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Result Incalculable When the Incalculable flag is presented for measured analytes it indicates that the required measurement criteria were not met during sample analysis medicine 8 discogs order online avodart. The Incalculable flag is displayed by a derived parameter when a required measured analyte result is not available medications you cant take while breastfeeding avodart 0.5 mg. A measured parameter with an Incalculable flag or a measured parameter outside of the reportable range is an example of when a measured analyte will not be available for use in a calculation symptoms kidney failure buy avodart with a visa. If an entered value required for the calculation is not supplied Incalculable will also be displayed treatment 3 nail fungus order 0.5mg avodart fast delivery. Absorbance Error An absorbance error is an indicator of a residual spectrum inaccuracy during the sample analysis. The presence of unknown interfering species, clots or other foreign matter within the blood sample that alters the optical spectrum will result in higher levels of residual spectrum. A sample with an absorbance error should not be reported and the sample should be repeated, as results can be outside specification claims. Sulfhemoglobin Interference Detected this flag is displayed when the Sulfhemoglobin detection is equal to or greater than 10 percent. High Turbidity Detected A turbidity flag is presented when turbidity equal to or greater than 5 percent, created by Intraplipid fat emulsion, is detected. Temporary Sensor Error A temporary sensor error reflects a failure for the Process Control solution B post analysis check to pass the reference check. High Methemoglobin Warning Methemoglobin detection is equal to or greater than 30 percent. Sulfhemoglobin and High Methemoglobin Warning the sulfhemoglobin detection is equal to or greater than 0. Corrected for Sulfhemoglobin this flag indicates that Sulfhemoglobin less than 10 percent has been detected in the sample. The appropriate correction algorithm is applied to eliminate the impact of Sulfhemoglobin on other hemoglobin fractions. Although excluded, the results will be kept in the analyzer database and can be retrieved. For example, if the results contain values which exceed critical limits, then your system may require that the results be manually accepted. The system will return to the Start New Sample tab following a 5 minute time period. The Notify button allows the operator to record any notification made to the clinician. The analyzer will display the most recent test results for the same patient and same sample type as the current sample. The delta (fi) value represents the difference between values for the current sample and for the one prior to it. These function as data entry fields or dropdown menus (example shown here is from a standalone analyzer). Date and time frame criteria (lower righthand corner of the screen) are required for all searches. For the Area/Analyzer criterion, if All is selected while the analyzer is networked, the search will be performed on all analyzers in the network (included those that have been deleted). When the analyzer is disconnected or standalone, only information stored on the current analyzer will be searched. If the search criteria will result in more than 500 records, a message will appear instructing you to narrow the entered criteria. Performing database searches Search Results Results are displayed in list format, along with the criteria used in the search. This button is presented if there is at least one connection configured to send patient results. Sample Details Details of a specific sample can be accessed by pressing one of the patient name buttons from the sample list; this launches the Sample Results screen, which displays patient demographic information as well as the sample results. Pressing this button will launch a Patient History screen showing the five most recent samples run in the last month for that patient. Sample Information If you are authorized to do so, patient temperature and patient demographic information may be amended by selecting the blue Sample Information button, located in the upper right corner of the Sample Details screen. Whenever the patients temperature or demographic information have been amended, a new report will be generated and marked as an Amended sample. Removing the cartridge from the analyzer Removing the cartridge is generally a task that should be performed only when the cartridge is completely used and the analyzer indicates that the cartridge needs to be replaced. A supervisor may decide to manually remove a cartridge when there are a few tests left for convenience (for example, in the operating room when a cartridge change in the middle of a case is not practical). If a cartridge has reached its maximum onboard use-life or test capacity, the cartridge door will automatically open and display a message to the operator to remove the cartridge. To remove a cartridge prior to its maximum onboard use-life or test capacity, follow the instructions provided below. Removing the cartridge is a simple operation but one that requires