By X. Mufassa. Berry College. 2019.
Treatment is iron supplementation and 20mg cialis soft, if needed cialis soft 40mg, dilation of the web to permit normal swal- pleural space The tiny area between the two lowing and the passage of food cialis soft 20 mg. Also known as pleurae 40 mg cialis soft, which is normally filled with a small Paterson-Kelly syndrome; sideropenic dysphagia cialis soft 20mg. A physician can often hear with a stethoscope the friction generated by the rub- pneumatic larynx A device that uses air to pro- bing of the two inflamed layers of pleurae with each duce sound 20 mg cialis soft, helping a person whose larynx has breath cialis soft 40 mg. Removal of pleu- ral fluid 40mg cialis soft, when present , with a needle and syringe is pneumococcal immunization A vaccine that pre- key in diagnosing the cause of pleurisy and can also vents one of the most common and severe forms of relieve the pain and shortness of breath associated pneumonia , the form that is caused by Streptococcus with pleurisy. Radiation pneu- pneumoconiosis Inflammation and irritation monitis typically occurs after radiation treatments caused by deposition of dust or other particulate for cancer within the chest or breast. Pneumoconiosis usually occurs pneumonitis usually manifests itself 2 weeks to 6 in workers in certain occupations and in people months after completion of radiation therapy. If radiation pneumonitis persists, range from nearly harmless forms to destructive or it can lead to scarring of the lungs, referred to as fatal conditions, such as asbestosis and silicosis. Pneumothorax can occur spontaneously, fol- and life-threatening in premature or malnourished low a fractured rib or other trauma, occur in the infants and in immunosuppressed persons. See also Appendix A, “Prescription between the lungs (mediastinum), which may give Abbreviations. Pneumonia ated with widened capillaries (telangiectasia) in the is frequently but not always due to infection. Symptoms may include fever, chills, cough with spu- poikiloderma congenita See Rothmund- tum production, chest pain, and shortness of Thomson syndrome. For example, a point mutation is the cause lungs due to the sucking in of food particles or flu- of sickle cell disease. Poison treatment depends on the pneumonia, giant cell A deadly but fortunately substance. The lung tissue shows multinucleated giant center set up to inform people about how to cells lining the alveoli (air sacs) of the lungs. Chemicals pro- percent of patients recover, with no residual paraly- duced by this vine cause an immune reaction, pro- sis; about 25 percent are left with mild disabilities, ducing redness, itching, and blistering of the skin. The ideal strategy with polio is clearly to prevent it by immunizing poison oak Skin inflammation that results from against poliovirus. See also poison; Poison malaise, headache, sore throat, and vomiting— control center. Its cause is uncertain, and it does not shown to actually cause polio in extremely rare appear to run in families. Small numbers of virus polio vaccine, killed See polio vaccine, particles enter the blood and go to other sites, inactivated. Another round of virus in the bloodstream leads to invasion polio vaccine, live See polio vaccine, oral. Polio is a minor illness in 80 to 90 percent of clini- cal infections; this is termed the abortive type of polio vaccine, Sabin See polio vaccine, oral. Symptoms are polio vaccine, Salk See polio vaccine, inacti- slight fever, malaise, headache, sore throat, and vated. Symptoms usually pollen Small, light, dry protein particles from appear without prior illness, particularly in older trees, grasses, flowers, and weeds that may be children and adults, 7 to 14 days after exposure. Pollen particles are usually the Symptoms are fever, severe headache, stiff neck and male sex cells of a plant, and they are smaller than back, deep muscle pain, and sometimes areas of the tip of a pin. It lodges in the mucous membranes further progression from this type of illness, which http://www. The gene for the disease is on chromosome poly A short form for polymorphonuclear leuko- 6. Polyarteritis nodosa most commonly problem, also known as polycystic ovarian disease, affects muscles, joints, intestines, nerves, kidneys, that causes women to have symptoms that include and skin. Inflammation of the arteries can lead to irregular or no menstruation, acne, obesity, and inadequate blood supply and permanent damage to excess hair growth. Much of this polyarticular Involving many joints, as opposed risk can be reversed with exercise and weight loss. Medication is generally prescribed to induce regular menstruation, thereby reducing the cancer risk. For polycystic kidney disease An inherited disor- acne and excess hair growth, the diuretic medication der that is characterized by the development of spironolactone (brand name: Aldactazide) can help. Surgical The cysts eventually reduce kidney function, leading procedures involving the removal or destruction of a to kidney failure. Treatment involves managing pain and affected women contain a number of small cysts. Polycythemia can lead to heart failure, stroke, and polycystic kidney disease, adult See polycys- other medical problems when severe. Other features of the disease can leukemia or myelofibrosis, in which the marrow is be cysts in other organs, such as the liver and replaced by scar tissue. Polydipsia occurs in untreated or sive An early-onset disorder that is characterized poorly controlled diabetes mellitus. For example, eye color is polyneuritis, acute idiopathic See Guillain- polygenically controlled because many genes are Barre syndrome. The flat areas of increased skin pigment are called polyhydramnios Too much amniotic fluid. See also sleep polymyositis An autoimmune inflammatory dis- apnea; sleep apnea, central; sleep apnea, ease of muscle that begins when white blood cells obstructive; sleep disorders. Blood testing in a person with polymyositis shows Pompe disease An inherited deficiency of the significantly elevated creatinine phosphokinase lev- enzyme alpha-glucosidase which helps the body els. The diagnosis is further suggested by elec- break down glycogen, a complex carbohydrate that tromyogram testing and confirmed with muscle is converted to glucose for energy. Treatment of polymyositis requires high enzyme, glycogen builds up in the heart and other doses of cortisone-related medications, such as muscles, causing extensive damage. There are sev- prednisone, and immune suppression with medica- eral different forms of Pompe disease which vary in tions, such as methotrexate and cyclophosphamide. Due to popliteal pterygium syndrome An inherited an abnormal aggregation of capillaries, a port-wine condition that is characterized by a web (ptery- stain is a type of hemangioma. See also popliteal pterygium syndrome are cleft palate (with Sturge-Weber syndrome. The opposite of posterior is in an autosomal dominant manner and is due to anterior. See also Appendix B, “Anatomic mutation of the interferon regulatory factor 6 gene. Most porphyrias affect the skin or the nerv- with the chest against the film plate and the X-ray ous system. See patient may suffer rapid heartbeat, mania, muscle also Appendix B, “Anatomic Orientation Terms. Acute attacks are often pre- postherpetic neuralgia See neuralgia, pos- cipitated by the use of certain drugs, such as therpetic. One type of porphyria, acute intermittent occurs together with balanitis, inflammation of the porphyria, may have affected members of the House glans, as balanoposthitis. See also