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  • Clinical Pharmacist, University of Michigan Health System, Ann Arbor, Michigan

https://pharmacy.umich.edu/people/rimam

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Pro videstim ely interventio n f o rla the ef ects these guidelinesrepresenta sta tem ento f co nsensus ro m a pa nelo f expertsin the la the ocu s ef ectso pedia tricca ncertrea tm ent. The guidelinesa re bo th evidence- ba sed utilizing these guidelinesa re intended f o ruse esta blished a sso cia tio nsbetween thera peuticexpo suresa nd la the ef ectsto identiy high- c, a nd pro vide a f ra m ewo rk f o ro ngo ing la the ef ectsm o nito ring risk ca tego ries a nd gro unded in the co llective clinica lexperience o f experts m a tching the in childho o d ca ncersurvivo rs v e v i d m a gnitude o the risk with the intensity o f the screening reco m m enda tio ns g v i v o Since thera peuticinterventio ns o ra specif cpedia tricm a ligna ncy m a y va ry co nsidera bly T arg etP opu l ation ba sed o n the pa tient sa ge, presenting f ea tures, a nd trea tm entera, a thera py- ba sed design wa scho sen to perm itm o dula r o rm a tting o f the guidelinesby thera peuticexpo sure. M edica lcita tio nssuppo rting the a sso cia tio n o f ea ch la the ef ectwith o o ngo ing issuesrela ted to the lo ng- term f o llo w- up needso thispa tientpo pula tio n is a specif cthera peuticexpo sure a re included. R evisio nswere m a de ba sed ca re f o rsurvivo rso f childho o d, a do lescent, a nd yo ung a dultca ncers. The revised dra f twa sthen sento utto a dditio na lm ultidisciplina ry to putthe reco m m enda tio nsin perspective, a vo id o ver testing, a ddresspo tentia la nxieties, a nd experts o r urtherreview. The C hildren sO nco lo gy guidelinessubsequently underwentco m prehensive review a nd sco ring by a pa nelo expertsin G ro up itsel do esno tpro vide individua lized trea tm enta dvice to survivo rso rtheir a m ilies, a nd the la the ef ectso pedia tricm a ligna ncies, co m prised o m ultidisciplina ry representa tives ro m stro ngly reco m m endsdiscussing thisinf o rm a tio n with a qua lif ed m edica lpro f essio na l the C O L a the Ef ectsC o m m ittee. Ea ch Hea lth L ink underwenttwo levelso f G ro up Nursing D iscipline a nd L a the Ef ectsC o m m ittee a nd a re m a inta ined a nd upda ted by review; f rstby the Nursing C linica lPra ctice Subco m m ittee to veriy a ccura cy o co ntenta nd the C hildren sO nco lo gy G ro up sL o ng- Term F o llo w- Up G uidelinesC o re C o m m ittee a nd its reco m m enda tio ns, a nd then by m em berso the L a the Ef ectsC o m m ittee to pro vide expert a sso cia ted Ta sk F o rces llC hildren sO nco lo gy G ro up m em bersha ve co m plied with the m edica lreview) a nd Pa tient dvo ca cy C o m m ittee to pro vide f eedba ck rega rding presenta tio n C O co nf icto f interestpo licy, which requiresdisclo sure o f a ny po tentia lf na ncia lo ro ther o co ntentto the la y public co nf icting interests P re- R el ease R eview E vidence C ol l ection the initia lversio n o the guidelines Versio n 1 ? C hildren sO nco lo gy G ro up the ffe ts Pertinentinf o rm a tio n f ro m the published m edica llitera ture o verthe pa st yea rs upda ted a s u i d s wa srelea sed to the C hildren sO nco lo gy G ro up m em bership in M a rch o f O cto ber wa sretrieved a nd reviewed during the develo pm enta nd upda ting o f these o ra six- m o nth tria lperio d. R evisions R ef erences ro m the biblio gra phieso f selected a rticleswere used to bro a den the sea rch. The guidelineswere initia lly relea sed to the public Versio n 1 ? u r M ethods w - u i d s o n the C hildren sO nco lo gy G ro up W ebsite in Septem ber In 2, the lea dership o f the C hildren sO nco lo gy G ro up L a the Ef ectsC o m m ittee a nd Nursing o llo wing thisrelea se, cla rif ca tio n rega rding the a pplica bility o the guidelinesto the D iscipline a ppo inted a 7 m em berta sk f o rce, with representa tio n f ro m the L a the Ef ects a do lescenta nd yo ung a dultpo pula tio nso ca ncersurvivo rswa srequested. In respo nse, C o m m ittee, Nursing D iscipline, a nd Pa tient dvo ca cy C o m m ittee. The ta sk f o rce wa sco nvened a dditio na lm ino rm o dif ca tio nswere m a de a nd the title o the guidelineswa scha nged. A to review a nd sum m a rize the m edica llitera ture a nd develo p a dra f to f clinica lpra ctice revised versio n Versio n 1 ? w - u i d s fo u r s o f C guidelinesto directlo ng- term f o llo w- up ca re f o rpedia tricca ncersurvivo rs. These ta sk f o rcesa re the o rigina ldra f twentthro ugh severa litera tio nswithin the ta sk f o rce prio rto initia lreview. Ta sk f o rce m em bersa re a ssigned a cco rding to theirrespective were a ssigned a cco rding to a m o dif ed versio n o the Na tio na lC o m prehensive C a ncerNetwo rk a rea so expertise a nd clinica linteresta nd m em bership