Antivert

Leonard Samuel Feldman, M.D.

• Director, Osler Medical Residency Urban Health Track
• Associate Professor of Medicine

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0019344/leonard-feldman

Axial presacral lumbar interbody fusion and percutaneous posterior fixation for stabilization of lumbosacral isthmic spondylolisthesis medicine naproxen 500mg purchase antivert 25mg without prescription. Results and complications after 2-level axial lumbar interbody fusion with a minimum 2-year follow up symptoms enlarged prostate 25mg antivert. Back to Top Date Sent: 3/24/2020 86 these criteria do not imply or guarantee approval treatment irritable bowel syndrome buy discount antivert 25 mg. Back to Top Date Sent: 3/24/2020 87 these criteria do not imply or guarantee approval symptoms 5 weeks pregnant cramps purchase 25 mg antivert mastercard. Service Criteria Used Vibrant Soundbridge There is insufficient evidence in the published medical literature to show that this service/therapy is as safe as standard services/therapies and/or provides better long-term outcomes than current standard services/therapies medicine synonym 25 mg antivert with mastercard. Background Vibrant Soundbridge System the Vibrant Soundbridge System is an implantable alternative to standard hearing aids symptoms 6 weeks order antivert 25 mg overnight delivery. It is intended for use in adults with moderate to severe sensorineural hearing loss, who desire an alternative to an acoustic hearing aid. Back to Top Date Sent: 3/24/2020 88 these criteria do not imply or guarantee approval. The vibration manually stimulates the auditory ossicles and is perceived by the patient as sound (manufacturer?s documents. The implant, a titanium fixture, is implanted behind the ear where it ?osseointegrates? or bonds with the living bone. Most were conducted in Europe where there is longer experience with the device compared to the U. There were two publications on one of the studies, so a total of three articles were reviewed. The studies that were critically appraised are: Sterkers O, Boucarra D, Labassi S. A middle ear implant, the Symphonix Vibrant Soundbridge: Retrospective study of the first 125 patients implanted in France. Intraindividual comparison of the bone-anchored hearing aid and air-conduction hearing aids. Long-term results of bone-anchored hearing aid recipients who had previously used air-conduction hearing aids. Back to Top Date Sent: 3/24/2020 89 these criteria do not imply or guarantee approval. Back to Top Date Sent: 3/24/2020 90 these criteria do not imply or guarantee approval. Back to Top Date Sent: 3/24/2020 91 these criteria do not imply or guarantee approval. Local Coverage Article Bariatric Surgery Coverage (A53028) 1999 Kaiser Foundation Health Plan of Washington. Back to Top Date Sent: 3/24/2020 92 these criteria do not imply or guarantee approval. Obesity the following procedures are not covered (benefits are varied and need to be verified): Biliopancreatic bypass, Distal gastric bypass, Duodenal switch (Single-Anastomosis Duodenal Switch), Mini-gastric bypass. It is provided for historical purposes and does not necessarily reflect the most current published literature. According to national survey data, an estimated one-third of adults in the United States are overweight. Back to Top Date Sent: 3/24/2020 93 these criteria do not imply or guarantee approval. Lifestyle changes, including diet, exercise, and behavior modification, are generally considered first-line therapy for overweight and obesity. Pharmacotherapy can be used as an adjunctive therapy when lifestyle changes alone are ineffective. There are two main strategies for surgically inducing weight loss, gastric restriction and intestinal malabsorption. This limits the amount of food a patient can consume at a single meal and causes early satiety. Substantial dietary compliance is required, because individuals are still able to consume high-calorie liquids or soft foods. Malabsorption procedures involve bypassing a portion of the intestines which decreases the proportion of nutrients that are absorbed from food. The stomach is reduced to a small gastric pouch, and this pouch is connected to a segment of the jejunum, bypassing the duodenum and proximal small intestine. Adjustable gastric banding is a restrictive technique, using the Lap-Band System? (Inamed. A small gastric pouch is formed by laparoscopically placing a silicone ring (the Lap-Band) around the upper part of the stomach just below the gastro-esophageal junction. The band is connected via tubing to an access port that is secured beneath the skin of the abdomen. Reoperation or revisional surgery was required in 3% of patients in one series and 36% in another series. Reoperation or revisional surgery was required in 6% of patients in one series and not reported in the other series. Differentiated long-term effects of intentional weight loss on diabetes and hypertension. Back to Top Date Sent: 3/24/2020 94 these criteria do not imply or guarantee approval. Gastric surgery was not associated with more complications than the Lap Band procedure, and studies generally found a higher reoperation rate after Lap-Band surgery. There is evidence from one randomized controlled trial that Lap-Band surgery is more effective for weight loss than a non-surgical intervention. However, in the two years of follow-up 4 of the 39 patients who received the Lap-Band experienced prolapse of the posterior gastric wall. In addition, limitations of the study were that it was not blinded, follow-up was only two years, and the nonsurgical intervention was not well described beyond 6 months. The best evidence comparing the Lap-Band and Roux-en Y gastric bypass comes from two non-randomized comparative studies (Weber et al. Both studies found significantly more weight loss at 2-3 years and fewer co-morbidities in the group that underwent gastric bypass. There appeared to be a greater reduction in co-morbidities and fewer complications in the gastric bypass group, but numbers were too small to accurately compare the groups in these areas. In all of the non-randomized studies, there may be confounding variables, differences between groups that affect the outcome (such as differences in commitment to losing weight. A large case series conducted in Italy (n=1893) provides additional information on the safety of the Lap-Band technique. The most common post-operative complications were gastric pouch dilation (5%) and tube port complications (4%. The ideal study would be a randomized