balanitis; bal- of Hanover in England, including “Mad” King anoposthitis. Normally, the veins from the stomach, intestine, spleen, and pancreas postmenopausal After menopause, the period merge into the portal vein, which then branches into of time after a woman has experienced 12 consecu- smaller vessels and travels through the liver. It can cause gastrointestinal bleeding, back of the nose and throat that leads to or gives the ascites, and symptoms related to decreasing func- sensation of mucus dripping down from the back of tion of the liver. Postnasal drip is one of the most common consequences of sinusitis, nasal allergies, and the portal vein A large vein formed by the union of the common cold. It can occur a the body, the attitude or carriage of the body as a few days, weeks, or even months after childbirth. A whole, or the position of the limbs (the arms and woman with postpartum depression may have feel- legs). Treatment involves counseling postural hypotension See hypotension, and/or medications. An abnormal increase in potas- sium (hyperkalemia) or decrease in potassium postpolio syndrome A constellation of symp- (hypokalemia) can profoundly affect the nervous toms and signs that appear years after an initial system and heart, and when extreme, can be fatal. Other symptoms include fatigue, joint pain, and slowly progressive muscle Pott’s disease See tuberculous diskitis. This is an (floppiness), poor sucking and feeding problems in important calculation because if delivery is delayed early infancy, and, later in infancy, excessive eating 3 weeks beyond term, the possibility of infant mor- that, if unchecked, leads gradually to marked obe- tality increases dramatically. Other sypmtoms include developmental delay, mild to moderate mental retar- post-traumatic stress disorder A psychologi- dation with multiple learning disabilities, and small cal disorder that develops in some individuals who gonads. The child can have two vived or witnessed violent crimes, or been through copies of chromosome region 15q11–15q13, but if wars. When the same Although preeclampsia is relatively common, occur- region of the maternally contributed chromosome is ring in about 5 percent of all pregnancies and more missing, the result is a different disease, called frequently in first pregnancies than in others, it can Angelman syndrome. In some cases, untreated preeclampsia can Prayer of Maimonides See Daily Prayer of a progress to eclampsia, a life-threatening situation Physician. The Pregnancy lasts for about 40 weeks, measured from aim of a preclinical study is to collect data in sup- the date of the woman’s last menstrual period. Preclinical conventionally divided into three trimesters, each studies are required before clinical trials in humans roughly 3 months long. There is little to no chance that a first- precocious puberty The onset of secondary trimester fetus can survive outside the womb, even sexual characteristics, such as breast buds in girls, with the best hospital care; its systems are simply too undeveloped. In the first trimester, some women growth of the penis and thinning of the scrotum in boys, and the appearance of pubic hair in both experience morning sickness. With the best medical care, a second-trimester fetus For example, preconceptual counseling is the inter- born prematurely has at least some chance of sur- change of information prior to pregnancy. In the third trimester, preconceptual counseling The interchange of the fetus enters the final stage of preparation for information prior to pregnancy. It increases rapidly in weight, as does the counseling usually occurs for pregnancy planning mother. Swelling of the ankles, back pain, and bal- and care, but sometimes it takes the form of genetic ance problems are sometimes experienced during counseling. See also acute fatty liver of pregnancy; prediabetes A state in which blood glucose lev- birth; birth defect; conception; eclampsia; els are higher than normal but not elevated enough ectopic pregnancy; fetal alcohol effect; fetal alco- to warrant a diagnosis of diabetes. People with prediabetes can prevent the prenatal care; prenatal development; teratogen. Many procedures are available to prevent prema- pregnancy, molar See hydatidiform mole. If prema- ture birth is medically necessary or inevitable, pregnancy, pernicious vomiting of See hyper- however, it may be accomplished via C-section to emesis gravidarum. Tubal pregnancies premature contraction of the heart A single are due to the inability of the fertilized egg to make heartbeat that occurs earlier than normal. Lifestyle changes are recommended for anyone with The premature contraction is followed by a pause as prehypertension. A battery of techniques irritability, tension, sleep and appetite changes, are available to remove or kill the tissue, thereby fatigue, and physical problems such as pain or preventing the development of cancer. Symptoms generally treatment method depends on the particular prema- begin the week before menstruation and end a few lignant tissue involved. The earlier in development that birth support of family and friends, and medications, takes place, the greater the likelihood that life-sup- including diuretics, pain killers, oral contracep- port systems will be needed and the greater the risk tives, drugs that suppress ovarian function, and anti- for birth defects and death. The next 3 weeks see intense cell differentiation, as the cell mass divides into separate primitive sys- presentation, footling See footling birth. At the end of 8 weeks, the embryo takes on a roughly human shape and is called a fetus. For the remaining weeks of develop- prevalence The proportion of individuals in a ment, the fetus continues to gain weight, and its population having a disease or characteristic. Prevalence is a statistical concept referring to the number of cases of a disease that are present in a prenatal diagnosis Diagnosis before birth. A growing number screening for hypertension and treating it before it of birth defects and diseases can be diagnosed pre- causes disease is good preventive medicine. Also Preventive medicine takes a proactive approach to known as antenatal diagnosis. Treatments include medications, anesthesia, and drainage of blood prepuce See foreskin. The first sign of presbyopia is primary care A patient’s main source for regular often the need to hold reading material farther away. All family physicians, and many pediatricians and internists, practice pri- prescription A physician’s order for the prepa- mary care. The aims of primary care are to provide ration and administration of a drug or device for a the patient with a broad spectrum of preventive and patient. A prescription has several parts, including curative care over a period of time and to coordi- the superscription, or heading, with the symbol R or nate all the care that the patient receives. A private mutation occurs and is passed to a few family members, but not to future generations. Treatment includes cholestyramine to diminish itching, antibi- indicates that the likelihood of something occurring by chance alone is less than 5 in 100, or 5 percent. Most patients die example, a proband might be a baby with Down syn- within 10 years of diagnosis unless a liver transplant drome. Also known as idiopathic sclerosing case, propositus (if male), or proposita (if female). Also known as baby teeth, milk teeth, primary den- probiotic A substance that appears to replenish tition, temporary teeth, and deciduous teeth.