isupda ted every 2 yea rs listo f C a tego rieso C o nsensus, a s o llo ws these ta sk f o rcesa nd theirm em bership isincluded in the C o ntributo rs sectio n o f this C ateg ory tatem entof C onsensu s do cum ent, ref ecting co ntributio nsa nd reco m m enda tio nsreleva ntto the currentrelea se o these guidelines Versio n 5 ? O cto ber There isunio rm co nsensuso the pa neltha t 1 There ishigh- levelevidence linking the la the ef ectwith the thera peutic A llrevisio nspro po sed by the ta sk f o rceswere eva lua ted by a pa nelo f experts, a nd i expo sure a ccepted, a ssigned a sco re see Sco ring Expla na tio n sectio n o f Pref a ce). Pro po sed revisio ns 2 the screening reco m m enda tio n isa ppro pria the ba sed o n the co llective tha twere rejected by the expertpa nelwere returned with expla na tio n to the releva ntta sk clinica lexperience o pa nelm em bers f o rce cha ir. I desired, ta sk f o rce cha irswere given a n o ppo rtunity to respo nd by pro viding a dditio na ljustif ca tio n a nd resubm itting the rejected ta sk f o rce reco m m enda tio n( s o r urther There isunio rm co nsensuso the pa neltha t co nsidera tio n by the expertpa nel There islo wer levelevidence linking the la the ef ectwith the thera peutic expo sure P l an for U pdates 2 the screening reco m m enda tio n isa ppro pria the ba sed o n the co llective the m ultidisciplina ry ta sk f o rcesdescribed a bo ve willco ntinue to m o nito rthe litera ture a nd clinica lexperience o pa nelm em bers repo rtto the C O L o ng- Term F o llo w- Up G uideline C o re C o m m ittee during ea ch guideline 2 There isno n- unio rm co nsensuso the pa neltha t review/ upda the cycle. Perio dicrevisio nsto these guidelinesa re pla nned a snew inf o rm a tio n 1 There islo wer levelevidence linking the la the ef ectwith the thera peutic beco m esa va ila ble, a nd a tlea stevery 5 yea rs. C linicia nsa re a dvised to check the C hildren s O nco lo gy G ro up website perio dica lly f o rthe la testupda tesa nd revisio nsto the guidelines expo sure which willbe po sted a t v i v o the screening reco m m enda tio n isa ppro pria the ba sed o n the co llective clinica lexperience o pa nelm em bers S coring xpl anation 3 There ism a jo rdisa greem enttha tthe reco m m enda tio n isa ppro pria te. These guidelinesrepresenta sta tem ento f co nsensus ro m a m ultidisciplina ry pa nelo f U niform consensu s Nea r una nim o usa greem ento the pa nelwith so m e po ssible neutra lpo sitio ns expertsin the la the ef ectso f pedia tricca ncertrea tm ent. The guidelineso utline m inim um N on- u niform consensu s : the m a jo rityo pa nelm em bersa gree with the reco m m enda tio n; ho wever there reco m m enda tio ns o rspecif chea lth screening eva lua tio nsin o rderto detectpo tentia lla the isreco gnitio na m o ng pa nelm em berstha tgiventhe qua lityo evidence, clinicia nsm a ycho o se to a do pt ef ectsa rising a sa resulto f thera peuticexpo suresreceived during trea tm ento f childho o d, di erenta ppro a ches a do lescent, a nd yo ung a dultca ncers H ig h- evel evidence Evidence derived ro m high qua lityca se co ntro lo rco ho rtstudies L ow er evel evidence Evidence derived ro m no n- a na lyticstudiesca se repo rtsca se seriesa ndclinica l Ea ch sco re rela testo the strength o f the a sso cia tio n o f the identif ed la the ef ectwith experience. Thisisdue to the f a cttha tthere a re no ra ndo m ized clinica ltria ls a nd C a tego ry 2 reco m m enda tio nsa re designa ted a s 2 there isunio rm ity o co nsensus no ne f o rthco m ing in the f o reseea ble f uture) o n which to ba se reco m m enda tio ns o rperio dic a m o ng the reviewersrega rding strength o evidence a nd a ppro pria tenesso the screening screening eva lua tio nsin thispo pula tio n; theref o re, the guidelinessho uld no tbe m isco nstrued reco m m enda tio n) o r 2 there isno n- unio rm co nsensusa m o ng the reviewersrega rding a srepresenting co nventio na l evidence- ba sed clinica lpra ctice guidelines o r sta nda rdso strength o evidence a nd a ppro pria tenesso the screening reco m m enda tio n) ca re. R a thertha n subm itting reco m m enda tio nsrepresenting m a jo rdisa greem ents, item ssco red Ea ch item wa ssco red ba sed o n the levelo f evidence currently a va ila ble to suppo rtit. C o nsidera tio nsin this Screening a nd f o llo w- up reco m m enda tio nsa re o rga nized by thera peuticexpo sure a nd rega rd include the pra ctica lity a nd ef f ciency o a pplying these bro a d guidelinesin individua l included thro ugho utthe guidelines. Pedia tricca ncersurvivo rsrepresenta rela tively sm a llbut clinica lsitua tio ns. Studiesto a ddressguideline im plem enta tio n a nd ref nem enta re a to p gro wing po pula tio n a thigh risk f o rva rio usthera py- rela ted co m plica tio ns ltho ugh severa l prio rity o the C O L o ng- Term F o llo w- Up G uideline C o re C o m m ittee; studieso ea