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Prophylactic cranial irradiation in locally advanced non-small-cell lung cancer after multi-modality treatment: long-term follow-up and investigations of late neuropsychologic effects 1d infection tumblr order ordipha in united states online. The role of pretreatment white matter abnormalities in developing white matter changes following whole brain radiation: a volumetric study antibiotics for ethmoid sinus infection buy ordipha 100 mg with mastercard. Factors impacting volumetric white matter changes following whole brain radiation therapy virus how about now discount ordipha 250 mg overnight delivery. Radiation-induced cognitive impairments are associated with changes in indicators of hippocampal neurogenesis antibiotics for bordetella dogs order ordipha 250 mg with amex. A phase 2 study of weekly albumin-bound paclitaxel (Abraxane(R)) given as a two-hour infusion. Randomized doubleblind placebo-controlled trial of acetyl-L-carnitine for the prevention of taxane-induced neuropathy in women undergoing adjuvant breast cancer therapy. A systematic review and meta-analysis of alpha-lipoic acid in the treatment of diabetic peripheral neuropathy. Alpha lipoic acid for symptomatic peripheral neuropathy in patients with diabetes: a meta-analysis of randomized controlled trials. Effect of duloxetine on pain, function, and quality of life among patients with chemotherapyinduced painful peripheral neuropathy: a randomized clinical trial. Efficacy of gabapentin in the management of chemotherapy-induced peripheral neuropathy: a phase 3 randomized, double-blind, placebo-controlled, crossover trial (N00C3). Interventions for preventing neuropathy caused by cisplatin and related compounds. Physician-assessed and patient-reported outcome measures in chemotherapy-induced sensory peripheral neurotoxicity: two sides of the same coin. Phase I and pharmacologic study of paclitaxel and cisplatin with granulocyte colonystimulating factor: neuromuscular toxicity is dose-limiting. Comparison of survival and quality of life in advanced non-small cell lung cancer patients treat- 59. Until the late 1990s, treatment of advanced lung cancer followed the straightforward algorithm of platinum-based combination therapy, irrespective of histologic subtype, without any option for further lines of treatment. In the past two decades, there has been a gradual shift in therapy from the use of systemic chemotherapy in all patients, to the current approach in which histology and molecular status play a key role in treatment selection. This has been made possible by greater insights into lung cancer biology, the availability of novel therapeutic agents, and the increasing focus on identification of biomarkers to guide therapy. Lung cancer presents at an advanced stage at the time of diagnosis in the majority of patients. The overall goals of treatment for advanced stage disease are palliation and improvement in survival. Local treatment modalities such as radiotherapy and surgery play a limited role and are implemented primarily for symptom control. The variables that are associated with prognosis can be grouped into categories: tumor-related, such as primary site, histology, and extent of disease; patient-related, such as performance status, comorbidity, and sex; and environmental factors, such as nutrition and the choice and quality of treatment. Clinical Factors Performance status and comorbid conditions are amongst the most important prognostic factors. Moreover, these determinants are also of utmost importance for the selection of therapy, as outlined later. The systematic determination of comorbidities is an essential component to preselect appropriate chemotherapy regimens and to provide the best supportive care. In addition to noncancer-related comorbidities, patients also suffer from symptoms related to the primary tumor, mediastinal spread, or paraneoplastic syndromes. Moreover, lung cancer commonly produces systemic effects such as anorexia, weight loss, weakness, and profound fatigue. Nowadays, the clear majority of lung cancer cases are diagnosed in patients aged >65 years. Often, increasing age is accompanied by multiple comorbidities, which further limit therapeutic options and outcome of the patient. Ethnicity While lung cancer remains a leading cause of mortality for all races, recent research has focused on ethnic variations in this disease. One of the most striking disparities seen is the difference in lung cancer risk and survival for African and Asian ethnicities. Epidemiologic research has focused on behavioral, cultural, and socioeconomic factors that may influence risk, although no clear link has been established. Finally, within metastatic disease, patients with a solitary metastasis in a single extrathoracic organ will be classified as M1b. Presence of oligometastases merits consideration of local therapies in addition to systemic therapy. Hence, accurate diagnosis of tumor histology has become essential in treatment decision-making and can impact considerations of both toxicity and potential efficacy of selected agents used in the management of this disease. The tumor is very heterogeneous in every aspect: pathology, presence of molecular alterations, radiographic appearance, clinical presentation, and response to systemic therapy. The initial diagnostic biopsies often have a limited amount of material that is inadequate to conduct necessary tests to identify histology and genotype. The prognostic role of K-Ras mutations in lung adenocarcinoma has been debated extensively. Earlier evidence suggested poor sensitivity to chemotherapy and overall prognosis with K-Ras mutation, but emerging recent data have failed to confirm this. The knowledge of the prognostic and predictive potential of various molecular markers is bound to increase significantly in the coming years as molecular testing is adopted to routine practice settings. Among several combinations, platinum-based chemotherapy was shown to lead to higher response rates and prolonged survival in comparison with monotherapy, albeit with the cost of increased toxicity. The results, updated in 2008, demonstrated a 27% reduction in the risk of death for patients treated with cisplatin-containing regimens compared with supportive care alone, which translated to an absolute improvement in survival of 10% (5% to 15%) at one year. The choice of the newer agent (gemcitabine, paclitaxel, or vinorelbine) that is combined with cisplatin does not seem to significantly affect the treatment efficacy (see Table 44.
