Eclipse™ is a comprehensive treatment planning system that simplifies modern radiation therapy planning for all kinds of treatment, including 3D conformal, intensity-modulated radiation therapy (IMRT), electron, proton, and brachytherapy.
With the rich functionality in Eclipse, dosimetrists, physicists, and physicians can efficiently create, select, and verify the best treatment plans for their patients. In addition to ensuring high standards of care and effective protocols, Eclipse provides clinicians with the flexibility to quickly tailor plans for each patient.
Designed to meet the needs of modern clinics and evolving technologies, Eclipse supports advanced processes such as image-guided radiation therapy (IGRT) and Dynamic Adaptive Radiation Therapy (DART™). The efficiency and cost effectiveness of Eclipse enables growing clinics to adopt advanced techniques, protecting investments while improving the quality of care.
Thursday, August 27, 2009
oncology
Port access Needles
Oncology non-coring color coded by needle gauge and needle length. Fixed wings allow for an easy grasp and comfortable insertion technique. Competitively priced and available from stock.
Extension Sets, Adapters and I.V. Filters
Extension sets and adapters of various sizes, lengths and priming volumes. Bifercated, Trifercated, and ' T ' configurations are available with and without filters
PICC Catheters
Our catheter is complete, convenient, and cost effective. The fine quality instruments included in this tray are for ease of catheter placement. The PICC uses a unique coaxial silicone extrusion method. This means that the X-ray opaque material is sealed between coaxial layers of pure silicone. The result is a smoother surface and improved bio-compatability when compared to a conventional silicone catheter. Available with or without guidewire and your choice of splitting needle or peelable cannula. Our PICC Kit contains all the components, dressings required for a efficient catheter placement.
Blood Draw Safety Syringes
These unique devices virtually eliminate your exposure to contaminated needles during the blood draw procedure. Our Blood Collection Device and Safety Syringe provide automated retraction of the needle into the syringe barrel to instantly remove the needle directly from the patient.
Custom Procedure Trays
Procedure trays for any application are available in quantities as small as ten (10) trays. You specify the items to be included in the tray. We build, sterilize and store the tray for you. If you are doing procedures that require multiple items to be gathered, why not stop wasting time and storage space. Give us the specifications of the tray along with your anticipated annual purchase volume and we'll give you a sample tray with your price
Oncology non-coring color coded by needle gauge and needle length. Fixed wings allow for an easy grasp and comfortable insertion technique. Competitively priced and available from stock.
Extension Sets, Adapters and I.V. Filters
Extension sets and adapters of various sizes, lengths and priming volumes. Bifercated, Trifercated, and ' T ' configurations are available with and without filters
PICC Catheters
Our catheter is complete, convenient, and cost effective. The fine quality instruments included in this tray are for ease of catheter placement. The PICC uses a unique coaxial silicone extrusion method. This means that the X-ray opaque material is sealed between coaxial layers of pure silicone. The result is a smoother surface and improved bio-compatability when compared to a conventional silicone catheter. Available with or without guidewire and your choice of splitting needle or peelable cannula. Our PICC Kit contains all the components, dressings required for a efficient catheter placement.
Blood Draw Safety Syringes
These unique devices virtually eliminate your exposure to contaminated needles during the blood draw procedure. Our Blood Collection Device and Safety Syringe provide automated retraction of the needle into the syringe barrel to instantly remove the needle directly from the patient.
Custom Procedure Trays
Procedure trays for any application are available in quantities as small as ten (10) trays. You specify the items to be included in the tray. We build, sterilize and store the tray for you. If you are doing procedures that require multiple items to be gathered, why not stop wasting time and storage space. Give us the specifications of the tray along with your anticipated annual purchase volume and we'll give you a sample tray with your price
Conquering the lethal complication of bone marrow transplantation
NFCR Fellow Curt Civin, M.D.
University of Maryland School of Medicine
Bone marrow transplantation is a life-saving procedure used in patients with leukemia and other diseases to replenish their vital blood-forming system, which is often destroyed by high-dose chemotherapy treatment. However, the very same procedure may cost a patient’s life if a severe complication known as the graft-versus-host disease (GVHD) occurs. When a patient receives a bone marrow transplant from a donor (allogeneic transplant), a subset of the immune cells from the transplant can be activated to mount vigorous immunologic attacks on the patient’s (the recipient’s) tissues, causing GVHD. This side effect could be lethal, which greatly limits the clinical application of allogeneic bone marrow transplantation.
NFCR Fellow Curt Civin, M.D. (formerly at the Johns Hopkins University School of Medicine) and his team have developed a unique strategy in the laboratory which sends the anti-recipient immune cells onto a suicidal path, while keeping intact the “recipient-friendly” cells from the transplant, which is essential for successful blood replenishment in the patient. Recently, in a project supported by NFCR and another sponsor, he and his team have successfully completed preclinical tests with this approach using human cells. Now this promising treatment strategy is one step away from being launched into clinical tests in patients, giving them hope of conquering the complications during precious bone marrow transplantation. The work of Dr. Civin was recently published in the Journal of Immunology.
University of Maryland School of Medicine
Bone marrow transplantation is a life-saving procedure used in patients with leukemia and other diseases to replenish their vital blood-forming system, which is often destroyed by high-dose chemotherapy treatment. However, the very same procedure may cost a patient’s life if a severe complication known as the graft-versus-host disease (GVHD) occurs. When a patient receives a bone marrow transplant from a donor (allogeneic transplant), a subset of the immune cells from the transplant can be activated to mount vigorous immunologic attacks on the patient’s (the recipient’s) tissues, causing GVHD. This side effect could be lethal, which greatly limits the clinical application of allogeneic bone marrow transplantation.
NFCR Fellow Curt Civin, M.D. (formerly at the Johns Hopkins University School of Medicine) and his team have developed a unique strategy in the laboratory which sends the anti-recipient immune cells onto a suicidal path, while keeping intact the “recipient-friendly” cells from the transplant, which is essential for successful blood replenishment in the patient. Recently, in a project supported by NFCR and another sponsor, he and his team have successfully completed preclinical tests with this approach using human cells. Now this promising treatment strategy is one step away from being launched into clinical tests in patients, giving them hope of conquering the complications during precious bone marrow transplantation. The work of Dr. Civin was recently published in the Journal of Immunology.
Banner Image
Pancreatic cancer is the uncontrolled growth of malignant (cancerous) cells formed in the tissues of the pancreas. The cancer may develop in the head, body, or tail of the pancreas.
The pancreas is a gland found behind the stomach and extends across the abdomen. It has two distinct functions. The exocrine gland cells make pancreatic juices that have enzymes to break down fats and proteins in foods so the body can use them. Most of the cells in the pancreas are part of the exocrine system. A smaller number of cells in the pancreas are endocrine cells. These cells are arranged in clusters called islets, which make hormones, such as insulin, that help balance the amount of sugar in the blood.
