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Evidence to cholesterol efflux discount pravachol 10 mg with mastercard recommendations Research has established that the current licensed indications for alteplase treatment should be widened lower cholesterol foods eat list buy 20mg pravachol otc. These analyses emphasise how critical it is that treatment is given as quickly as possible after the onset of stroke cholesterol test birmingham order 20 mg pravachol free shipping. The Cochrane review and meta-analysis shows that older patients benefit at least as much as those below the age of 80 years cholesterol levels young adults order pravachol 10 mg with visa, so there is no upper age limit for treatment, particularly within the first 3 hours. Patients with mild and severe stroke and those with early signs of infarction on initial brain imaging also benefit from treatment, as long as early radiological changes are consistent with the stated time of onset. These findings suggest that there may be circumstances in which the treating physician and/or the patient wish to forgo some of the potential disability benefit from standard dose alteplase in order to reduce the early risk of intracerebral haemorrhage through the use of the lower dose. A meta-analysis of risk factors for intracerebral haemorrhage with alteplase (Whiteley et al, 2012) suggested a greater risk with atrial fibrillation, congestive cardiac failure, renal impairment, prior antiplatelet treatment, leukoaraiosis and visible cerebral infarction on pre-treatment brain imaging, but the extent to which any of these factors should influence dose selection for alteplase remains unknown. In an individual patient meta-analysis of these 5 trials involving 1287 patients (Goyal et al, 2016) endovascular therapy showed significant improvements in functional outcomes at 90 days. The trials varied in onset to endovascular treatment from a maximum of 6 up to 12 hours, and it is pertinent that all the trials with an extended time window required a favourable profile of salvageable brain tissue imaging prior to randomisation. The proven time window for endovascular therapy without such imaging is to perform thrombectomy. Decisions to undertake major life-saving surgery need to be carefully considered on an individual basis, but patients should not be excluded from treatment by age alone. B Patients with acute ischaemic stroke under the age of 80 years in whom treatment can be started between 3 and 4. C Patients with acute ischaemic stroke over 80 years in whom treatment can be started between 3 and 4. In doing so, treating clinicians should recognise that the benefits of treatment are smaller than if treated earlier, but that the risks of a worse outcome, including death, will on average not be increased. E Alteplase should only be administered within a well-organised stroke service with: − processes throughout the emergency pathway to minimise delays to treatment, to ensure that thrombolysis is administered as soon as possible after stroke onset; − staff trained in the delivery of thrombolysis and monitoring for post-thrombolysis complications; − nurse staffing levels equivalent to those required in level 1 or level 2 nursing care with training in acute stroke and thrombolysis; − immediate access to imaging and re-imaging, and staff appropriately trained to interpret the images; − protocols in place for the management of post-thrombolysis complications. F Emergency medical staff, if appropriately trained and supported, should only administer alteplase for the treatment of acute ischaemic stroke provided that patients can be subsequently managed on a hyperacute stroke unit with appropriate neuroradiological and stroke physician support. J Hyperacute stroke services providing endovascular therapy should participate in national stroke audit to enable comparison of the clinical and organisational quality of their services with national data, and use the findings to plan and deliver service improvements. L Patients with acute ischaemic stroke treated with thrombolysis should be started on an antiplatelet agent after 24 hours unless contraindicated, once significant haemorrhage has been excluded. M Patients with acute ischaemic stroke should be given aspirin 300mg as soon as possible within 24 hours (unless contraindicated): − orally if they are not dysphagic; − rectally or by enteral tube if they are dysphagic. Thereafter aspirin 300 mg daily should be continued until 2 weeks after the onset of stroke at which time long-term antithrombotic treatment should be initiated. Patients being transferred to care at home before 2 weeks should be started on long-term treatment earlier. N Patients with acute ischaemic stroke reporting previous dyspepsia with an antiplatelet agent should be given a proton pump inhibitor in addition to aspirin. O Patients with acute ischaemic stroke who are allergic to or intolerant of aspirin should be given an alternative antiplatelet agent. Provision of hyperacute stroke care should be organised to minimise time to treatment for the maximum number of people with stroke, and in some areas this will require reconfiguration of hyperacute stroke services with some hospitals stopping providing acute stroke services altogether. Death (12% at 3 months) and institutionalisation (9%) were not affected by intensive treatment (Anderson et al, 2013). A recent trial of idarucizumab in patients taking the direct thrombin inhibitor dabigatran has shown the agent to be safe, rapid in action and effective in reversing the anticoagulant effect (Pollack et al, 2015), and andexanet alfa has been shown in normal volunteers to reverse the anticoagulant effect of the factor Xa inhibitors apixaban and rivaroxaban (Siegal et al, 2015). In contrast to the long-standing and clear role for neurosurgical intervention in posterior fossa haemorrhage, the role of neurosurgery for supratentorial intracerebral haemorrhage remains small, with a recent neutral neurosurgical trial in lobar haemorrhage without intraventricular haemorrhage (Mendelow et al, 