controlled trial comparing long-term outcomes of gastric surgery with the Lap Band and commonly accepted bariatric surgery procedures or optimal non-surgical management. Five non-randomized comparative studies were identified comparing the Lap-Band to gastric bypass. One study conducted in Sweden was excluded because it compared two case series of patients treated at different institutions. A second study was excluded because only preliminary findings were reported: there was 60% follow-up at 1 year and 15% at 2 years. A large case series from Italy (n=1863) was also reviewed to evaluate the long-term safety of Lap-Band surgery. Treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program. Laparoscopic gastric bypass is superior to laparoscopic gastric banding for treatment of morbid obesity. Laparoscopic gastric bypass is superior to adjustable gastric band in super morbidly obese patients. Lap-Band adjustable gastric banding system: the Italian experience with 1863 patients operated on over 6 years. The use of adjustable gastric banding and lap-band in the treatment of obesity does not meet the Kaiser Permanente Medical Technology Assessment Criteria. Back to Top Date Sent: 3/24/2020 95 these criteria do not imply or guarantee approval. Colquitt and colleagues? 2014 systematic review and meta-analysis on surgery for morbid obesity was the last published update of previous Cochrane reviews and updates on that topic conducted by the same group of authors over the last decade. The meta-analysis included 15 trials (N=1,180 participants) that compared different bariatric surgery procedures used for weight loss (seven additional trials compared surgery to non-surgical weight loss therapies. The meta-analysis had valid methodology and analysis, but the majority of the studies included had uncertain or high risk of bias. The studies had relatively short-term follow-up durations, which was insuffient to study the long-term effects of the surgical procedures. The meta-analysis combined the results of a small number of randomized and non-randomized studies with small sample sizes and short-term follow-up durations. The study was large and included a diverse group of patients but was retrospective and not randomized. Data were obtained from records which did not included all required information, and the subsequent interventions and hospitalizations may have been due to causes unrelated to the bariatric procedures. Back to Top Date Sent: 3/24/2020 96 these criteria do not imply or guarantee approval. Three of these studies were judged by the authors to have good quality and the rest were of fair quality. The authors could not perform a meta-analysis due to the heterogeneity of the studies but performed some cumulative analyses when suitable. Buchwald and colleagues (2009) performed a systematic review and meta-analysis of 621 experimental and observational studies (N=136,134 participants) on bariatric surgery that were published in English between 1990 2006, and that reported on the resolution of type 2 diabetes. Nineteen studies with 43 treatment arms and 11,175 patients reported on both weight loss and diabetes resolution separately for diabetic patients (N=4,070. Weight loss and diabetes resolution were greatest for patients undergoing biliopancreatic diversion/duodenal switch, followed by gastric bypass, and least for banding procedures. Insulin levels declined significantly postoperatively, as did hemoglobin A1C and fasting glucose values. Very few small randomized controlled trials compared the effects of one surgical bariatric procedure versus another. Comparison between laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding for morbid obesity: a meta-analysis. Non-resorbable polypropylene fasteners are then deployed across the fold to hold the tissue in place. The pleats created in the stomach will reduce its size, which would potentially lead to early satiety and weight loss. According to the manufacturer, the StomaphyX? procedure is incisionless, adjustable, and revisable. It is usually performed as an outpatient procedure, and is intended for individuals who want an alternative to invasive weight loss surgery, or those who have had previous gastric bypass surgery and are regaining weight. The InScope? Tissue Apposition System is a sterile, single patient used disposable suture system for approximating and securing soft tissue within the gastrointestinal tract. Back to Top Date Sent: 3/24/2020 97 these criteria do not imply or guarantee approval. While treatment with acid suppressing medications such as proton pump inhibitors and histamine 2-receptor blockers are effective, they do not treat the underlying mechanical disorder. Additionally, not all patients respond to these therapies (Zagol 2011, Stefanidid 2010. Opt for surgery despite medical management (due to quality-of-life considerations, lifelong need for medication intake, expense of the medication, etc. With fundoplication, the gastric fundus is wrapped around the lower end of the esophagus to reduce gastric reflux. Studies suggest that approximately 90% of patients who undergo Nissen fundoplication achieve symptom relief. Transoral incisionless fundoplication using the EsophyX device (EndoGastric Solutions, Inc. This procedure attempts to decrease the reflux of stomach acid into the esophagus through the reconstruction of an anti-reflux barrier. The EsophyX device is inserted transorally, under direct endoscopic visualization, into the stomach and is positioned at the junction of the stomach and the esophagus. The result is an omega shaped valve 3-5 cm in length and 200-300? in circumference. This procedure may also reduce hiatal hernias that are less than 2 cm in size through the use of a built-in vacuum invaginator. As this procedure is incisionless and can often be performed on an outpatient basis it is an attractive alternative to conventional surgical procedures (Jafri 2009, Louis 2010. The EsophyX system has not been previously reviewed by the Medical Technology Assessment Committee and is being review based on request from bariatric surgery and a member appeal. The use of endoluminar fasteners in the treatment of obesity does not meet the Kaiser Permanente Medical Technology Assessment Criteria. The first study followed 110 subjects for a 1999 Kaiser Foundation Health Plan of Washington. Back to Top Date Sent: 3/24/2020 98 these criteria do not imply or guarantee approval. Criteria | Codes | Revision History median of 7 months and the second study followed 86 subjects for 12 months.