Prevalence1
* The American Cancer Society predicts that in 2008 almost 38,000 people in the United States will be diagnosed with pancreatic cancer and about 34,000 will die of the disease.1
Types2
* Most pancreatic tumors originate in the exocrine duct cells or in the cells that produce digestive enzymes (acinar cells). Ninety-five percent of pancreatic cancers are called "adenocarcinomas."
* Endocrine and ampullary cancers are the two other types of pancreatic cancer that are less common. Tumors that begin in the islet cells are referred to as endocrine tumors. Ampullary tumors develop in the ampulla of Vater — the place where the bile and pancreatic ducts empty into the small intestine. These tumors often block the bile duct, leading to jaundice.
Treatment2,3
* There are four main types of treatment for cancer of the pancreas: surgery, radiation therapy, chemotherapy, and targeted therapy. Depending on the stage of the cancer, two or even three of these types of treatment could be given — either at the same time or one after the other.3
* For advanced pancreatic cancer patients, other treatments may include pancreatic enzyme tablets and insulin therapy.2
Survival Rates4,5,6
* Pancreatic cancer is difficult to treat, as it is often resistant to chemotherapy and radiotherapy and tends to spread quickly to other parts of the body,5,6 leading to high mortality and short life expectancy.4
* Despite significant advances in the treatment of many other human tumors, the five-year survival rate for persons diagnosed with pancreatic cancer has not changed in decades and remains at about five percent.2
* For those patients with localized disease (has not spread to other organs), the 5-year relative survival rate is about 20 percent.2
The pancreas is a gland found behind the stomach and extends across the abdomen. It has two distinct functions. The exocrine gland cells make pancreatic juices that have enzymes to break down fats and proteins in foods so the body can use them. Most of the cells in the pancreas are part of the exocrine system. A smaller number of cells in the pancreas are endocrine cells. These cells are arranged in clusters called islets, which make hormones, such as insulin, that help balance the amount of sugar in the blood.
Prevalence1
* The American Cancer Society predicts that in 2008 almost 38,000 people in the United States will be diagnosed with pancreatic cancer and about 34,000 will die of the disease.1
Types2
* Most pancreatic tumors originate in the exocrine duct cells or in the cells that produce digestive enzymes (acinar cells). Ninety-five percent of pancreatic cancers are called "adenocarcinomas."
* Endocrine and ampullary cancers are the two other types of pancreatic cancer that are less common. Tumors that begin in the islet cells are referred to as endocrine tumors. Ampullary tumors develop in the ampulla of Vater — the place where the bile and pancreatic ducts empty into the small intestine. These tumors often block the bile duct, leading to jaundice.
Treatment2,3
* There are four main types of treatment for cancer of the pancreas: surgery, radiation therapy, chemotherapy, and targeted therapy. Depending on the stage of the cancer, two or even three of these types of treatment could be given — either at the same time or one after the other.3
* For advanced pancreatic cancer patients, other treatments may include pancreatic enzyme tablets and insulin therapy.2
Survival Rates4,5,6
* Pancreatic cancer is difficult to treat, as it is often resistant to chemotherapy and radiotherapy and tends to spread quickly to other parts of the body,5,6 leading to high mortality and short life expectancy.4
* Despite significant advances in the treatment of many other human tumors, the five-year survival rate for persons diagnosed with pancreatic cancer has not changed in decades and remains at about five percent.2
* For those patients with localized disease (has not spread to other organs), the 5-year relative survival rate is about 20 percent.2
Non-Hodgkin's Lymphoma
Non-Hodgkin's lymphoma is the sixth most frequently diagnosed cancer and one of the most rapidly increasing types of cancer in the United States. Since the early 1970s, its incidence has nearly doubled. In 2009, nearly 66,000 people will be diagnosed and more than 19,000 individuals will die from the disease. This year about 574,000 people will be living with the disease.
Non-Hodgkin's lymphoma is a cancer of the white blood cells in the lymphatic system. There are two types of white blood cells that can give rise to non-Hodgkin's lymphoma, B-lymphocytes and T-lymphocytes. Of the more than 30 types of non-Hodgkin's lymphoma, diffuse large B-cell lymphoma and follicular (low-grade) lymphoma are the two most common. Approximately 85 percent of non-Hodgkin's lymphoma cases occur in abnormal B-cells.
Risk Factors and Symptoms
* Age — the most common types of non-Hodgkin's lymphoma occur more often in people age 60 and older
* Gender — the disease occurs equally in men and women
* Symptoms — swollen, painless lymph nodes in the neck, armpits or groin, weight loss, fever and excessive night sweats
* Screening — no screening tests for early detection are available, but a diagnosis can be made from a lymph node biopsy
Prognosis and Survival
* With appropriate treatment, about half of people with diffuse large B-cell lymphoma, a common and aggressive form of non-Hodgkin's lymphoma, can survive beyond five years
* Follicular lymphoma, a common form of low-grade lymphoma that progresses slowly, is not curable
o Several factors determine risk for follicular lymphoma, which correspond to survival rates, and include age, number of lymph nodes affected, whether the disease has spread beyond the lymph system, overall health and the amount of a specific protein (lactate dehydrogenase) in the blood
Follicular Lymphoma
Risk Group Description 5-Year Survival Rate
Low risk 0-1 98%
Intermediate risk 2-3 78%
High risk 4-5 53%
Treatment
* Treatment varies based on type and stage, size of the tumor and overall health; common options include a targeted medicine (monoclonal antibody), chemotherapy, radiation and radioimmunotherapy
* The goal of treating diffuse large B-cell lymphoma is to cure the disease; the current treatment goals for follicular lymphoma, an incurable form of the disease, include improving response and duration of response
Non-Hodgkin's lymphoma is a cancer of the white blood cells in the lymphatic system. There are two types of white blood cells that can give rise to non-Hodgkin's lymphoma, B-lymphocytes and T-lymphocytes. Of the more than 30 types of non-Hodgkin's lymphoma, diffuse large B-cell lymphoma and follicular (low-grade) lymphoma are the two most common. Approximately 85 percent of non-Hodgkin's lymphoma cases occur in abnormal B-cells.
Risk Factors and Symptoms
* Age — the most common types of non-Hodgkin's lymphoma occur more often in people age 60 and older
* Gender — the disease occurs equally in men and women
* Symptoms — swollen, painless lymph nodes in the neck, armpits or groin, weight loss, fever and excessive night sweats
* Screening — no screening tests for early detection are available, but a diagnosis can be made from a lymph node biopsy
Prognosis and Survival
* With appropriate treatment, about half of people with diffuse large B-cell lymphoma, a common and aggressive form of non-Hodgkin's lymphoma, can survive beyond five years
* Follicular lymphoma, a common form of low-grade lymphoma that progresses slowly, is not curable
o Several factors determine risk for follicular lymphoma, which correspond to survival rates, and include age, number of lymph nodes affected, whether the disease has spread beyond the lymph system, overall health and the amount of a specific protein (lactate dehydrogenase) in the blood
Follicular Lymphoma
Risk Group Description 5-Year Survival Rate
Low risk 0-1 98%
Intermediate risk 2-3 78%
High risk 4-5 53%
Treatment
* Treatment varies based on type and stage, size of the tumor and overall health; common options include a targeted medicine (monoclonal antibody), chemotherapy, radiation and radioimmunotherapy
* The goal of treating diffuse large B-cell lymphoma is to cure the disease; the current treatment goals for follicular lymphoma, an incurable form of the disease, include improving response and duration of response
Breast Cancer Tumor Marker Testing
Tumor markers are characteristics of cancer cells that can provide information to help treat different types of cancer. A variety of tests to identify breast cancer tumor markers can be performed.