sibility o f wellco nducted studieso n la rge po pula tio nso f childho o d ca ncersurvivo rsha ve dem o nstra ted guideline use ha ve been repo rted in lim ited institutio nsa nd o thersa re currently underwa y a sso cia tio nsbetween specif cexpo suresa nd la the ef ects, the size o f the survivo rpo pula tio n Issuesbeing a ddressed include descriptio n o a nticipa ted ba rriersto a pplica tio n o the a nd the ra the o f o ccurrence o f la the ef ectsdo esno ta llo w f o rclinica lstudiestha two uld a ssess reco m m enda tio nsin the guidelinesa nd develo pm ento review criteria f o rm ea suring cha nges the im pa cto f screening reco m m enda tio nso n the m o rbidity a nd m o rta lity a sso cia ted with the in ca re when the guidelinesa re im plem ented. Theref o re, sco ring o f ea ch expo sure ref ectsthe expertpa nel sa ssessm ento f the evidence esta blishing the ef f ca cy o screening f o rla the co m plica tio nsin pedia tricca ncer levelo f litera ture suppo rtlinking the thera peuticexpo sure with the la the ef ectco upled with a n survivo rs. W hile m o stclinicia nsbelieve tha to ngo ing surveilla nce f o rthese la the co m plica tio ns a ssessm ento f the a ppro pria tenesso f the reco m m ended screening m o da lity in identiying the isim po rta ntin o rderto a llo w f o rea rly detectio n a nd interventio n f o rco m plica tio nstha tm a y po tentia lla the ef ectba sed o n the pa nel sco llective clinica lexperience. W hile reco gnizing tha tthe length a nd identif ca tio n o a nd interventio n f o rla the o nsetthera py- rela ted co m plica tio nsin thisa trisk depth o these guidelinesisim po rta ntin o rderto pro vide clinica lly- releva nt, evidence- ba sed po pula tio n, po tentia lly reducing o ra m elio ra ting the im pa cto f la the co m plica tio nso n the hea lth reco m m enda tio nsa nd suppo rting hea lth educa tio n m a teria ls, clinicia n tim e lim ita tio nsa nd sta tuso f survivo rs. In a dditio n, o ngo ing hea lthca re tha tpro m o teshea lthy liestyle cho icesa nd the ef o rtrequired to identiy the specif creco m m enda tio nsreleva ntto individua lsurvivo rs pro videso ngo ing m o nito ring o f hea lth sta tusisim po rta nt o ra llca ncersurvivo rs ha ve been identif ed a sba rriersto theirclinica la pplica tio n. Theref o re, the C O L o ng- Term Po tentia lha rm so f guideline im plem enta tio n include increa sed pa tienta nxiety rela ted to o llo w- Up G uideline C o re C o m m ittee ha spa rtnered with the B a ylo rScho o lo M edicine to enha nced a wa renesso f po ssible co m plica tio ns, a swella sthe po tentia l o r a lse- po sitive develo p a web- ba sed intera ce, kno wn a s Pa sspo rt o rC a re, tha tgenera tesindividua lized screening eva lua tio ns, lea ding to unnecessa ry f urtherwo rkup. In a dditio n, co stso f lo ng- expo sure- ba sed reco m m enda tio ns ro m these guidelinesin a clinicia n- o cused f o rm a t o rea se term f o llo w- up ca re m a y be pro hibitive f o rso m e survivo rs, pa rticula rly tho se la cking o pa tientspecif ca pplica tio n o the guidelinesin the clinica lsetting. The Pa sspo rt o rC a re hea lth insura nce, o rtho se with insura nce tha tdo esno tco verthe reco m m ended screening a pplica tio n isa va ila ble to C hildren sO nco lo gy m em berinstitutio nsa tno co st o ra dditio na l eva lua tio ns inf o rm a tio n, plea se co nta ctM a rcE. Ho ro witz, M o rSusa n K ra use P atientP references Ultim a tely, a swith a llclinica lguidelines, decisio nsrega rding screening a nd clinica l u nding ou rce m a na gem ent o ra ny specif cpa tientsho uld be individua lly ta ilo red, ta king into co nsidera tio n Thiswo rk wa ssuppo rted by the C hildren sO nco lo gy G ro up C ha ir s ra nt U1 C a nd the pa tient strea tm enthisto ry, risk f a cto rs, co - m o rbidities, a nd liestyle. These guidelinesa re the Na tio na lC linica lTria lsNetwo rk G ro up O pera tio nsC enter ra nt U1 C ro m the theref o re no tintended to repla ce clinica ljudgm ento rto exclude o therrea so na ble a lterna tive Na tio na lC a ncerInstitute. The Versio n 5 upda te, including typesetting, wa ssuppo rted by the f o llo w- up pro cedures. The C hildren sO nco lo gy G ro up reco gnizestha tspecif cpa tientca re St a ldrick s o unda tio n. A s c t, a u n u l t C s a re o rga nized a cco rding to thera peuticexpo sures Sco re a ssigned by expertpa nelrepresenting the strength o da ta a rra nged by co lum n a s o llo ws f ro m the litera ture linking a specif cla the ef ectwith a thera peutic S ection N u m ber Unique identif er o rea ch guideline sectio n. T herapeu tic A g ent Thera peuticinterventio n f o rm a ligna ncy, including chem o thera py See Sco ring Expla na tio n in the Pref a ce f o rm o re inf o rm a tio n. Included a re m edica lcita tio nstha tpro vide evidence f o r psycho so cia la ssessm ent. R eco m m enda tio n f o rm inim um f requency the a sso cia tio n o the