careful consideration to avoid underutilizing a cartridge. Removing the cartridge from the analyzer 3 Once you press Yes, the door will click open slightly. The system will now be inactive until you insert a new cartridge (see Section V: Starting Up the Analyzer). Use universal precautions as designated by your facility when handling a used cartridge. Viewing Training Videos 3 Select a topic and press Play from the Action buttons located along the bottom of the screen. Viewing Training Videos 4 While watching a training topic the operator can adjust the volume, pause the video or stop playing the video. Powering down properly Shutting down the analyzer is an important step that requires careful consideration before completing. Once the analyzer is shut down you will need to replace the cartridge if power is not restored within 20 minutes. If, when power is restored the cartridge cannot be recovered, the analyzer will alert the operator to remove the cartridge. To power the instrument off, it is necessary to utilize the Shut Down command in the instrument software, which is accessed! If the power switch is pressed and held for 5 seconds or longer, the instrument will shut down. However, this will result in an illegal shut down, and the instrument software may not be able to recover. This section highlights the key diagnostics tasks available on the analyzer, which are of primary interest to technical personnel. The Diagnostics function is available via the blue Menu button and provides an entry point to perform various diagnostic activities with the analyzer. System diagnostics 3 Analytes lists the analyte concentrations in the reagent bags for the selected cartridge. Therefore, cartridge data files will be overwritten if copying a different cartridge file set onto rewritable media that already contains cartridge data. System diagnostics 7 Service the Service function is for use by authorized service personnel. However, should you encounter any system errors or other issues, this information will help you understand the code or message displayed. Error Codes Associated With System Malfunctions Error Cause of Error Operator Message Code 201 Process Control solution not Process control solution not detected. The operator should check the analyzer environment blocked ventilation, excessive ambient temperature, etc. Resolving errors Error Codes Associated With Software Malfunctions Error Error Can Cause of Error Message to operator Code Occur On: Analyzer, Server or Both 3001 Both the file system check, performed File system check error. System will be reset 3012 Analyzer An illegal script command or an illegal Script error. If you do not have your original instrument packaging, a new box will be sent to you. You will also be notified when the instrument has been repaired and has been shipped back to your facility (U. Preventive maintenance, cleaning, and fuse replacement Prepare a biohazard waste bag for waste disposal.

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Inform at-risk personnel about the transmission medicine 751 buy 0.5mg avodart overnight delivery, prevention and clinical aspects of rabies symptoms 9 weeks pregnant cheap avodart 0.5mg with amex. Stress the importance of reporting animal bites or other suspicious animal contact treatment dynamics order 0.5mg avodart with visa. Suggestions for a host nation landfill operation: Identify a large area of land that will not be used for many years after the landfill is closed medicine express generic avodart 0.5mg otc. Find an area close to the site to store excavated dirt while the landfill is constructed. The pit will need to be lined will a nonporous membrane (such as clay) to prevent pollutants from leaching into the water table and contaminating the water. The pit must be accessible to vehicles (dump trucks) and allow them to enter the pit. The bucket loader must cover the refuse throughout the day and at the end of the day. Accept only those animals that are healthy, free of harmful diseases and chemicals and capable of being converted into wholesome products for consumption. A postmortem exam should be conducted prior to consuming any tissue or organ system (see section on Postmortem Exam). What You Need: Gloves and a stethoscope What To Do: Observe the animal at rest and in motion. You may see lameness, pain, neuromuscular deficits and/or systemic disease states in a moving animal that are not apparent in an animal at rest. Look for abnormal conditions such as continuous scratching/rubbing, emaciation or depression. Examination Specifics: Lameness: Reject if limbs are deformed or have gross swelling around joints. Emaciation: Reject animal if in poor state of nutrition, as evidenced by extreme thinness. Organ Systems Analysis: Respiratory: Reject if animal has difficulty breathing, severe coughing or excessive muco-purulent discharges. Urinary: Reject if posture is abnormal when urinating, if animal strains to urinate or if urine has an unnatural color (hematuria). Reproductive: Reject animals with foul discharges from vulva, mammaries or prepuce; or with retained placentas/fetal membranes. Skin and Hair coat: Reject if skin is yellow-colored