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Cushing Response

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261. Late Effects of Treatment for Childhood Cancer (PDQ®): Health Professional Version

for Childhood Cancer During the past five decades, dramatic progress has been made in the development of curative therapy for pediatric malignancies. Long-term survival into adulthood is the expectation for more than 80% of children with access to contemporary therapies for pediatric malignancies.[ , ] The therapy responsible for this survival can also produce adverse long-term health-related outcomes, referred to as late effects , which manifest months to years after completion of cancer treatment (...) exposure-based medical evaluation 2 or more years after completion of therapy. Health Links. Patient education materials called Health Links provide detailed information on guideline-specific topics to enhance health maintenance and promotion among this population of cancer survivors.[ ] Comprehensive reviews. Multidisciplinary system-based (e.g., cardiovascular, neurocognitive, and reproductive) task forces who are responsible for monitoring the literature, evaluating guideline content, and providing

2018 PDQ - NCI's Comprehensive Cancer Database

262. Small Cell Lung Cancer Treatment (PDQ®): Health Professional Version

, approximately 30% of patients with SCLC will have tumors confined to the hemithorax of origin, the mediastinum, or the supraclavicular lymph nodes. These patients are designated as having limited-stage disease (LD).[ ] Patients with tumors that have spread beyond the supraclavicular areas are said to have extensive-stage disease (ED). SCLC is more responsive to chemotherapy and radiation therapy than other cell types of lung cancer; however, a cure is difficult to achieve because SCLC has a greater tendency (...) and include neurological defect or personality change from brain metastases or pain from bone metastases. Infrequently, patients with SCLC may present with symptoms and signs of one of the following paraneoplastic syndromes: Inappropriate antidiuretic hormone secretion. Cushing syndrome from secretion of adrenocorticotropic hormone. Paraneoplastic cerebellar degeneration. Lambert-Eaton myasthenic syndrome.[ ] Physical examination may identify enlarged supraclavicular lymphadenopathy, pleural effusion

2018 PDQ - NCI's Comprehensive Cancer Database

263. Adrenocortical Carcinoma Treatment (PDQ®): Health Professional Version

. [ ] Allolio B, Fassnacht M: Clinical review: Adrenocortical carcinoma: clinical update. J Clin Endocrinol Metab 91 (6): 2027-37, 2006. [ ] Cellular Classification of Adrenocortical Carcinoma Adrenocortical carcinoma (ACC) can be classified into functioning and nonfunctioning tumors by clinical and biochemical assessment. Approximately 60% of ACCs produce hormones.[ ] The associated clinical syndromes include the following: Hypercortisolism (Cushing syndrome). Hirsutism/virilization. Feminization (...) are appropriate for newly diagnosed patients when possible. Radiation therapy (approximately 50 to 70 Gy given over a period of 4 weeks) may be given to patients with localized but unresectable tumors.[ ] For patients unable to undergo complete resection, mitotane in doses as high as 10 to 12 g per day to achieve a blood level of 14 to 20 mg/L should be considered. This adrenolytic drug produces useful clinical responses in about 20% to 30% of patients with measurable tumor burden.[ , ] Two other cytotoxic

2018 PDQ - NCI's Comprehensive Cancer Database

264. Genetics of Kidney Cancer (Renal Cell Cancer) (PDQ®): Health Professional Version

.[ ] Cell cycle control pVHL reintroduction induces cell cycle arrest and p27 upregulation after serum withdrawal in VHL null cell lines.[ ] Additionally, pVHL destabilizes Skp2, and upregulates p27 in response to damage.[ ] Nuclear localization and intensity of p27 is inversely associated with tumor grade.[ ] pVHL binds to [ ] and facilitates phosphorylation of p53 in an ATM-dependent fashion.[ ] Extracellular matrix control Functional pVHL is needed for appropriate assembly of an extracellular

2018 PDQ - NCI's Comprehensive Cancer Database

265. Unusual Cancers of Childhood Treatment (PDQ®): Health Professional Version

of EBV-specific cytotoxic T-lymphocyte therapy in patients with refractory disease, response rates were observed in 33.3% of patients, and long-term remissions were obtained in 62% of patients treated in their second or subsequent remission.[ ] Anti–programmed death-ligand 1 (PD-L1) monoclonal antibodies have been studied in two phase II trials in adults with refractory nasopharyngeal carcinoma, with response rates of 20.5% to 25.9% (33% in patients with PD-L1–positive tumors) and evidence of long (...) on for more information.) The risk increases after exposure to a mean dose of more than 0.05 Gy to 0.1 Gy (50–100 mGy), and follows a linear dose-response pattern up to 30 Gy and then declines, which is greater at younger age of exposure and persists more than 45 years after exposure.[ , ] Papillary thyroid carcinoma is the most frequent form of thyroid carcinoma diagnosed after radiation exposure.[ ] Molecular alterations, including intrachromosomal rearrangements, are frequently found; among them, RET