Lung cancer is the leading cause of cancer-related deaths worldwide antibiotic resistant klebsiella pneumoniae cheap ordipha 100mg amex, despite knowledge of the primary etiologic factor (tobacco use) and advances in identifying underlying mechanisms antibiotics for uti with least side effects buy ordipha with american express, detecting mutations antibiotic resistance of e. coli in sewage and sludge buy ordipha 250mg with amex, and developing new treatments vanquish 100 antimicrobial cheap ordipha 250mg line. The addition of targeted therapies to the armamentarium for lung cancer necessitates testing for the presence of particular key driver mutations in lung adenocarcinomas to determine if a patient is eligible for a targeted therapy. Small histologic and cytologic specimens obtained by core-needle biopsy and fine-needle aspiration are increasingly common. In one study, it was reported that catheter aspiration was associated with a higher diagnostic yield than biopsy. When both sampling procedures are going to be performed, experience has shown that it is better to conduct the aspiration first because doing so produces a less bloody sample without diluting the cells of interest. Algorithm for optimal procurement and triage small specimens Diagnostic tests. The absence of a standardized algorithm for optimal procurement, processing, and triaging of small specimens has created a practice gap. The cytologist obtains the pertinent history and can correlate the morphologic features with clinical findings and imaging study results. For instance, when treatment is urgent or patients have travelled far for care, processing can be initiated when the sample arrives in the laboratory. Sparse cellularity obscured by blood, inflammation, or foreign material in a cytologic specimen can contribute to falsenegative results. For example, if the initial small sample is needed only to confirm a diagnosis of malignant disease before definitive removal of the tumor, it is unnecessary to obtain additional samples because samples needed for advanced diagnostic studies could be obtained later during the surgical resection. Techniques for the optimal triage and preparation of small specimens for diagnosis and ancillary studies are outlined in this chapter. Critics of fineneedle aspiration question whether it is possible to obtain sufficient material for molecular diagnosis with this technique. Avoiding unnecessary passes decreases the duration of anesthesia or sedation and reduces potential morbidity. Benefits of shorter biopsy time include rapid turnover of the procedure room and imaging facilities and fewer repeat procedures, resulting in cost savings. Neither of these approaches ensures that an adequate specimen has been procured for ancillary testing or that the specimen will be triaged appropriately, however. To minimize suboptimal smearing and specimen use, the specimen can be placed directly into a fixative for liquidbased cytologic examination, or a cell block can be prepared; the usefulness of this technique has not been formally studied, though. Above all, it is essential to define a process for handling specimens in coordination with the cytopathology laboratory. Algorithm for Processing Small Samples No standardized algorithm exists for processing small specimens, and few methods have been outlined. The algorithm for optimizing samples obtained using fine-needle aspiration with rapid onsite evaluation is divided into three stages: (1) specimen procurement and triage, (2) slide preparation, and (3) tissue evaluation for diagnosis and assessment of sample adequacy for ancillary studies, if necessary. For each pass of the needle, expel the specimen onto a single slide with a syringe. If clotting prevents the material from being expelled, use a stylet to dislodge the specimen. Identify diagnostic tissue particles, often tan or white specks but may vary depending on the nature of the lesion. When there is significant clot formation, gently press the specimen in between two slides to identify tissue particles. Place the remaining specimen in media appropriate for ancillary studies and/or cell block preparation. Cell blocks can be made by allowing the specimen to clot on the expelled slide for a few minutes and then placing it into formalin. Separate diagnostic material or more cellular elements from nondiagnostic ones. If yes, and ancillary studies are needed, determine whether the specimen includes sufficient material. Optimal tissue use involves preparing smears of selected tissue particles, which are stained with Diff-Quik and Papanicolaou stains, and then placing excess material in media for ancillary studies, if needed. With suboptimal preparation, slides are thick and bloody and contain clots, and the specimen is spread across almost the entire slide surface. Suboptimal preparation obscures cellular detail, hinders accurate interpretation of