Treatment of acoustic marised the mechanisms of sensory hair cell death after various trauma cialis soft 40 mg. In addi- of cochlear damage from noise trauma by an iron chelator 20mg cialis soft, a free tion to permanent hearing loss 40mg cialis soft, exposure to noise or ototoxic radical scavenger and glial cell line-derived neurotrophic factor in drugs also induces tinnitus cialis soft 20 mg. Ischemic spinal tion to providing evidence for the site and mechanism of gen- cord injury induced by aortic cross-clamping: prevention by rilu- eration of tinnitus induced by salicylates 40 mg cialis soft, these results support zole cialis soft 20mg. Calpain inhibitors protect of cochleoneural activity by long-term salicylate treatment in the auditory sensory cells from hypoxia and neurotrophin-withdrawal guinea pig: a plausible index of tinnitus cialis soft 40mg. Apoptosis in neuronal apoptosis in auditory cells: role of death receptor and mitochon- cells: role of caspases 20 mg cialis soft. Caspase inhibitors , but not nists protect cochlear auditory neurons from excitotoxicity . Cell endoplasmic reticulum stress and nucleus-independent apoptotic 1996; 86:147–157. The possibilities range from cell replacement to the more ambitious and still futuristic idea of generating whole potential for cell-based therapy organs in vitro for transplantation. Stem cells can be classiﬁed into different types, depending on the source tissue, the time of Deafness is a highly common disability, with substantial social and derivation, and the potential to produce different lineages. More than 3 million adults in the United The primordial, master stem cell is the zygote. Almost 90% of these type in the body, including extraembryonic tissue such as the suffer sensorineural loss, which involves loss of sensory hair cells trophoblast. To compound the problem, congenital from all the three germ layers (endoderm, mesoderm, and ecto- deafness affects 1 in 1000 children. There is no cure for deafness derm), including all the somatic lineages as well as germ cells but although, with a suitable nerve supply, the sensory function of the rarely if ever can produce extraembryonic lineages such as those inner ear can be replaced by a cochlear implant. Finally, “multipotent” stem cells have a more The recent developments in stem cell technologies are open- limited ability, producing cell types usually restricted to a single ing novel therapeutic possibilities for the treatment of deafness. Pluripotent stem cells have the widest range Possible strategies could involve triggering of sensory cell of potential applications. They can generally be classiﬁed as regeneration from existing cells, or, alternatively, replacement of embryonic or adult, depending on their developmental stage of lost cells by transplantation of exogenous in vitro-maintained derivation. Different types of stem cells Stem cells have been deﬁned as “clonal precursors of both more Embryonic pluripotent cells stem cells of the same type and a deﬁned set of differentiated progeny” (2). The enormous potential of therapies employing Three different cell types, derived from mammalian embryos, stem cells has raised great hopes and expectations in almost every have manifested pluripotency. These cells are present in teratocarcino- transplantation into lethally irradiated mice. It is believed they are derived blood lineages for 8 to 12 weeks when transplanted. An intrinsic them from the tumours and growing them on mitotically inac- advantage of these kinds of stem cells is the possibility of using tive layers of ﬁbroblasts (feeder layers). They can be used to replenish considered for therapeutic applications, the presence of aneu- the bone marrow of cancer patients who have undergone ploidy was a cause for concern (3,6). Seven months after transplantation, 30% and it is necessary to grow them on feeder layers or feeder-con- to 50% of the liver mass in the treated animals was derived from ditioned medium. The mechanisms underlying this phenomenon are the blastocyst, and they are roughly equivalent to these cells, still unclear. Evidence suggests that the new hepatocytes although in vivo they do not persist for any great length of time. Regardless of the mechanism, these experiments entiation predictably to enable selection of speciﬁc cell types show that stem cells can be successfully used to treat a genetic for therapeutic application (11). Given their higher numbers during development, adherent cells in culture and can differentiate into osteoblasts, foetal tissue is an ideal source for the initial isolation and set- chondroblasts, and adipocytes in vitro and in vivo. They can proliferate for more than 100 Haematopoietic stem cells population doublings without undergoing senescence. When transplanted into early embryos, they Stem cells in the inner ear 281 contribute to most, if not all, of the somatic cell types. When utricular macular epithelia of three- to four-month old mice by grafted into an adult host, they can differentiate into the their ability to form ﬂoating spheres. When dissociated and haematopoietic lineages as well as contributing to the lung, gut, plated as adherent cultures, the cells differentiated into hair cell and liver epithelium. Cells also expressed neuronal These cells might prove fundamental in treating a broad markers and, when grafted into chicken embryos, contributed range of diseases or conditions, regardless of the tissue involved. They could well have the potential to produce inner ear sensory cells if exposed to the right cues and introduced into the appro- Can stem cells be isolated from the normal priate cellular environment. This work showed that hair cells and the surrounding supporting cells are born at around embryonic day 14. The synchrony of their terminal Neural stem cells mitoses suggested that hair cells and supporting cells probably share a common progenitor. This idea was supported by a study The long-standing dogma that there were no cells in the adult on the effects of retinoic acid (39). Supernumerary hair cells central nervous system with proliferative capacity was shattered and supporting cells were produced after treating embryonic by the discovery of proliferating neuronal precursors (26,27). They are normally grown as aggregates in suspension, tion into one with the potential to produce hair cells and sup- known as neurospheres, although some labs have grown them porting cells. Laser ablation of hair cells in the developing mouse organ appears to stretch beyond the boundaries of neural tissue. Sev- of Corti provided further evidence that new hair cells can be eral reports have shown their ability to produce non-neural lin- derived from supporting cells (40). Hair cells and their immediate supporting cells also share ing proves to be correct, it would indicate the need to derive a clonal relationship with the neurons (43). Injected into the have the potential to replace themselves and to produce cells amniotic cavities of stage-4 chick embryos or in clonal culture with clear, neonatal hair cell phenotypes (46). These results imply that these cells have only been isolated from the vestibular organs stem cells in different adult tissues may be quite closely related and not from the cochlea (37). Ini- tial attempts to isolate a population of embryonic auditory Adult inner ear stem cells progenitors have led to the derivation of several mouse and rat immortalised cell lines with different potential (47–51). This gene has been associated with multipo- tency and with the proliferation and maintenance of stem cells phenotypes and cell transplantation from diverse origins. In the ear, however, it has been proposed as having an