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By: Mikayla Spangler, PharmD, BCPS

  • Associate Professor, Creighton University School of Pharmacy and Health Professions
  • Clinical Pharmacist, CHI Health Clinic—Lakeside, Omaha, Nebraska

https://spahp.creighton.edu/faculty-directory-profile/505/mikayla-spangler

Expectant management of prostate cancer with curative intent: an update of the Johns Hopkins experience hair loss kidney disease buy dutasteride 0.5mg lowest price. Patient and treatment factors associated with complications after prostate brachytherapy hair loss in men rings buy 0.5mg dutasteride with visa. Feasibility study: watchful waiting for localized low to hair loss 9 reasons buy discount dutasteride 0.5 mg on-line intermediate grade prostate carcinoma with selective delayed intervention based on prostate specific antigen, histological and/or clinical progression. Active surveillance for the management of prostate cancer in a contemporary cohort. Prostate brachytherapy seed migration to a coronary artery found during angiography. Prostate brachytherapy seed migration to the right ventricle found at autopsy following acute cardiac dysrhythmia. Safety and morbidity of first and repeat transrectal ultrasound guided prostate needle biopsies: results of a prospective European prostate cancer detection study. Radioactive seed migration to the chest after transperineal interstitial prostate brachytherapy: extraprostatic seed placement correlates with migration. Intraoperative blood loss and transfusion requirements for robotic-assisted radical prostatectomy versus radical retropubic prostatectomy. Intra and peri-operative outcomes comparing radical retropubic and laparoscopic radical prostatectomy: results from a prospective, randomised, single-surgeon study. Patterns of care for radical prostatectomy in the United States from 2003 to 2005. The cost of radical prostatectomy: retrospective comparison of open, laparoscopic, and robot-assisted approaches. Decline in urinary retention incidence in 805 patients after prostate brachytherapy: the effect of learning curve? Clinical results of long-term follow-up of a large, active surveillance cohort with localized prostate cancer. Active surveillance for favorable risk prostate cancer: what are the results, and how safe is it? Active surveillance versus radical treatment for favorable-risk localized prostate cancer. The calculated risk of fatal secondary malignancies from intensity-modulated radiation therapy. The new economics of radical prostatectomy: cost comparison of open, laparoscopic, and robot assisted techniques. Learn from the trials and tribulations of one hospital-based community cancer center in its ongoing?and often arduous?effort to offer this groundbreaking treatment. Pulmonary embolization of permanently implanted radioactive palladium-103 seeds for carcinoma of the prostate. Helical Tomotherapy Hi-Art System for External Cancer Radiotherapy: Horizon Scanning Technology Briefing. Comparison of length of hospital stay between radical retropubic prostatectomy and robot-assisted laparoscopic prostatectomy. Radioactive implant migration in patients treated for localized prostate cancer with interstitial brachytherapy. Brachytherapy & proton beam therapy for treatment of clinically-localized, low-risk prostate cancer. Active surveillance & radical prostatectomy for the management of clinically-localized, low-risk prostate cancer. Active surveillance: towards a new paradigm in the management of early prostate cancer. Laparoscopic radical prostatectomy?the experience of the German Laparoscopic Working Group. Prospective study of determinants and outcomes of deferred treatment or watchful waiting among men with prostate cancer in a nationwide cohort.