2013). Most patients with primary intracerebral haemorrhage do not require surgical intervention and should receive monitoring and initial medical treatment on a hyperacute stroke unit, such as those with small, deep haemorrhage; lobar haemorrhage without hydrocephalus, intraventricular haemorrhage or neurological deterioration; large haemorrhage and significant co-morbidities before the stroke; and those with supratentorial haemorrhage with a Glasgow Coma Scale score below 8 unless this is because of hydrocephalus. B Patients with intracerebral haemorrhage in association with dabigatran treatment should have the anticoagulant urgently reversed with idarucizumab. C Patients with intracerebral haemorrhage in association with factor Xa inhibitor treatment should receive urgent treatment with 4-factor prothrombin complex concentrate. D Patients with primary intracerebral haemorrhage who present within 6 hours of onset with a systolic blood pressure above 150mmHg should be treated urgently using a locally agreed protocol for blood pressure lowering to a systolic blood pressure of 140 mmHg for at least 7 days, unless: ‒ the Glasgow Coma Scale score is 5 or less; ‒ the haematoma is very large and death is expected; ‒ a structural cause for the haematoma is identified; ‒ immediate surgery to evacuate the haematoma is planned. E Patients with intracerebral haemorrhage should be admitted directly to a hyperacute stroke unit for monitoring of conscious level and referred immediately for repeat brain imaging if 44 deterioration occurs. F Patients with intracranial haemorrhage who develop hydrocephalus should be considered for surgical intervention such as insertion of an external ventricular drain. Case fatality and unfavourable outcomes rise with age and are highest in the over 65 age group (Society of British Neurosurgeons, 2006), and in those patients of a ‘poor clinical grade’ (Hunt and Hess or World Federation of Neurological Surgeons grades 4 & 5). Recurrent haemorrhage from the culprit aneurysm is the most frequent cause of death after the initial presentation. Diagnosis, referral to a tertiary centre and treatment to prevent rebleeding are therefore urgent. B Patients with spontaneous subarachnoid haemorrhage should be referred immediately to a neurosciences centre and receive: − nimodipine 60 mg 4 hourly unless contraindicated; − frequent neurological observation for signs of deterioration. Treatment to secure the aneurysm should be undertaken within 48 hours of ictus for good grade patients (Hunt and Hess or World Federation of Neurological Sciences grades 1-3), or within a maximum of 48 hours of diagnosis if presentation was delayed. D After any immediate treatment, patients with subarachnoid haemorrhage should be monitored for the development of treatable complications, such as hydrocephalus and cerebral ischaemia. E After any immediate treatment, patients with subarachnoid haemorrhage should be assessed for hypertension treatment and smoking cessation. F Patients with residual symptoms or disability after definitive treatment of subarachnoid haemorrhage should receive specialist neurological rehabilitation including appropriate clinical/neuropsychological support. G People with two or more first-degree relatives affected by aneurysmal subarachnoid haemorrhage and/or a polycystic kidney disease should be referred to a neurovascular and/or neurogenetics specialist for information and advice regarding the risks and benefits of screening for cerebral aneurysms. As non-invasive carotid and vertebral imaging becomes more accessible and of higher quality, the proportion of patients diagnosed with dissection increases. This group of patients tends to be younger, and may have experienced preceding neck trauma. The incidence of either outcome was low, with a 2% stroke rate within 3 months and no deaths. This low rate may reflect greater diagnostic yield in patients previously classified as ‘cryptogenic’. There is no evidence to suggest that thrombolysis carries any greater risk in patients with cervical artery dissection compared to stroke from other causes (Engelter et al, 2012). B Patients with acute ischaemic stroke suspected to be due to cervical arterial dissection should receive alteplase if they are otherwise eligible. C Patients with acute ischaemic stroke suspected to be due to cervical arterial dissection should be treated with either an anticoagulant or an antiplatelet agent for at least 3 months. Headache, seizures and focal (sometimes bilateral) neurological deficits are typical presenting features. Older patients and those with sepsis had the greatest risk of in-hospital mortality. Hydrocephalus, intracranial haemorrhage, and motor deficits were also associated with a worse outcome. Although not reaching statistical significance, there was a trend toward a positive benefit from anticoagulation for at least three months. Patients need specialist care on a stroke unit focused initially on preserving life, limiting brain damage and preventing complications before rehabilitation can begin in earnest. Patients with stroke often have significant disturbances of physiological homeostasis with raised temperature, raised blood glucose, hypoxia, etc. During the first week, 5% of patients with acute stroke develop urinary sepsis, and 9% require antibiotic treatment for pneumonia (Intercollegiate Stroke Working Party, 2016). Evidence to recommendations Patients with acute stroke are at high risk of dehydration, malnutrition, infection, hypoxia and hyperglycaemia. Middleton et al (2011) showed that training stroke unit staff in the use of standardised protocols to manage physiological status can significantly improve outcomes. The management of blood pressure after acute ischaemic stroke remains an area with little evidence to guide practice (see Section 3. There is no evidence for the use of hyperbaric oxygen therapy in stroke (Bennett et al, 2014) nor for the use of supplemental oxygen in normoxic patients (Roffe et al, 2011) and from the evidence available, the Working Party recommends that mannitol for the treatment of cerebral oedema should not be used outside of a clinical trial. There is very little trial evidence on which to base the management of hydration in acute stroke. A Cochrane review of the signs and symptoms of impending and current water-loss dehydration in older people (Hooper et al, 2015) concluded that there is little evidence that any one symptom, sign or test, including many that clinicians customarily rely on, have any diagnostic utility for dehydration.