slides, and may leave inadequate material for ancillary studies. If the core adheres to the slide, lift it with a needle and place it in the appropriate medium for fixation or transport. In suboptimal touch preparations, the core is smeared or rubbed onto a slide, which can result in crush artifact and the transfer of a significant portion of lesional cells onto the slide, hindering final interpretation and compromising the core. Touching the core on a slide once or twice while it is still in the sheath yields the best results. If excessive material is transferred to the slide, it can be smeared with a second slide to distribute the cells thinly. Even if the slide is touched rapidly and immediately placed in alcohol, the slide may have air-drying artifacts. Artifacts can be minimized by hydrating the slide with a few drops of normal saline, which is available in syringes, for a few minutes. This technique can also be applied to fine-needle aspirate smears when there is a delay in alcohol fixation.
The prostate can be a di cult organ to e ect clearance of bacteria and yeasts bacteria names a-z purchase 500mg ordipha amex, as penetration of antibiotics is variable antibiotic 1 hour during 2 hours after meal how to scheduled cheap ordipha 100mg fast delivery, and prostatic calculi can act as foci human eye antibiotics for dogs buy 250mg ordipha visa. The prostate should be considered a source of infection in the immunocompromised male patient antibiotics drugs buy discount ordipha. Organisms usually considered to be associated with other organs can be found here, and the yeast Cryptococcus neoformans is an example. In higher-income parts of the world, Campylobacter is the commonest cause of bacterial gastroenteritis, usually acquired from contaminated, undercooked, fresh chicken carcasses. In tropical and lower-income areas of the world, organisms such as Vibrio cholerae assume importance. In any outbreak, for example food poisoning, it is important to identify the source of the organism involving a family, school, institution or the wider community, so that this can be removed at the earliest opportunity. The key to this detective work is obtaining a detailed history from the a ected individuals, which not only includes where and when food was consumed but listing every food item. An outbreak of gastroenteritis in Germany in 2011 caused by a shiga toxin-producing strain of Escherichia coli O104 a ected nearly 4000 individuals, 800 of whom had haemolytic uraemic syndrome, and 51 died. This outbreak was traced to contaminated fresh bean sprouts, which were a minor ingredient of salad consumed by only certain individuals in the first groups a ected. Antibiotic-associated diarrhoea is usually linked to Clostridium difficile, and is a particular problem in the older hospitalized patient, in whom it can produce a life-threatening diarrhoeal illness. Norovirus is brought into hospital via infected patients, visitors and sta, and every e ort must be made to limit its spread. Although this is usually a self-limiting infection, the virus has a significant impact on the functioning of hospitals. Not infrequently wards are closed for extended periods and elective surgery cancelled for days. Perhaps the most unusual organism causing disease in the alimentary canal is Helicobacter pylori. This bacterium can inhabit the inhospitable environment of the stomach and is a cause of gastric and duodenal ulcer disease and malignancy. The oral streptococci and anaerobes of the mouth are the agents of dental caries and periodontal infection. The bacterial flora of the intestine is involved in appendix and diverticular abscesses and biliary tract sepsis. The streptococci of the mouth and bowel can cause infective endocarditis, and the specific association of Streptococcus gallolyticus and a large bowel malignancy has been discussed (Chapter 7). The bacterial contents of the lumen, the structural integrity of the mucosal and submucosal layers of the bowel and the bowel-associated lymphoid aggregates are three broad defences. Some examples of how changes to the natural defences of the alimentary canal can predispose to infection are shown in Figure 11. Food, water and animals are a common source of exogenous bacteria, but Clostridium difficile can be acquired from the nursing home or hospital environment, where it survives as a heat-stable spore. In the case of enterotoxigenic Staphylococcus aureus and Bacillus cereus, these organisms multiply in contaminated food that is stored incorrectly, for example at room temperature rather than in a refrigerator. The acid metabolic by-products of these 173 174 Chapter 11 Infections of the Alimentary Canal Decreased saliva production can result in significant dental decay Perforation of the oesophagus can result in a polymicrobial mediastinitis Reducing stomach acidity decreases the numbers of organisms such as Vibrio cholerae