In some cases the disorder can be shown to be due to some associated encephalopathy but the diagnosis should be made on the behavioural features medicine 19th century buy generic antivert canada. In adolescence treatment zoster ophthalmicus discount 25 mg antivert mastercard, the overactivity tends to be replaced by underactivity (a pattern that is not usual in hyperkinetic children with normal intelligence treatment h pylori buy cheap antivert 25mg on line. This syndrome is also often associated with a variety of developmental delays treatment 5th toe fracture buy antivert visa, either specific or global medications ranitidine purchase antivert online now. It differs from autism primarily in the fact that there is no general delay or retardation in language or in cognitive development symptoms 4dp5dt fet antivert 25 mg with visa. There is a strong tendency for the abnormalities to persist into adolescence and adult life. Hyperkinetic children are often reckless and impulsive, prone to accidents, and find themselves in disciplinary trouble because of unthinking breaches of rules rather than deliberate defiance. Their relationships with adults are often socially disinhibited, with a lack of normal caution and reserve. Impairment of cognitive functions is common, and specific delays in motor and language development are disproportionately frequent. Such behaviour should amount to major violations of age-appropriate social expectations; it should therefore be more severe than ordinary childish mischief or adolescent rebelliousness and should imply an enduring pattern of behaviour (six months or longer. Features of conduct disorder can also be symptomatic of other psychiatric conditions, in which case the underlying diagnosis should be preferred. Examples of the behaviours on which the diagnosis is based include excessive levels of fighting or bullying, cruelty to other people or animals, severe destructiveness to property, fire-setting, stealing, repeated lying, truancy from school and running away from home, unusually frequent and severe temper tantrums, and disobedience. Any one of these behaviours, if marked, is sufficient for the diagnosis, but isolated dissocial acts are not. Includes: Conduct disorder, solitary aggressive type Unsocialized aggressive disorder F91. Includes: Conduct disorder, group type Group delinquency Offences in the context of gang membership Stealing in company with others Truancy from school F91. Caution should be employed before using this category, especially with older children, because clinically significant conduct disorder will usually be accompanied by dissocial or aggressive behaviour that goes beyond mere defiance, disobedience, or disruptiveness. Developmental appropriateness is used as the key diagnostic feature in defining the difference between these emotional disorders, with onset specific to childhood, and the neurotic disorders (F40-F48. It is differentiated from normal separation anxiety when it is of a degree (severity) that is statistically unusual (including an abnormal persistence beyond the usual age period), and when it is associated with significant problems in social functioning. Excludes: mood [affective] disorders (F30-F39) neurotic disorders (F40-F48) phobic anxiety disorder of childhood (F93. Other fears that arise in childhood but that are not a normal part of psychosocial development (for example agoraphobia) should be coded under the appropriate category in section F40-F48. This category should be used only where such fears arise during the early years, and are both unusual in degree and accompanied by problems in social functioning. A sibling rivalry disorder should be diagnosed only if the degree or persistence of the disturbance is both statistically unusual and associated with abnormalities of social interaction. In many instances, serious environmental distortions or privations probably play a crucial role in etiology. The disorder is usually associated with marked personality features involving social anxiety, withdrawal, sensitivity, or resistance. The syndrome probably occurs as a direct result of severe parental neglect, abuse, or serious mishandling. Use additional code to identify any associated failure to thrive or growth retardation. A tic is an involuntary, rapid, recurrent, nonrhythmic motor movement (usually involving circumscribed muscle F98. Tics tend to be experienced as irresistible but usually they can be suppressed for varying periods of time, are exacerbated by stress, and disappear during sleep. Common simple motor tics include only eye-blinking, neck-jerking, shoulder shrugging, and facial grimacing. The tics usually take the form of eye-blinking, facial grimacing, or head-jerking. The disorder usually worsens during adolescence and tends to persist into adult life. The vocal tics are often multiple with explosive repetitive vocalizations, throat-clearing, and grunting, and there may be the use of obscene words or phrases. Sometimes there is associated gestural echopraxia which may also be of an obscene nature (copropraxia. Some of the conditions represent well-defined syndromes but others are no more than symptom complexes that need inclusion because of their frequency and association with psychosocial problems, and because they cannot be incorporated into other syndromes. The enuresis may have been present from birth or it may have arisen following a period of acquired bladder control. The enuresis may or may not be associated with a more widespread emotional or behavioural disorder. The condition may represent an abnormal continuation of normal infantile incontinence, it may involve a loss of continence following the acquisition of bowel control, or it may involve the deliberate deposition of faeces in inappropriate places in spite of normal physiological bowel control. The condition may occur as a monosymptomatic disorder, or it may form part of a wider disorder, especially an emotional disorder (F93. Includes: Functional encopresis Incontinence of faeces of nonorganic origin Psychogenic encopresis Use additional code to identify the cause of any coexisting constipation. It generally involves food refusal and extreme faddiness in the presence of an adequate food supply, a reasonably competent caregiver, and the absence of organic disease. There may or may not be associated rumination (repeated regurgitation without nausea or gastrointestinal illness. Includes: Rumination disorder of infancy Excludes: anorexia nervosa and other eating disorders (F50. It may occur as one of many symptoms that are part of a more widespread psychiatric disorder (such as autism), or as a relatively isolated psychopathological behaviour; only the latter is classified here. The phenomenon is most common in mentally retarded children and, if mental retardation is also present, F70-F79 should be selected as the main diagnosis. When such movements occur as symptoms of some other disorder, only the overall disorder should be recorded. The movements that are of a non self-injurious variety include: body-rocking, head-rocking, hair plucking, hair-twisting, finger-flicking mannerisms, and hand-flapping. Stereotyped self injurious behaviour includes repetitive head-banging, face-slapping, eye-poking, and biting of hands, lips or other body parts. All the stereotyped movement disorders occur most frequently in association with mental retardation (when this is the case, both should be recorded. If eye poking occurs in a child with visual impairment, both should be coded: eye-poking under this category and the visual condition under the appropriate somatic disorder code. Includes: Stereotype/habit disorder Excludes: abnormal involuntary movements (R25. It should be classified as a disorder only if its severity is such as to markedly disturb the fluency of speech. The "sequelae" include conditions