Risk-adapted management for patients with clinical stage I seminoma: the Second Spanish Germ Cell Cancer Cooperative Group study cholesterol test mayo clinic buy cheap pravachol 20 mg online. Risk factors for relapse in clinical stage I nonseminomatous testicular germ cell tumors: results of the German Testicular Cancer Study Group Trial cholesterol lowering foods pdf order pravachol 20 mg with amex. Stage I non-seminomatous germ-cell tumours of the testis: identification of a subgroup of patients with a very low risk of relapse cholesterol what to eat buy discount pravachol. Impact of cytotoxic treatment on long-term fertility in patients with germ-cell cancer cholesterol medication at night generic pravachol 20mg with visa. Pharmacology and clinical use of testosterone, in Testosterone-Action, Deficiency, Substitution. Feelings of loss and uneasiness or shame after removal of a testicle by orchidectomy: a population-based long-term follow-up of testicular cancer survivors. Multicenter study evaluating a dual policy of postorchiectomy surveillance and selective adjuvant single-agent carboplatin for patients with clinical stage I seminoma. Management of seminomatous testicular cancer: a binational prospective population-based study from the Swedish norwegian testicular cancer study group. Randomized trials in 2466 patients with stage I seminoma: patterns of relapse and follow-up. Optimal planning target volume for stage I testicular seminoma: A Medical Research Council randomized trial. Long term results and morbidity of paraaortic compared with paraaortic and iliac adjuvant radiation in clinical stage I seminoma. Seminoma of the testis: is scrotal shielding necessary when radiotherapy is limited to the para-aortic nodes? Risk-adapted treatment in clinical stage I testicular seminoma: the third Spanish Germ Cell Cancer Group study. Histopathology in the prediction of relapse of patients with stage I testicular teratoma treated by orchidectomy alone. Medical Research Council prospective study of surveillance for stage I testicular teratoma. Prognostic factors in clinical stage I nonseminomatous germ cell tumors of the testis: multivariate analysis of a prospective multicenter study. Active surveillance is the preferred approach to clinical stage I testicular cancer. Short-course adjuvant chemotherapy in high-risk stage I nonseminomatous germ cell tumors of the testis: a Medical Research Council report. Adjuvant chemotherapy for high-risk clinical stage I nonseminomatous testicular germ cell cancer: long-term results of a prospective trial. Fertility and sexual function following orchiectomy and 2 cycles of chemotherapy for stage I high risk nonseminomatous germ cell cancer. Cardiovascular disease as a long-term complication of treatment for testicular cancer. Long-term followup results of 1 cycle of adjuvant bleomycin, etoposide and cisplatin chemotherapy for high risk clinical stage I nonseminomatous germ cell tumors of the testis. Cost and risk-benefit considerations in the management of clinical stage I nonseminomatous testicular tumors. Multicentre risk-adapted management for stage I non-seminomatous germ cell tumours. Complications of primary nerve sparing retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumors of the testis: experience of the German Testicular Cancer Study Group. Retroperitoneal lymph node dissection with no adjuvant chemotherapy in clinical stage I nonseminomatous germ cell tumours: long-term outcome and analysis of risk factors of recurrence. Primary retroperitoneal lymph node dissection in low-stage testicular germ cell tumors: a detailed pathologic study with clinical outcome analysis with special emphasis on patients who did not receive adjuvant therapy. Long-term results of laparoscopic retroperitoneal lymph-node dissection for clinical stage I nonseminomatous germ-cell testicular cancer. The management of patients with nonseminomatous germ cell tumors of the testis with serologic disease only after orchiectomy. The role of retroperitoneal lymphadenectomy in clinical stage B testis cancer: the Indiana University experience (1965 to 1989). Metastatic seminoma treated with either single agent carboplatin or cisplatin based combination chemotherapy: a pooled analysis of two randomised trials. Refining the optimal chemotherapy regimen in good prognosis germ cell cancer: interpretation of the current body of knowledge. Importance of bleomycin in combination chemotherapy for good-prognosis testicular nonseminoma: a randomized study of the European Organization for Research and Treatment of Cancer Genitourinary Tract Cancer Cooperative Group. Randomized trial of bleomycin, etoposide, and cisplatin compared with bleomycin, etoposide, and carboplatin in good-prognosis metastatic nonseminomatous germ cell cancer: a Multiinstitutional Medical Research Council/European Organization for Research and Treatment of Cancer Trial. Equivalence of three or four cycles of bleomycin, etoposide, and cisplatin chemotherapy and of a 3 or 5-day schedule in good-prognosis germ cell cancer: a randomized study of the European Organization for Research and Treatment of Cancer Genitourinary Tract Cancer Cooperative Group and the Medical Research Council. Comparison of two standard chemotherapy regimens for good-prognosis germ cell tumors: updated analysis of a randomized trial. Filgrastim during combination chemotherapy of patients with poor-prognosis metastatic germ cell malignancy. European Organization for Research and Treatment of Cancer, Genito-Urinary Group, and the Medical Research Council