needed to initiate disease In liver cirrhosis, portal hypertension occurs. Instead of being cleared from the liver, bacteria in the portal vein may enter the perihepatic lymphatics, and from there the peritoneum Before Antibiotics alter the normal flora of the colon by killing sensitive organisms. The normal flora can be replaced by more antibiotic resistant bacteria such as Enterobacter and Pseudomonas spp. Enamel Dentine Pulp Periodontal membrane Streptococcus mutans and Streptococcus sanguinis colonize the surfaces of teeth the gingival crevice is occupied by anaerobes such as Fusobacterium and Prevotella spp. Cementum Apical foramen Streptococcus salivarius is commonly found on the surface of the buccal cavity Figure 11. Certain bacteria of the normal mouth flora occupy certain ecological niches around the tooth and have the potential to cause dental infection. Teeth are protected by the cleaning action of the tongue, the bu ering e ect of saliva and the acquired pellicle, derived from saliva, which coats the surface of teeth. This coating, which becomes colonized with bacteria, is removed by regular cleaning and is replaced by new pellicle, preventing decay. In the setting of poor oral hygiene, where for example crevices are not cleaned properly, a nidus of infection may arise, with the development of dental caries. Infections of the teeth can spread into adjacent bone to initiate osteomyelitis, cause local so tissue abscesses and reach the facial sinuses. In the setting of widespread tooth decay, aspiration of mouth flora can result in development of a lung abscess. Profound halitosis may be present, indicating that the oral anaerobes are growing in the 176 Chapter 11 Infections of the Alimentary Canal (a) = No caries Tooth with natural groove covered with pellicle (b) = Caries Tooth with natural groove covered with pellicle Rapidly colonized with bacteria Poor cleaning does not remove pellicle from groove Bacterial metabolic acids attack enamel initiating decay Rapidly colonized with bacteria Cleaning removes colonized pellicle New pellicle coats tooth (c) Continuing decay occurs as a result of bacterial growth and acid production (d) Subgingival plaque precedes Porphyromonas and Prevotella spp. Some local and distant sites where the consequences of tooth decay can manifest are shown in Figure 11. Dilators used to alleviate dysphagia in the patient with oesophageal carcinoma or endoscopes can do this. Perforation of the duodenum as a result of ulcer disease can result in spillage of bacteria into the peritoneum. In all these circumstances, there should be a low threshold for also considering Candida.
With regard to the extent of pulmonary resection virus hunter island walkthrough ordipha 100 mg mastercard, a recent series showed that pneumonectomy combined with chest wall resection is feasible for highly selected patients antibiotic resistance originates by order ordipha 250 mg with amex. For patients with N0 antibiotic dosage for uti purchase ordipha 250mg line, N1 antibiotics nerve damage order genuine ordipha, and N2 disease, the 5-year survival rates were 60%, 56%, and 17%, respectively. In a retrospective series of 51 patients who were treated with chest wall resection, quality of life was only moderately impaired. The prosthesis is secured to the remaining half of the sternum medially and to the ribs inferiorly and laterally. Originally described by a radiologist, Henry Pancoast, in 1932,24 Pancoast tumors were thought to be uniformly fatal until the 1950s, when, on the basis of anecdotal experience, induction radiotherapy and resection were found to be curative. Other studies subsequently corroborated the results of the North American trial (see Table 30. The posterior compartment contains the nerve roots of the brachial plexus, the stellate ganglion, and the vertebral column. However, they also may be located anteriorly, with predominantly vascular involvement rather than neurologic or vertebral involvement. Surgeons should be adept at both anterior and posterior approaches, as a combined procedure may be necessary to obtain a complete resection. Other diseases, including lymphoma, tuberculosis, and primary chest wall tumors, may be associated with an apical mass and chest wall involvement. Transthoracic needle biopsy should be performed to establish a diagnosis before treatment. Because Pancoast tumors with mediastinal node metastases (N2 or N3 disease) have a poor prognosis, mediastinal staging via either endobronchial ultrasound or mediastinoscopy should be considered. Resection of the T1 nerve root usually does not cause motor function deficit, but resection of the C8 nerve root or lower trunk of the brachial plexus leads to loss of hand and arm function. Weakness of the intrinsic muscles of the hand indicates involvement of the C8 nerve root or lower trunk of the brachial plexus. Resection of a Pancoast tumor