instructive role, helping on the speciﬁcation of the Given their immense capacity to proliferate and expand in prosensory ﬁeld by acting upstream of math1. Ini- in the inner spiral sulcus, remaining in the inner spiral sulcus of tially, cells were allowed to aggregate into embryoid bodies in the rat cochlea up to two weeks of age (56). A detailed ulation of Deiters cells, located underneath the outer hair cells, experimental protocol can be found in Ref. This work provides a preliminary indication that cochlear transcription factors brn3c and math1 in a single cell. However, nestin alone plantation into developing chicken otocysts was followed by cannot be considered an exclusive marker for stem cells. Given that Attempts to isolate populations from the adult cochlea progenitors are generated after the ﬁrst stage of induction, it is have produced very limited results. A population of neural pre- surprising that a vast majority of hair cell phenotypes were cursors has been isolated from adult guinea pig and human spi- observed, with relatively few grafted cells that did not express ral ganglions, although with very limited proliferative capacity hair cell markers. It is not yet clear if this is a peculiarity of the and restricted lineage potential (58). Zhao (59) attempted to system or if other instructive signals are needed to support the derive stem cells from young adult guinea pigs. Cells from six to differentiation of these progenitors into the remaining cell eight organs of Corti were cultured in a keratinocyte medium types, i. Epithelial clones were derived, which been treated with stromal cell–derived inducing activity. Differentiation was not complete, since cells Studies in the mammalian retina illustrate the kind of evi- were still proliferating and expressing stage-speciﬁc embryonic dence that may be required (14). Stem cells in the inner ear 283 In very preliminary attempts to explore therapeutic appli- and neurons, but also to rebuilding the entire cytological frame. The experimental evidence in this study is limited but there was some indication of survival and integration after two to four Endogenous stem cells or weeks. The ﬁrst is to trans- Preliminary transplantation studies of naïve, untreated plant stem cells into the region of the damaged tissue. If the growth factors are applied simul- no characterisation of the surface markers was performed (70). Proliferation of replacement for a few weeks, and cells were retained mainly in the scala tym- neurons occurs within four days of treatment, preceding neu- pani and along the auditory nerve ﬁbres of the modiolus, but no ronal loss. By 28 days, there are clear signs of both structural evidence has yet been produced of the formation of synaptic and functional recovery. These are not stem cells or with the appropriate growth factors at the appropriate time can progenitors, and hence they do not offer an expandable, renew- activate an effective endogenous response. This type of experiment, however, could offer to know whether this can also be done following long-term insights into the feasibility of integration and survival of donor damage. By drawing information from other systems and the limited studies in the ear so far, it could be suggested that a more suc- cessful approach would be obtained when stem cells, regardless of their origin, are exposed in vitro to speciﬁc signals that would Stem cell–based therapy holds trigger the initial programs of differentiation. Transplanted “naïve” stem cells, although homing and surviving into the dif- promise, but many challenges ferent regions of the cochlea, may not produce the diversity of lie ahead fully differentiated cell types needed. It is likely that the neces- sary signals and cues to drive a particular lineage are no longer The application of stem cells to the development of therapies in place in the adult cochlea and the cells would need to be for deafness is creating hopes and expectations. Gene therapy cells pretransplantation would be particularly important with for instance aims to replace or correct a single defective gene. The main targets for transplantation have ondary degeneration of several cell types (74–77). Although been Parkinson’s disease, Huntington’s disease, epilepsy, and exciting results including restoration of auditory function have stroke (80). In these cases, clinical trials have been based been obtained by replacing the math1 gene into acutely deaf- mainly upon the use of primary foetal neural tissue, a rather ill ened guinea pigs (78), this kind of approach alone may not deﬁned and controversial source. Successful experiments with work in many chronic conditions where the general cytoarchi- retinal tissue have been discussed earlier. A cell-based ther- replacement of hair cells by transplantation is probably harder apy could contribute not only to restoring the critical hair cells than replacement of brain cells, retinal cells, or pancreatic cells. A con- need to be placed with micron accuracy to be coupled to the siderable number of transplanted cells were located in the scala sound stimulus. This kind of intervention would be most constructive in conjunction with cochlear implants. In the same context, it may be easier to replace or Xenotransplantation regenerate spiral ganglion neurons. To transfer this technology to a clinical application, sources for stem cells will need to be scrutinised, not only in terms of tissue How to deliver them? The use of animal tissue as donors for transplantation into humans, or xenotransplanta- The delivery of stem cells will very likely require improvement tion, is certainly a possibility. Pig cells, for instance, have been and sophistication of current surgical techniques. A potential used to treat certain conditions such as diabetes (85) and way of access could involve the round window, a route increas- Parkinson’s disease (86). This approach, although attractive for ingly used for drug administration (81), or a cochleostomy in its the relatively availability of the source, is saddled with several proximity, as normally performed to place the array of elec- limitations. Xenotransplants elicit a signiﬁcant immune rejec- trodes in a cochlear implant (82). Experiments performed so far tion both from the acquired and from the innate systems. This have delivered the cells into the modiolus (69,83) or into the is a formidable obstacle to overcome, requiring substantial perilymphatic space by drilling a small hole either into the scala immmunosuppression, even considering that the inner ear may tympani at the basal cochlear turn (73) or into the lateral semi- be an immunoprivileged organ. These ways of delivery should be appropri- pathogens crossing across species is a certain risk. Porcine ate for neurons, but for the replacement of the sensory endogenous retrovirus, for instance, has been shown to infect epithelium, cells would ideally have to be injected directly into human cells (87), and more control experiments and closely the scala media. Stem cells in the inner ear 285 of) all these limitations, an increased resistance is building up 3. The morphology and growth of a pluripo- diabetes type 1, more than 70% of the patients interviewed tent teratocarcinoma cell line and its derivatives in tissue culture. The end of the beginning for pluripotent minimised by the use of human stem cells. Isolation of a pluripotent cell line from early mouse develop a human-based system. Basic differences in the biology embryos cultured in medium conditioned by teratocarcinoma stem of human stem cells are becoming more apparent when cells. Nature 2001; (93,94) as well as by massively parallel signature sequencing 414:88–91. Derivation of pluripotential embry- scripts expressed as well as in the use of signalling cascades. Translating stem and progenitor cell biology to the infancy, important advances are already taking place. Puriﬁed hematopoi- vestibular epithelia has opened the possibility of devising strate- etic stem cells can differentiate into hepatocytes in vivo. Transplanted bone peutic target, but all the attempts so far to prove if that popula- marrow regenerates liver by cell fusion. Cell fusion is the princi- sensible complementary strategy and a few labs worldwide are pal source of bone-marrow-derived hepatocytes. Nature 2003; working on ﬁnding ways to instruct these stem cells into the 422:897–901. Finally, the identiﬁcation and Hematopoietic stem cells convert into liver cells within days with- isolation of human auditory stem cells will take these technolo- out fusion.