or has diffuse discolorations (red or black) or lesions. Consider rejecting animals that have obvious hair loss indicative of systemic disease. If lesions are localized they may be trimmed and the carcass retained for consumption. Do not consume an animal from an unknown source unless the carcass passes the antemortem and postmortem examinations and is cleared for consumption. The following guide is one of many ways to humanely slaughter and dress animals in a field environment. Perform an antemortem exam prior to slaughtering the animal, and a post mortem exam after. Figure 5-21: Humane Kill: the following diagrams illustrate the proper position for humane kill of various livestock species: 2. If the head is to be salvaged, then insert knife at point B, cutting deeply until blood flows freely. Preparation: Pork: After slaughter, ensure animal is bled out completely before scalding or boiling off the hair. Poultry: There are several methods of slaughter: wringing the neck, dislocating the neck or beheading. The following guidelines are for any species that may be consumed in the field environment. General: Condemn animals with gross contamination of interior surfaces or organ systems and/or discoloration of peritoneal or pleural cavities. Generalized abscesses, emaciation, and jaundiced organs or tissues are reasons for condemnation. Lymphadenopathy indicates disease or inflammation in the area drained by the enlarged nodes. Local adenopathy may indicate a local process only (condemn only affected area), while more extensive adenopathy probably implies widespread disease process. Palpate and examine lymph nodes of the head and neck for gross swellings or lesions. Inspect and palpate all surfaces for abnormalities, discoloration, masses and parasites; examine the heart, lungs and diaphragm as well. Slice open organs and examine for parasites, infection or disease states such as tumors. Joints and Skeletal Muscles: Bruises and localized lesions may be removed and the rest of the carcass consumed. For arthritic and swollen joints, remove affected limb, and then consume carcass if arthritis is not due to systemic disease such as septicemia or caseous (cheese-like) lymphadenitis. Neoplasia, Tumors or Abnormal Growths: Condemn organ system and/or carcass if spread throughout. Off Odors: Condemn carcass with strong odors of urine, ketones (a fruity smell) or pungent sexual odors. When excess food must be stored and preserved for future use, follow these rules: preserve and store only wholesome foods that were initially safe to eat; use only potable water and spices when curing or preserving food; cold storage/freezing is the best method if available; periodic re-examination of stored products is essential to ensure wholesomeness and prevent consumption of contaminated or deteriorated food (moldy, infested, stale). What You Need: Knife, meat, potable water, salt, 1% salt solution (brine), string, green hardwoods, building, saltpeter (potassium nitrate), spices, fire source, hay, salt box and/or brine pan, boiling pot. Curing Although it may be done alone, curing should be done in association with smoking. Raw meat should be clean, edible and sliced against the grain into manageable pieces (step one of beef prep for smoking). If using brine, then the solution should be 1% salt (one pound of salt to 9 pints water). Use clean plastic, glass or earthenware containers, not wood or metal containers to hold brine solutions. Smoking There are several acceptable procedures for smoking meat and different step by step processes. Smokehouse Use any well-sealed building with a vented roof and a floor that can have a fire pit. Let fire burn down to coals and then stoke it with green wood to produce cold smoke (less than 85F). Allow even smoking and avoid contact spoilage by ensuring that all meat hangs free. Time Smoke meat for 4-5 days, depending on size of house, size and number of pieces of meat to smoke. The hole for string should be centralized enough to prevent meat ripping during smoking. Hang meat and prepare smoking record (see preservation records and recommendations below). Smoked meat should be edible for up to one year depending on climate, condition of meat prior to smoking and insect and rodent control. Meat may also be dried over slow coals or sun-dried (sprinkle with pepper and hang about 20 ft into air above insect line). Pemmican Two basic ingredients: lean meat that is not salt cured and rendered fat. Prepare a casing, such as intestine, by cleaning (strip out contents and boil) and tying one end. The fat will separate into tallow, the liquefied oil from fat, and (cracklings), the fat residue. For pickling, mix 50 pounds of salt and 5 pounds of saltpeter with 20 gallons of water. Canning and Other Methodsthese procedures are effective but require resources and equipment not readily available in a field environment. Records should have the following information at a minimum: meat type, date, source of meat, weight and cut of meat, total time cured (preserved), wood used and/or type and amount of salt/seasoning/brine used. What Not To Do: Do not use meat that is unfit for consumption based on anteor postmortem exams.