We recommend restarting metformin no sooner than 48 hours after administration of contrast material as long as renal function has remained 1 C stable (<25% increase in creatinine concentration above baseline) hair loss cure stem cell buy dutasteride 0.5mg with amex. We recommend perioperative transfusion of packed red blood cells if the 1 B hemoglobin level is <7 g/dL We suggest hematologic assessment if the preoperative platelet count is 2 C <150 hair loss stages 0.5 mg dutasteride,000/? Aneurysm imaging Level of Quality of Recommendation recommendation evidence We recommend using ultrasound hair loss cure yellow buy dutasteride 0.5 mg low cost, when feasible, as the preferred 1 A imaging modality for aneurysm screening and surveillance. Screening should be performed 2 C in first-degree relatives who are between 65 and 75 years of age or in those older than 75 years and in good health. Aneurysm imaging Level of Quality of Recommendation recommendation evidence If initial ultrasound screening identified an aortic diameter >2. We suggest elective repair for the patient who presents with a 2 C saccular aneurysm. We recommend a thrombin inhibitor, such as bivalirudin or argatroban, as an alternative to heparin for patients with a history of heparin-induced 1 B thrombocytopenia. We recommend that all portions of an aortic graft be excluded from direct 1 A contact with the intestinal contents of the peritoneal cavity. The patient with a ruptured aneurysm Level of Quality of Recommendation recommendation evidence We suggest a door-to-intervention time of <90 minutes, based on Ungraded a framework of 30-30-30 minutes, for the management of the Good Practice Statement patient with a ruptured aneurysm. Good Practice Statement We recommend implementing hypotensive hemostasis with restriction of fluid resuscitation in the conscious 1 B patient. We recommend that any potential sources of dental sepsis Ungraded be eliminated at least 2 weeks before implantation of an Good Practice Statement aortic prosthesis. Intraoperative fluid resuscitation and blood conservation Level of Quality of Recommendation recommendation evidence We recommend using cell salvage or an ultrafiltration 1 B device if large blood loss is anticipated. If the intraoperative hemoglobin level is <10 g/dL and blood loss is ongoing, we recommend transfusion of packed 1 B blood cells along with fresh frozen plasma and platelets in a ratio of 1:1:1. Cardiovascular monitoring Level of Quality of Recommendation recommendation evidence We suggest using pulmonary artery catheters only if the 1 B likelihood of a major hemodynamic disturbance is high. We recommend postoperative troponin measurement for all patients with electrocardiographic changes or chest pain after 1 A aneurysm repair. Maintenance of body temperature Level of Quality of Recommendation recommendation evidence We recommend maintaining core body temperature at or 1 A above 36?C during aneurysm repair. Nasogastric decompression and perioperative nutrition Level of Quality of Recommendation recommendation evidence We recommend optimization of preoperative nutritional status before elective open aneurysm repair if repair will not be unduly 1 A delayed. We recommend using nasogastric decompression intraoperatively for all patients undergoing open aneurysm repair but 1 A postoperatively only for those patients with nausea and abdominal distention. We recommend parenteral nutrition if a patient is unable to tolerate 1 A enteral support 7 days after aneurysm repair. We suggest thromboprophylaxis with unfractionated or low molecular-weight heparin for patients undergoing aneurysm 2 C repair at moderate to high risk for venous thromboembolism and low risk for bleeding. Postoperative blood transfusion Level of Quality of Recommendation recommendation evidence In the absence of ongoing blood loss, we suggest a threshold for blood transfusion during or after aneurysm repair at a hemoglobin 2 C concentration of 7 g/dL or below. Postoperative surveillance Late outcomes Level of Quality of Recommendation recommendation evidence We recommend treatment of type I endoleaks. We suggest treatment for ongoing aneurysm expansion, even in the 2 C absence of a visible endoleak. We suggest antibiotic prophylaxis before respiratory tract procedures, gastrointestinal or genitourinary procedures, and demotologic or 2 C musculoskeletal procedures for any patient with an aortic prothesis if the potential for infection exists or the patient is immunocompromised. After aneurysm repair, we recommend prompt evaluation for possible graft infection if a patient presents with generalized sepsis, groin 1 A drainage, pseudoaneurysm formation, or ill-defined pain. Late outcomes Level of Quality of Recommendation recommendation evidence We recommend prompt evaluation for possible aortoenteric fistula in a patient presenting with gastrointestinal bleeding after aneurysm 1 A repair. In patients presenting with an infected graft in the presence of extensive contamination with gross purulence, we recommend extra 1 B anatomic reconstruction followed by excision of all graft material along with aortic stump closure covered by an omental flap In patients presenting with an infected graft with minimal contamination, we suggest in situ reconstruction with a 2 B cryopreserved allograft. In a stable patient presenting with an infected graft, we suggest in situ 2 B reconstruction with femoral vein after graft excision and debridement. Aneurysmal vascular disease (including thoracic and abdominal aorta, intracranial and peripheral arterial vessels) or arteriovenous malformation.