Testicular Cancer Working Party, Cambridge, United Kingdom. Randomized comparison of cisplatin and etoposide and either bleomycin or ifosfamide in treatment of advanced disseminated germ cell tumors: an Eastern Cooperative Oncology Group, Southwest Oncology Group, and Cancer and Leukemia Group B Study. Failure of high-dose cyclophosphamide and etoposide combined with double-dose cisplatin and bone marrow support in patients with high-volume metastatic nonseminomatous germ-cell tumours: mature results of a randomised trial. Population-based study of treatment guided by tumor marker decline in patients with metastatic nonseminomatous germ cell tumor: a report from the Swedish-Norwegian Testicular Cancer Group. Compliance with guidelines and correlation with outcome in patients with advanced germ-cell tumours. Prognostic implications of tumour marker analysis in non-seminomatous germ cell tumours with poor prognosis metastatic disease. Serum tumor marker decline is an early predictor of treatment outcome in germ cell tumor patients treated with cisplatin and ifosfamide salvage chemotherapy. The growing teratoma syndrome: results of therapy and long-term follow-up of 33 patients. Serum alpha-fetoprotein surge after the initiation of chemotherapy for non seminomatous testicular cancer has an adverse prognostic significance. Management strategies and outcomes of germ cell tumor patients with very high human chorionic gonadotropin levels. Prognostic factors in patients progressing after cisplatin-based chemotherapy for malignant non-seminomatous germ cell tumours. Chemotherapy in advanced seminoma and the role of postcytostatic retroperitoneal lymph node dissection. Chemotherapy of metastatic seminoma: the Southeastern Cancer Study Group experience. Residual mass: an indication for further therapy in patients with advanced seminoma following systemic chemotherapy. Is post-chemotherapy resection of seminomatous elements associated with higher acute morbidity? Management of residual mass in advanced seminoma: results and recommendations from the Memorial Sloan-Kettering Cancer Center. Post-chemotherapy nerve-sparing retroperitoneal lymph node dissection for advanced germ cell tumor. Improved clinical outcome in recent years for men with metastatic nonseminomatous germ cell tumors. Management of disseminated nonseminomatous germ cell tumors with risk-based chemotherapy followed by response-guided postchemotherapy surgery. Comparison of histological results from the resection of residual masses at different sites after chemotherapy for metastatic non-seminomatous germ cell tumours. Metastatic nonseminomatous germ cell tumors of the testis: results of elective and salvage surgery for patients with residual retroperitoneal masses. The role of adjunctive postchemotherapy surgery for nonseminomatous germ-cell tumors: current concepts and controversies. Prediction models for the histology of residual masses after chemotherapy for metastatic testicular cancer. Long-term clinical outcome after postchemotherapy retroperitoneal lymph node dissection in men with residual teratoma.
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Respiratory yolk cholesterol in eggs from various avian species pravachol 10mg free shipping, thoracic and mediastinal disorders Respiratory cholesterol ratio explained cheap 10 mg pravachol mastercard, thoracic and mediastinal disorders Grade Adverse Event 1 2 3 4 5 Adult respiratory distress Present with radiologic Life-threatening respiratory or Death syndrome findings; intubation not hemodynamic compromise; indicated intubation or urgent intervention indicated Definition: A disorder characterized by progressive and life-threatening pulmonary distress in the absence of an underlying pulmonary condition high cholesterol medication uk discount pravachol 10 mg with mastercard, usually following major trauma or surgery cholesterol test houston discount 10 mg pravachol with visa. Allergic rhinitis Mild symptoms; intervention Moderate symptoms; medical not indicated intervention indicated Definition: A disorder characterized by an inflammation of the nasal mucous membranes caused by an IgE-mediated response to external allergens. Apnea Present; medical intervention Life-threatening respiratory or Death indicated hemodynamic compromise; intubation or urgent intervention indicated Definition: A disorder characterized by cessation of breathing. Aspiration Asymptomatic; clinical or Altered eating habits; Dyspnea and pneumonia Life-threatening respiratory or Death diagnostic observations only; coughing or choking episodes symptoms. Bronchopulmonary Mild symptoms; intervention Moderate symptoms; medical Transfusion, radiologic, Life-threatening respiratory or Death hemorrhage not indicated intervention indicated endoscopic, or operative hemodynamic compromise; intervention indicated. Epistaxis Mild symptoms; intervention Moderate symptoms; medical Transfusion, radiologic, Life-threatening Death not indicated intervention indicated. Hypoxia Decreased oxygen saturation Decreased oxygen saturation Life-threatening airway Death with exercise. Laryngeal edema Asymptomatic; clinical or Symptomatic; medical Stridor; respiratory distress; Life-threatening airway Death diagnostic observations only; intervention indicated. Laryngeal inflammation Mild sore throat; raspy voice Moderate sore throat; Severe throat pain; analgesics indicated endoscopic intervention indicated Definition: A disorder characterized by an inflammation involving the larynx. Laryngeal mucositis Endoscopic findings only; mild Moderate discomfort; altered Severe pain; severely altered Life-threatening airway Death discomfort with normal intake oral intake eating/swallowing; medical compromise; urgent intervention indicated intervention indicated. Laryngospasm Transient episode; Recurrent episodes; Persistent or severe episodes Death intervention not indicated noninvasive intervention associated with syncope; indicated. Mediastinal hemorrhage Radiologic evidence only; Moderate symptoms; medical Transfusion, radiologic, Life-threatening