Tumor marker testing provides vital information about the cancer at the cellular level. Together with physical characteristics, such as size, type and stage of the tumor, marker testing can help determine the appropriate medicine and timing of treatment needed to treat the disease most effectively.
Testing Tissue Samples
* When a woman is diagnosed with breast cancer, her doctor will often obtain a tissue sample from the tumor and send it to a laboratory for testing; the doctor will then receive a report outlining the test results.
* The American Society of Clinical Oncology (ASCO), the College of American Pathologists (CAP) and National Comprehensive Cancer Network (NCCN) have established guidelines regarding interpretation of tumor marker tests.
* Genentech does not endorse any specific tests, but believes tests should be used only after they have been reviewed and approved by the U.S. Food and Drug Administration (FDA).
Who Should be Tested
* Guidelines recommend that women with invasive breast cancer be tested for tumor markers.1,2
* A woman who has already had a biopsy (a sample taken from the tumor for testing) and knows she did not receive a tumor marker test for a specific characteristic may request a tumor marker test from her doctor.
* If a woman is told her sample is no longer being stored, she might consider requesting a new biopsy if her tumor is still present or if her breast cancer returns.
* Women should ask their doctor for additional information about testing.
Types of Tumor Marker Tests for Breast Cancer Human Epidermal Growth Factor Receptor 2 (HER2)
* Assessment of HER2 status is needed to decide if HER2-targeted medicines are appropriate1.
* Standard HER2 tests measure how many copies of the HER2 gene are present in tumor cells or how many HER2 receptors are on the surface of tumor cells; either method is appropriate for determining HER2 status.1
o Fluorescence in-situ Hybridization (FISH) — a gene-based diagnostic test used to identify women whose breast cancer cells carry amplified HER2 genes and therefore make too much HER2 protein.1
o Immunohistochemistry (IHC) — a protein-based diagnostic test used to identify women whose breast cancer cells overexpress the HER2 protein as a result of too many copies of the HER2 gene.1
o Tests are available for assessing HER2 status using other technologies, but not all are FDA-approved.1
* A tumor may be HER2-positive if the test shows a higher than normal number of HER2 genes or receptors.
* Approximately 15 to 30 percent of breast cancers are HER2-positive.3
Estrogen and Progesterone Receptors (ER and PR)
* Studies have shown that estrogen and progesterone, two of the female sex hormones, often contribute to the growth of breast cancer.
* Knowledge of whether a tumor is positive or negative for the presence of estrogen or progesterone receptors is used for determining prognosis and selection for anti-hormonal therapy.
During the clinical development process for each of our potential breast cancer therapies, Genentech evaluates tumor markers that will help healthcare providers identify patients who might benefit from our medicines. Each of our breast cancer therapies in development is being studied with an existing test or a new test is being developed. Genentech is committed to identifying individual patients that may benefit from our medicines.
Tumor marker testing provides vital information about the cancer at the cellular level. Together with physical characteristics, such as size, type and stage of the tumor, marker testing can help determine the appropriate medicine and timing of treatment needed to treat the disease most effectively.
Testing Tissue Samples
* When a woman is diagnosed with breast cancer, her doctor will often obtain a tissue sample from the tumor and send it to a laboratory for testing; the doctor will then receive a report outlining the test results.
* The American Society of Clinical Oncology (ASCO), the College of American Pathologists (CAP) and National Comprehensive Cancer Network (NCCN) have established guidelines regarding interpretation of tumor marker tests.
* Genentech does not endorse any specific tests, but believes tests should be used only after they have been reviewed and approved by the U.S. Food and Drug Administration (FDA).
Who Should be Tested
* Guidelines recommend that women with invasive breast cancer be tested for tumor markers.1,2
* A woman who has already had a biopsy (a sample taken from the tumor for testing) and knows she did not receive a tumor marker test for a specific characteristic may request a tumor marker test from her doctor.
* If a woman is told her sample is no longer being stored, she might consider requesting a new biopsy if her tumor is still present or if her breast cancer returns.
* Women should ask their doctor for additional information about testing.
Types of Tumor Marker Tests for Breast Cancer Human Epidermal Growth Factor Receptor 2 (HER2)
* Assessment of HER2 status is needed to decide if HER2-targeted medicines are appropriate1.
* Standard HER2 tests measure how many copies of the HER2 gene are present in tumor cells or how many HER2 receptors are on the surface of tumor cells; either method is appropriate for determining HER2 status.1
o Fluorescence in-situ Hybridization (FISH) — a gene-based diagnostic test used to identify women whose breast cancer cells carry amplified HER2 genes and therefore make too much HER2 protein.1
o Immunohistochemistry (IHC) — a protein-based diagnostic test used to identify women whose breast cancer cells overexpress the HER2 protein as a result of too many copies of the HER2 gene.1
o Tests are available for assessing HER2 status using other technologies, but not all are FDA-approved.1
* A tumor may be HER2-positive if the test shows a higher than normal number of HER2 genes or receptors.
* Approximately 15 to 30 percent of breast cancers are HER2-positive.3
Estrogen and Progesterone Receptors (ER and PR)
* Studies have shown that estrogen and progesterone, two of the female sex hormones, often contribute to the growth of breast cancer.
* Knowledge of whether a tumor is positive or negative for the presence of estrogen or progesterone receptors is used for determining prognosis and selection for anti-hormonal therapy.
During the clinical development process for each of our potential breast cancer therapies, Genentech evaluates tumor markers that will help healthcare providers identify patients who might benefit from our medicines. Each of our breast cancer therapies in development is being studied with an existing test or a new test is being developed. Genentech is committed to identifying individual patients that may benefit from our medicines.