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We included observational studies that reported one or more cases of sexual transmission symptoms 7 days after implantation buy avodart online now, one or more measurements of presence of virus in bodily fiuids 2 medications that help control bleeding buy generic avodart on-line, or both treatment xanax overdose buy avodart 0.5mg. We did not include reviews medications kosher for passover purchase avodart pills in toronto, editorials or commentaries that did not report original data. Primary outcomes can be directly estimated from observational studies and secondary outcomes are calculated or inferred from indirect evidence. Study selection and data extraction One reviewer screened titles and abstracts of retrieved papers. In addition, we used data from included studies to calculate estimates for the serial interval, the period between the start of symptoms in the primary and the secondary individual, and the duration 76 5. We performed the assessment by a consensus-driven approach among multiple reviewers. We downgraded the level of certainty for small sample size and evidence from case reports or case series. We assessed outcomes of mathematical modelling studies as high, medium, low or very low certainty. Numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage. Intravaginal infection of mice led to systemic infection [266, 592, 596, 598, 608, 611, 613, 619] and to adverse congenital outcomes [592]. In mice, viral titres were lower in the salivary glands than the testes and ovaries. Risk of bias in invivo studies Most studies did not describe in detail the methods used to avoid bias. Thirty-four of 36 episodes of transmission were from man to woman (94%), one (3%) was from woman to man [632] and one (3%) was from man to man [634]. Penile-vaginal intercourse was reported as the most likely mode of transmission between men and women, butoralandanalintercoursewerementionedaspossibletransmissionroutesinsomereports [44, 621, 629, 631, 632, 634, 638, 639, 647, 671, 672]. Amongst primary infected individuals, 27/36 (75%) were symptomatic, 2/36 (6%) were asymptomatic and no symptom status was not reported for the remaining 7/36 (19%). In5/36(14%)couples, the secondary partner had a history of travel to an endemic region [621, 635, 636, 639, 671]. Thirteen reports about 15 couples reported on dates of symptom onset for both partners. In semen (data available from 37 case reports and case series from 119 individuals, Figure 5. Thereweretoofewdatafor analysis of viral culture specimens in female genital tract fiuids and saliva. Only three out of 19 of the semen samples provided within 30 days a ter symptom onset could be cultured; none of the 59 samples provided a ter 30 days could be cultured. The labels on the Y-axis represent the date of publication of the studies and the date of analysis for the last line, in ascending order. Blue lines represent the interval between the last positive measurement and the first subsequent negative measure (red dot). The black dots and whisker bars represent median aggregated values and 95% confidence intervals for [a] a prospective cohort (n=55 men) [49], and [b] the aggregation of all available case reports and case series. Maximum values in these data sets are shown with a red diamond or a red greater than symbol for values outside the range of the image. Lines for which the date is not provided are from the same date as the line above. Many studies reporting on transmission events did not use reliable diagnostic methods in both partners, potentially leading to misclassification bias. Risk of bias of mathematical modelling studies For both modelling studies, the data used to populate the model was not suitable to derive 5 the outcome. The results of these studies did not provide information about the size of the risk of sexual transmission. Tenof18studies(56%)wereinvitroexperimentsorobservations in animals and eight studies (44%) were case reports or case series. Estimates of the outcomes and publications that provide evidence for these di ferent parameters of the sexual transmission framework are listed per outcome. Female mice that were mated to Tick-borne encephalitis virus infected male mice had worse reproductive outcomes than the ones mated to a group of non-infected males; in one female mouse the virus was detected [681]. Male to female transmission was more frequent than female to male transmission in animal models and in humans. In humans, we estimated the serial interval for sexually transmitted infection to be 12 (interquartile range: 10-14. We found no evidence that other arthropod-borne fiaviviruses can be sexually transmitted. Most of these studies explored the suitability of animal models or investigated pathophysiological pathways and source of bias were