Death minimal symptoms; intervention indicated endoscopic, or elective consequences; urgent intervention not indicated operative intervention intervention indicated indicated. Nasal congestion Mild symptoms; intervention Moderate symptoms; medical Associated with bloody nasal not indicated intervention indicated discharge or epistaxis Definition: A disorder characterized by obstruction of the nasal passage due to mucosal edema. Pharyngeal hemorrhage Mild symptoms; intervention Moderate symptoms; medical Transfusion, radiologic, Life-threatening respiratory or Death not indicated intervention indicated endoscopic, or operative hemodynamic compromise; intervention indicated. Pleural effusion Asymptomatic; clinical or Symptomatic; intervention Symptomatic with respiratory Life-threatening respiratory or Death diagnostic observations only; indicated. Pneumothorax Asymptomatic; clinical or Symptomatic; intervention Sclerosis and/or operative Life-threatening Death diagnostic observations only; indicated. Postnasal drip Mild symptoms; intervention Moderate symptoms; medical not indicated intervention indicated Definition: A disorder characterized by excessive mucous secretion in the back of the nasal cavity or throat, causing sore throat and/or coughing. Pulmonary fibrosis Mild hypoxemia; radiologic Moderate hypoxemia; Severe hypoxemia; evidence Life-threatening Death pulmonary fibrosis <25% of evidence of pulmonary of right-sided heart failure; consequences. Respiratory failure Life-threatening Death consequences; urgent intervention, intubation, or ventilatory support indicated Definition: A disorder characterized by impaired gas exchange by the respiratory system resulting in hypoxemia and a decrease in oxygenation of the tissues that may be associated with an increase in arterial levels of carbon dioxide. Retinoic acid syndrome Fluid retention; <3 kg of Moderate signs or symptoms; Severe symptoms; Life-threatening Death weight gain; intervention with steroids indicated hospitalization indicated consequences; ventilatory fluid restriction and/or support indicated diuretics indicated Definition: A disorder characterized by weight gain, dyspnea, pleural and pericardial effusions, leukocytosis and/or renal failure originally described in patients treated with all-trans retinoic acid. Sneezing Mild symptoms; intervention Moderate symptoms; medical not indicated intervention indicated Definition: A disorder characterized by the involuntary expulsion of air from the nose. Voice alteration Mild or intermittent change Moderate or persistent Severe voice changes from normal voice change from normal voice; still including predominantly understandable whispered speech; may require frequent repetition or face-to-face contact for understandability; may require assistive technology Definition: A disorder characterized by a change in the sound and/or speed of the voice. Skin and subcutaneous tissue disorders Skin and subcutaneous tissue disorders Grade Adverse Event 1 2 3 4 5 Alopecia Hair loss of <50% of normal Hair loss of >=50% normal for for that individual that is not that individual that is readily obvious from a distance but apparent to others; a wig or only on close inspection; a hair piece is necessary if the different hair style may be patient desires to completely required to cover the hair loss camouflage the hair loss; but it does not require a wig or associated with psychosocial hair piece to camouflage impact Definition: A disorder characterized by a decrease in density of hair compared to normal for a given individual at a given age and body location. Body odor Mild odor; physician Pronounced odor; intervention not indicated; self psychosocial impact; patient care interventions seeks medical intervention Definition: A disorder characterized by an abnormal body smell resulting from the growth of bacteria on the body. Hypertrichosis Increase in length, thickness Increase in length, thickness or density of hair that the or density of hair at least on patient is either able to the usual exposed areas of camouflage by periodic the body [face (not limited to shaving or removal of hairs or beard/moustache area) is not concerned enough plus/minus arms] that requires about the overgrowth to use frequent shaving or use of any form of hair removal destructive means of hair removal to camouflage; associated with psychosocial impact Definition: A disorder characterized by hair density or length beyond the accepted limits of normal in a particular body region, for a particular age or race. Nail discoloration Asymptomatic; clinical or diagnostic observations only; intervention not indicated Definition: A disorder characterized by a change in the color of the nail plate. Nail ridging Asymptomatic; clinical or diagnostic observations only; intervention not indicated Definition: A disorder characterized by vertical or horizontal ridges on the nails. Periorbital edema Soft or non-pitting Indurated or pitting edema; Edema associated with visual topical intervention indicated disturbance; increased intraocular pressure, glaucoma or retinal hemorrhage; optic neuritis; diuretics indicated; operative intervention indicated Definition: A disorder characterized by swelling due to an excessive accumulation of fluid around the orbits of the face. Also known as morbillform rash, it is one of the most common cutaneous adverse events, frequently affecting the upper trunk, spreading centripetally and associated with pruritus. Skin ulceration Combined area of ulcers <1 Combined area of ulcers 1 2 Combined area of ulcers >2 Any size ulcer with extensive Death cm; nonblanchable erythema cm; partial thickness skin loss cm; full-thickness skin loss destruction, tissue necrosis, or of intact skin with associated involving skin or involving damage to or damage to muscle, bone, or warmth or edema subcutaneous fat necrosis of subcutaneous supporting structures with or tissue that may extend down without full thickness skin loss to fascia Definition: A disorder characterized by circumscribed, inflammatory and necrotic erosive