thera peuticinterventio n with the specif c o f perio diceva lua tio nsisba sed o n risk f a cto rsa nd m a gnitude o f risk, trea tm entco m plica tio n a nd/ o reva lua tio n o predispo sing risk f a cto rs a ssuppo rted by the m edica llitera ture a nd/ o rthe co m bined clinica l In a dditio n, so m e genera lreview a rticlesha ve been included in the experience o f the reviewersa nd pa nelo f experts R ef erence sectio n f o rclinicia n co nvenience. H eal th C ou nsel ing H eal th L ink s: Hea lth educa tio n m a teria lsdevelo ped specif ca lly to C ancer S creening Sectio ns co nta in preventive screening reco m m enda tio ns o r F u rther a cco m pa ny these guidelines. Title( s o f Hea lth L ink( s releva ntto R ecom m endations co m m o n a dulto nsetca ncers, o rga nized by co lum n a s o llo ws C onsiderations ea ch guideline sectio n a re ref erenced in thisco lum n. Preventive ServicesTa sk F o rce reco m m enda tio ns o rsta nda rd- risk po pula tio ns C ou nsel ing Suggested pa tientco unseling rega rding m ea sures a nd a re included here f o rref erence. H ig hestR isk P aram eters and S creening u idel ines: P otential C onsiderations for F u rther T esting and I ntervention: High risk po pula tio nswere tho se co nsidered by the pa nelo experts R eco m m enda tio ns o r urtherdia gno sticeva lua tio nsbeyo nd o ro thereva lua ting bo dies such a sthe A m erica n C a ncerSo ciety) m inim um screening f o rindividua lswith po sitive histo ry a nd/ a sbeing a tsignif ca ntly increa sed risk f o rthe specif ed m a ligna ncy o rphysica lexa m ina tio n f ndingso rpo sitive screening tests R eco m m enda tio ns o rhigh- risk po pula tio ns, when a pplica ble, a re reco m m enda tio ns o rco nsulta tio n a nd/ o rref erra l, a nd specif ed a nd m a y di er ro m reco m m enda tio ns o rthe sta nda rd reco m m enda tio ns o rm a na gem ento f exa cerba ting o rpredispo sing risk gro upsdue to the signif ca ntly increa sed risk o the specif ed co nditio ns m a ligna ncy within the high- risk gro up. Sectio ns llsurvivo rswho underwenthem a to po ieticcelltra nspla nt a pplica tio n isa va ila ble to C hildren sO nco lo gy m em berinstitutio nsa tno co st o ra dditio na l ? Sectio n 9 is o rm a leso nly inf o rm a tio n, plea se co nta ctM a rcE. Sectio n 9 o rsurvivo rswho underwenta uto lo go ushem a to po ieticcelltra nspla nt W e a re ho pef ultha tthisrevised versio n o the C hildren sO nco lo gy G ro up w -. Sectio ns o rsurvivo rswho underwenta llo geneichem a to po ieticcell u i d s fo u r s o f C s c t, a u n u l t C s willenha nce tra nspla nt, include releva ntsectio ns the f o llo w- up ca re pro vided to thisunique gro up o ca ncersurvivo rs. Sectio ns o rsurvivo rswho underwentsurgery, include releva ntsectio ns suggestio ns, o rco ncernsrega rding use o these guidelines, plea se co nta ct. Sectio ns o rsurvivo rswho received o therthera peuticm o da lities, include o- hairs, C O ong T erm F ol l ow - U p G u idel ines C ore C om m ittee: releva ntsectio ns M elissa M. Theref o re, we stro ngly a dvise tha ta co m prehensive trea tm entsum m a ry be prepa red f o rea ch childho o d ca ncersurvivo r including a reco rd o f a llthera peuticexpo sureswith a pplica ble da tes, deta ilso f a dm inistra tio n, a nd cum ula tive do seso f a lla gents, including tho se no tcurrently a ddressed by these guidelines the C O L o ng- Term F o llo w- Up G uidelinesC o re C o m m ittee reco gnizestha tthe tim e required to identiy pa tientspecif creco m m enda tio ns ro m these guidelinesissignif ca nt, a nd ha sbeen identif ed a sa ba rrierto clinica luse. Thus, i clinicia nsha ve m o re deta iled inf o rm a tio n tha t were included f o rca ta ra ctm o nito ring o nly) sectio ns suppo rtsref ra ining f ro m a specif cscreening f o ra pa rticula rpa tient, clinica ljudgm ent sho uld be used to guide the individua leva lua tio n. R ef era sindica ted to scho o llia iso n in co m m unity o rca ncercenter psycho lo gist so cia lwo rker, scho o lco unselo r to a cilita the a cquisitio n o educa tio na lo r vo ca tio na lreso urces R ef era sindica ted f o rneuro psycho lo gica leva lua tio n. Neuro O nco l 4 J a nso nC L eisenring W, C o xC eta l Predicto rso f m a rria ge a nddivo rce ina dultsurvivo rso f childho o dca ncersa repo rt ro m the C hildho o dC a ncerSurvivo rStudy. C a ncerEpidem io l io m a rkersPrev K ina ha nK E, Sha rp L K SeidelK eta l Sca rring, disf gurem enta ndqua lityo f lie inlo ng- term survivo rso f childho o dca ncer: a repo rt ro m the C hildho o dC a ncerSurvivo rStudy. C linO nco l K irchho C K rullK R NessK K eta l O ccupa tio na lo utco m eso f a dultchildho o dca ncersurvivo rs repo rt ro m the C hildho o d C a ncerSurvivo rStudy. C a ncer K irchho C L eisenring W, K rullK R eta l Unem plo ym enta m o ng a dultsurvivo rso f childho o dca ncer: a repo rt ro m the C hildho o dC a ncerSurvivo rStudy.

