes. Normal Cell Growth & Division In a normal cell, division is controlled; it divides only when appropriate for its type and circumstances, and it does not lose its specialized differentiated identity. Cells in the basal layer (bottom row) divide just fast enough to replenish cells that are shed. The Transition to Tumor Formation Skin cancer occurs when the normal balance between cell division/cell loss is disrupted. Warts Warts are benign tumors of the epidermis caused by any one of 60 types of human papillomavirus (some of which cause cervical cancer). They spread by direct contact, and frequently resolve over several months, but some may take years. Hyperplasia & Dysplasia Hyperplasia: Cell number is increased, but structure & arrangement are normal. Normal Pap Smear Dysplasia On A Pap Smear Large, darker staining nuclei with irregular shapes. Characteristics of Cancer Cells Large # of dividing cells Large, variably shaped nuclei Large nucleus to cytoplasm ratio Variation in size and shape Loss of normal cell features Disorganized arrangement Poorly defined tumor boundary Primary Characteristics of Cancer 1. The vertical growth phase and metastatic melanoma are notable for striking changes in the control of cell adhesion.
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The definition of a successful outcome differs greatly between medical provid ers and patients erectile dysfunction support groups generic super viagra 160 mg. Questions in follow-up studies tend to focus on heterosexual sexual behavior as being the standard for success erectile dysfunction treatment exercise order 160mg super viagra otc, as opposed to fertility or pleasure erectile dysfunction prostate purchase 160mg super viagra visa. It is more common to ask a patient if she or he is married than to ask if that patient has a pleasing sexual life impotent rage man 160mg super viagra otc, is able to procreate erectile dysfunction medications otc order 160 mg super viagra fast delivery, or has the ability to achieve orgasm erectile dysfunction causes in young men generic super viagra 160mg line. Such participation would require a level of disclosure by doctors that many inter sex people have been denied, because traditional approaches encourage con cealment of intersex status, and a person may not know they have an intersex anatomy having been protected from this information by doctors. The emotional impact of normalizing medical interventions has not been studied by clinicians that assign sex and gender to intersex people. Most intersex people who have been subjected to nonconsensual surgical and/or sex hormone treatments and who have been asked state that they would have preferred to have their bodies left intact. Most intersex people who have not had surgery are grateful and do not wish to undergo medical procedures to normal ize their genitals. There are few long-term follow-up studies on normalizing genital surgery per formed on intersex children. Most follow-up studies focus on acceptance of gen der assignment and have not adequately addressed quality of life issues for in tersex adults. Research is not a suitable substitute for immediately ending normalizing inter ventions. There is no medical consensus regarding whether normalizing genital surgeries are advisable or beneficial. There is great inconsistency among doctors and medical associations regarding the medical treatment of intersex children. There is no written standard of care, and decisions to normalize genitals are based upon subjective standards and cultural prejudices. The American Medical Association, American Association of Clinical Endocri nologists, and the American Urological Association no longer have official poli cies on the management of intersexuality, and state that they defer to the deci sions of individual doctors and membership associations. The American Association of Pediatrics, American Medical Association, and American Urological Association have called having ambiguous genitals a social emergency that necessitates an immediate medical response. All surgery carries the risk of death, and that risk increases in younger patients. All surgery carries the risk of infection; healthy intersex children have had their good health impaired or permanently compromised as a result of normalizing interventions. Most infant genital surgeries are performed with a treatment goal of normaliz ing the visual appearance of an intersex child. The subjective determination of what appears normal is left to individual physicians. Genital surgeries performed on intersex infants and children are essentially irre versible. Performing infant genital surgery for normalizing purposes can destroy or limit reproductive capacity, eliminate options for expression of gender and sexual identity, and diminish or destroy sexual function and pleasure. Vaginoplasty can have negative outcomes: it can cause infertility; vaginal dilation is often painful and humiliating; the constructed vagina can smell like bowel; it can necessitate constant use of sanitary napkins; it frequently requires repeated surgical revisions; and it is usually created or deepened for the expressed goal of accommodating a penis, rather than for the satisfaction of the patients; vaginal dilation is painful and can be