lesion on the skin. Social circumstances Social circumstances Grade Adverse Event 1 2 3 4 5 Menopause Menopause occurring at age Menopause occurring at age Menopause occurring before 46 53 years of age 40 45 years of age age 40 years of age Definition: A disorder characterized by the permanent cessation of menses, usually defined by 12 consecutive months of amenorrhea in a woman over 45 years of age. Vascular disorders Vascular disorders Grade Adverse Event 1 2 3 4 5 Capillary leak syndrome Symptomatic; medical Severe symptoms; Life-threatening Death intervention indicated intervention indicated consequences; urgent intervention indicated Definition: A disorder characterized by leakage of intravascular fluids into the extravascular space. Hematoma Mild symptoms; intervention Minimally invasive evacuation Transfusion, radiologic, Life-threatening Death not indicated or aspiration indicated endoscopic, or elective consequences; urgent operative intervention intervention indicated indicated Definition: A disorder characterized by a localized collection of blood, usually clotted, in an organ, space, or tissue, due to a break in the wall of a blood vessel. Hypotension Asymptomatic, intervention Non-urgent medical Medical intervention or Life-threatening and urgent Death not indicated intervention indicated hospitalization indicated intervention indicated Definition: A disorder characterized by a blood pressure that is below the normal expected for an individual in a given environment. Lymph leakage Symptomatic; medical Severe symptoms; radiologic, Life-threatening Death intervention indicated endoscopic or elective consequences; urgent operative intervention intervention indicated indicated Definition: A disorder characterized by the loss of lymph fluid into the surrounding tissue or body cavity. Lymphocele Asymptomatic; clinical or Symptomatic; medical Severe symptoms; radiologic, diagnostic observations only; intervention indicated endoscopic or elective intervention not indicated operative intervention indicated Definition: A disorder characterized by a cystic lesion containing lymph. Peripheral ischemia Brief (<24 hrs) episode of Recurring or prolonged (>=24 Life-threatening Death ischemia managed non hrs) and/or invasive consequences; evidence of surgically and without intervention indicated end organ damage; urgent permanent deficit operative intervention indicated Definition: A disorder characterized by impaired circulation to an extremity. Phlebitis Present Definition: A disorder characterized by inflammation of the wall of a vein. Superficial thrombophlebitis Present Definition: A disorder characterized by a blood clot and inflammation involving a superficial vein of the extremities. Vasculitis Asymptomatic, intervention Moderate symptoms, medical Severe symptoms, medical Life-threatening; evidence of Death not indicated intervention indicated intervention indicated. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association [published online ahead of print May 1, 2014]. Patients should be educated on salt restriction, weight loss, the consumption of a diet rich in fruits, vegetables, and low-fat dairy products, regular aerobic physical activity, and limited alcohol consumption. Glucose Disorders Recommendations 2014 Recommendation Revisions (2011) Patients should be screened for diabetes with New Recommendation testing of fasting plasma glucose, HbA1c, or an oral glucose tolerance test. Choice of test and timing should be guided by clinical judgment and recognition that acute illness may temporarily perturb measures of plasma glucose. In general, HbA1c may be more accurate than other screening tests in the immediate post-event period. Intensive treatment does not appear to reduce all-cause mortality or stroke risk and increases risk for severe hypoglycemia 20 ©2014 American Heart Association, Inc. Physical Inactivity Recommendations 2014 Recommendation Revisions (2011) For those who are capable of engaging in Further specification of levels of physical activity, at least 3-4 sessions per exercise recommended. Moderate-intensity exercise is typically defined as sufficient to break a sweat or noticeably raise heart rate. Nutrition Recommendations 2014 Recommendation Revisions (2011) Reasonable to conduct a nutritional assessment looking for signs of New over-nutrition or under-nutrition. The Mediterranean-type diet emphasizes Recommendation vegetables, fruits, and whole grains and includes low-fat dairy products, poultry, fish, legumes, and nuts. The American Academy of Sleep Medicine’s Adult Obstructive Sleep Apnea Task Force recommends the use of polysomnography 3. Newer research has extended concerns over smoking by showing that exposure to environmental tobacco smoke or passive (“second-hand”) smoke also increases the risk of stroke. Light to moderate alcohol consumption has been associated with a reduced risk of first-ever stroke (1/drink/day for women) and (2/drinks/day for men). Elevated stroke risk with heavier alcohol and greater risk of hemorrhagic stroke 26 ©2014 American Heart Association, Inc. Three trials demonstrated optimal timing of carotid revascularization after a non-disabling stroke – Median time from randomization to surgery was 2-14 days and /13 of perioperative stroke attributed to surgery occurred during this time. In medically treated patients the stroke risk was greatest in the first 2 weeks and then declined within 2-3 years approaching the rate observed for asymptomatic patients. The writing group recommends surgery within 2 weeks if no patient contraindication – A detailed review of the data on non disabling stroke patients with surgical treatment of ≥70% had a risk reduction of stroke or death within 30 day of 30% within first 2 weeks to 18% at 2-4 weeks and 11% at 4-12 weeks 33 ©2014 American Heart Association, Inc. Early trials did not use embolic devices and either stenting or medical management were comparable. The New text regarding choice selection of an antithrombotic agent should be individualized of agent. Atrial Fibrillation Recommendations 2014 Recommendation Revisions (2011) In the presence of high risk for hemorrhagic conversion. Patients with ischemic or non-ischemic dilated cardiomyopathy are at an increased risk for stroke. The magnitude of risk for brain embolism from a diseased heart valve depends on the nature and severity of the disease.