Associated Disorders the most common diagnosis treated with laminectomy is spinal stenosis allergy symptoms to kefir order nasonex nasal spray 18 gm fast delivery. In spinal stenosis allergy testing knoxville tn 18 gm nasonex nasal spray with visa, the spinal canal (vertebral foramen) is narrowed allergy testing what do the numbers mean 18 gm nasonex nasal spray mastercard, thus compressing the spinal cord allergy medicine to take while breastfeeding purchase nasonex nasal spray us. Other conditions that cause pressure on the spine and spinal nerve roots include those where a mass lesion is present (eg, tumor, abscess, other localized infection). Surgical Techniques Laminectomy is an inpatient procedure performed under general anesthesia. An incision is made in the back over the affected region, and the back muscles are dissected to expose the spinal cord. The lamina is then removed from the vertebral body, along with any inflamed or thickened ligaments that may be contributing to compression. Following resection, the muscles are reapproximated and the soft tissues sutured back into place. The extent of laminectomy varies, 16 but most commonly extends 2 levels above and below the site of maximal cord compression. It can be performed by minimally invasive techniques, which minimizes the extent of resection. Laminoplasty is a more limited procedure in which the lamina is cut but not removed, thus allowing expansion of the spinal cord. Foraminotomy and/or foramenectomy, which involve partial or complete removal of Page | 16 of 26 the facet joints, may be combined with laminectomy when the spinal nerve roots are compressed at the foramen. Spinal fusion is combined with laminectomy when instability of the spine is present preoperatively, or if the procedure is sufficiently extensive to expect postoperative spinal instability. Surgical Variations Hemilaminotomy and laminotomy, sometimes called laminoforaminotomy, are less invasive than laminectomy. These procedures focus on the interlaminar space, where most of the pathologic changes are concentrated, minimizing resection of the stabilizing posterior spine. A laminotomy typically removes the inferior aspect of the cranial lamina, the superior aspect of the subjacent lamina, the ligamentum flavum, and the medial aspect of the facet joint. Unlike laminectomy, laminotomy does not disrupt the facet joints, supra- and interspinous ligaments, a major portion of the lamina, or the muscular attachments. Muscular dissection and retraction are required to achieve adequate surgical visualization. Microendoscopic decompressive laminotomy is similar to laminotomy but uses endoscopic visualization. For microendoscopic decompressive laminotomy, an endoscopic curette, rongeur, and drill are used for the laminotomy, facetectomy, and foraminotomy. The working channel may be repositioned from a single incision for multilevel and bilateral dissections. Adverse Events Complications of laminectomy can include spinal cord and nerve root injuries, which occur at 16 rates from 0% to 10%. Worsening myelopathy and/or radiculopathy can occur in a small percentage of patients independent of surgical injuries. Infection and bleeding can occur; hematomas following surgery often require reoperation if they are close to critical structures. Leakage of spinal fluid may occur and occasionally be persistent requiring treatment. Instability of the spine can result from extensive laminectomy involving multiple levels. This is usually an indication for spinal fusion as an adjunct to laminectomy, but if fusion is not performed, the instability may lead to progressive symptoms and additional surgery. Specific complication rates depend on the indication and location treated, surgical approach, and extent of surgery. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, and treatment- related mortality and morbidity. In patients with lumbar radiculopathy with disc herniation who receive discectomy, there is sufficient evidence to support the use of discectomy in patients who have not responded to usual care for six weeks. In most, a high percentage of patients in the conservative care group crossed over to surgery. This high degree of crossover reduced the power to detect differences when assessed by intention-to-treat analysis. Analysis by treatment received was also flawed because of the potential noncomparability of groups resulting from the high crossover rate. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. In patients with spinal stenosis, there is sufficient evidence that laminectomy is more effective than nonoperative usual care in individuals with spinal stenosis who do not improve after eight weeks of conservative treatment. The superiority of laminectomy is sustained through up to eight years of follow-up. This conclusion applies best to individuals who do not want to undergo intensive, organized conservative treatment, or who do not have access to such a program. For individuals who want to delay surgery and participate in an organized program of physical therapy and exercise, early surgery with the combination of conservative initial treatment and delayed surgery in selected patients have similar outcomes at two years. From a policy perspective, this means that immediate laminectomy and intensive conservative care are both viable options. The evidence is Page | 18 of 26 sufficient to determine that the technology results in a meaningful improvement in the net health outcome. For individuals who have space-occupying lesion(s) of the spinal canal or nerve root compression who receive lumbar laminectomy, the evidence includes case series. They have reported that most patients with myelopathy experience improvements in symptoms or abatement of symptom progression after laminectomy. However, this uncontrolled evidence does not provide a basis to determine the efficacy of the procedure compared with alternatives. The current standard of care, clinical input obtained in 2015, clinical practice guidelines, and the absence of alternative treatments all support the use of laminectomy for space-occupying lesions of the spinal canal. As a result, laminectomy may be considered medically necessary for patients with space-occupying lesions of the spinal cord. Ongoing and Unpublished Clinical Trials A currently unpublished trial that might influence this review is listed in Table 1. Clinical Input from Physician Specialty Societies and Academic Medical Centers While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted. In response to requests, input was received from two specialty societies and four academic medical centers when this policy was in development in 2015. Input informed criteria for medical necessity for the indications of mass lesions. Table 2 summarizes the recommendations specific to open discectomy or microdiscectomy. There is insufficient evidence to make a recommendation for or against the use of automated I percutaneous discectomy compared with open discectomy. Discectomy is suggested to provide more effective symptom relief than medical/interventional care for B patients whose symptoms warrant surgical care. In patients with less severe symptoms, both surgery and medical/interventional care appear to be effective in short and long term relief. Use of an operative microscope is suggested to obtain comparable outcomes to open discectomy for B patients whose symptoms warrant surgery. There is insufficient evidence to make a recommendation for or against the use of tubular discectomy I compared with open discectomy. The North American Spine Society issued evidence-based guidelines (2011) on the diagnosis 18 and treatment of degenerative lumbar spinal stenosis. The guidelines stated that patients with mild symptoms of lumbar spinal stenosis are not considered surgical candidates; however, decompressive surgery was suggested to improve outcomes in patients with moderate-to- severe symptoms of lumbar spinal stenosis (grade B recommendation). The Society also indicated that current evidence was insufficient to recommend for or against the placement of interspinous process spacing devices to treat spinal stenosis. Excerpts from the North American Spine Society Coverage Recommendations: Laminectomy 1. Spinal Stenosis (including recurrent spinal stenosis, congenital stenosis, stenosis associated with achondroplasia) meeting the following criteria: a. Regulatory Status Discectomy and laminectomy are surgical procedures and, as such, are not subject to regulation by the U. Some instrumentation used during laminectomy may be subject to Food and Drug Administration approval.