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Main Models of Experimental Saccular Aneurysm in Animals 45 Regarding the animal type hair loss 3 months after stress purchase 0.5 mg dutasteride with mastercard, researchers should be thoroughly aware of its biological characteristics hair loss 8 weeks pregnant cheap dutasteride 0.5 mg with amex, behavior hair loss male vitamins buy discount dutasteride 0.5 mg, vascular anatomy, and phylogenetic similarity with humans. Among the biological characteristics, the size and metabolism of the animals exert a direct influence on the selection. Large animals are more difficult to handle and require more complex infrastructure (lodging, feeding, care, anesthesia, and specialized human resources), which increases the cost of research. Thus, for ethical reasons, studies that use large animals such as dogs and monkeys restrict their number to the bare minimum needed to ensure the validity of the results. A reduced number of animals influences the statistical methods applied to the analysis, because small samples can reduce the statistical power of tests and lead researchers to infer inaccurate conclusions. In addition, the calculation of the minimum number of animals is difficult because unpredictable losses can also occur as a function of the initial training and pilot study. With regard to metabolism, different animal species also exhibit different patterns of metabolic rate; for instance, the metabolism of rodents is often faster than that of humans. This metabolic power (also known as metabolic body weight) interferes with the effects of drugs on the organism, as well as with its processing, distribution across organic fluids and tissues, and modes of excretion. Thus, the calculation of experimental doses should be performed according to the metabolic weight rather than the absolute body weight of the animals. In surgical studies, different metabolic rates (influenced by factors such as age, gender, diet, and circadian rhythm) interfere with wound healing and regeneration of tissues and organs, thus encouraging researchers to learn the principles of veterinary anesthesia that correspond to the involved animals, the characteristics of the drugs that will be used, and more specifically, the potential interference of medications with the parameters analyzed in the study[18]. In addition to the biological characteristics, researchers must also be familiar with the intracranial and cervical arterial anatomy of each animal species, and the histology, diameters, flow patterns, and anastomoses of the vessels, because these are essential factors in the selection of the aneurysm construction technique. The phylogenetic similarity between animals and humans is also important in species selection, but it does not suggest that the extrapolation of the results to humans will be reliable. Transgenic animals have been increasingly used in research studies; however, caution is needed because such animals might exhibit unknown disorders that may interfere with the extrapolation of the results to humans[18]. Once the animal model has been selected, the experiment performed, and the data selected, the stage of explaining the phenomena by means of induction begins. This process consists of verifying a particular fact and its adequation to a known general law. This mode of reasoning has inherent odds of error; thus, one must be cautious in the extrapolation of the 46 Aneurysm results of experiments performed with non-human species to humans. In other words, compounds that might be noxious to a given non-human species might be innocuous or even beneficial to humans. For example, penicillin is lethal for guinea pigs, but is well tolerated and even beneficial for humans. In addition, aspirin is teratogenic in cats, dogs, rats, guinea pigs, mice, and monkeys, but it is innocuous in pregnant women. Thalidomide is teratogenic in human beings and monkeys, but innocuous in rats and other species. Therefore, phylogenetic proximity is not a fully reliable measure of similarity between the physiological phenomena of animals and humans [18]. To reduce the odds of selecting an inappropriate animal model for a given experiment, the multispecies approach is recommended. At least two different species including non rodents must be used in studies employing drugs, whereas the use of more than one animal species is rare in studies of surgical techniques. Accordingly, some animal species have become traditional standard models for specific surgical procedures. However, surgical studies focusing on the physiological features of a disease require more than one animal species, which despite its usefulness, does not ensure the absolute reliability of the extrapolation of the results from animals to humans [18]. Regarding the aneurysm model, a comprehensive awareness of the available models is required, in addition to their construction techniques, advantages and disadvantages, and more specifically, which features of human aneurysms one seeks to simulate, that is, their histological, geometric, physiopathological, and hemodynamic characteristics. Finally, the aims of the study are essential in the selection of the animal species and the techniques that will be used in aneurysm construction. Regarding the latter issue, medical training using animals is justified as training on humans exposes patients to medical error. Thus, practical training using animal models is indispensable for medical education because it contributes to the development of psychomotor skills and enables physicians to safely perform invasive techniques. Main animal species used in the construction of experimental saccular aneurysms Despite all of the considerations above, the selection of the ideal animal species for studies on experimental saccular aneurysms is not yet well established. As spontaneous intracranial aneurysms rarely occur in animals, most studies employ induced models, which have the advantage of allowing for the free selection of species. Animals such as rats[19], rabbits[24], dogs[20], pigs[21], and monkeys[23] have been used in studies on physiopathology [25, 26], hemodynamics[27-31], and the training of surgical[32, 33] and endovascular techniques, in addition to the testing of embolization devices and new materials[21, 34-38].