rarely reported. Case reports and case series are early sources of information about a new disease but, by their nature, researchers report novel and unusual findings. Parametersande fectsizesestimatedfromaggregatingdatafromthesesourcesare likely to be overestimates, the so-called random high; extreme values in a distribution that are observed by chance and are more likely to be reported because of they are noteworthy. However, viral cultures might underestimate the duration of infectiousness if low pH or other specimen-dependent factors produce false negative results [627, 692]. The estimated serial interval was based on observations from only 15 couples, but was consistent with that of several respiratory infectious diseases [693]. The serial interval for sexual transmission was towards the lower end of estimates for mosquito borne transmission (10-23 days) [694]. In mathematical models published so far [168, 169, 695], the estimates were based on assumptions about transmissibility of mosquito-borne infection. Estimates from our review might provide more reliable data for use in future modelling studies. This review did not find evidence supporting sexual transmission of other arthropod borne fiaviviruses. However, it remains to be clarified for many viruses if detection in semen means that there is a risk of sexual transmission [572]. The automation of search and deduplication processes makes it feasible to keep the review updated as new information becomes available. Future updates of this review will alsoallowforincorporationoftechniquestosynthesisemathematicalmodellingstudies,such as multi-model ensembles. Screening and data extraction were not done by two independent reviewers because of time constraints but we believe that we reduced errors by having a second reviewer to check decisions and data extracted. The certainty of this body of evidence was assessed as being of low or very low because of bias in the observational study designs, and indirectness of evidence from animal studies. The certainty of the evidence base could increase if the design and reporting of both animal and human studies improve and if their findings are consistent with, and increase the precision of the evidence presented here. Research about the potential for sexual transmission of other fiaviviruses is needed, although these viruses o ten display di ferent symptomatology or a finity for di ferent species. Current guidelines for travellers returning from endemic areas advise six months of protected intercourse [566]. As more information becomes available a revision of the duration of protection might be indicated. Planned regular updates will allow timely updating of relevant data from a rapidly expanding evidence base. Contribution: I came up with the study idea, I contributed to the methodology, I wrote the model code, performed the analysis and made the figures. I wrote the first dra t of the manuscript and incorporated all feedback until publication. We show that vaccination could curb the risk of infection and could extend to herd immunity, but introduction within the next decade is crucial to provide the most benefit. Before 2007, circulation of the virus only occurred sporadically in African and Asian countries [699, 700]. The risk of an a fected pregnancy appears highest during the first trimester, with estimates between 1. Protective immunity conferred by infection, combined with high attack rates and herd immunity, can explain the ending of epidemics and the lack of early recurrence [156], as has 90 6. A direct consequence of population renewal will be an unequal distribution of immunity by age group, with younger age groups at higher risk from a new epidemic than older people [173]. The number of symptomatic infections is likely much higher, owing to under-reporting.

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Axillary dissection may be replaced with sentinel node biopsy to medicine 657 buy 0.5mg avodart otc evaluate node involvement medicine you can give dogs buy generic avodart 0.5 mg online. The sentinel node is identified by injecting a dye in the tumor site at surgery; the first node in which dye appears is the sentinel node treatment canker sore cheap 0.5mg avodart fast delivery. Women with tumors <1 cm and negative axillary nodes require no additional therapy beyond their primary lumpectomy and breast radiation medicine ads generic avodart 0.5mg without a prescription. Adjuvant combination chemotherapy for 6 months appears to benefit premenopausal women with positive lymph nodes, preand postmenopausal women with negative lymph nodes but with large tumors or poor prognostic features, and postmenopausal women with positive lymph nodes whose tumors do not express estrogen receptors. Estrogen receptorpositive tumors >1 cm with or without involvement