Colorectal Cancer
Colorectal cancer is the third most commonly diagnosed cancer in both men and women in the United States and the third leading cause of cancer deaths.1 In 2009, more than 146,000 people will be diagnosed and nearly 50,000 individuals will die from the disease in the United States.1
Colorectal cancer is the uncontrolled growth of cancerous cells originating in either the colon or the rectum. While the specific cause is unknown, the most common type, adenocarcinoma, begins in the lining of the colon or rectum, and accounts for approximately 95 percent of tumors.2 Adenocarcinomas are preceded by colorectal polyps (adenomas).2
Risk Factors and Symptoms
* Age — more than 90 percent of colorectal cancers occur in people age 50 and older.1
* Gender — colorectal cancer strikes men and women equally.1
* Risk factors — colorectal polyps or chronic inflammatory bowel disease (Crohn's disease or ulcerative colitis), family history of colorectal cancer, obesity, diabetes and smoking.1
* Symptoms — changes in bowel habits (diarrhea and/or constipation), constant need to evacuate the bowel, blood in the stool, and cramping and/or steady abdominal/ stomach pain3
Prognosis and Survival
* More than 90 percent of individuals diagnosed with early-stage colorectal cancer that has not spread (metastasized) beyond the colon or the rectum survive five years; many live much longer.4
* Sixty-eight percent of people whose colorectal cancer spreads to nearby lymph nodes or organs will survive five years.1
* If colorectal cancer spreads to distant organs, such as the lungs or the liver, 5-year survival declines to 11 percent.1
Stage
Description
5-Year Survival Rate4
Stage I
Tumor is limited to the inner layer of the colon
93%
Stage IIA
Tumor has spread to the outer layers of the colon
85%
Stage IIB
72%
Stage IIIA
Tumor has spread to the outer layers of the colon and to nearby lymph nodes or other organs and tissues
83%
Stage IIIB
64%
Stage IIIC
44%
Stage IV
Tumor has spread to organs and lymph nodes beyond the colon
8%
Treatment
* Standard treatments include surgery, radiation therapy, chemotherapy and targeted medicines (monoclonal antibodies).5
* Depending on the stage of cancer and if it has spread to other organs, treatments may be combined or administered sequentially.5
References 1 American Cancer Society. Cancer Facts and Figures 2009. Available at http://www.cancer.org/downloads/STT/500809web.pdf. Accessed May 5, 2009.
2 American Cancer Society. Cancer Reference Information: What Is Colorectal Cancer? Available at http://www.cancer.org. Accessed February 24, 2009.
3 American Cancer Society. Cancer Reference Information: How Is Colorectal Cancer Diagnosed? Available at http://www.cancer.org. Accessed February 24, 2009.
4 American Cancer Society. Cancer Reference Information: How Is Colorectal Cancer Staged? http://www.cancer.org. Accessed March 23, 2009.
5 American Cancer Society. Cancer Reference Information: How is Colorectal Cancer Treated? Available at http://www.cancer.org. Accessed February 24, 2009.
Colorectal cancer is the uncontrolled growth of cancerous cells originating in either the colon or the rectum. While the specific cause is unknown, the most common type, adenocarcinoma, begins in the lining of the colon or rectum, and accounts for approximately 95 percent of tumors.2 Adenocarcinomas are preceded by colorectal polyps (adenomas).2
Risk Factors and Symptoms
* Age — more than 90 percent of colorectal cancers occur in people age 50 and older.1
* Gender — colorectal cancer strikes men and women equally.1
* Risk factors — colorectal polyps or chronic inflammatory bowel disease (Crohn's disease or ulcerative colitis), family history of colorectal cancer, obesity, diabetes and smoking.1
* Symptoms — changes in bowel habits (diarrhea and/or constipation), constant need to evacuate the bowel, blood in the stool, and cramping and/or steady abdominal/ stomach pain3
Prognosis and Survival
* More than 90 percent of individuals diagnosed with early-stage colorectal cancer that has not spread (metastasized) beyond the colon or the rectum survive five years; many live much longer.4
* Sixty-eight percent of people whose colorectal cancer spreads to nearby lymph nodes or organs will survive five years.1
* If colorectal cancer spreads to distant organs, such as the lungs or the liver, 5-year survival declines to 11 percent.1
Stage
Description
5-Year Survival Rate4
Stage I
Tumor is limited to the inner layer of the colon
93%
Stage IIA
Tumor has spread to the outer layers of the colon
85%
Stage IIB
72%
Stage IIIA
Tumor has spread to the outer layers of the colon and to nearby lymph nodes or other organs and tissues
83%
Stage IIIB
64%
Stage IIIC
44%
Stage IV
Tumor has spread to organs and lymph nodes beyond the colon
8%
Treatment
* Standard treatments include surgery, radiation therapy, chemotherapy and targeted medicines (monoclonal antibodies).5
* Depending on the stage of cancer and if it has spread to other organs, treatments may be combined or administered sequentially.5
References 1 American Cancer Society. Cancer Facts and Figures 2009. Available at http://www.cancer.org/downloads/STT/500809web.pdf. Accessed May 5, 2009.
2 American Cancer Society. Cancer Reference Information: What Is Colorectal Cancer? Available at http://www.cancer.org. Accessed February 24, 2009.
3 American Cancer Society. Cancer Reference Information: How Is Colorectal Cancer Diagnosed? Available at http://www.cancer.org. Accessed February 24, 2009.
4 American Cancer Society. Cancer Reference Information: How Is Colorectal Cancer Staged? http://www.cancer.org. Accessed March 23, 2009.
5 American Cancer Society. Cancer Reference Information: How is Colorectal Cancer Treated? Available at http://www.cancer.org. Accessed February 24, 2009.
AVASTIN
Full Prescribing Information
Avastin (RPLS) Dear Healthcare Provider Letter (76K/PDF)
Lucentis/Avastin Dear Healthcare Provider Letter (469K/PDF)
Avastin (TE Fistula) Dear Healthcare Provider Letter (75K/PDF)
Avastin (MAHA) Dear Healthcare Provider Letter (66K/PDF)
Avastin® (bevacizumab) is the first U.S. Food and Drug Administration (FDA) approved therapy designed to inhibit angiogenesis, the process by which new blood vessels develop and carry vital nutrients to a tumor.
Avastin is approved, in combination with intravenous 5-fluorouracil-based (5-FU) chemotherapy, for first- or second-line treatment of patients with metastatic carcinoma of the colon or rectum; in combination with carboplatin and paclitaxel for the first-line treatment of patients with unresectable, locally advanced, recurrent or metastatic non-squamous non-small cell lung cancer (NSCLC); and for the treatment of metastatic renal cell carcinoma in combination with interferon alfa.
Avastin is also approved, in combination with paclitaxel, for the treatment of patients who have not received chemotherapy for metastatic HER2-negative breast cancer. The effectiveness of Avastin in metastatic breast cancer is based on an improvement in progression-free survival. Avastin is not indicated for patients with breast cancer that has progressed following anthracycline and taxane chemotherapy administered for metastatic disease. Currently, no data are available that demonstrate an improvement in disease-related symptoms or increased survival with Avastin in breast cancer.
Status The FDA approved Avastin in February 2004 for use in combination with intravenous 5-FU-based chemotherapy as a treatment for first-line metastatic colorectal cancer. In June 2006, the FDA approved Avastin in combination with intravenous 5-FU-based chemotherapy for patients with metastatic colorectal cancer who have been previously treated for their cancer (or second-line metastatic colorectal cancer). In October 2006, the FDA approved Avastin in combination with carboplatin and paclitaxel for the first-line treatment of patients with unresectable, locally advanced, recurrent or metastatic non-squamous NSCLC.