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The important thing is less time has to hair loss in men rat generic 0.5 mg dutasteride with mastercard be spent on chasing after all to hair loss cure on the way buy dutasteride 0.5 mg low price make sure that the neck is not left hanging the small bleeding sites hair loss dogs generic dutasteride 0.5mg overnight delivery. An appropriate number of soft neous fat lie the fascial layer and the spinous pillows is used to achieve optimal head posi processes. In case methyl head is not supposed to carry any extra body ene blue was used, the targeted spinous proc weight. During hemilaminectomy, we open the muscle fascia at the midline on the ipsilateral border of We do not use low molecular weight heparin the spinous processes. Then we follow the lat to prevent venous thrombus during the kneel eral wall of the spinous process, while stripping ing position, as seems to be the standard at the paravertebral muscle attachments with some other departments. Despite this, the risk diathermia until the actual vertebral lamina of thromboembolic complications has not been is reached. In cranio-caudal direction the exposure is tailored according to the length of the lesion. Approach One of the challenges in performing a multiple With the patient in position, the appropri level hemilaminectomy is selecting an optimal ate level for the approach needs to be iden retraction system. For cervical and lumbar spine this can that one or two level hemilaminectomy is suf be achieved easily with C-arm? Intradural dissection ilaminectomies we have not yet found an opti mal retractor. We use the framed laminectomy the intradural dissection depends entirely on retractor, which is very powerful, but unless the lesion. A common factor is the use of very the retractor blades are placed optimally, the high magni? The le Once the appropriate laminas have been ex sion removal should be planned so that normal posed, we proceed by performing the bony neural structures are manipulated as little as hemilaminectomy. If the bone is expected to be thin, cularize the tumor and then try to separate it we start immediately with a diamond tip, oth from all the surrounding structures before the erwise the outer cortex and the cancellous actual removal. All the leave only a very thin bony shell against the bleeding points should be taken care of imme ligamentum? Even a small amount of blood obscures by removing the ligament together with the re easily the view down in the deep, and narrow maining bony shell with a Kerrison rongeur. Closure With the dura exposed, the lesion is sometimes Once the lesion has been removed the dura is already visible through the partially transpar closed in one layer. Before lene) or with AnastoClips originally developed opening the dura, we place Surgicel along the for vascular anastomosis. We do not close the edges of the exposure to prevent venous ooz arachnoid as a separate layer. The a small cut with microscissors to penetrate muscle fascia is closed in a single layer with the dura. Then subcutaneous into this opening and pulled both cranially and layer and skin are closed separately. We do not caudally to open the dura along its longitudi use drains and there are no restrictions with nal? Finally, the arachnoid membrane is opened in the same longitudinal fashion and it can be attached to the dural edge with a hemoclip. Residency program the Neurosurgery Department in Helsinki is List of residents trained during the largest unit for training neurosurgeons in Prof. How to become a neurosurgeon in Helsinki the resident years by Aki Laakso It is actually quite hard to tell why anybody would want to be a neurosurgeon. Almost eve ry day you put yourself willingly, even eagerly, into situations where your performance may dictate the quality of life or even the di?er ence between life and no life for another hu man being. When I look at my colleagues here in Helsinki, I see an extremely wide variety of di?erent human personalities everything from a quiet, unassuming philosophical type to extroverted,? What is common, however, is that eve rybody seems to love what he or she is doing. I was rather car, I had no choice but (Although heard by old, 32 years, when I started my training, and many, the story itself must be an urban legend, had spent years doing research after medical since nobody in the States gives a hoot about school. I have the great answer for me, however, is twofold: the human est admiration for science and scientists, and brain and the consciousness arising within it should a thing or two in my life have happened being the greatest mysteries of the modern di?erently, I might still get my daily dose of day biology (and the brain is pretty much the playing with neurons in the lab instead of in only organ I?

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References:

  • http://dresselstyn.com/JFP_06307_Article1.pdf
  • https://www.escardio.org/static-file/Escardio/Subspecialty/EHRA/Publications/EP%20Wire/EP_Wire_AFibCKDPatients.pdf
  • https://academic.oup.com/neurosurgery/article-pdf/80/1/17/32596209/nyw013.pdf
  • http://swimed.org/wp-content/uploads/2016/05/ACGGuideline-Liver-Disease-and-Pregnancy-2016-1.pdf