Frequent assessment of anticoagula- tion status is necessary during warfarin therapy to ensure drug efﬁcacy and to prevent or minimize hemorrhagic events 40 mg cialis soft. Thus cialis soft 40mg, the identiﬁcation of factors that inﬂuence warfarin dosage requirements would be of great beneﬁt in the manage- ment of patients at risk for coagulation disorders 20 mg cialis soft. Invasive procedures on patients receiving anticoagulation therapy require an individualized assessment of the risk of bleeding versus the risk of thrombo-embolic events 40mg cialis soft. Availability of two approved doses of dabigatran etexilate for thromboprophylaxis following orthope- dic surgery enables the dose to be tailored to the individual patient’s characteristics cialis soft 40 mg, based on the age and renal function of the patient 20mg cialis soft, as recommended by the European Medicines Agency cialis soft 20mg, in order to maintain efﬁcacy while decreasing bleeding risk cialis soft 20 mg. Acenocoumarol (Sintrom or Sinthrome) , a derivative of coumarin , is an anticoagulant that functions as a vita- min K antagonist like warfarin. Antiplatelet Therapy Prasugrel, an approved antiplatelet drug for cardiovascular thrombotic disease, is a prodrug with rapid and almost complete absorption after oral ingestion of a loading dose. Hydrolysis by intestinal carboxylesterases and oxidation by intestinal and hepatic cytochrome P-450 enzymes convert prasugrel into its active metabolite. Prasugrel has a greater antiplatelet effect than clopidogrel because it is metabolized more efﬁciently. Genetic polymorphisms affecting the cytochrome P450 system may explain some of the differences in metabolism between prasugrel and clopidogrel. Resistance to clopidogrel, an antiplatelet therapy, has been shown to be present in 25–30 % of Caucasians and an even higher percentage in Asians. A crucial point in evaluating the use of these polymorphisms in clinical practice, besides test accuracy, is the cost of the genetic test and rapid availability of the results. Genotyping results obtained by the classical TaqMan approach and the rapid Verigene approach showed a 100 % concordance for all the ﬁve polymorphisms investigated. The cost of reagents for TaqMan genotyping was lower than that for the Verigene system, but the effective staff involvement and the relative cost resulted in higher cost for TaqMan than for Verigene. In conclusion, Verigene system demon- strated good performance in terms of turnaround time and cost for the evaluation of the clopidogrel poor metabolizer status, giving genetic information in suitable time (<2. Genetic testing for aspirin resistance is not yet recommended because of incom- plete genetic data. Studies to determine the value of genetic testing before the administration of warfarin are ongoing. Nanobiotechnology-Based Personalized Therapy of Cardiovascular Diseases The future of cardiovascular diagnosis already is being impacted by nanosystems that can both diagnose pathology and treat it with targeted delivery systems. The potential dual use of nanoparticles for both imaging and site-targeted delivery of therapeutic agents to cardiovascular disease offers great promise for individualizing therapeutics. Image-based therapeutics with site-selective agents should enable ver- iﬁcation that the drug is reaching the intended target and a molecular effect is occur- ring. Experimental studies have shown that binding of paclitaxel to smooth muscle Universal Free E-Book Store 506 14 Personalized Management of Cardiovascular Disorders cells in culture has no effect in altering the growth characteristics of the cells. If paclitaxel-loaded nanoparticles are applied to the cells, however, speciﬁc binding elicits a substantial reduction in smooth muscle cell proliferation, indicating that selective targeting may be a requirement for effective drug delivery for in this situ- ation. Intravenous delivery of fumagillin (an antiangiogenic agent)-loaded nanoparticles targeted to αvβ3-integrin epitopes on vasa vasorum in growing plaques results in marked inhibition of plaque angiogenesis in cholesterol fed rabbits. The unique mechanism of drug delivery for highly lipophilic agents such as paclitaxel con- tained within emulsions depends on close apposition between the nanoparticle car- rier and the targeted cell membrane and has been described as “contact facilitated drug delivery. The rate of lipid exchange and drug delivery can be greatly increased by the application of clinically safe levels of ultrasound energy that increase the propensity for fusion or enhanced contact between the nanoparticles and the targeted cell membrane. Monitoring and conﬁrmation of therapeutic efﬁcacy of the therapeutic agents at the targeted site would permit personalized medical regimens. It was completed in 2012 and the ﬁnal results were published on web site: http://www. The project combined 16 industrial, clinical and academic partners, whose collective goal was the development of individualized, computer-based, human heart models. These computer models integrated the behavior of the heart and the aorta at molecular, cellular, tissue and organ-level. They also incorporated clinical knowl- edge about how cardiovascular disease disturbs the correct functioning of the heart at these levels. Atrial modeling is currently in a transition from the sole use in basic research to future clinical applications (Krueger et al. The project demonstrated the predictive value and clinical potential of personalized car- diac simulations for several clinically relevant settings. As a result, it may be possible to develop simulation tools that physicians can use to predict the outcome of different Universal Free E-Book Store References 507 types of therapy, and because the models will be personalized to individual patients, the therapy could be equally personalized. The technology can modify treatment of heart rhythm disorders by a minimally invasive procedure known as radio-frequency ablation. During this procedure, a catheter is inserted into the patient’s heart and the tissue responsible for propagating abnormal electrical signals through the heart mus- cle is destroyed using heat from a radio-frequency ﬁeld generated at the tip of the catheter. Currently, physicians have to rely on their experience to decide which areas of tissue to destroy–a task that is complicated by the fact that the electrical activity in every patient’s heart is subtly different. With the aid of a computerized model that reﬂects the patient’s unique heart structure and function, it may be possible to test the results of destroying different areas of tissue before