specified as such or as late effects, or those present one year or more after onset of the causal condition. For use of this category reference should be made to the relevant morbidity and mortality coding rules and guidelines. Excludes: epileptic seizure related to psychoactive substance withdrawal (F10-F19 with common fourth characters. Includes: with mention of hypertension (I10-I15) Use additional code to identify presence of hypertension. I20 Angina pectoris Use additional code from category (E10-E14) with fourth and fifth characters. Use additional code from (I11) (hypertensive heart disease) or (I13) (hypertensive heart and renal disease) for heart failure due to hypertension Excludes: complicating:. J09 Influenza due to certain identified influenza virus Note: Influenza caused by influenza virus strains of special epidemiological importance with an animal-human or inter-human transmission limited to the inclusions. Includes: Influenza A/H1N1 pandemic 2009 [swine flu] Influenza A/H5N1 epidemic [avian influenza] Use additional code to identify pneumonia or other manifestations. Complicated haemorrhoids include those with additional signs of strangulation, thrombosis, necrosis and/or ulceration. Includes: bedsore plaster ulcer Use additional code from category (E10-E14) with fourth and fifth characters. Includes: Decubitus [pressure] ulcer limited to erythema [redness] only, without skin breakdown L89. Distinction is made between the following types of etiological relationship a) direct infection of joint, where organisms invade synovial tissue and microbial antigen is present in the joint; b) indirect infection, which may be of two types: a reactive arthropathy, where microbial infection of the body is established but neither organisms nor antigens can be identified in the joint, and a postinfective arthropathy, where microbial antigen is present but recovery of an organism is inconstant and evidence of local multiplication is lacking. M00 Pyogenic arthritis Excludes: infection and inflammatory reaction due to internal joint prosthesis (T84. The term primary has been used with its customary clinical meaning of no underlying or determining condition identified. M99 the following fifth characters represent the following sites of involvement 0 Head region occipitocervical 1 Cervical region cervicothoracic 2 Thoracic region thoracolumbar 3 Lumbar region lumbosacral 4 Sacral region sacrococcygeal, sacroiliac 5 Pelvic region hip, pubic 6 Lower extremity 7 Upper extremity acromioclavicular,sternoclavicular 8 Rib cage costochondral, costovertebral, sternochondral 9 Abdomen and other M99. Use additional codes to identify any associated hypertensive renal disease (I12) or hypertensive heart and renal disease (I13. Excludes: erosion and ectropion of cervix without cervicitis (N86) N73 Other female pelvic inflammatory diseases Use additional code (B95-B97) to identify infectious agent. N77* Vulvovaginal ulceration and inflammation in diseases classified elsewhere N77. O03 Spontaneous abortion Note: Incomplete abortion includes retained products of conception following abortion. For use of this category reference should be made to the morbidity coding rules and guidelines. O08 O08 Complications following abortion Ectopic Hydatidiform Spontaneous Medical Other Unspecified and ectopic and molar pregnancy pregnancy mole and abortion abortion abortion type of other abortion, abnormal subsequent products of episode of conception care only O08. O94 Sequelae of complication of pregnancy, childbirth and the puerperium Note: Category O94 is to be used for morbidity coding only to indicate previous episodes of conditions in categories (O00-O75 and O85-O92) as the cause of sequelae, which are themselves classified elsewhere. Not to be used for chronic complications of pregnancy, childbirth and the puerperium. Excludes: that resulting in death (O96, O97) O95 Obstetric death of unspecified cause Includes: maternal death from unspecified cause occurring during pregnancy, labour and delivery, or the puerperium O95. Includes: the listed conditions, without further specification, as the cause of mortality, morbidity or additional care, in newborn Excludes: low birth weight due to slow fetal growth and fetal malnutrition (P05. Usually implies a birth weight>90th percentile for gestational age or 4000g or more at term Excludes: birth weight of 4500g or more (P08. In general, categories in this chapter include the less well-defined conditions and symptoms that, without the necessary study of the case to establish a final diagnosis, point perhaps equally to two or more diseases or to two or more systems of the body. The Alphabetical Index should be consulted to determine which symptoms and signs are to be allocated here and which to other chapters. The conditions and signs or symptoms included in categories (R00-R99) consist of:. The category is for use in multiple coding to identify this condition resulting from any cause. Where multiple sites of injury are specified in the titles, the word "with" indicates involvement of both sites, and the word "and" indicates involvement of either or both sites. The principle of multiple coding of injuries should be followed wherever possible. Combination categories for multiple injuries is provided for use when there are insufficient detail as to the nature of the individual conditions, or for primary tabulation purposes when it is more convenient to record single code; otherwise, the component injuries should be coded separately. S84 Injury of nerves at lower leg level Excludes: injury of nerves at ankle and foot level (S94. T32 Total Body Surface Involved in Burn (any degree) T31 Less than 10 to 19% 20 to 29% 30 to 39% 40 to 49% 50 to 59% 60 to 69% 70 to 79% 80 to 89% More than Proportion of 10% or 90% burn that is unspecifie third degree d (choose from this column) 0% or T31. It may be used as a supplementary code with categories (T20-T25, T29) when the site is specified. Total Body Surface Involved in Corrosion (any degree) T32 Less than 10 to 19% 20 to 29% 30 to 39% 40 to 49% 50 to 59% 60 to 69% 70 to 79% 80 to 89% More than Proportion of 10% or 90% corrosion that unspecifie is third degree d (choose from this column) 0% or T32. The "sequelae" include those specified as such, or as late effects, and those present one year or more after the acute injury. Where a code from this section is applicable, it is intended that it shall be used in addition to a code from another chapter of the Classification indicating the nature of the condition. The vehicle of which the injured person is an occupant is identified in the first two characters since it is seen as the most important factor to identify for prevention purposes. Definitions related to transport accidents (a) A transport accident (V01-V99) is any accident involving a device designed primarily for, or being used at the time primarily for, conveying persons or goods from one place to another. A roadway is that part of the public highway designed, improved and customarily used for vehicular traffic. Includes: minibus (o) A motor vehicle or vehicle may refer to various transport vehicles. The local usage of the terms should be established to determine the appropriate code. Includes interurban (operated chiefly on its own right-of-way, not open to other traffic):. Includes interurban electric car or streetcar, when specified to be operating on a street or public highway:. Examples of special design are high construction, special wheels and tyres, tracks, and support on a cushion of air. If an event is unspecified as to whether it was a traffic or nontraffic accident, it is assumed to be (a) A traffic accident when the event is classifiable to categories V10-V82 and V87. For these categories the victim is either a pedestrian, or an occupant of a vehicle designed primarily for off-road use.