The original Avastin FDA approval was based on data from a large, placebo controlled, randomized study demonstrating prolongation in the median survival of patients treated with Avastin plus the IFL (5-FU/Leucovorin/CPT-11) chemotherapy regimen by approximately five months, compared to patients treated with the IFL chemotherapy regimen alone (20.3 months versus 15.6 months). This is one of the largest improvements in survival ever reported in a randomized, Phase III study of patients with metastatic colorectal cancer.
The second approval was based on results of a randomized, controlled, multicenter Phase III trial (E3200) of 829 patients with advanced or metastatic colorectal cancer who had received previous treatment with irinotecan and 5-FU as initial therapy for metastatic disease or as adjuvant therapy. The study showed that patients who received Avastin plus the 5-FU-based chemotherapy regimen known as FOLFOX4 (oxaliplatin/5-FU/leucovorin) had a 25 percent reduction in the risk of death (based on a hazard ratio of 0.75), the primary endpoint, which is equivalent to a 33 percent improvement in overall survival, compared to patients who received FOLFOX4 alone. Median survival for patients receiving Avastin plus FOLFOX4 was 13.0 months, compared to 10.8 months for those receiving FOLFOX4 alone.
The third approval was based on results from E4599, a randomized, controlled, multicenter trial that enrolled 878 patients with unresectable, locally advanced, recurrent or metastatic non-squamous NSCLC. The most common Grade 3-5 (severe) adverse events in Study E4599 seen in Avastin-treated patients, were neutropenia (low white blood cell count), fatigue, hypertension (high blood pressure), infection and hemorrhage. Results showed that patients receiving Avastin plus paclitaxel and carboplatin chemotherapies had a 25 percent improvement in overall survival, the trial's primary endpoint, compared to patients who received chemotherapy alone (based on a hazard ratio of 0.80). One-year survival was 51 percent in the Avastin arm versus 44 percent in the chemotherapy-alone arm. Median survival of patients treated with Avastin plus chemotherapy was 12.3 months, compared to 10.3 months for patients treated with chemotherapy alone.
The FDA granted accelerated approval for Avastin in combination with paclitaxel chemotherapy for the first-line treatment of advanced HER2-negative breast cancer in February 2008.
Safety Patients treated with targeted therapies, including Avastin, may experience side effects. In clinical trials, some patients treated with Avastin experienced serious side effects, including:
Gastrointestinal (GI) perforation: The incidences of GI perforation, some fatal, in Avastin-treated patients range from 0.3% to 2.4%. Discontinue Avastin in patients with GI perforation.
Surgery and wound healing complications: The incidence of wound healing and surgical complications, including serious and fatal complications, is increased in Avastin-treated patients. Do not initiate Avastin for at least 28 days after surgery or until the surgical wound is fully healed. The appropriate interval between termination of Avastin and subsequent elective surgery required to reduce the risks of impaired wound healing/wound dehiscence has not been determined. Discontinue Avastin at least 28 days prior to elective surgery and in patients with wound dehiscence requiring medical intervention.
Hemorrhage: Severe or fatal hemorrhage, including hemoptysis, GI bleeding, central nervous system hemorrhage, epistaxis, and vaginal bleeding, occurred up to 5-fold more frequently in patients receiving Avastin. Across indications, the incidence of grade >3 hemorrhagic events among patients receiving Avastin ranged from 1.2% to 4.6%. Do not administer Avastin to patients with serious hemorrhage or recent hemoptysis (>1/2 tsp of red blood). Discontinue Avastin in patients with serious hemorrhage (i.e., requiring medical intervention).
Additional serious adverse events for which the incidence was increased in the Avastin-treated arm vs control included non-GI fistula formation (<0.3%), arterial thromboembolic events (grade >3, 2.4%), hypertension (grade >3, 5%-18%), reversible posterior leukoencephalopathy syndrome (RPLS) (<0.1%), and proteinuria including nephrotic syndrome (<1%). Infusion reactions with the first dose of Avastin were uncommon (<3%), and severe reactions occurred in 0.2% of patients. The most common grade 3-5 (nonhematologic) and 4-5 (hematologic) events that occurred at a higher incidence in the Avastin-treated arms included neutropenia, fatigue, hypertension, infection, hemorrhage, asthenia, abdominal pain, pain, deep vein thrombosis, intra-abdominal thrombosis, syncope, diarrhea, constipation, leukopenia, nausea, vomiting, dehydration, ileus, neuropathy-sensory, neurologic-other, headache, infection without neutropenia, proteinuria, and cerebrovascular ischemia. The most common adverse reactions observed in Avastin patients at a rate >10% and at least twice the control arm rate were epistaxis, headache, hypertension, rhinitis, proteinuria, taste alteration, dry skin, rectal hemorrhage, lacrimation disorder, back pain, and exfoliative dermatitis.
Please see the Avastin full prescribing information including Boxed WARNINGS and additional important safety information.
Proposed Mechanism of Action Avastin is a therapeutic antibody that is believed to work by targeting and inhibiting the function of a natural protein called "vascular endothelial growth factor" (VEGF) that stimulates new blood vessel formation, a process known as angiogenesis. Researchers have shown in preclinical models that anti-VEGF agents like Avastin may work by causing the following changes to occur in the blood vessels supporting tumor growth (tumor vasculature):
* Regression of existing microvessels — helps arrest tumor growth and reduce tumor size
* "Normalization" of surviving mature vasculature — makes the tumor vasculature more conducive to effective anti-cancer therapy
* Inhibition of vessel growth and neovascularization (e.g., the sprouting of new micro-vasculature from existing vessels)
Colorectal Cancer According to the American Cancer Society, every ten minutes someone dies from colorectal cancer in the United States. Colorectal cancer is the third leading cause of cancer death in the U.S. and the third most frequently diagnosed cancer in both men and women in the U.S. The ACS estimates there will be 148,000 new cases of colorectal cancer diagnosed and nearly 50,000 colorectal cancer deaths in 2008. Colorectal cancer begins in either the colon or the rectum. The colon and rectum form part of the body's digestive system, which separates nutrients and waste from food and stores the latter until it can be passed out of the body. The colon has four sections: the ascending colon, the transverse colon, the descending colon and the sigmoid colon. Cancer can start in any portion of the colon or the rectum. About 95 percent of colorectal cancers are adenocarcinomas, which are cancers of the cells lining the inside of the colon and rectum.
Lung Cancer Lung cancer is one of the most common cancers, with newly diagnosed cases expected to exceed 215,000 in the U.S. this year. Lung cancer is the leading cause of cancer deaths, accounting for approximately 30 percent of all cancer deaths (more than breast, colon and liver cancers combined) expected to occur in the U.S. this year. In 2005, lung cancer killed an estimated 1.3 million people worldwide.
Breast Cancer According to the American Cancer Society, in 2008 an estimated 182,000 American women will be diagnosed with breast cancer. Currently, there are approximately 2.5 million breast cancer survivors in the United States.
Clinical Trials Based on data showing that VEGF may play a broad role in a range of cancers, a global development program for Avastin currently includes more than 450 clinical trials in more than 30 different tumor types, including early-stage cancers. It is also being studied in combination with other targeted therapy agents in the absence of chemotherapy.