2018 PDQ - NCI's Comprehensive Cancer Database

266. Oncogenetic testing for persons with hereditary endocrine cancer syndromes

, psychologists (indicative and non- exhaustive list). a The KCE has sole responsibility for the recommendations. COLOPHON Title: Oncogenetic testing for persons with hereditary endocrine cancer syndromes – Abstract Authors: Joan Vlayen (KCE), Marie Bex (UZ Leuven), Bert Bravenboer (UZ Brussel), Kathleen Claes (UZ Gent), Bruno Lapauw (UZ Gent), Alexandre Persu (Cliniques universitaires Saint-Luc), Kris Poppe (CHU Saint-Pierre), Urielle Ullman (Institut de Pathologie de Gosselies), Tom Van Maerken (UZ Gent (...) investigator or researcher: Marie Bex (somatostatine analogen in acromegalie and cushing, NOVARTIS), Kris Poppe (Takeda “L. Thyroxine” study) Layout: Ine Verhulst Disclaimer: The external experts were consulted about a (preliminary) version of the scientific report. Their comments were discussed during meetings. They did not co-author the scientific report and did not necessarily agree with its content. Subsequently, a (final) version was submitted to the validators. The validation of the report results

2015 Belgian Health Care Knowledge Centre

267. Towards a better managed off-label use of drugs

access to the pharmaceutical, unless the non-industrial sponsor finances it himself. 4 ‘Off-label’ drugs KCE Report 252Cs LIABILITY ? The choice of therapy is primarily the physician’s responsibility. The off- label use of medicines is covered by the legally recognized principle of the therapeutic freedom. Off-label use is lawful if the medication is prescribed with the care, skill and forethought of a medical practitioner in the same circumstances. To evaluate this, the scientific basis plays (...) to which it could reasonably be expected that the product would be put”. It is unlikely, however, that the producer will be held liable if the patient was sufficiently informed on the possible risks by the package leaflet and by the physician and if the injury was not caused by a defect inherent to the product or an error in the leaflet. ? Pharmacists can be held liable for damage caused by a defective magistral formula. They are responsible for the quality of the magistral formula: correct weighing

2015 Belgian Health Care Knowledge Centre

268. Hypertension - not diabetic

African or Caribbean ethnic origin (of any age), a calcium-channel blocker is recommended. If not suitable due to oedema or drug intolerance, or if there is evidence of heart failure, or a high risk of heart failure, a low-dose thiazide-type diuretic should be offered. Management also includes: Offering lifestyle advice. Monitoring response to treatment. Target clinic BPs — aged under 80 years: BP < 140/90 mmHg; aged 80 years and older: BP < 150/90 mmHg. Checking renal function annually (...) sodium and potassium and renal function within 1 month, and repeat as required thereafter. An alpha- or beta-blocker if further diuretic therapy is contraindicated, not tolerated, or ineffective. If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, seek expert advice if this has not yet been obtained. Use clinic blood pressure measurements to monitor the response to treatment or lifestyle modifications: For people who are being treated with lifestyle

2018 NICE Clinical Knowledge Summaries

269. Eczema - atopic

response and further damage of the skin barrier. Another theory is that T helper cell dysregulation (a predominace of Th2 cells rather than Th1) results in production of IgE and mast cell hyperactivity, leading to the development of pruritus, inflammation, and other clinical features of atopic eczema [ ; ; ]. About 70% of people with atopic eczema have a positive family history of atopic disease (atopic eczema, asthma, and/or hay fever) [ ; ]. Atopic eczema presents in about 80% of children where both (...) and/or exacerbation of established atopic eczema [ ]. Possible trigger factors include soap and detergent, animal dander, house-dust mites, extreme temperatures, rough clothing, pollen, certain foods, and stress. While most triggers lead to reactions confined to the skin, allergic triggers can induce both skin and systemic responses. These responses are largely mediated via IgE and T cell responses causing immediate (type 1) allergic reactions and/or delayed (late-phase or type 4) allergic reactions. Immediate

2018 NICE Clinical Knowledge Summaries

270. Polycystic ovary syndrome

congenital adrenal hyperplasia, Cushing's syndrome, or an androgen-secreting tumour) if: There are signs of virilization, for example, deep voice, reduced breast size, increased muscle bulk, and clitoral hypertrophy. There is rapidly progressing hirsutism (less than 1 year between hirsutism being noticed and seeking medical advice). The total testosterone level is significantly elevated (greater than 5 nmol/l or more than twice the upper limit of normal reference range). Basis for recommendation Basis (...) recommended in those with amenorrhea and more severe clinical features, including consideration of hypogonadotropic hypogonadism, Cushing’s disease, or androgen-producing tumours [ ]. Differential diagnosis What else might it be? The diagnosis of polycystic ovary syndrome involves the exclusion of all of the following disorders, which may have a similar clinical presentation: Simple obesity Raised androgen levels with or without symptoms. Oligomenorrhoea or amenorrhoea is not often present. See the CKS