To that end symptoms 16 dpo cheap antivert 25mg free shipping, human performance and environmental effects are evaluated periodically by monitoring both the sustained physiological changes during space flight and the spacecraft environment medications such as seasonale are designed to buy discount antivert line. When necessary medications causing thrombocytopenia discount antivert 25 mg on line, appropriate treatment is administered and effective countermeasures are prescribed to prevent or ameliorate the adverse effects of exposure to 4 treatment models cheap 25 mg antivert with amex,24 microgravity medicine uses order antivert paypal. Selection of particular monitoring modalities is influenced by program-specific medications vertigo 25 mg antivert amex, mission-specific, and individual factors. The latter group can be divided further into factors associated with individual flight assignment and duties and those related to medical history and baseline medical data. Comparison of such documents from various missions shows a clear evolution based on the knowledge and experience gained during previous space programs. In some complex programs these requirements partially depend on the duration of missions, with the range of screening and monitoring modalities increasing with flight duration. Within a particular program, medical monitoring modalities can still largely vary depending on the features of the particular mission. For example, mission-specific pre and postflight monitoring modalities can depend on mission 3 V 4 Ch 3 Medical Monitoring Before and After Flight Billica et al. The individual pre and postflight monitoring plan is composed by the crew surgeon on the basis of program specific requirements, mission-specific factors, individual mission assignments as well as data on the individuals responses to the previous missions, particularities, and the speed of recovery and rehabilitation processes. Real-time corrections to the individual pre and postflight monitoring program are also possible at any time to relieve any concerns of the crew surgeon. Individual Baseline Databases Health monitoring data collection is planned at fixed intervals in conjunction with the physical health evaluations at astronaut selection and before the first mission; they collectively establish a baseline normative database against which in-flight management and postflight recovery will be implemented. Prior experience has demonstrated significant diversity of individual physiological responses to space flight factors; in particular, it is believed important to establish a baseline profile for each crewmember in terms of metabolic and endocrine functions, and 19 electrolyte and acid-base balance ; prior experience has demonstrated significant diversity of individual 3,19,20 physiological responses to space flight factors. During subsequent missions, depending on available information and the clinical judgment of the crew surgeons, only select protocols may be implemented if adequate baseline data already exist. The established baseline may be re-established periodically, as clinically indicated. In the postflight phase, guided by clinical manifestations and physical evaluation, only those protocols can be implemented that are required for diagnostic purposes or to guide the rehabilitation process and the return to flight duties. Preflight Medical Evaluation and Monitoring Activities Medical fitness for flight is determined by the crew surgeon, who conducts preflight medical evaluations of all crewmembers. In Russia, data obtained from cosmonauts physical examinations are reviewed by the Main Medical Board of the Ministry of Public Health and the Ministry of Defense of the Russian Federation 45 days before space flight. Depending on the nature and duration of the flight, there are minimum sets of tests/examinations required at certain intervals referenced to the launch or landing date. In Russia, this is conducted in accordance with regulations put into effect by an Order from the Minister of Public Health and the Minister of Defense (see Chapter 1. The International Space Station Program has adopted most of the principles of preflight medical evaluation and monitoring that have been verified during various programs conducted by space, military, and civilian agencies in several countries, primarily the United States and Russia. Skylab and Space Shuttle programs and the Russian long-duration space flight experience aboard the Salyut and Mir stations are the main sources of current knowledge in this area. Significant contribution to the knowledge base of space medicine monitoring has been made by ground-based experiments and simulations. As described in Chapter 1, astronaut candidate finalists undergo thorough 5-day physical and laboratory exams, including a treadmill stress test; pulmonary function tests; sigmoidoscopic and imaging examinations; and exams conducted by specialists in ophthalmology, neurology, psychiatry, dentistry and otolaryngology. After selection, astronauts undergo yearly medical examinations to recertify their fitness for flight. This training includes familiarization with the medical and physiological problems encountered in microgravity, including space motion sickness, cardiovascular deconditioning, reduced-pressure effects and decompression sickness, radiation, habitability and countermeasures, and use of in-flight medical equipment. Two crewmembers are designated crew medical officers and receive additional training in diagnosing and treating common medical problems, administering intramuscular and intravenous medications, and using onboard clean-up kits for decontamination and protection from potentially hazardous contaminants. Crew medical officers are equipped with a medical checklist, a quick reference to common ambulatory and emergency medical problems and a complete description of all onboard medications and their side effects. All crewmembers undergo extensive preflight medical examinations in addition to those associated with biomedical research and longitudinal data collection. Preflight exams, typically scheduled 10 days and again 2 days before launch, are conducted to detect any medical problems that might require attention and to provide baselines for postflight comparison. Results from these examinations are compared to those from two postflight sessions held the day of landing and three days thereafter. In addition to the certification process, astronauts also undergo real-time medical monitoring during potentially hazardous activities, such as underwater and hypobaric-chamber training sessions and some forms of biomedical testing. Medical staff oversee all potentially hazardous activities as a means of ensuring safety and quality assurance. Russian Program Cosmonaut selection and training are considered to be an integrated, continuous process. The goal of the outpatient phase is to identify overt pathology and functional disorders that would represent absolute contraindications for space flight (Table 1. Examinations in the hospital are designed to identify latent (occult) pathology, incipient preclinical forms of disease, and slight deviations in the functional status of organs and systems, as well as to evaluate physiological functional reserves. Candidate cosmonauts undergo comprehensive assessments by internists, surgeons, otolaryngologists, dentists, neuropathologists, and psychologists. Special provocative tests also are used to evaluate the reserve potential of the physiological system being tested. The results of these tests and evaluations, and those from tests conducted after cosmonauts are assigned to a crew (see below), are assessed by the Medical Certification Board, which declares individuals either qualified for special training, qualified with reservations, or not qualified (see Chapter 1. Qualification with reservations usually reflects the discovery, during the evaluation process, of a medical condition that requires treatment; such individuals are deemed temporarily unfit for special training for up to 6 months. Individuals who pass the inpatient testing stage subsequently undergo special training (see Chapter 2), the goals of which are to improve tolerance and induce adaptive physiological reactions to specific space flight factors, and to impart the skills needed to control spacecraft systems and equipment. If a cosmonaut has a health problem that requires clarification or reassessment of the Boards recommendation, then a special examination and Board session are held. Other medical assessments conducted between regular Board meetings (during the training process) are observations during tests, physical training and daily life; interim medical examinations; and quarterly in-depth medical examinations. Interim examinations (Table 2) are held before and after any training procedure that makes unusual demands on cosmonaut health (e. Interim exams including analysis of blood and urine, and evaluations by internists, neuropathologists, and 5 V 4 Ch 3 Medical Monitoring Before and After Flight Billica et al. If the results of preliminary interim examination are positive, the cosmonaut is