These regions might have a crucial role in the information processing required by the task how is cholesterol ratio determined buy pravachol 10 mg with visa, but their bloodflow might not be signifi cantly modulated by the task cholesterol quantity in food discount pravachol 20 mg visa. Regions that are com m only dam aged in (a) three ‘the absence of evidence is not evidence of patients with Broca’s aphasia after left hem isphere lesion10 and (b) ten patients with spatial neglect after absence’ less cholesterol in raw eggs order pravachol overnight delivery. Note that these overlay style im ages fail to cholesterol medication and weight gain buy pravachol no prescription take advantage of the inform ation does not show changes in bloodflow during a offered by control groups with brain dam age. This style of lesion overlay plot has been adopted by m any task is not involved with that task. It is clear that the left and weaker level of inference than the lesion designs and analyses that are required to right hem ispheres have different roles in method (which measures brain disruption). The power of seconds, offering better temporal resolution other hand, resection of the activation foci cognitive neuroscience com es from using than can be achieved by exam ining perm a observed in the left hem isphere during the convergent tools to investigate the same theo nent brain injury. Other brain activation tech sam e tasks would usually lead to profound retical question and to reveal the anatomy and niques, such as m agnetoencephalography speech deficits. Furtherm ore,functional imaging can that have docum ented the consequences of However, it is worth considering whether show every part of a neural network that is left (but not right) brain damage on language, new technologies can be used to optimize the involved in a task or a behaviour. Although som e of the lesion Despite these advantages,the interpretation hum an speech m echanism s27,28 and, for method’s limitations are inherent to the tech of brain activation studies can be difficult and example, the W ada test (which transiently dis nique, other weaknesses can be addressed by has clear limitations19. In particular, that a particular task correlates with activation As these techniques m easure disruption em erging im aging protocols and im proved in a particular brain region. However, it is instead of activation they can reveal the analysis of lesion data should im prove our not clear whether this region is necessary to structures that are required for language ability to m easure the functional extent of perform this task. It is even possible that some function — located predominantly in the left brain dam age and help us to refine our activated areas have no direct role in informa hemisphere. Techniques such as perfusion imaging can enable us to m easure the am ount of blood flow that reaches different regions of the brain. This scan shows high resolution of tissues and anatom ical landm arks, aiding functional recovery over time corresponded scientists in identifying com m on regions of dam age across groups of individuals with sim ilar deficits. These created excitem ent because they provide detection of hyperacute infarcts and can tools have clear im plications for im proving clearer pictures with m ore detail and in less accurately predict the final infarct size34–37. This flexibility offers great poten stroke, and how the white m atter has been the anatomical basis of a particular behaviour tial for future lesion method studies. T1-weighted to understand brain dysfunction, this applica value of identifying a group of control patients scans offer good contrast between grey and tion poses unique challenges. Simple overlay plots for white matter and have typically superior spa current techniques are much more sensitive patients who have a disorder can be mislead tial precision com pared with T2-weighted in younger people than in older people38. A control tional T1 and T2 scans often fail to detect to detect robust activity in neurological group of neurological patients who do not acute strokes (when clinical intervention is patients for two reasons. First, brain injury exhibit the deficit of interest is therefore indis necessary and the pathological behaviour is can result in reduced m etabolism (as the pensable for valid anatomical conclusions. The resulting subtraction image specifically high lights regions that are both frequently damaged in experimental patients and typically spared in control patients. Statistical analysis of lesion data Ideally,we want to know whether differences 40 32 24 16 8 0 –8 –16 in lesion frequency (for exam ple, between % patients who show the disorder of interest and –100–80 –60 –40 –20 0 20 40 60 80 100 patients who do not) might be due to chance or are reliable predictors of behaviour. The percentage of overlapping lesions after subtraction is illustrated by different colours, which code increasing frequencies, from dark red (difference basis,allowing fairly high spatial precision. For these techniques to work effec showed speech production difficulties but also lobes. But does this mean that these regions are tively, we have to align brain im ages from of those who did not show such deficits. It could different patients into a com m on stereo patients who have dam age to this region do be that these regions are typically damaged by taxic space. This ‘normalization’process is a not have speech production problems41,and major strokes. These control m atter concentrations for every voxel To show the importance of control groups patients should have brain lesions in the same throughout the brain. For exam ple, a voxel for overcoming the problem of differential vul hemisphere and must be similar to