2018 NICE Clinical Knowledge Summaries

271. Infertility

with ovulation disorders have a group II ovulation disorder. PCOS is the most commonly encountered type of WHO Group II ovulation disorder and is responsible for the majority of ovulation disorders. Common clinical features include oligo- or amenorrhoea, anovulatory infertility, obesity, and hyperandrogenism. See the CKS topic on for more information. Group III ovulation disorders are caused by ovarian failure and are characterized by high gonadotrophins and hypogonadism and a low oestrogen level. About 4–5 (...) % of women with ovulation disorders have a group III ovulation disorder. Other conditions that can cause ovulatory disorders include [ ; ; ; ; ]: Thyroid abnormalities — hyperthyroidism and hypothyroidism may lead to menstrual disorders and ovulatory dysfunction. See the CKS topics on and for more information. Adrenal abnormalities — Cushing's syndrome and congenital adrenal hyperplasia may cause anovulation. Chronic debilitating disease (such as uncontrolled diabetes, cancer, AIDS, end-stage kidney

2018 NICE Clinical Knowledge Summaries

272. Amenorrhoea

, or for 6–12 months in women with previous oligomenorrhoea. Causes of primary amenorrhoea include: In those with normal secondary sexual characteristics — physiological causes (constitutional delay and pregnancy), genito-urinary malformations (such as imperforate hymen, transverse septum, and absent vagina or uterus), and endocrine disorders (such as hypothyroidism, hyperthyroidism, hyperprolactinaemia, and Cushing's syndrome). In those with no secondary sexual characteristics — primary ovarian (...) (for example, due to chemotherapy, radiotherapy, or autoimmune disease). In those with features of androgen excess (such as hirsutism, acne, and virilization) — polycystic ovary syndrome (PCOS), Cushing's syndrome, late-onset congenital adrenal hyperplasia, and androgen-secreting tumours of the ovary or adrenal gland. A thorough history and examination should be done to help identify the cause of amenorrhoea. The following preliminary investigations may be considered in primary care to aid diagnosis

2018 NICE Clinical Knowledge Summaries

273. Corticosteroids - topical (skin), nose, and eyes

of psoriasis and psoriatic arthritis [ ]. Application How should topical corticosteroids be applied? A thin layer of topical corticosteroid should be applied once or twice daily, adjusting the potency to control symptoms. For many conditions, once-daily application is usually sufficient. Increase to twice-daily application only if the condition does not respond adequately. The corticosteroid should typically be used in bursts of 3–7 days in order to achieve control. Once a clinical response is seen (...) topical corticosteroid treatment gradually. Abrupt withdrawal can cause a relapse or rebound of the condition being treated (for example psoriasis or eczema). Be aware that: Gradual withdrawal may adversely influence adherence (especially when treating children). Once a clinical response has been seen, taper the dose of topical corticosteroid. See the section on for more information. The following options can be considered: Step down to a lower-potency corticosteroid. Use a lower-potency

2018 NICE Clinical Knowledge Summaries

274. Hypothyroidism

peripheral vision. Abnormal pituitary hormone production such as skin depigmentation, atrophic breasts, galactorrhoea, amenorrhoea, erectile dysfunction, loss of body hair, Cushing’s syndrome, or acromegaly. Postpartum thyroiditis (PPT) The hypothyroid phase of PPT usually occurs between 3–8 months (most often at 6 months) postpartum and lasts typically 4–6 months. Myxoedema coma Presents with typical features of hypothyroidism with hypothermia, coma, and occasionally seizures. This is a medical (...) and assess response to treatment 3–4 months after TSH stabilises within the reference range — see the section on for further information on initiation and titration of LT4. If there is no improvement in symptoms, stop LT4. In older people (especially those aged over 80 years), follow a 'watch and wait' strategy, generally avoiding hormonal treatment. If a decision is made to treat, prescribe LT4 and recheck TSH two months after starting and adjust the dose accordingly. In asymptomatic people, observe

2018 NICE Clinical Knowledge Summaries

275. Hypertensive disorders of pregnancy

be appropriate. This guideline does not address all elements of standard practice and accepts that individual clinicians are responsible for: • Providing care within the context of locally available resources, expertise, and scope of practice • Supporting consumer rights and informed decision making in partnership with healthcare practitioners including the right to decline intervention or ongoing management • Advising consumers of their choices in an environment that is culturally appropriate and which (...) enables comfortable and confidential discussion. This includes the use of interpreter services where necessary • Ensuring informed consent is obtained prior to delivering care • Meeting all legislative requirements and professional standards • Applying standard precautions, and additional precautions as necessary, when delivering care • Documenting all care in accordance with mandatory and local requirements Queensland Health disclaims, to the maximum extent permitted by law, all responsibility