allowed to participate in further tests and training. Results of the last interim examinations are used to assess the effect of training on the cosmonauts health and tolerance of the factors to which he or she has been exposed. Measures are taken as needed to improve physiological tolerance of particular factors. In-depth examinations (also conducted as part of the outpatient selection process) take place quarterly (Table 3. These examinations include general clinical analyses of blood, urine, and feces; cosmonauts older than 40 years also undergo tests of blood sugar and cholesterol every 6 months. Cosmonauts also are examined by specialists in internal medicine, neuropathology, surgery, otolaryngology, ophthalmology, and dentistry. Results from medical and psychological observations and from interim medical examinations during training also are considered during the in-depth examination. Tests for recertification closely resemble those of the inpatient selection phase (Tables 4 and 5. Cosmonauts undergo additional clinical and physiological tests once before they are assigned to a prime or a back-up crew, again 30 to 60 days before launch, and again 5 to 7 days before launch. When an individual is assigned to a crew, results from the last regular inpatient certification can be used if the Board finds no reason to repeat any of the component tests. The tests constituting preflight examinations are similar to those of the annual recertification but include 24-hour Holter monitoring and assessments of tolerance of low atmospheric pressure and +4 to +8 Gx accelerations. The different acceleration profiles used for annual versus preflight certifications reflect the different goals of the two processes. The annual test (tolerance of +3 Gz and 5 Gz for 30 seconds each) seeks to evaluate general tolerance and allows cosmonauts to begin flight training. Preflight certification tests (tolerance of +4 to +8 Gz) seek to predict individual tolerance of acceleration profiles expected during actual space flights. Good tolerance of transverse (+Gx) acceleration (magnitude up to 8 G, duration up to 40 seconds) has been shown to predict good tolerance of acceleration during the active phases of flight on Soyuz-type spacecraft, including emergency ejection and descent from orbit. Conditions such as contusions (with limited tissue edema), minor cuts or bruises, limited 1 or nd 2 -degree burns or frostbite, single boils that are not associated with fever or do not affect the individuals general state, or acute infectious laryngitis and pharyngitis (without severe symptoms of toxicity) are generally treated on an outpatient basis. After either inpatient or outpatient treatment, a short period of rest (not longer than 15 days) may be prescribed, during which the cosmonaut cannot participate in training. When the recovery and rest periods are over, the cosmonaut resumes classroom work first and then special training. The final preflight medical examination takes place 5 to 7 days before launch and again on the day of launch. Launch-day evaluations are conducted by internists, neuropathologists, and otolaryngologists. Scientific studies and experiments are conducted independent of the preflight medical evaluations. These studies are conducted in accordance with special programs developed before each flight, and theoretically can include experiments in any area of physiology, medicine, pharmacology, hygiene, or psychology. The results from such studies, like those from baseline medical monitoring, can be significant in the flight certification process, although they are not a mandatory part of the decision making. At this time, a crew surgeon, deputy crew surgeon, and biomedical mission manager are assigned to the mission. Further medical data reviews and monitoring activities become the responsibility of the crew surgeon. This individual schedules and arranges for every evaluation, assessment, data sampling, and other activities. The crew surgeon ensures that all existing monitoring and preparatory requirements are satisfied and that each individual crewmembers medical records precisely reflect all acquired information. Six months before the scheduled launch date, the crew aeromedical summaries and drug sensitivity testing records are updated. Nutritional assessment and counseling, and radiation history reviews are required at this time, and individual exercise programs are initiated. One month before launch, the crew surgeon and deputy crew surgeon meet with the crew for medical examinations and preflight medical testing to include a full flight physical examination. For short missions (less than 30 days), this session replaces the medical evaluation held 10 days before launch. Further medical examinations fall into the category of near-flight exams (L–10 days or closer. These evaluations are conducted at the launch site or at the training site before crew transfer to the prelaunch crew quarters. Near flight examinations are conducted to detect any medical problems that might require attention and to provide fresh baselines for postflight comparison. A comprehensive preflight examination is performed 10 days (for short flights) or 7 days (for intermediate or long flights) before launch. Additional studies commensurate with the annual evaluations requirements may be added so that this exam, if performed within 30 days of the crewmembers birthday, will substitute for the annual exam. For short flights, this preflight medical evaluation consists of a full physical, otolaryngology and ophthalmology evaluation, cardiovascular/cardiopulmonary studies, a battery of laboratory tests, and microbiological assessments (Table 6. For long flights, nutritional assessment and repeated microbiological sampling are required. Findings are released on the crews health status, and this is equivalent to confirming that the crew is flight-ready. On launch day, a brief medical evaluation (several minutes long) takes place on the launch site, which terminates the preflight medical evaluation and monitoring sequence. Results from these preflight examinations are later compared to those from the postflight sessions on the day of landing and three days thereafter. After main engine cutoff, the crew surgeon and deputy crew surgeon return to the Johnson Space Center to begin the in-flight portion of crew medical monitoring. For a launch from Russia, the procedures for examining the crews are in keeping with the final preflight examinations program described above in the Russian Program section. Russian Program As noted earlier, the difference between medical assessment/certification and preflight countermeasures is somewhat blurred in the Russian space program, since training is considered an extension of the selection and assessment process. The primary goal of the general training is to improve cosmonauts physiological tolerance of space flight factors as they acquire new occupational and professional skills. Traits revealed during training, such as speed and stability of an individuals adaptive responses, are important in evaluating a candidates performance. For this reason, the provocative tests used during this phase simulate space flight factors as closely as possible. Special attention is given to cosmonaut-researchers (payload specialists) during this training so that their performance and abilities can be expanded as much as possible. Some means by which general conditioning is improved have 7 V 4 Ch 3 Medical Monitoring Before and After Flight Billica et al. As the durations of space flight continue to increase, it becomes apparent that maintaining the adaptive capacities of crewmembers during those flights will necessitate the development of additional prophylactic countermeasures that can be used both during preflight training as well as during actual missions. Program Many preflight activities have been implemented to protect crew health before launch and to prevent medical problems that could delay or impair missions. The Health Stabilization Program was designed to minimize crew exposure to infectious disease before missions. The brevity of early Mercury and Gemini flights was such that the possibility of infectious diseases manifesting themselves during flight was not considered a concern. As the duration of the Gemini flights increased, the corresponding increase in risk of disease prompted reducing the number of people to whom the crews were exposed before launch. Although no serious episodes took place during flight, Gemini crews did experience minor illnesses such as colds and influenza during the period before launch. During the Apollo program, concern increased over the possibility and consequences of infectious diseases, particularly with regard to the difficulty of completing a lunar landing should a crewmember become seriously ill during the mission. During preparations for Apollo-8, every crewmember suffered viral gastroenteritis during the preflight period. However, the recurrence 28 of the infection in one crewmember during flight greatly increased awareness of the need for more stringent preflight measures to protect astronaut health during missions.