experienced as sexual abuse; there is no medical need for a preadolescent girl to have a vagina. Hypospadias repair (surgically moving the urinary opening to the end of the penile shaft) often involves many, often painful, surgeries. As the body tissue used to reconstruct the urinary tract lacks the beneficial properties of real urinary tract tissue, it can require ongoing medical intervention. Adult men with small phalluses can and do learn to be sexual in ways that satisfy both themselves and their partners. Most adult men with small penises would not want to have them removed and would prefer to participate in such decisions. Adult women with large clitorises can and do learn to be sexual in ways that sat isfy both themselves and their partners. Most adult women with large clitorises would not want to have them removed or resized, and would prefer to participate in such decisions. Adults with atypical genitalia usually would not choose the procedures to which intersex infants and children are subjected, such as the removal of a small penis or the removal, reduction, or recession of a large clitoris. Ambiguous genitalia can be a sign of metabolic concerns that may need urgent treatment; however, ambiguous genitals themselves do not need urgent surgical or hormonal treatment to normalize or correct their appearance. Most medical interventions performed on children are available to young adults when they are able to give consent. It is easier to operate on larger anatomy and results are more likely to be seen by the patient as positive. Early childhood sur geries often necessitate revisions to accommodate body growth. Medical providers often tell parents that there is something wrong with the child. Parents of intersex children report feeling shame, fear, horror, humiliation, regrets, and ongoing doubt about the choices they may have made for their children. Because genital surgery affects one of the most sensitive parts of the body, it can hinder sexual response. Historically, preservation of sexual pleasure and orgasmic capacity has not been prioritized as a surgical goal, or even taken into consideration. In addition, it is virtually impossi ble to cut tissue without causing nerve damage. This is particularly true for tissue that is as densely innervated as the genital and pelvic area. Intersex adults report undergoing sex hormone treatments even when there is evidence that such treatments may harm their general health. Future negative effects of sex hormone treatments may not be disclosed to intersex individuals before the treatment is started, and the negative effects of those treatments are not adequately medically addressed. The preponderance of evidence suggests that gender identity cannot be surgi cally assigned. The outcomes of such surgical assignments can be devastating to the patient, and to their family. Most intersex children can live happy and healthy lives without surgical interven tion. Rationales for normalizing medical interventions are based upon social mores and norms and are not evidence-based. Current treatment protocols are homophobic in that they use heterosexuality as the measure of a successful gender assignment. Parents often are made to believe that their intersex children will be homosexual and/or suicidal if they do not undergo normalizing genital surgery. Prejudice against people with nonstandard genitals is culturally determined, and this negative bias does not exist in every culture. Intersex people are subjected to normalizing medical interventions that are in tended to reinforce gender assignment. Sometimes patients are assigned a gender that is incongruent with their own gender identity. When that assignment has been reinforced surgically and/or hormonally, transitioning to an appropriate gender is problematic. Intersex people who were assigned a sex and gender that is wrong for them face the additional hard ship of transitioning to their actual sex or gender identity. This could cause complications for intersex people who are legally married or desire to marry. It is also problematic when le gal identification appears inconsistent with gender expression. This becomes a barrier to acquiring vital information and support from other parents that will help them care for their intersex children. Ad ditionally, some people are discovered to have some type of intersex condition later in life. In the United States, approximately five normalizing surgeries are performed on infants each day. Due to their experiences, many intersex people fear medical providers and clini cal settings and are therefore reluctant to seek routine, necessary, or emergency medical attention. The practice of utilizing normalizing interventions and concealment fosters shame and secrecy. Clinicians often do not tell intersex children anything about the intersex aspects of their bodies or about the surgeries and/or sex hormone treatments to which they were subjected, even after the patient becomes an adult. Often, intersex people and adults are told lies to cover up the true nature of their bodies and medical interventions, and this system of deception is recom mended to the family members of the intersex person. While access to accurate information and peer support helps people accept in tersexuality as normal