of lymph nodes are treated with aromatase inhibitors. Women who began treatment with tamoxifen before aromatase inhibitors were approved should switch to an aromatase inhibitor after 5 years of tamoxifen and continue for another 5 years. High-dose adjuvant therapy with marrow support does not appear to benefit even women with high risk of recurrence. Pts with locally advanced breast cancer benefit from neoadjuvant combination chemotherapy. Treatment for metastatic disease depends on estrogen receptor status and treatment philosophy. Randomized trials do not show that the use of high-dose therapy with hematopoietic stem cell support improves survival. Median survival is about 16 months with conventional treatment: aromatase inhibitors for estrogen receptorpositive tumors and combination chemotherapy for receptor-negative tumors. Some advocate sequential use of active single agents in the setting of metastatic disease. Active agents in anthracyclineand taxane-resistant disease include capecitabine, vinorelbine, gemcitabine, irinotecan, and platinum agents. Pts progressing on adjuvant tamoxifen may benefit from an aromatase inhibitor such as letrozole or anastrozole. Bisphosphonates reduce skeletal complications and may promote antitumor effects of other therapy. Women at increased risk of breast cancer can reduce their risk by 49% by taking tamoxifen for 5 years. Highest incidence in focal regions of China, Iran, Afghanistan, Siberia, Mongolia. In the United States, blacks more frequently affected than whites; usually presents sixth decade or later; 5-year survival <5% because most pts present with advanced disease. Pathology 60% squamous cell carcinoma, most commonly in upper two-thirds; <40% adenocarcinoma, usually in distal third, arising in region of columnar metaplasia (Barretts esophagus), glandular tissue, or as direct extension of proximal gastric adenocarcinoma; lymphoma and melanoma rare. Risk Factors Major risk factors for squamous cell carcinoma: ethanol abuse, smoking (combination is synergistic); other risks: lye ingestion and esophageal stricture, radiation exposure, head and neck cancer, achalasia, smoked opiates, Plummer-Vinson syndrome, tylosis, chronic ingestion of extremely hot tea, deficiency of vitamin A, zinc, molybdenum. Clinical Features Progressive dysphagia (first with solids, then liquids), rapid weight loss common, chest pain (from mediastinal spread), odynophagia, pulmonary aspiration (obstruction, tracheoesophageal fistula), hoarseness (laryngeal nerve palsy), hypercalcemia (parathyroid hormonerelated peptide hypersecretion by squamous carcinomas); bleeding infrequent, occasionally severe; examination often unremarkable. Adenocarcinoma: Curative resection rarely possible; <20% of pts with resectable tumors survive 5 years. Palliative measures include laser ablation, mechanical dilatation, radiotherapy, and a luminal prosthesis to bypass the tumor. Preoperative chemotherapy with concurrent radiation therapy is somewhat more effective but more toxic therapy. Male:female = 2:1; peak incidence sixth and seventh decades; overall 5-year survival <15%. Risk Factors Increased incidence in lower socioeconomic groups; environmental component is suggested by studies of migrants and their offspring. Laboratory findings: iron-deficiency anemia in two-thirds of pts; fecal occult blood in 80%; rarely associated with pancytopenia and microangiopathic hemolytic anemia (from marrow infiltration), leukemoid reaction, migratory thrombophlebitis, or acanthosis nigricans. Diagnosis Double-contrast barium swallow useful; gastroscopy most sensitive and specific test; pathologic confirmation by biopsy and cytologic examination of mucosal brushings; superficial biopsies less sensitive for lymphomas (frequently submucosal); important to differentiate benign from malignant gastric ulcers with multiple biopsies and follow-up examinations to demonstrate ulcer healing. Subtotal gastrectomy has similar efficacy to total gastrectomy for distal stomach lesions, but with less morbidity; no clear benefit for resection of spleen and a portion of the pancreas, or for radical lymph node removal. Palliative therapy for pain, obstruction, and bleeding includes surgery, endoscopic dilatation, radiation therapy, chemotherapy. Treatment: Full colonoscopy to detect synchronous lesions (present in 30%); endoscopic resection (surgery if polyp large or inaccessible by colonoscopy); follow-up surveillance by colonoscopy every 23 years. Nonpolyposis syndrome: Familial syndrome with up to 50% risk of colon carcinoma; peak incidence in fifth decade; associated with multiple primary cancers (esp. Juvenile polyposis: Multiple benign colonic and small-bowel hamartomas; intestinal bleeding common. Diagnosis requires three or more relatives with colon cancer, one of whom is a