The benefcial effects of dobutamine S diminish over 48 hours due to downregulation of beta receptors professional english medicine generic 25 mg antivert fast delivery. T Safety and handling: Dilute to a 25 ?g/ml solution in dextrose or normal saline and store solution in the fridge when not in use treatment 2 degree burns order antivert paypal. The reconstituted solution is stable for at least 24h medicine 44390 order antivert 25mg otc, after this V discoloured solutions should be discarded treatment 5 shaving lotion buy antivert 25 mg with visa. Adverse reactions: Dobutamine is short-acting symptoms xxy discount antivert 25 mg free shipping, therefore adverse X reactions such as tachycardia 97140 treatment code discount antivert line, proarrhythmia and hypertension can usually be managed by stopping the drug infusion. Hypokalaemia can Y develop with prolonged use; this can predispose to tachyarrhythmias. A Drug interactions: Diabetic patients treated with dobutamine may B experience increased insulin requirements. Increased systemic vascular resistance may develop if dobutamine is administered with C beta-blocking drugs such as propanolol, doxapram or monoamine oxidase inhibitors (e. Concomitant use with halothane D may result in an increased incidence of arrhythmias. Clinical studies in humans indicate that concomitant use of dobutamine and E nitroprusside results in a higher cardiac output than when either drug is used alone. G Start at the bottom end of the dose range and increase slowly until the desired effect is achieved. Start J at the bottom end of the dose range and increase slowly until the desired effect is achieved. R Action: Anionic surfactant acting as emulsifying, wetting and S dispersing agent. Action: the substance is derived from components of the dermal G secretions produced by the bitch after whelping, which help to orientate pups towards the safety of the den. A similar signal appears to form part of the social signal controlling groups of adult dogs. I Detection of the substance in the aerial environment results in limbic activity which helps to antagonize the effect of certain forms of J aversion in the environment. Use: Helps control signs of stress associated with separation, noise K sensitivity, travel, introduction to a new home, visits to a novel environment (e. The diffuser should be placed in the room most frequently occupied by the dog and, in the management of behavioural M disorders, where the inappropriate behaviour most frequently occurs. For behavioural problems involving hyperattachment to the owner, a N treatment period of 3 months is recommended. It can be used in cars, hospitalization cages, kennels, indoor pens or refuge areas, and P applied directly on to bedding. The collar formulation is particularly useful to Q help control reactions which occur outside the home. If multiple dogs are affected by a problem, each dog should wear a collar and R possibly a diffuser considered for problems based around the home. The S collar formulation should not be used for animals with a known reactivity to collars. Avoid contact with water when the collar is in use T as this may wash out the active ingredients. V Drug interactions: None known, although anecdotally an apparently W synergistic action with benzodiazepines has been reported in some instances. The application can be renewed after 1-2 h or D when the effects appear to be reducing. However, maropitant is authorized for J veterinary use and there is more clinical experience with K metoclopramide and ondansetron. Adverse reactions: There is little information on the use of this drug M in veterinary medicine, but it may cause gastroparesis in dogs. T Action: Dopamine is an endogenous catecholamine and precursor of noradrenaline, with direct and indirect (via release of noradrenaline) U agonist effects on dopaminergic and beta-1 and alpha-1 adrenergic receptors. Main indications are treatment of shock following correction of fuid defciencies, acute W heart failure, and support of blood pressure during anaesthesia. Dobutamine is preferred for support of systolic function in patients with X heart failure. Dopamine is a potent and short-acting drug, therefore it should be given in low doses by continuous rate infusion, and accurate Y dosing is important. At higher doses (>10 ?g/kg/min) dopaminergic effects are overridden by the alpha C effects, resulting in an increase in systemic vascular resistance and reduced peripheral blood fow. There may be an improvement in urine output but this may be entirely due to inhibition of E + proximal tubule Na reabsorption and an improved cardiac output and blood pressure rather than directly improving renal blood fow. The F dose of dopamine should be adjusted according to clinical effect, G therefore monitoring of arterial blood pressure during administration is advisable. Contraindications: Discontinue or reduce the dose of dopamine J should cardiac arrhythmias arise. K Adverse reactions: Extravasation of dopamine causes necrosis and sloughing of surrounding tissue due to tissue ischaemia. Should L extravasation occur, infltrate the site with a solution of 5-10 mg phentolamine in 10-15 ml of normal saline using a syringe with a fne M needle. Nausea, vomiting, tachyarrhythmias and changes in blood pressure are the most common adverse effects. Hypotension may N develop with low doses, and hypertension may occur with high doses. O All dopamine-induced arrhythmias are most effectively treated by stopping the infusion. P Drug interactions: Risk of severe hypertension when monoamine oxidase inhibitors, doxapram and oxytocin are used with dopamine. Action: Reduces intraocular pressure by reducing the rate of Y aqueous humour production by inhibiting the formation of bicarbonate ions within the ciliary body epithelium. Dorzolamide/timolol A combination may be more effective in dogs than either drug alone. It may be less tolerated than brinzolamide because of its less B physiological pH of 5. The concurrent use of a topical and a systemic C carbonic anhydrase inhibitor is not benefcial as there is no additional decrease in intraocular pressure compared with either route alone. E Dorzolamide/timolol is not the drug of choice in uveitis or anterior lens luxation. Small mammals: Rats: 1 drop 1% solution (dilute standard K formulation with sterile water) q12h. Action: Stimulates respiration by increasing the sensitivity of aortic P and carotid body chemoreceptors to arterial gas tensions. In neonatal puppies and kittens, used to stimulate or initiate respiration R after birth, particularly in animals delivered by caesarean