operating on the patient. Concluding Remarks on Personalized Management of Cardiovascular Diseases Individual responses to drugs vary and are partly determined by genes. Simple genetic analyses can improve response prediction and minimize side effects in cases such as warfarin and high doses of simvastatin. In contrast to monogenic diseases genetic testing plays no practical role yet in the management of multifactorial car- diovascular diseases. Biomarkers can identify individuals with increased cardiovascular risk and biomarker-guided therapy represents an attractive option with troponin- guided therapy of acute coronary syndromes as a successful example (Eschenhagen and Blankenberg 2013). Personalized approaches will gain increasing importance in the management of cardiovascular diseases in the future. Hypertension in the United States 1999–2012: progress toward healthy people 2020 goals. Adducin- and ouabain-related gene variants predict the antihypertensive activity of rostafuroxin, part 1: experimental studies. Genome-wide association analysis of blood-pressure traits in African-ancestry individuals reveals common associated genes in African and non-African populations. Effects of a 5-lipoxygenase–activating pro- tein inhibitor on biomarkers associated with risk of myocardial infarction: a randomized trial. Lipoprotein-associated phospholipase A2 adds to risk prediction of incident coronary events by C-reactive protein in apparently healthy middle-aged men from the general population: results from the 14-year follow-up of a large cohort from southern Germany. Towards personalized clinical in-silico modeling of atrial anatomy and electrophysiology. Adducin- and ouabain-related gene variants predict the antihypertensive activity of rostafuroxin, part 2: Clinical studies. A polymorphism within a conserved beta(1)- adrenergic receptor motif alters cardiac function and beta-blocker response in human heart failure. BiDil in the clinic: an interdisciplinary investigation of physicians’ prescription patterns of a race-based therapy. Universal Free E-Book Store References 509 Polisecki E, Muallem H, Maeda N, et al. Genetic susceptibility to coronary heart disease in type 2 diabetes: 3 independent studies. A new approach with anticoagulant development: tailoring anticoagu- lant therapy with dabigatran etexilate according to patient risk. Pharmacogenetics of clopidogrel: comparison between a standard and a rapid genetic testing. A kinesin family member 6 variant is associated with coronary heart disease in the Women’s Health Study. Using beneﬁt-based tailored treatment to improve the use of antihypertensive medications. Inherited cardiomyopathies: molecular genetics and clinical genetic testing in the postgenomic era. Beta-adrenergic receptor polymorphisms and responses during titration of metoprolol controlled release/extended release in heart failure. A randomized trial of genotype-guided dosing of acenocou- marol and phenprocoumon. Association of vitamin D status with arterial blood pressure and hypertension risk: a mendelian randomisa- tion study. Pharmacogenetic predictors of statin-mediated low-density lipoprotein cholesterol reduction and dose response. Serum parathyroid hormone as a potential novel biomarker of coronary heart disease. Universal Free E-Book Store Chapter 15 Personalized Management of Pulmonary Disorders Introduction There are a large number of pulmonary disorders some of which present challenges in management. There is still limited information on pharmacogenomics and pharmacogenetics of pulmonary therapeutics. Personalized approaches to some pulmonary diseases will be described brieﬂy as examples in this chapter. Role of Genetic Ancestory in Lung Function A study shows that incorporating measures of individual genetic ancestry into nor- mative equations of lung function in persons who identify themselves as African Americans may provide more accurate predictions than formulas based on self- reported ancestry alone (Kumar et al. The same argument may apply to other ancestrally deﬁned groups; further studies in this area are necessary. Further studies are also needed to determine whether estimates informed by genetic ancestry are associated with health outcomes. The authors noted that environmental factors such as premature birth, prenatal nutrition, and socioeconomic status may also play an important role in the association between lung function and ancestry. It remains to be seen whether differences associated with race or ethnic group in the response to medications that control asthma are more tightly associated with estimates of ances- try. Although measures of individual genetic ancestry may foster the development of personalized medicine, large clinical trials and cohort studies that include assess- ments of genetic ancestry are needed to determine whether measures of ancestry are more useful clinically than a reliance on self-identiﬁed race. Biomarkers of pulmonary disorders with exception of lung cancer are listed in Table 15. It is there- fore of interest to identify biomarkers that are associated with impaired lung func- tion. This indicates that combination of two biomarkers yielded more information than assessing them one by one when analyzing the association between systemic inﬂammation and lung function. Biomarkers of Oxidative Stress in Lung Diseases Oxidative stress is the hallmark of various chronic inﬂammatory lung diseases. Traditionally, the measurement of these biomarkers has involved inva- sive procedures to procure the samples or to examine the affected compartments, to the patient’s discomfort. Oxidative stress biomarkers also have been measured for various antioxidants in disease prognosis. Despite its prevalence, there are many challenges to proper diagnosis and management of pneumonia. There is no accurate and timely gold standard to differentiate bacterial from viral disease, and there are limitations in precise risk stratiﬁcation of patients to ensure appropriate site-of-care decisions. In addition, lower levels of the coagulation marker protein C were independently associated with an increased risk of death. These associations exist despite consistent use of lung protective ventilation and persist even when control- ling for clinical factors that also impact upon outcomes. It might help prevent further tissue damage by improving oxy- gen and nutrient delivery to the tissues, while helping to decrease the amount of toxic oxygen species. Personalized Therapy of Asthma Asthma affects 5–7 % of the population of North America and may affect more than 150 million persons worldwide. It is a chronic inﬂammatory dis- ease but there is no clear deﬁnition of the disease and no single symptom, physical ﬁnding or laboratory test is diagnostic of this condition. The disease is manifested as variable airﬂow obstruction and recurrent bouts of respiratory symptoms. Little is known about the mechanisms that determine asthma development and severity and why some individuals have mild symptoms and require medication only when symptomatic whereas others have continuous symptoms despite high doses of several medica- tions (refractory asthma). Asthma is often triggered by an allergic response and the environmental factors play an important role in manifestations of the disease. Although there is a signiﬁcant hereditary component, genetic studies have been dif- ﬁcult to perform and results have been difﬁcult to interpret. Only a few therapeutic agents based on novel mechanisms of action have been developed over the past two decades. Asthma is a complex disease with marked