firstdegree relative; one or more cases diagnosed before age 50; and involvement of at least two generations. Environmental factors also play a role; increased prevalence in developed countries, urban areas, advantaged socioeconomic groups; increased risk in pts with hypercholesterolemia, coronary artery disease; correlation of risk with low-fiber, high-animal-fat diets, although direct effect of diet remains unproven; decreased risk with long-term dietary calcium supplementation and, possibly, daily aspirin ingestion. Risk increased in first-degree relatives of pts; families with increased prevalence of cancer; and pts with history of breast or gynecologic cancer, familial polyposis syndromes, >10-year history of ulcerative colitis or Crohns colitis, >15-year history of ureterosigmoidostomy. Tumors in pts with strong family history of malignancy are frequently located in right colon and commonly present before age 50; high prevalence in pts with Streptococcus bovis bacteremia. Pathology Nearly always adenocarcinoma; 75% located distal to the splenic flexure (except in association with polyposis or hereditary cancer syndromes); may be polypoid, sessile, fungating, or constricting; subtype and degree of differentiation do not correlate with course. Degree of invasiveness at surgery (Dukes classification) is single best predictor of prognosis (Fig. Rectosigmoid tumors may spread to lungs early because of systemic paravertebral venous drainage of this area. Clinical Features Left-sided colon cancers present most commonly with rectal bleeding, altered bowel habits (narrowing, constipation, intermittent diarrhea, tenesmus), and abdominal or back pain; cecal and ascending colon cancers more frequently present with symptoms of anemia, occult blood in stool, or weight loss; other complications: perforation, fistula, volvulus, inguinal hernia; laboratory findings: anemia in 50% of right-sided lesions. Radiographic or virtual colonoscopy has not been shown to be a better diagnostic method than colonoscopy. Total mesorectal excision is more effective than conventional anteroposterior resection in rectal cancer. Follow-up after curative resection: Yearly liver tests, complete blood count, follow-up radiologic or colonoscopic evaluation at 1 yearif normal, repeat every 3 years, with routine screening interim (see below); if polyps detected, repeat 1 year after resection. Annual digital rectal exam and fecal occult blood testing recommended for pts over age 40, screening by flexible sigmoidoscopy every 3 years after age 50, earlier in pts at increased risk (see above); careful evaluation of all pts with positive fecal occult blood tests (flexible sigmoidoscopy and air-contrast barium enema or colonoscopy alone) reveals polyps in 2040% and carcinoma in ~5%; screening of asymptomatic persons allows earlier detection of colon cancer. Abdominoperineal resection with permanent colostomy is reserved for those with large lesions or whose disease recurs after chemoradiotherapy. Most are found incidentally but may cause pain; intratumoral hemorrhage may cause circulatory collapse. Focal nodular hyperplasia is also more common in women but seems not to be caused by birth control pills. Male:female = 4:1; tumor usually develops in cirrhotic liver in persons in fifth or sixth decade. High incidence in Asia and Africa is related to etiologic relationship between this cancer and hepatitis B and C infections. Aflatoxin exposure contributes to etiology and leaves a molecular signature, a mutation in codon 249 of the gene for p53. Physical Findings Jaundice, asthenia, itching, tremors, disorientation, hepatomegaly, splenomegaly, ascites, peripheral edema. The tumors are ductal adenocarcinomas and are not usually detected until the disease has spread. About 70% of tumors are in the pancreatic head, 20% in the body, and 10% in the tail. Mutations in K-ras have been found in 85% of tumors, and the p16 cyclin-dependent kinase inhibitor on chromosome 9 may also be implicated. Long-standing diabetes, chronic pancreatitis, and smoking increase the risk; coffee-drinking, alcoholism, and cholelithiasis do not. Pts present with pain and weight loss, the pain often relieved by bending forward. Gemcitabine plus erlotinib or capecitabine may palliate symptoms in pts with advanced disease. Carcinoid tumors of the small bowel and bronchus have a more malignant course than tumors of other sites. About 5% of pts with carcinoid tumors develop symptoms of the carcinoid syndrome, the classic triad being cutaneous flushing, diarrhea, and valvular heart disease. Octreotide scintigraphy identifies sites of primary and metastatic tumor in about two-thirds of cases. Symptoms may be controlled with histamine blockers and octreotide, 1501500 mg/d in three doses.

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