the patients that encom passes a region of the cortex is nerability owing to vasculature,consider that of interest with respect to other variables,such m ostly grey m atter, whereas a voxel in the we are interested in identifying the regions of as other neuropsychological sym ptom s or fibre tracts between the two hem ispheres is the brain that are responsible for speech pro visual field defects. If we look at a large group of patients pared,regions of the brain that are simply vul been segm ented into grey and white m atter who have problems with speech production, nerable to brain damage should be commonly m aps, we can analyse whether different we will probably find that,as a group,they have damaged in both groups,but regions that are groups of people have different concentra damage to the frontal,temporal and parietal specifically involved with speech production tions of these tissues. A common between different groups,for example a group step for both the lesion method and for functional neuroimaging studies is to normalize or ‘warp’ of patients who show a disorder of interest and each person’s brain scan so that they all have roughly the same size,shape and orientation. The patients with deficits tend to have larger quality of normalization is crucial: if different individuals’brains are not matched accurately,we injuries than control patients who do not have will not be comparing the same regions of their brains (reducing our statistical power). For exam ple, healthy people,normalization is a delicate process and there is no perfect solution. A system that patients with large lesions in the left hem i accurately matches the locations of the major sulci will distort the volume of different regions. On sphere are more likely to show speech deficits the other hand,a system that rigidly preserves the overall size of brain regions will not accurately than those with small lesions. Some functions tend to be reliably related to specific sulcal istic regression to ensure that regions are only locations,whereas the anatomy of other regions tends to be better predicted by the region’s overall 61 reported to be statistically significant if they size. As Brett and colleagues noted,even in young,neurologically healthy adults,normalization is a serious problem. Older can still predict the deficit even after overall stroke patients typically have larger and more variable ventricles (owing to both age-related lesion volum e has been accounted for. Furthermore,the injured brain region can m ethod reduces our tendency to detect disrupt automated normalization techniques,because the injured location will differ greatly from areas that correlate with large lesions but not the template image. Brett and colleagues62 have devised a method to tackle this: the region of the specifically with the deficit being investigated. However, these this technique can greatly improve the accuracy of spatial normalization in individuals with brain voxel-by-voxel methods raise the same issues injury. However,it offers only an approximation of brain shape,and cannot completely of the m ultiple com parisons problem as compensate for variability of ventricle size and other features commonly found in stroke patients. Because we are con the resulting images should be manually inspected to ensure that the automated algorithm has ducting so many tests, we must control for the worked correctly. In many cases,there is still no replacement for having a skilled individual considerable risk of false positives (claiming a manually mark the location and extent of brain injury on a high-resolution template brain image. Conventional m ethods such as Bonferroni correction will greatly reduce our with temporal lobe epilepsy tend to have grey pioneered a range of new features, including statistical power (often we will not detect real m atter atrophy in the hippocam pal region digital tem plates for lesion overlay, inte effects), and a huge num ber of patients will and in other brain regions that have strong grated statistics and an ability to show brain need to be tested. Of particular interest, false discovery rate correction54,55 might pro and white matter. Another direction routines cannot identify that a tissue has been instance, each individual’s Z-score perfor would be to conduct region of interest analy damaged. For exam ple, Bates and plausible regions, thereby greatly reducing the the region of brain injury is clearly defined. Conclusions W e have argued that the lesion m ethod has much to offer neuroscience,despite its limita tions. New techniques for imaging the brain and analysing lesion data have the potential to improve the lesion method,and can be used to address several of the com m on criticism s of this technique. This figure 2 Each technique on its own has only lim ited shows the χ -distribution which resulted when patients with visual field cuts were com pared with patients with intact visual fields. The regions of the occipital cortex and optic radiation shown in orange, yellow and explanatory power. However,the strengths and white are statistically significant predictors of visual field cuts (controlled for dependent m ultiple weaknesses of these tools are complementary. The large striatocapsular infarct: a clinical and investigate the same theoretical question. The case of aphasia or neglect after paring and contrasting the lesion m ethod Raichle, M. Planum temporale and Brodmann’s area visual recognition of emotion as revealed by three 22. Controlling the false discovery guided by the behavioural tasks that are used Howard, D. Temporal lobe regions rate: a practical and powerful approach to multiple testing. Hemispheric specialization discovery rate controlling multiple test procedures for for language. Degeneracy and cognitive Hans-Otto Karnath is at the Center of Neurology, generation task: effects of learning and comparison to anatomy. Non-spatially lateralized Hertie Institute for Clinical Brain Research, 33–38 (2002). Intracarotid injection of sodium behaviour relationship by induction of ‘virtual lesions’.