Avastin (RPLS) Dear Healthcare Provider Letter (76K/PDF)
Lucentis/Avastin Dear Healthcare Provider Letter (469K/PDF)
Avastin (TE Fistula) Dear Healthcare Provider Letter (75K/PDF)
Avastin (MAHA) Dear Healthcare Provider Letter (66K/PDF)
Avastin® (bevacizumab) is the first U.S. Food and Drug Administration (FDA) approved therapy designed to inhibit angiogenesis, the process by which new blood vessels develop and carry vital nutrients to a tumor.
Avastin is approved, in combination with intravenous 5-fluorouracil-based (5-FU) chemotherapy, for first- or second-line treatment of patients with metastatic carcinoma of the colon or rectum; in combination with carboplatin and paclitaxel for the first-line treatment of patients with unresectable, locally advanced, recurrent or metastatic non-squamous non-small cell lung cancer (NSCLC); and for the treatment of metastatic renal cell carcinoma in combination with interferon alfa.
Avastin is also approved, in combination with paclitaxel, for the treatment of patients who have not received chemotherapy for metastatic HER2-negative breast cancer. The effectiveness of Avastin in metastatic breast cancer is based on an improvement in progression-free survival. Avastin is not indicated for patients with breast cancer that has progressed following anthracycline and taxane chemotherapy administered for metastatic disease. Currently, no data are available that demonstrate an improvement in disease-related symptoms or increased survival with Avastin in breast cancer.
Status The FDA approved Avastin in February 2004 for use in combination with intravenous 5-FU-based chemotherapy as a treatment for first-line metastatic colorectal cancer. In June 2006, the FDA approved Avastin in combination with intravenous 5-FU-based chemotherapy for patients with metastatic colorectal cancer who have been previously treated for their cancer (or second-line metastatic colorectal cancer). In October 2006, the FDA approved Avastin in combination with carboplatin and paclitaxel for the first-line treatment of patients with unresectable, locally advanced, recurrent or metastatic non-squamous NSCLC.
The original Avastin FDA approval was based on data from a large, placebo controlled, randomized study demonstrating prolongation in the median survival of patients treated with Avastin plus the IFL (5-FU/Leucovorin/CPT-11) chemotherapy regimen by approximately five months, compared to patients treated with the IFL chemotherapy regimen alone (20.3 months versus 15.6 months). This is one of the largest improvements in survival ever reported in a randomized, Phase III study of patients with metastatic colorectal cancer.
The second approval was based on results of a randomized, controlled, multicenter Phase III trial (E3200) of 829 patients with advanced or metastatic colorectal cancer who had received previous treatment with irinotecan and 5-FU as initial therapy for metastatic disease or as adjuvant therapy. The study showed that patients who received Avastin plus the 5-FU-based chemotherapy regimen known as FOLFOX4 (oxaliplatin/5-FU/leucovorin) had a 25 percent reduction in the risk of death (based on a hazard ratio of 0.75), the primary endpoint, which is equivalent to a 33 percent improvement in overall survival, compared to patients who received FOLFOX4 alone. Median survival for patients receiving Avastin plus FOLFOX4 was 13.0 months, compared to 10.8 months for those receiving FOLFOX4 alone.
The third approval was based on results from E4599, a randomized, controlled, multicenter trial that enrolled 878 patients with unresectable, locally advanced, recurrent or metastatic non-squamous NSCLC. The most common Grade 3-5 (severe) adverse events in Study E4599 seen in Avastin-treated patients, were neutropenia (low white blood cell count), fatigue, hypertension (high blood pressure), infection and hemorrhage. Results showed that patients receiving Avastin plus paclitaxel and carboplatin chemotherapies had a 25 percent improvement in overall survival, the trial's primary endpoint, compared to patients who received chemotherapy alone (based on a hazard ratio of 0.80). One-year survival was 51 percent in the Avastin arm versus 44 percent in the chemotherapy-alone arm. Median survival of patients treated with Avastin plus chemotherapy was 12.3 months, compared to 10.3 months for patients treated with chemotherapy alone.
The FDA granted accelerated approval for Avastin in combination with paclitaxel chemotherapy for the first-line treatment of advanced HER2-negative breast cancer in February 2008.
Safety Patients treated with targeted therapies, including Avastin, may experience side effects. In clinical trials, some patients treated with Avastin experienced serious side effects, including:
Gastrointestinal (GI) perforation: The incidences of GI perforation, some fatal, in Avastin-treated patients range from 0.3% to 2.4%. Discontinue Avastin in patients with GI perforation.
Surgery and wound healing complications: The incidence of wound healing and surgical complications, including serious and fatal complications, is increased in Avastin-treated patients. Do not initiate Avastin for at least 28 days after surgery or until the surgical wound is fully healed. The appropriate interval between termination of Avastin and subsequent elective surgery required to reduce the risks of impaired wound healing/wound dehiscence has not been determined. Discontinue Avastin at least 28 days prior to elective surgery and in patients with wound dehiscence requiring medical intervention.
Hemorrhage: Severe or fatal hemorrhage, including hemoptysis, GI bleeding, central nervous system hemorrhage, epistaxis, and vaginal bleeding, occurred up to 5-fold more frequently in patients receiving Avastin. Across indications, the incidence of grade >3 hemorrhagic events among patients receiving Avastin ranged from 1.2% to 4.6%. Do not administer Avastin to patients with serious hemorrhage or recent hemoptysis (>1/2 tsp of red blood). Discontinue Avastin in patients with serious hemorrhage (i.e., requiring medical intervention).
Additional serious adverse events for which the incidence was increased in the Avastin-treated arm vs control included non-GI fistula formation (<0.3%), arterial thromboembolic events (grade >3, 2.4%), hypertension (grade >3, 5%-18%), reversible posterior leukoencephalopathy syndrome (RPLS) (<0.1%), and proteinuria including nephrotic syndrome (<1%). Infusion reactions with the first dose of Avastin were uncommon (<3%), and severe reactions occurred in 0.2% of patients. The most common grade 3-5 (nonhematologic) and 4-5 (hematologic) events that occurred at a higher incidence in the Avastin-treated arms included neutropenia, fatigue, hypertension, infection, hemorrhage, asthenia, abdominal pain, pain, deep vein thrombosis, intra-abdominal thrombosis, syncope, diarrhea, constipation, leukopenia, nausea, vomiting, dehydration, ileus, neuropathy-sensory, neurologic-other, headache, infection without neutropenia, proteinuria, and cerebrovascular ischemia. The most common adverse reactions observed in Avastin patients at a rate >10% and at least twice the control arm rate were epistaxis, headache, hypertension, rhinitis, proteinuria, taste alteration, dry skin, rectal hemorrhage, lacrimation disorder, back pain, and exfoliative dermatitis.
Please see the Avastin full prescribing information including Boxed WARNINGS and additional important safety information.