heterogeneity in the clinical course and in the response to treatment. Despite treatment with inhaled glucocorti- coids, many patients continue to have uncontrolled asthma that requires more intensive therapy. Approximately one in three patients with asthma who use inhaled glucocorticoids may not beneﬁt from this therapy. Biomarkers and some of the other methods for guiding therapy of asthma are described here. Biomarkers of Asthma Although the aim of management of patients with asthma is to control their symp- toms and prevent exacerbations and morbidity of the disease, optimal management may require assessment and monitoring of biomarkers, i. Universal Free E-Book Store 516 15 Personalized Management of Pulmonary Disorders Biomarker for Rhinovirus-Induced Asthma Exacerbation Clinical observations suggest that rhinovirus infection induces a speciﬁc inﬂamma- tory response in predisposed individuals that results in worsened asthmatic symp- toms and increased airway inﬂammation. Biomarkers for Predicting Response to Corticosteroid Therapy International guidelines on the management of asthma support the early introduction of corticosteroids to control symptoms and to improve lung function by reducing airway inﬂammation. However, not all individuals respond to corticosteroids to the same extent and it would be a desirable to be able to predict the response to cortico- steroid treatment. Several biomarkers have been assessed following treatment with corticosteroids including measures of lung function, peripheral blood and sputum indices of inﬂammation, exhaled gases and breath condensates. Of these, sputum eosinophilia has been demonstrated to be the best predictor of a short-term response to corticoste- roids. More importantly, directing treatment at normalizing the sputum eosinophil count can substantially reduce severe exacerbations. The widespread utilization of sputum induction is hampered because the procedure is relatively labor intensive.
A lateral hemisection syndrome (the Brown-Séquard syndrome) is classically due to penetrating trauma from a knife or bullet injury and produces ipsilat- eral weakness and contralateral loss of pain and temperature sensation 40mg cialis soft. Amyotrophic lat- eral sclerosis presents with combined upper and lower motor neuron ﬁndings; sensory deﬁcits are uncommon cialis soft 40 mg. Hyperventilation causes vasoconstriction cialis soft 40mg, reducing cerebral blood vol- ume and decreasing intracranial pressure 20mg cialis soft. However 20 mg cialis soft, this can be used only for a short pe- riod as the decrease in cerebral blood ﬂow is of limited duration cialis soft 20 mg. Mannitol 40 mg cialis soft, an osmotic diuretic cialis soft 20mg, is recommended in cases of increased intracranial pressure resulting from cyto- toxic edema . Instead , hypertonic saline is given to elevate sodium levels and prevent worsening of edema. Further decreases in mean arterial pressure may worsen the patient’s clinical status. The patient already has had more than a 20% reduction in mean arterial pressure, which is the recommended reduc- tion in cases of hypertensive emergency. Finally, in cases of increased intracranial pressure, nitroprusside is not a recom- mended intravenous antihypertensive agent because it causes arterial vasodilation and may decrease cerebral perfusion pressure and worsen neurologic function. It is also associated with increased complications during pregnancy (premature rupture of membranes, placenta previa, abruption placenta), delay in healing of peptic ulcers, osteoporosis, cataracts, macular degeneration, cholecystis in women, and impo- tence in men. Children born to smoking mothers are more likely to have preterm deliv- ery, higher perinatal mortality, higher rates of infant respiratory distress, and higher rates of sudden infant death. In this disorder paroxysmal vertigo resulting from labyrinthine lesions is associated with nausea, vomiting, rotary nystagmus, tinnitus, high-tone hearing loss with recruitment, and, most characteristically, fullness in the ear. Vertebral-basilar insufﬁciency and multiple sclerosis typically are asso- ciated with brainstem signs. Acoustic neuroma only rarely causes vertigo as the initial symptom, and the vertigo it does cause is mild and intermittent. A positive sign occurs when the patient has head/neck pain when pas- sively straightening the knee. The sensitivity and speciﬁcity of this sign (also Brudzinski’s) for bacterial meningitis are unknown, but they imply meningeal irritation, not an intracra- nial lesion or elevated intracranial pressure. While cerebrospinal ﬂuid cultures may be im- pacted by administration of antibiotics prior to lumbar puncture, stains, antigen tests, and polymerase chain reaction tests will not be affected. The normal respiratory response to decreased atmospheric oxygen tension is to increase the respiratory rate. This hyperventilation causes a mild respiratory alkalosis and is experienced as acral and periorbital dysesthesias. Acetazolamide is often given to patients who have a past history of altitude sickness manifested as headache, nausea with vomiting, and in severe cases pulmonary edema. This patient is experiencing none of those symptoms, and in fact, dysesthesias are a common side effect related to treatment with acetazolamide. No further blood testing is necessary as the symptoms are not asso- ciated with any neurologic abnormalities. Diabetes mellitus, vitamin B12 deﬁciency, and tertiary syphilis are all associated with a sensory neuropathy, which this patient does not demonstrate. The course can ﬂuctuate over the course of a day, which may explain why his symptoms appear worse at the end of the day. The absence of any sensory deﬁcit is also characteristic of a neuromuscular junction disorder. Diseases of the muscle usually do not exhibit such a marked difference on the examination over the course of hours. Spinal root disorders are symptomatic in a nerve root distribution, and limb pain is usu- ally a prominent component. Clues to a brainstem disease are isolated cranial nerve pal- sies and “crossed” weakness and sensory abnormalities of the head and limbs. Because the clinical scenario is consistent with a myelopathy, an electromyogram is not indicated. Migraine headache, limb weakness, and breathing difﬁculties are non- speciﬁc but may be seen in serotonin syndrome or alcohol withdrawal. Hypertension, tachycardia, and diaphoresis may be seen in a patient with an Arnold-Chiari malformation. Postconcus- sive syndrome is a constellation of symptoms including fatigue, headache, dizziness, and difﬁculty concentrating that follows a concussion. The patient described above ﬁts this di- agnosis; strict diagnostic criteria do not exist. Patients who were energetic and highly functioning prior to their trauma have an excellent prognosis. The human prion diseases described to date include Creutzfeldt- Jacob disease, kuru, Gerstmann-Straüssler-Scheinker disease, and fatal insomnia. Symptoms are often not present, and severe ﬁndings such as paralysis and urinary incontinence are rare. Acquired factors that contribute to spinal stenosis include trauma, osteoporosis, hypo- parathyroidism, renal osteodystrophy, and Paget’s disease. Tethered cord syndrome usu- ally presents as a cauda equina disorder (urinary incontinence, perineal anesthesia) in a young adult. Pain associated with disk herniation is differentiated from spinal stenosis when the pain is made worse with sitting. Vertebral metastases are a common cause of back pain in patients at risk of common malignancies. Mesial temporal lobe epilepsy is