2016 Queensland Health

276. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient

, and dietitians was jointly convened by the 2 societies. Literature searches were then performed using keywords ( critically ill , critical care , intensive care , nutrition , enteral , parenteral , tube feeding , and those related to assigned topics, such as pancreatitis , sepsis , etc) to evaluate the quality of evidence supporting a response to those questions, which were then used to derive a subsequent treatment recommendation. The literature search included MEDLINE, PubMed, Cochrane Database of Systemic (...) Reviews, the National Guideline Clearinghouse, and an Internet search using the Google search engine for scholarly articles through an end date of December 31, 2013 (including ePub publications). While preference was given to RCTs, other forms of resource material were used to support the response, including nonrandomized cohort trials, prospective observational studies, and retrospective case series. Use of publications was limited to full‐text articles available in English on adult humans. For all

2016 American Society for Parenteral and Enteral Nutrition

277. American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice Guidelines for Comprehensive Medical Care of Patients with Obesity

negatively affects an individual patient’s health. In response to this emergent concept from the CCO, the AACE proposed an “Advanced Framework for a New Diagnosis of Obesity.” This document features an anthro- pometric component that is the measure of adiposity (i.e., BMI) and a clinical component that describes the presence and severity of weight-related complications (15 [EL 4; NE]). Given the multiple meanings and perspectives asso- ciated with the term “obesity” in our society, there was also (...) recommendations based on the evidence in response to each question. Clinical questions are labeled “Q,” and recommendations are labeled “R.” Formulation of Recommendations The task force discussed and critiqued each of the evidence reviews and recommendations, which were then revised for consensus approval. The evidence ratings were used to grade the scientific strength of the recommenda - tions. Recommendations (numerically labeled “R1, R2,” etc.) are based on strength-of-evidence, indexed to the BEL, which

2016 American Association of Clinical Endocrinologists

278. Practice Guidelines for the Diagnosis and Management of Aspergillosis

is not recommended ( strong recommendation; moderate-quality evidence) . Contrast is recommended when a nodule or a mass is close to a large vessel ( strong recommendation; moderate-quality evidence) . 15. We suggest a follow-up chest CT scan to assess the response of IPA to treatment after a minimum of 2 weeks of treatment; earlier assessment is indicated if the patient clinically deteriorates ( weak recommendation; low-quality evidence). When a nodule is close to a large vessel, more frequent monitoring may (...) with a nonoverlapping side-effect profile (strong recommendation; low-quality evidence) . 42. For salvage therapy, agents include lipid formulations of AmB, micafungin, caspofungin, posaconazole, or itraconazole. The use of a triazole as salvage therapy should take into account prior antifungal therapy, host factors, pharmacokinetic considerations, and possible antifungal resistance (strong recommendation; moderate-quality evidence) . How Can Biomarkers Be Used to Assess Patient Response to Therapy? Recommendations

2016 Infectious Diseases Society of America

279. Diagnosis of Right Lower Quadrant Pain and Suspected Acute Appendicitis

Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2012-00012-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the investigators have (...) number is CRD42013006480. AHRQ TOO and External Stakeholder Input A panel of Key Informants, including patients and other stakeholders, gave input on the Key Questions to be examined. These Key Questions were posted on AHRQ’s Effective Health Care Web site for public comment and revised in response to comments. A Technical Expert Panel, including representatives of professional societies and experts in the diagnosis and treatment of RLQ abdominal pain and appendicitis, provided input to help further

2016 Effective Health Care Program (AHRQ)

280. Mental Pathologies at the Root of Modern Medical Training: Lessons from the Life of Professor William Stewart Halsted

of minds at Hopkins to meet or exceed him, and when students were called on for an answer, an incorrect response could be met with biting sarcasm or open ridicule. From his students he culled candidates for his surgical residency program—the first in the world and a highly influential model for the academic surgery to follow, with greats such as Harvey Cushing directly indebted to Halsted’s mentorship. 10 As the longest witness to Halsted’s academic trials, surgical resident John M.T. Finney sums up (...) responsibilities. Spoken or unspoken, this fear is a corroding thread that innervates the medical education experience. It has ruined lives, pushing medical students, residents, and fellows 1,2,3 Male physicians commit suicide at twice the national average, . 4 Perhaps this is something we carry into medicine, generation after generation of sensitive souls, trying to help others in ways we can’t help ourselves. Poetic as this may sound, we have evidence to believe it isn’t true. A survey of students prior

2016 Clinical Correlations

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