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This paper reviews have devastating consequences such as quadriple- the different etiologies allergy treatment emergency order line nasonex nasal spray, divided into compressive gia quercetin allergy treatment buy 18gm nasonex nasal spray visa, paraplegia and severe sensory defcits allergy treatment nhs order nasonex nasal spray discount. The history allergy treatment clinic discount 18gm nasonex nasal spray with mastercard, an adequate neurological ex- 1Neuroradiologist, Fundacion Valle de amination and the study of the cerebrospinal fuid Defnition and clinical picture Lili, Cali, Colombia. Central syndrome: spino-thalamic crossing, cortico-spinal (includes non-infammatory etiologies) and transverse myelitis and autonomic tracts (syringomyelia, neuromyelitis have been used as synonyms in the published literature (5). Medullary cone: sacral emerging fbres (post-viral my- dysfunction, or urinary retention, point to a spinal cord injury. Cauda equina: cauda equina nerves (acute cytomegalovi- as myopathy or disorders of the neuromuscular junction, but rus infection, polyradiculits and compression) the absence of a sensory defcit rules them out. Tractopathies: selective disorders (vitamin B12 def- hand, bilateral frontal mesial lesions may mimic myelopathy ciency, paraneoplastic myelopathy and multiple sclerosis). There are cases where the etiology is never identifed, and Myelopathies may have a variable course and may manifest they are classifed as idiopathic myelopathy. Chronic myelopa- Spinal cord pathologies may be classifed as acute, subacute/ thies include, among others, spondylotic myelopathy, vascular intermittent (6) or chronic, depending on the time course, the malformations, retrovirus-associated myelopathy (human im- extent of the involvement, the clinical picture or syndrome, or munodefciency virus), syringomyelia, chronic myelopathy due the etiology (2-4,6,7). Patients with myelopathies but no evident to multiple sclerosis, combined subacute degeneration (vitamin lesions, or who present with multiple lesions of chronic appear- B12 defciency), tabes dorsalis, and familial spastic paraplegia. If there is evidence of spinal cord Compressive diseases of the spinal cord are divided into compression due to an acute lesion (epidural metastasis or acute and chronic, including degenerative changes, trauma, abscess), defnitive management is required in order to avoid tumor infltration, vascular malformations, infections with damage or to adequately manage all other potential diagnoses. Patients with If the symptoms progress for more than three weeks, transverse clinical fndings of compressive myelopathy that show exten- myelitis is improbable, and other conditions must be considered, sive (more than three vertebral segments) fusiform spinal cord such as a spinal tumor, chronic compressive disease, dural hyperintensity in T2 weighted sequences, are often mistakenly arterio-venous fstula, metabolic disorder, sarcoidosis, or a thought to have optic neuritis, or classifed as idiopathic. Complete spinal cord: involvement of all the tracts myelomalacia, gliosis, tethering damage, vascular or infamma- (trauma, compression or acute transverse myelitis). Brown Sequard or hemi-spinal cord syndrome: ipsilateral enhancement is limited to the region of maximum compression cortico-spinal tract, posterior columns and contralateral (12). Granados A; Garcia L; Ortega C; Lopez A review articles Surgery improved or stabilized all patients with compressive pre-operative T2 image correlates with patient age, chronicity of disease, consistent with the hypothesis of spinal cord edema or the disease, and post-operative recovery. Conse- argument that the clinical and imaging fndings may differenti- quently, this parameter may be used as a predictor of surgical ate those patients who will beneft from surgical decompression prognosis (13). Patients with compressive myelopathy due to stenosis due to cervical spondylolysis (15), cervical spinal fusion, Morquios syndrome have cervical disease due to atlanto-axial myelomeningocele or epidural masses. Canal ste- patients with rheumatoid arthritis have a cervical lesion, either an nosis secondary to nucleus pulposus herniation is more frequently atlanto-axial subluxation, atlanto-axial impaction (basilar invagi- found in C6-C7, but it may occur in C5-C6 and, to a lesser extent, nation), or Luschka joint disease, and pannus transfer to the disc in C4-C5. Neurological decline may be irreversible, although (most common), anterolateral with motor symptoms, or central with the lower cervical spine is the most vulnerable to myelopathy spinal cord compression resulting in myelopathy (18). Increased intensity of the spinal cord in C2 in the T2 weighted sequence due to Figure 2. Increased intensity and thickening of the spinal cord from the bulbo-medullary compressive myelopathy secondary to rheumatoid arthritis. Motor vehicle acci- enhancement limited to the point of greatest stenosis, plus a 4 Diagnostic approach to myelopathies. Granados A; Garcia L; Ortega C; Lopez A review articles dents are the most common cause, accounting for 50% of the events, (19). The most mobile segments are more often affected, in par- followed by violence (frearm or stab wounds), falls from heights, ticular C5-C7 and T10-L2. Clinically, quadriplegia predominates and sports injuries (diving,American football and horseback-riding) in 30-40% of cases, and paraplegia occurs in 6-10% (16). B) Sagittal section with T2 information in C7 showing diminished height and signal intensity with annulus protrusion in C5-C6 and C6-C7; there is also central and left subarticular protrusion of the annulus associated with annulus and ligament tear