the most common syndrome associated with complex partial seizures. Patients are unable to respond to verbal or visual commands during the seizure and they often manifest complex automatisms or complex posturing. Patients often have a history of febrile seizures or a family history of seizures. Hypothy- roidism, herpes virus infection, diabetes, and tuberous sclerosis are not associated with mesial temporal lobe epilepsy. Primidone is an alternative for treatment of partial and generalized tonic-clonic seizures. Levetiracetam is an alternative for simple partial, complex partial, and second- arily generalized seizures. Vagus nerve stimulation is an option for patients refractory to antiepileptic medication with seizures arising from more than one site. Spindle af- ferent neurons directly stimulate α motor neurons in the spinal cord, causing a muscle contraction. The reﬂex arc operates independent of upper motor neurons (pyramidal neurons); however, loss of the inhibitory input from upper motor neurons produces an exaggerated deep tendon reﬂex. This rapidly develop- ing ophthalmologic disorder is associated with partial or total loss of vision, pain on mo- tion of the involved eye, scotoma affecting macular vision, and a variety of other visual ﬁeld defects. Common sensory ﬁndings include abnormal sensation in the thumb and ﬁngers (except the little ﬁnger), radial hand, and dorsal forearm. Decreased pin-prick sensation over the lateral deltoid would be mediated by injury to the C5 nerve root. Finger ﬂexors and sensation to the axilla and medial arm are mediated by C8 and T1. True cerebellar ataxia is devoid of vertiginous symptoms and is clearly an unsteady gait due to imbalance. Alcohol intoxication, lithium toxicity, and viral cerebritis usually cause acute or subacute (days to weeks) cerebellar ataxia. Ter- tiary syphilis is a common cause of chronic cerebellar ataxia (months to years). The pain is persistent and severe, affecting only the contralateral side of the body. Other symptoms that may be associated with thalamic infarcts include hemianes- thesia, hemiataxia, choreoathetoid movements, and athetoid posture. Smokers can compensate for the lower levels of nicotine in low-yield cigarettes by smoking more cigarettes or by adjusting their smoking technique. Therefore, smoking low-yield cigarettes is not a reasonable al- ternative to smoking cessation. Moreover, there is no difference in the harmful physical effects of smoking or in the potential for drug interactions. When performing electronystagmography using cold and warm water sequentially, the velocity of the slow-phase of nystagmus is compared from side to side. When warm water at 44°C is infused into an ear, the normal response is nystagmus with the fast component toward the infused ear. The opposite response occurs when cold water at 30°C is infused; the normal response is nystagmus with the fast component away from the cold water–infused ear. The volume of water can be increased if no response occurs with the initial attempt. Velocity of the slow phase should be similar in patients without vestibular nerve abnormalities. An absence of response to the cold caloric indicates a laby- rinth system that is “dead” and nonfunctional, such as in complete destruction of the neu- ral input with acoustic neuroma. The peripheral nerve dysfunction seen with aminoglycoside antibiotics is usually bilateral. Unilateral symptoms should raise the suspicion for an anatomic as opposed to a systemic cause of the vertigo. Labyrinthine ischemia will also manifest as a “dead” labyrinth; however, the pa- tient’s age makes ischemic brainstem lesions less likely than a schwannoma. The standard approach in a neurologically stable patient is to treat the patient for toxoplasmosis for 2–3 weeks then repeat neuroimaging. In the absence of neuro- logic collapse, it is reasonable to treat empirically for toxoplasmosis in such a patient. The leptomeninges are a common site for metastases for patients with systemic lymphoma and those patients usually have a B cell lymphoma or leukemia. However, in the absence of a deﬁnitive diagnosis, a biopsy should be pur- sued for a deﬁnitive diagnosis. If there is no response to therapy after 2 weeks, therapy does not need to be continued. Muscle wasting in the lower neck, shoulders, arms, and hands with asymmetric or absent reﬂexes reﬂects extension of the cav- ity to the anterior horns. With progression, spasticity and weakness of the lower extremities and bladder and bowel dysfunction may occur. Syringomyelia associated with Chiari malformations may require extensive decompressions of the posterior fossa. Syringomyelia secondary to trauma or infec- tion is treated with decompression and a drainage procedure, with a shunt often inserted that drains into the subarachnoid space. The primary defect is a de- crease in the number of acetylcholine receptors at the neuromuscular junction secondary to autoimmune antibodies. Women present typically in the second and third decades of life, and men present in the ﬁfth and sixth decades. Clinical features include weakness of the cranial mus- cles, particularly the lids and extraocular muscles. The diagnosis is suspected after the appearance of the characteristic symptoms and signs. Electrodiagnostic testing may show evidence of reduction in the ampli- tude of the evoked muscle action potentials with repeated stimulation. Antibodies to voltage- gated calcium channels are found in patients with the Lambert-Eaton syndrome. This patient exhibits several atypical features that should alert the physician to search for alternative diagnoses. These include early age of onset, promi- nent orthostasis, autonomic symptoms of ﬂushing and diaphoresis, and failure to respond to dopaminergic agents. In addition, recurrent urinary tract infections should prompt an evaluation for urinary retention due to autonomic dysfunction in this patient. The average age of onset is 50 years, and these individuals more frequently present with bi- lateral, symmetric tremor and more prominent spasticity than those with Parkinson’s dis- ease. On pathologic examination, α-synuclein-positive inclusions would be seen in the affected areas. Dopaminergic agents are not helpful in treatment of this disorder and are usually associated with drug- induced dyskinesias of the face and neck, rather than the limbs and trunk. Corticobasal de- generation is a sporadic tauopathy that presents in the sixth to seventh decades. In contrast to Parkinson’s disease, this disorder is frequently associated with myoclonic jerks and invol- untary purposeful movements of a limb. Neuropsy- chiatric complaints including paranoia, delusions, and personality changes are more com- mon than in Parkinson’s disease. Finally, this is unlikely to be inadequately treated Parkinson’s dis- ease because one would expect at least an initial improvement on dopaminergic agents. Acute hematomas (which would be as bright as the resolving blood shown in arrows) become hypodense in comparison with adjacent brain after ~2 months. During the isodense phase (2–6 weeks after injury), they may be difﬁcult to dis- cern. Chronic subdural hematoma may present without a history of trauma or injury in 20–30% of patients. Other symptoms may be vague as in this case, or there may be focal signs including hemiparesis mimicking stroke. In relatively asymptomatic patients with small he- matomas, observation and serial imaging may be reasonable; however, surgical evacua- tion is often necessary for large or symptomatic chronic hematomas.
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