Proposed Mechanism of Action Avastin is a therapeutic antibody that is believed to work by targeting and inhibiting the function of a natural protein called "vascular endothelial growth factor" (VEGF) that stimulates new blood vessel formation, a process known as angiogenesis. Researchers have shown in preclinical models that anti-VEGF agents like Avastin may work by causing the following changes to occur in the blood vessels supporting tumor growth (tumor vasculature):
* Regression of existing microvessels — helps arrest tumor growth and reduce tumor size
* "Normalization" of surviving mature vasculature — makes the tumor vasculature more conducive to effective anti-cancer therapy
* Inhibition of vessel growth and neovascularization (e.g., the sprouting of new micro-vasculature from existing vessels)
Colorectal Cancer According to the American Cancer Society, every ten minutes someone dies from colorectal cancer in the United States. Colorectal cancer is the third leading cause of cancer death in the U.S. and the third most frequently diagnosed cancer in both men and women in the U.S. The ACS estimates there will be 148,000 new cases of colorectal cancer diagnosed and nearly 50,000 colorectal cancer deaths in 2008. Colorectal cancer begins in either the colon or the rectum. The colon and rectum form part of the body's digestive system, which separates nutrients and waste from food and stores the latter until it can be passed out of the body. The colon has four sections: the ascending colon, the transverse colon, the descending colon and the sigmoid colon. Cancer can start in any portion of the colon or the rectum. About 95 percent of colorectal cancers are adenocarcinomas, which are cancers of the cells lining the inside of the colon and rectum.
Lung Cancer Lung cancer is one of the most common cancers, with newly diagnosed cases expected to exceed 215,000 in the U.S. this year. Lung cancer is the leading cause of cancer deaths, accounting for approximately 30 percent of all cancer deaths (more than breast, colon and liver cancers combined) expected to occur in the U.S. this year. In 2005, lung cancer killed an estimated 1.3 million people worldwide.
Breast Cancer According to the American Cancer Society, in 2008 an estimated 182,000 American women will be diagnosed with breast cancer. Currently, there are approximately 2.5 million breast cancer survivors in the United States.
Clinical Trials Based on data showing that VEGF may play a broad role in a range of cancers, a global development program for Avastin currently includes more than 450 clinical trials in more than 30 different tumor types, including early-stage cancers. It is also being studied in combination with other targeted therapy agents in the absence of chemotherapy.
Saturday, August 22, 2009
health
A source for alternative medical information that covers complementary therapies, herbs and remedies, and common medical diseases and conditions.
Examples: T'ai chi , meditation , Journal Therapy , more »
Anatomy Q&A:
Helps unravel the complexities and mysteries of how the human body works
Examples: How is the field of anatomy divided into subdivisions? , What are some specialties of physiology? , Which scientific disciplines study the human body? , more »
Aromatherapy:
Herbs and their uses in aromatherapy
Examples: Tea Tree , bergamot , myrrh , more »
Children's Health Encyclopedia:
Wide variety of health issues related to children, ranging from prenatal to adolescence.
Examples: Well-Baby Examination , night terror , Adaptive Behavior Scales for Infants and Early Childhood , more »
Dental Dictionary:
Definitions for words used in dentistry and all related medical fields, as well as law and insurance
Examples: cleoid , amalgam squeeze cloth , horizontal loss of bone , more »
Drug Info:
Drugs and their interactions, dosage, effects and side effects
Examples: Haemophilus influenzae type b Conjugate Vaccine , Telmisartan , Abciximab , more »
Genetics Encyclopedia:
Comprehensive and accessible reference for understanding the rapidly changing field of genetics
Examples: Androgen Insensitivity Syndrome , Inheritance Patterns , Arabidopsis thaliana , more »
Health Dictionary:
Terms associated with health, and their definitions
Examples: evolutionary medicine , biofeedback , Parkinson's disease , more »
Medical Dictionary:
Medical terms and abbreviations, with definitions
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Medical Encyclopedia:
Medical reference product designed to inform and educate readers about a wide variety of disorders, conditions, treatments, and diagnostic tests.
Examples: Retinoblastoma , Macular Degeneration , Echocardiography , more »
Medical Glossary:
Short descriptions of medical terms.
Examples: Papanicolaou or Pap smear , Kasabach-Merrit syndrome , Generalized infection , more »
Medical Tests:
Description of medical tests
Examples: amniocentesis , colonoscopy , cardiac catheterization and angiography , more »
Neurological Encyclopedia:
The Gale Encyclopedia of Neurological Disorders
Examples: repetitive motion disorders , motor neuron disease , attention deficit hyperactivity disorder , more »
Oncology Encyclopedia:
A guide to cancer and its treatments.
Examples: Immunologic therapies , Familial cancer syndromes , Cancer prevention , more »
Phobias:
Phobias and their descriptions
Examples: friendorphobia , bibliophobia , friggaphobia , more »
Psychoanalysis Dictionary:
The concepts, history, people and institutions of psychoanalysis
Examples: Case Histories , William C. Bullitt , Animal Magnetism , more »
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Information about important aspects of the sciences, organization, essential functions, and historical traditions of the public health field.
Examples: Periodic Health Examination , family planning , Ambient Air Quality (Air Pollution) , more »
Sports Science and Medicine:
Terms related to health and fitness, from anatomy to sports psychology
Examples: gender verification , eccentric action , baseball finger , more »
Surgical Encyclopedia:
Surgical terms
Examples: General Anesthesia , kidney transplantation , Deep Brain Stimulation , more »
World of the Body:
The body and its growth, development, disorders, and role in religion and culture
Examples: alimentary system , breathing during exercise , body language , more »
World of the Mind:
Every important aspect of the mind, brain and consciousness
Examples: common sense , cocktail party effect , more »
Examples: T'ai chi , meditation , Journal Therapy , more »
Anatomy Q&A:
Helps unravel the complexities and mysteries of how the human body works
Examples: How is the field of anatomy divided into subdivisions? , What are some specialties of physiology? , Which scientific disciplines study the human body? , more »
Aromatherapy:
Herbs and their uses in aromatherapy
Examples: Tea Tree , bergamot , myrrh , more »
Children's Health Encyclopedia:
Wide variety of health issues related to children, ranging from prenatal to adolescence.
Examples: Well-Baby Examination , night terror , Adaptive Behavior Scales for Infants and Early Childhood , more »
Dental Dictionary:
Definitions for words used in dentistry and all related medical fields, as well as law and insurance
Examples: cleoid , amalgam squeeze cloth , horizontal loss of bone , more »
Drug Info:
Drugs and their interactions, dosage, effects and side effects
Examples: Haemophilus influenzae type b Conjugate Vaccine , Telmisartan , Abciximab , more »
Genetics Encyclopedia:
Comprehensive and accessible reference for understanding the rapidly changing field of genetics
Examples: Androgen Insensitivity Syndrome , Inheritance Patterns , Arabidopsis thaliana , more »
Health Dictionary:
Terms associated with health, and their definitions
Examples: evolutionary medicine , biofeedback , Parkinson's disease , more »
Medical Dictionary:
Medical terms and abbreviations, with definitions
Examples: temporal fossa , semilunar , Gardner's syndrome , more »
Medical Encyclopedia:
Medical reference product designed to inform and educate readers about a wide variety of disorders, conditions, treatments, and diagnostic tests.