section. The dose should be adjusted according to the requirements of the S situation; adequate but not excessive doses should be used. Adverse reactions: Overdose can cause excessive hyperventilation, X which may be followed by reduced carbon dioxide tension in the blood leading to cerebral vasoconstriction. Doxapram is irritant and may cause a thrombophlebitis, avoid extravasation or repeated i. Use doxapram injection with caution in neonates because A it contains benzyl alcohol which is toxic. As doxapram may stimulate the release of adrenaline, its use within 10 min of the administration of anaesthetic F agents that sensitize the myocardium to catecholamines (e. Doxapram is compatible with 5% G dextrose or normal saline but is incompatible with sodium bicarbonate or thiopental. High doses administered during or after anaesthesia H with halogenated hydrocarbon anaesthetics, such as halothane, may precipitate cardiac arrhythmias. Doxapram injection should be used I with extreme caution in dogs that have been sedated with morphine. Administration of doxapram at 10 mg/kg to such animals may be J followed by convulsions. M Small mammals: Ferrets, Rabbits, Chinchillas, Hamsters, Gerbils, Rats, Mice: 5-10 mg/kg i. Action: Doxepin blocks noradrenaline and serotonin re-uptake in the S brain, resulting in antidepressive activity, while the H1 and H2 blockage result in antipruritic effects. U Use: Management of pruritus and psychogenic dermatoses where there is a component of anxiety, including canine acral lick dermatitis V and compulsive disorders. The atypical tricyclic antidepressant clomipramine W is an authorized preparation for use in dogs. Y Contraindications: Hypersensitivity to tricyclic antidepressants, glaucoma, history of seizure or urinary retention and severe liver Z disease. B Drug interactions: Should not be used with monoamine oxidase C inhibitors or drugs which are metabolized by cytochrome P450 2D6. Use: Treatment of lymphoma, soft tissue sarcomas, osteosarcoma L and haemangiosarcoma, and may have a role in the management of carcinomas in the dog and soft tissue sarcomas in the cat. The reconstituted drug O should be administered over a minimum period of 10 min into the side port of a freely running i. Use with caution in patients previously treated with radiation R as can cause radiation recall. S Safety and handling: Potent cytotoxic drug that should only be prepared and administered by trained personnel. Adverse reactions: Allergic reactions have been reported; acute X anaphylactic reactions should be treated with adrenaline, steroids and Y fuids. Doxorubicin causes a dose-dependent cumulative cardiotoxicity in dogs (leading to cardiomyopathy and congestive heart failure. Anorexia, vomiting, severe leucopenia, thrombocytopenia, haemorrhagic B gastroenteritis and nephrotoxicity (in cats if dosages >100 mg/m2) are the major adverse effects. If neutrophil count drops below 2 x 109/l or platelet count drops below 50 x 109/l, treatment should be D suspended. Extravasation injuries secondary to perivascular administration may F be serious, with severe tissue ulceration and necrosis possible. Concurrent administration with cyclophosphamide H increases the risk of nephrotoxicity in cats. Doxorubicin is incompatible with dexamethasone, 5-fuorouracil and heparin; concurrent use will lead to precipitate formation. Also used for 2 doses as part of specifc multi-drug protocols for lymphoma in ferrets. T Action: Bacteriostatic agent inhibiting protein synthesis at the initiation step by interacting with the 30S ribosomal subunit. U Use: Antibacterial (including spirochaetes such as Helicobacter and Campylobacter), antirickettsial (e. It is not affected by, and does W not affect, renal function as it is excreted in faeces, and is therefore recommended when tetracyclines are indicated in animals with renal X impairment. Being extremely lipid-soluble, it penetrates well into prostatic Y fuid and bronchial secretions. Injection is very irritant in birds must alternate injection sites or divide dose if large Z volume to inject. Oesophagitis C and oesophageal ulceration may develop; administer with food or a water bolus to reduce this risk. Administration during tooth D development may lead to discoloration of the teeth, although the risk is less than with other tetracyclines. E Drug interactions: Absorption of doxycycline is reduced by F antacids, calcium, magnesium and iron salts, although the effect is less marked than seen with water-soluble tetracyclines. G Phenobarbital, phenytoin and primidone may increase its metabolism, thus decreasing plasma levels. Dilute strong solution to a S concentration of 10 mg/ml in 5% dextrose before use. Blood lead levels may be confusing, therefore monitor clinical signs during T therapy. Measure blood lead levels 2-3 weeks after completion of treatment in order to determine whether a second course is required U or if the animal is still being exposed to lead. W Adverse reactions: Reversible nephrotoxicity is usually preceded by other clinical signs of toxicity (e. Dogs that respond slowly or have an initial (pre-treatment) blood lead level of >4. J Action: Edrophonium is a reversible and short-acting inhibitor of acetylcholinesterase with a very rapid onset of action. Use: To differentiate myasthenia gravis from other causes of exercise L intolerance (previously known as the Tensilon test. Also used to treat atrial tachycardia (vagal effects) and to antagonize non-depolarizing M neuromuscular blockade. Also used to distinguish between under and over-treatment of myasthenia gravis with other anticholinesterases by N giving doses at the lower end of the range for diagnostic tests. If treatment has been inadequate, edrophonium will improve muscle O weakness; in over-treatment, edrophonium will temporarily exacerbate muscle weakness. Use with caution in patients with P bronchial disease (especially feline asthma), bradycardia (and other arrhythmias), hypotension, renal impairment or epilepsy. S Adverse reactions: Include nausea, vomiting, increased salivation and diarrhoea. Severe bradyarrhythmias, even asystole, may occur if edrophonium is used to antagonize neuromuscular block without the U co-injection of atropine. V Drug interactions: Do not use at higher doses in conjunction with depolarizing neuromuscular relaxants (e. Improvement should be noted within 30 seconds, with the Z effects dissipating within 5 min, for a positive test. Continued E ventilatory support should be provided until full respiratory muscle activity is restored.

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