in C7, giving rise to central spinal hyperintensity due to compressive myelopathy resulting from nucleus pulposus herniation. Some studies have shown that hemorrhage and longer hemato- mas are associated with a lower rate of motor recovery (20). Abscess-related compressive myelopathy Epidural abscesses are uncommon but they constitute a surgi- cal emergency because they may progress rapidly within days and early diagnosis is diffcult, leading to delayed treatment. They affect mainly men, with no specifc age range (22), and the incidence has been shown to have increased in recent years. T2 weighted image with annulus protrusion in C4 and C5, giving rise to spinal diabetes mellitus, use of intravenous drugs, chronic renal failure, cord hyperintensity due to traumatic compressive myelopathy. Lumbar trauma has also Tumoral compressive myelopathy been described in one third of patients, as a cause for epidural Myelopathy may be the initial manifestation of a malignancy abscess. Human immunodefciency virus has not been shown in up to 20% of cases where the only systemic symptom is to be the cause of the increased incidence (23). Tumors compressing the spinal cord may be It usually presents as subacute lumbar pain, fever (may be divided into extradural and intradural. Extradural tumors may absent in subacute and chronic stages), increased local tender- be classifed as follows: ness, progressive radiculopathy or myelopathy. Benign: synovial cyst, osteoma, osteoblastoma, giant cell phase of radicular irritation is followed by neurologic defcit tumor, hemangioma, eosinophilic granuloma, schwanno- (muscle weakness, abnormal sensation and incontinence) and ma and meningioma. Malignant: bone metastasis (are the cause of the most result from mechanical compression and, in some cases, from common myelopathy due to extradural spinal cord ischemia. Any segment of the spinal cord may be affected, but compression) (28), multiple myeloma, lymphoma and the most frequent are the thoracic and lumbar segments. Mycobacterium tuberculosis is the second most frequent myelopathy associated with subacute dorsal pain that wors- pathogen, found in 25% of cases (22). It must be selected as the frst imaging technique because it is more sensitive than other imag- Myelopathy of vascular origin ing modalities and allows to rule out other causes. A spinal cord the arterial supply to the spinal cord consists of one anterior abscess develops by phases, starting with an infectious myelitis spinal artery and two posterior spinal arteries with their penetrat- that appears hyperintense on T2 with poorly defned enhance- ing vessels. It is provided mainly by the anterior spinal artery that ment, followed by a late phase with well-defned peripheral emerges from the vertebral arteries, the artery of Adamkiewicz enhancement and perilesional edema. The fnal phase is intra- (arteria radiculararis magna) of variable origin, generally left spinal abscess formation with low signal intensity in T1 images between T9 and T12, and by anastomosis between the anterior and high signal intensity in sequences with T2 information (25). The spinal cord may be affected by compressive and fcity of spinal cord diseases (acute ischemia, tumors or multiple non-compressive vascular diseases, of which the most com- sclerosis lesion). However, it is not performed frequently be- mon are malformations of the dural arteriovenous fstula type cause of limitations such as movement artifacts and the small (29). In cases of vascular malformation, patients present with size of the spinal canal. These diseases were classifed by Riche of reduced apparent diffusion coeffcient are visible in patients in 1985 (29) as follows: with spondylotic myelopathy, surrounded by a low-signal halo. The differential diagnosis includes extradural metastasis, tion (30): epidural hematoma, migrated disc fragments or epidural lipo-. Neplastic vascular lesions: hemangioblastoma and cav- matosis (22) (Figures 5a and 5b). These enhance with contrast, together with the thickened spinal cord due to myelopathy resulting from an epidural abscess. Arteriovenous malformations may be dural or Type I (extra- They are localized in the cervical spine in 46% of cases and in spinal, accounting for 75%) (31). The age of onset is low thoracic or lumbar regions, and in a lesser proportion, in the under 40 years, when hemorrhage is the main symptom, and sacral and cervical regions. Another cause of myelopathy of vascular origin of the non- Eighty per cent present with bladder dysfunction, when the mal- compressive type is acute vascular occlusion, which is less formation involves the cone (32). The disease may progress over frequent and may lead to an infarct that mimics myelitis (8). There is also enhancement of the prevertebral soft tissues and of the cervical muscles due to myelopathy secondary to a high-grade glioma. There is gadolinium enhancement of T1, T3 and Compressive myelopathy due to syringomyelia T4 and of the spinous processes, but no enhancement of the spinal cord due to metastatic disease. Syringomyelia is a rare neurologic disorder, characterized by the slow development of fuid-flled areas extending along the the diagnosis of myelopathy secondary to spinal cord ischemia spinal cord, and causing symptoms such as pain, weakness and is diffcult because of the lack of diagnostic criteria in the acute stiffness of the back, shoulders and limbs. In the United States, it is more common four hours and include severe motor and sphincter dysfunction, among African-Americans. It may be related to congenital or ac- temperature and pain alterations, with no alterations to vibration quired malformations. This vasculitis, embolism, arterial dissection, hypotension, and prothrombotic states.