secrecy, lies, and withholding patient information can produce a sense of freakishness about intersexuality. Intersex children often discover partial truths about their bodies and medical histories, and they do not always get this information from appropriate sources in appropriate ways. Fur ther, they are not routinely offered professional therapeutic support along with this information. Students are taught that human bodies always fall into one of two opposite categories: male or female. However, the definitions of male and female anatomies do not include intersex anatomies. Medical and mental health care providers are not being adequately trained in human sexuality. This inhibits most health care providers from understanding their patientsparticular needs and offering them the most appropriate care. There are insufficient numbers of medical and mental health providers who are adequately trained in providing appropriate intersex care and treatment. Cur rently, there are not enough medical and mental health professionals trained to help manage intersex births. Some teaching institutions recently have begun to create appropriate curricula to teach comprehensive intersex studies to medical and mental health providers. Because of increasing controversy regarding normalizing interventions, con cerned clinicians are questioning the traditional concealment model of intersex treatment. Before 1993, no intersex people were on record acknowledging their experience with normalizing practices. Because of the growing patient advocacy move ment, some intersex people are now able to speak publicly about these issues. The Internet is one of the primary vehicles intersex people use to gain informa tion about their conditions and find community support. Low-income people, in cluding many intersex people of color, are less likely to have access to email, the Internet, or other technological resources. Any proce dures that are not medically necessary should not be performed unless the pa tient gives their legal consent. Infant genital surgeries that are undertaken to improve the underlying physical health of an intersex child should be performed within that patient-centered model. Medical professionals should give a full disclosure of the condition, and all treat ment options, including non-treatment, to the patient, family, and/or parents: Par ents should be told that most cases are not medical emergencies and do not re quire normalizing interventions. Parents should be given access to studies that support any medical recommendations. Parents should be told that current prac tice of early surgery is criticized by many intersex adults, by some parents of in tersex people, and by some physicians, and is therefore highly controversial. Providers should acknowledge that there are no data supporting the belief that normalizing interventions are beneficial or necessary to the psychosocial health of the patient, and should provide parents with information about current and fu ture benefits, potential complications, potential side effects, and all treatment al ternatives, including non-intervention. All information regarding the risks of sex hormone treatments, including cancer risks should be provided to the patient and the parents. Ethics review boards, which include intersex people, should be established to consult with doctors on appropriate treatment protocols for intersex conditions. Doctors should receive approval for any intersex interventions from an outside entity, and an ethics review board which includes intersex people, that is sepa rated from medical peer-based review, in order to ensure accountability on inter sex treatment. Genital surgery and hormonal treatments should be available to fully informed and consenting patients. Providers should provide parents with access to peer support and appropriate mental health services. Mental healthcare providers and educators should offer ongoing mental health support and age-appropriate information to intersex people. Medical record keeping should be mandated, and that medical records and pho tographs should be kept for life, and that all patients should be given access to their records. The problem of social discrimination should be addressed rather than offer hor monal or surgical intervention. Intersex children should be encouraged to think positively about their bodies even if those bodies are different in some ways from others. Local, state, and federal legislators should investigate the question of necessity for having gender markers as a requirement for legal identification.