should be planned jointly with a spine neurosurgeon to allow optimal patient selection and the best chance of complete resection. Patients must be evaluated to determine whether they can tolerate combined-modality therapy. Performance status, renal function, and neurologic function must be adequate in order for the patient to receive platinum-based chemotherapy. Pulmonary function tests and, when necessary, cardiac stress tests are done to evaluate the ability of the patient to tolerate pulmonary resection. Anatomic Definition the original definition of a Pancoast tumor was a carcinoma of uncertain origin, arising in the extreme apex of the chest, that was associated with shoulder and arm pain, atrophy of the hand muscles, and Horner syndrome. Anatomically, the pulmonary sulcus is synonymous with the costovertebral gutter, which extends from the first rib to the diaphragm. The term superior pulmonary sulcus is used to describe the uppermost extent of this recess. Tumors involving the chest wall at the level of the second rib or below do not meet the criteria for classification as Pancoast tumors. Chest wall involvement may be limited to invasion of the parietal pleura in the superior sulcus but typically extends to involve the upper ribs, vertebral bodies, subclavian vessels, nerve roots of the brachial plexus, or stellate ganglion. The thoracic inlet can be divided into three compartments on the basis of the insertions of the anterior and middle scalene muscles on the first rib and the posterior scalene muscle on the second rib. The anterior compartment, located anterior to the anterior scalene muscle, contains the subclavian and internal jugular veins and the sternocleidomastoid and omohyoid muscles. Pancoast first described these tumors as "a peculiar neoplastic entity found in the upper portion of the pulmonary sulcus of the thorax. Preoperative magnetic resonance imaging showing a T4 Pancoast tumor that has invaded the thoracic spine. After induction chemoradiation therapy, complete (R0) resection was achieved by means of combined posterior resection of the involved area of the spine and posterolateral thoracotomy to complete the lobectomy and chest wall resection. In 1956, Chardack and MacCallum25 reported the case of a patient in whom a poorly differentiated squamous cell carcinoma was managed with en bloc resection of the right upper lobe, involved chest wall, and nerve roots, followed by adjuvant radiotherapy (65. In 1956, Shaw38 reported on a patient with the typical Pancoast syndrome who was referred for palliative radiotherapy. After treatment with 3000 cGy of radiation, the pain resolved and the tumor decreased in size, so Shaw performed a radical resection similar to that described by Chardack and MacCallum. The complete resection and long-term survival that were achieved in that case prompted Shaw et al. In 1961, they reported excellent local control and longer-than-anticipated survival in a study of 18 patients who were treated with 3000 to 3500 cGy of radiation over 2 weeks, followed by complete en bloc resection of the involved lobe, chest wall, and nerve roots 1 month later. For 30 years (the second era in the management of Pancoast tumors), the basic therapeutic strategy for these tumors remained unchanged. During the late 1980s and the 1990s (the third era in the management of Pancoast tumors), several thoracic surgery groups developed novel approaches for the resection of tumors involving the spine and subclavian vessels. This experience led to widespread acceptance of the anterior approach involving resection of the subclavian artery and graft reconstruction for the management of T4 tumors. Modifications of this approach included the development of a transmanubrial osteomuscular sparing approach that avoids clavicular resection or disarticulation, the addition of a posterior or anterolateral thoracotomy to facilitate exposure of the lung and spine, and the use of a hemiclamshell thoracotomy (anterior thoracotomy and partial median sternotomy). Such techniques were facilitated by improvements in the materials available for spine stabilization. During this same time period, several studies were performed to evaluate the results of treatment with radiation only. The results of these studies are difficult to interpret because they were retrospective, they included small numbers of patients, the tumors were only clinically staged, and the treatment techniques were highly variable. The results in terms of local control and survival appeared to be inferior to those reported after surgical treatment, but this difference reflects in part the patient population and the variable treatment techniques. Induction chemoradiation therapy followed by resection is a logical treatment strategy for a group of tumors that present a formidable challenge in terms of local control.
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