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Teir role in the management of the patient with include: hemophilia includes the following [9 allergy symptoms from alcohol effective 18 gm nasonex nasal spray,39-41]: ? serial casting to assist in correcting deformi- ? Assessment ties [28 allergy medicine cat dander order nasonex nasal spray 18 gm without a prescription,29] allergy symptoms with eyes 18 gm nasonex nasal spray free shipping. If these conservative measures fail to provide ities that may be needed afer bleeds allergy medicine non antihistamine buy nasonex nasal spray with a visa. Fractures are not frequent in people with hemo- relief and restoration of function. However, a person Pseudotumours with hemophilic arthropathy may be at risk for fractures around joints that have signifcant loss 1. The pseudotumour is a potentially limb and life- of motion and in bones that are osteoporotic. Treatment of a fracture requires immediate tissue bleeds, usually in muscle adjacent to bone, factor concentrate replacement. If not treated, the pseudotumour can reach least 50% and maintained for three to fve days. A fstula can develop through the over- while the fracture becomes stabilized and to lying skin. Radiographic fndings include a sof tissue mass ment under appropriate coverage of clotting with adjacent bone destruction. Prolonged immobilization, which can lead to Options include factor replacement and moni- signifcant limitation of range of movement in toring, aspiration, and surgical ablation. Specifc issues in relation to orthopedic surgery particularly if they erode long bones. Orthopedic surgeons should have had specifc challenge in surgical management of hemo- training in surgical management of persons with philia; surgery must only be performed by hemophilia [3]. Performing multiple site elective surgery in a of the details of the surgery performed and intra- simultaneous or staggered fashion to use clot- operative joint status will facilitate planning of ting factor concentrates judiciously should be an appropriate rehabilitation program. Rehabilitation may have to progress more slowly 3) [36,51,52] in persons with hemophilia. Adequate pain control is essential to allow appro- requires closer monitoring of pain and ofen priate exercise and mobilization. Tese principles also apply to fxation of frac- tures and excision of pseudotumours. In severe hemophilia, inhibitors do not change bodies that neutralize clotting factors. Bleeding manifestations in moderate/mild hemo- philia complicated by an inhibitor are more 3. In this situation, the of mucocutaneous, urogenital, and gastrointes- expected recovery and half-life of the transfused tinal bleeding sites [57]. Inhibitors are more frequently encountered in may be signifcant in these patients. Inhibitors are much less frequently encountered those with moderate or mild hemophilia. In all cases, inhibitors render treatment with in the range of 20-30% and approximately 5-10% replacement factor concentrates difcult. Choice of treatment product should be based on once every fve exposure days until 20 expo- titre of inhibitor, records of clinical response to sure days, every 10 exposure days between 21 product, and site and nature of bleed. For adults with more than 150 exposure days, be treated with specifc factor replacement at apart from a 6-12 monthly review, any failure to a much higher dose, if possible, to neutralize respond to adequate factor concentrate replace- the inhibitor with excess factor activity and ment therapy in a previously responsive patient stop bleeding. Patients with a history of a high responding 3) [56,62-64] inhibitor but with low titres may be treated 14. Inhibitor measurement should also be done in similarly in an emergency until an anamnestic all patients who have been intensively treated response occurs, usually in three to fve days, for more than fve days, within four weeks of precluding further treatment with concentrates the last infusion. Inhibitors should also be assessed prior to surgery or if recovery assays are not as expected, 5. Very low titre inhibitors may not be detected to one agent than the other, highlighting the by the Bethesda inhibitor assay, but by a poor need to individualize therapy. Management of bleeding in patients with inhib- itors must be in consultation with a centre 11. Such reac- much lower, especially in persons whose inhib- tions can be the first symptom of inhibitor itor is associated with an allergic diathesis. For the vast majority of patients, switching prod- Immune tolerance induction ucts does not lead to inhibitor development. As noted, some patients may develop an should be monitored for inhibitor develop- ment. As new treatments are continually emerging in virin, which give sustained virological response this rapidly changing feld, transfusion-trans- in 61% of people with hemophilia. All people with hemophilia treated with plasma- least every 6-12 months and whenever clini- derived products that are not adequately cally indicated. The diagnosis, counselling, initiation of treat- 6-12 months and whenever clinically indicated. In general, joint aspiration to treat hemarthrosis should be revaccinated with double the hepa- should be avoided, unless done early under appro- titis B vaccine dose. Bleeding is likely to delay healing and worsen infection in hemophilia infection and should therefore be well controlled [108]. The risk factors for bacterial infections in people with hemophilia are venous access catheter 4. Rehabilitation of treatment of haemophilic synovitis, target joints, synovitis in patients with haemophilia. Prophylaxis in the efcacy and safety of etoricoxib in the treatment of haemophilia: a double-blind controlled trial. J Tromb Haemost Yttrium90 citrate in haemophilic synovitis: Brazilian 2011;9(4):700-10. Haemophilic physiotherapy exercise programme in haemophilia - a arthropathy: the usefulness of intra-articular global perspective. Chemical synoviorthesis with rifampicin in subtalar joints in patients with haemophilic arthropathy. J therapy for invasive procedures in patients with Bone Joint Surg Am 1977;59(3):287-305. Mathews V, Viswabandya A, Baidya S, George B, Nair Expert Imageing Working Group of The International S, Chandy M, Srivastava A. De Kleijn P, Blamey G, Zourikian N, Dalzell R, Lobet Haemophilia 2008 Mar;14(2):303-14. Haemophilia 2009 and rehabilitation in the management of hemophilia Sep;15(5):1168-71. Hermans C, de Moerloose P, Fischer K, et al; European for assessment of haemophilic arthropathy in Haemophilia Terapy Standardisation Board. Haemophilia 2007 Management of acute haemarthrosis in haemophilia May;13(3):293-304. Non-operative pseudotumours: case study and comparison to historical treatment of fexion contracture of the knee in management. J Bone Joint Surg Am 2008 Oct;90 Suppl 2 Pt 11 patients from a tertiary centre in India. Retrograde intramedullary Haemophilic arthropathy of the ankle treated by nailing of supracondylar femoral fractures in total ankle replacement: a case series. Astermark J, Altisent C, Batorova A, et al; European surgery in haemophilia patients with inhibitors: Haemophilia Terapy Standardisation Board. International workshop on immune non-responsive bleeding episodes in patients with tolerance induction: consensus recommendations. Beutel K, Hauch H, Rischewski J, Kordes U, or zidovudine in three-drug combination therapy with Schneppenheim J, Schneppenheim R. Randomized double-blind, placebo-controlled trial of twice-daily zidovudine in asymptomatic haemophiliacs 97. Preliminary Study infected with the human immunodefciency virus type of Two Antiviral Agents for Hepatitis C Genotype 1. A 6-month Randomized study of didanosine monotherapy and versus a 12-month surveillance for hepatocellular combination therapy with zidovudine in hemophilic carcinoma in 559 hemophiliacs infected with the and nonhemophilic subjects with asymptomatic hepatitis C virus. J Bone Joint Surg Am suboptimal response and human immunodefciency 2003;85-A(5):969-70. Orthopaedic surgery Hemophilia A, idiopathic thrombocytopenia and of haemophilia in the 21st century: an overview.

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