Document if no other treatment was given safe erectile dysfunction pills super viagra 160 mg amex, or if it is unknown if intended other treatment was given erectile dysfunction gene therapy treatment discount 160 mg super viagra with amex. Assign code 1 when the patient receives treatment collected in any of the following fields: a erectile dysfunction treatment sydney order super viagra. Other therapy Note: Any type of first course cancer directed treatment erectile dysfunction in teens generic super viagra 160 mg line, including surgery erectile dysfunction pills over the counter purchase super viagra overnight, is to be coded as Treatment given erectile dysfunction doctor el paso buy genuine super viagra line. If the patient has multiple tumors, vital status should be the same for all tumors. If a patient has multiple primaries simultaneously, all records should have the same vital status. The text field must contain a description that has been entered by the abstractor. Text documentation should explain where the cancer started, where it went (lymph nodes, other organs) and how it got there (direct extension, metastasis, implants). Please do not enter text in treatment fields, including unknown or n/a, when treatment is either not done, or unknown if done. Be sure to record the furthest extension that the pathologist mentions, for example: confined to mucosa; into subserosa; through full thickness of abdomen wall, etc. Review all available reports and document all planned treatment, as well as the date 246 Texas Cancer Registry 2018/2019 Cancer Reporting Handbook Version 1. If no treatment is planned or the patient refuses recommended treatment, include this information in the text field. These are lymph nodes within body cavities that in most situations cannot be palpated, making them inaccessible. An example of this would be tumor adhering to another structure that the surgeon could not remove. Summary Stage Documentation (2520, 2530, 2540, 2550, 2560, 2570, 2600) 1/2/18 Mammogram: Lt breast no masses, Rt breast 4. It should be noted although there are shotty lymph nodes present, there is no definite lymphadenopathy demonstrated. No focal areas of increased uptake are seen in the liver to suggest hepatic metastasis. Based on these reports and findings, the patient may benefit from adjuvant chemotherapy. Provides detailed instructions and examples to promote consistent abstracting and coding. Involves only bladder and one or both ureters (no other urinary sites involved) 273 Texas Cancer Registry 2018/2019 Cancer Reporting Handbook Version 1. Urothelial carcinoma and small cell neuroendocrine carcinoma is equivalent to urothelial carcinoma with small cell neuroendocrine carcinoma. Documentation in the medical record that refers to original pathology, cytology, or scan(s) d. There is no priority order because scans are not a very reliable method for identifying specific histology(ies) for these sites. Code the most specific histology or subtype/variant, regardless of whether it is described as: 276 Texas Cancer Registry 2018/2019 Cancer Reporting Handbook Version 1. About 10 cm of the rectum lies below the lower edge of the peritoneum (below the peritoneal reflection), outside the peritoneal cavity C211 Anal canal Most distal 4-5 cm to anal verge Primary Site Code the subsite with the most tumor when the tumor overlaps two subsites of the colon and the point of origin cannot be determined. Code the histology documented by the physician when none of the above are available. Ninety-eight percent of colon cancers are adenocarcinoma and adenocarcinoma subtypes Polyps are now disregarded when coding histology. The first system divides the esophagus into the upper third, middle third, and lower third. It is important to rule out metastases from another organ/site before abstracting a lung primary. The left lung has 2 secondary bronchi, one in each of the two lobes: upper and lower b. Code to mainstem bronchus C340 when it is specifically stated in the operative report and/or documented by a physician. When only called bronchus, code to the lobe in which the bronchial tumor is located 2. This includes both invasive and in situ melanomas; early or evolving are not reportable. The priority list is used for single primaries (including multiple tumors abstracted as a single primary) this is a hierarchical list of source documentation. When a histologic type is identified using a biomarker, code the identified histology. Final diagnosis 304 Texas Cancer Registry 2018/2019 Cancer Reporting Handbook Version 1. Resection and/or biopsy performed, but operative report(s) and pathology are not available (minimal information): a. When the primary site is brain or intracranial glands, see (page 21)Table 5: Histologic Types of Non-Malignant Intracranial (Brain and Gland) Tumors to confirm site/histology combinations. This chapter applies to records of cases of cancer, diagnosed on or after January 1, 1979, and to records of all ongoing cancer cases diagnosed before January 1, 1979. The costs reimbursed under this subsection must be reasonable, based on the actual costs incurred by the department or by its authorized representative in the collection of data under Subsection (d), and may include salary and travel expenses. The department may assess a late fee on an account that is 60 days or more overdue. The late fee may not exceed one and one-half percent of the total amount due on the late account for each month or portion of a month the account is not paid in full. The reports, records, and information obtained under this chapter are for the confidential use of the department and the persons or public or private entities that the department determines are necessary to carry out the intent of this chapter. The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. The costs must be reasonable, based on the actual costs incurred by the department or by its authorized representative in the collection of the data and may include salary and travel expenses. It is presumed that a health care facility, clinical laboratory or health care practitioner acted knowingly or in bad faith if it failed to take corrective action within 60 days of the date of the original notification letter. All other requests for statistical cancer data shall be in writing and directed to: Texas Cancer Registry, Mail Code 1928, Department of State Health Services, P. Data Field 550: Registry Number See page 68 the first four digits identify the calendar year the patient was first seen at the facility with a reportable diagnosis. Data Field 2390: Patient Maiden Name See page 75 Enter the maiden name of female patients who are or have been married. Data Field 70: Patient City See page 80 Enter the city of residence at the time the cancer is diagnosed. The information may be coded from the medical record or may be based on Spanish/Hispanic names. Data Field 9961: Weight See page 107 Enter the weight as a 3 digit number measured in pounds. Data Field 410: Laterality See page 130 Enter the code to identify the laterality of a paired site. Data Field 1182: Lymphovascular Invasion See page 135 Indicates presence or absence of tumor cells in lymphatic channels. This code includes examination of fluid such as spinal fluid, peritoneal fluid, or pleural fluid. Assign code 7 when the diagnosis is confirmed by without microscopic radiology or other imaging techniques only. Data Field 2600: Summary Stage Documentation See page 150 Text field for documentation of extent of disease to support coding. Data Field 756: Tumor Size Summary See page 154 this data item records the most accurate measurement of a solid primary tumor, usually measured on the surgical resection specimen. The number of regional lymph nodes positive is cumulative from all procedures that removed lymph nodes through the completion of surgeries in the first course of treatment. Summary Stage refers to the extent of disease categorized as in-situ, localized, regional, and distant. Surgery performed solely for the purpose of establishing a diagnosis/stage (exploratory surgery), the relief of symptoms (bypass surgery), or reconstruction is not considered cancer-directed surgery. Data Field 1340: Reason for no Surgery See page 195 If no cancer directed surgery to the primary site was performed record the reason. List dates and types of all treatment given, even if it was done at another facility. This event occurred, but the date is unknown and cannot be estimated (radiation was given but the date is unknown). This data item identifies the radiation modality administered during the first phase of radiation treatment delivered during the first course of treatment. Code 88 if the only information available is that the patient was referred to an oncologist. This event occurred, but date is unknown (that is, immunotherapy was given but the date is unknown and cannot be estimated). If no other treatment was given or it is unknown if other treatment was given, leave the field blank. If patient is known to be deceased, but date of death is not available, date of last contact should be recorded in this field. Obtain disease indices including both inpatient and outpatient admissions after medical records are completed and coded (monthly or quarterly). Z9 Neoplasm of uncertain behavior of lymphoid, hematopoietic and related tissue, unspecified (9960/3, 9970/1, 9931/3) D47. Note: For specific instructions on coding this data field see page 212 of this manual Table H. Note: For specific instructions on coding this data field see page 229 of this manual. Considerable research remains dedicated to uncovering neuroprotective or neuroregenerative strategies, but to date, no such definitive therapies have been discovered. The occurrence of symptoms on only one side of the body is typical of the disease in its earliest stage. Non motor symptoms include changes in mood, memory, blood pressure, bowel and bladder function, sleep, fatigue, weight and sensation (Table 1). Motor symptoms typically begin on one side of the body, often as a rest tremor or a reduced ability to use the hand, arm or leg on the affected side. The motor symptoms come from the slow and progressive degeneration and death of these neurons in an area of the brain called the substantia nigra, which is in the brain stem. In other words, a person will lose at least 50% of the dopamine in his or her brain before noticing that something is wrong with his or her body. In 2011, a computerized brain scan utilizing a radio-isotope that labels the molecule transporting dopamine into the cell (DaTscan) first became available in the United States. Since these symptoms are largely due to the diminishing supply of dopamine in the brain, most symptomatic medications are designed to replenish, mimic or enhance the effect of this chemical. Regular exercise, physical therapy, occupational therapy, speech therapy, holistic practices, nutritional consultation, support groups, education, psychological counseling, intelligent use of assistive devices and caregiver relief are all important aspects of the best treatment plan. As they continued to explore ways to translate these observations to the human condition, their efforts led ultimately to the successful development of levodopa in the late 1960s.