Examples: Retinoblastoma , Macular Degeneration , Echocardiography , more »
Medical Glossary:
Short descriptions of medical terms.
Examples: Papanicolaou or Pap smear , Kasabach-Merrit syndrome , Generalized infection , more »
Medical Tests:
Description of medical tests
Examples: amniocentesis , colonoscopy , cardiac catheterization and angiography , more »
Neurological Encyclopedia:
The Gale Encyclopedia of Neurological Disorders
Examples: repetitive motion disorders , motor neuron disease , attention deficit hyperactivity disorder , more »
Oncology Encyclopedia:
A guide to cancer and its treatments.
Examples: Immunologic therapies , Familial cancer syndromes , Cancer prevention , more »
Phobias:
Phobias and their descriptions
Examples: friendorphobia , bibliophobia , friggaphobia , more »
Psychoanalysis Dictionary:
The concepts, history, people and institutions of psychoanalysis
Examples: Case Histories , William C. Bullitt , Animal Magnetism , more »
Public Health Encyclopedia:
Information about important aspects of the sciences, organization, essential functions, and historical traditions of the public health field.
Examples: Periodic Health Examination , family planning , Ambient Air Quality (Air Pollution) , more »
Sports Science and Medicine:
Terms related to health and fitness, from anatomy to sports psychology
Examples: gender verification , eccentric action , baseball finger , more »
Surgical Encyclopedia:
Surgical terms
Examples: General Anesthesia , kidney transplantation , Deep Brain Stimulation , more »
World of the Body:
The body and its growth, development, disorders, and role in religion and culture
Examples: alimentary system , breathing during exercise , body language , more »
World of the Mind:
Every important aspect of the mind, brain and consciousness
Examples: common sense , cocktail party effect , more »
Research Publications/ Articles
Rizamukhamedova M.Z., Shiranov I.A and Matchanov S.H. (date?). Enzymotherapy system of Kontab® (Bromelain and trypsin) on the patients of Rheumatic heart disease. Tashkent Medical Academy , Republic of Uzbekistan
• Sadia et al., (2007). Randomized trial on liquid antacids: A comparative study on palatability, efficacy and cost. Pakistan Medical Research Council and H.E.J Research Institute of Chemistry
• Joachim W. Herzig.(1999). Pharmacokinetic study of Roxin 500mg in healthy human volunteers. The Agha Khan University Hospital
• Khan M.A.S., Roohi B and Obaid A. (2002).Effect of food on the pharmacokinetics of orally administered Mefenamic acid tablets (250mg) Bioavailibility studies of Mefenamic acid tablets (250mg). R.O. Pharmaceutical Consultancy services and Central Laboratory, Ministry of Health, Govt of Pakistan
• Sadia et al., (2007). Randomized trial on liquid antacids: A comparative study on palatability, efficacy and cost. Pakistan Medical Research Council and H.E.J Research Institute of Chemistry
• Joachim W. Herzig.(1999). Pharmacokinetic study of Roxin 500mg in healthy human volunteers. The Agha Khan University Hospital
• Khan M.A.S., Roohi B and Obaid A. (2002).Effect of food on the pharmacokinetics of orally administered Mefenamic acid tablets (250mg) Bioavailibility studies of Mefenamic acid tablets (250mg). R.O. Pharmaceutical Consultancy services and Central Laboratory, Ministry of Health, Govt of Pakistan
New Product Development
The main focus of the New Product Research and Development program is to develop a patient acquiescent product with potent efficacy and safety. This requires comprehensive pre-formulation studies, Formulation development including optimizations, selection of suitable excipients, in vitro bioavailability/bioequivalence studies and formal stability studies according to ICH Guidelines. Efroze Chemicals has acquired sophisticated modern instruments for pharmaceutical research and routine analysis. These facilities make this organization one of the finest in the developing world. This includes latest version HPLC systems, LC-2010HT Series (Shimadzu Scientific Instruments), HPLC VP series with Autosampler (Shimadzu Scientific Instruments), UV-Vis Detector, RID detector and Fluorescence Detector, Gas Chromatography system GC-17A (Shimadzu Scientific Instruments), FT-NIR Spectrometer EP-Series (Perkin Elmer), Total Organic Carbon Analyzer, TOC-VCHS series (Shimadzu). The research department is equipped with other aligned instruments of high precision used in pharmaceutical formulation development..
Sales and Distribution
Efroze Distribution department has been the forefront of Marketing and sales efforts by anticipating the customer need investing in the resources to meet those needs, and delivering consistently and reliably. We strive each day to earn the trust of health system pharmacies that depend on our distribution strength. Our entire organization is driven to deliver to health system pharmacies — empowering you to deliver the highest quality patient care.
International Divisio
After ascertaining its credentials in the pharmaceutical industry of the country, international expansion is a priority for Efroze. Efroze began spreading its wing beyond Pakistan with thrust on becoming global player in the international market. Efroze is the only enterprise in Pharmaceutical Industry in Pakistan, amply recognized with 3 consecutive Export Merit Trophy, bestowed by the government of Pakistan for the 2005, 2006 and 2007.
The IMD team is completely geared for it in terms of technical capabilities, regulatory compliances, cost advantages and geographical reach.
With over 200 registrations in 27 countries Efroze has achieved good reputation in the medical fraternity and end consumers.
Read More about Efroze major export territories:
International Division Country
Afghanistan
Bangladesh
Belarus
Ghana
Kenya
Kyrgyzstan
Myanmar
Nigeria
Singapore
SriLanka
Sudan
Uzbekistan
Yemen
The IMD team is completely geared for it in terms of technical capabilities, regulatory compliances, cost advantages and geographical reach.
With over 200 registrations in 27 countries Efroze has achieved good reputation in the medical fraternity and end consumers.
Read More about Efroze major export territories:
International Division Country
Afghanistan
Bangladesh
Belarus
Ghana
Kenya
Kyrgyzstan
Myanmar
Nigeria
Singapore
SriLanka
Sudan
Uzbekistan
Yemen
Domestic Marketing
Marketing and sales team of Efroze Chemical Industries Pvt. Ltd.
work as the health administrator satisfying the needs of community
at every nick and corner of the State. The optimum health care services
are rendered through Efroze brands which are being considered as a
vital source of health within the end consumers.
The four guiding principles that derives the marketing strategy of Efroze are...
Knowledge Based Promotion:
Marketing platform of Efroze delivers the huge benefit of products through ethically designed promotional strategies. Essentially,these criteria ensure that a products will be promoted in the marketplace with a message that is focused, competitively advantageous, relevant and evocative to target audience segments, clinically supportable, and sustainable over time.
Building Loyalty:
Efroze marketers try to ensure that their product doesn’t either go out of fashion or be entirely superseded by alternative medicines. The continuous medical education programs by Efroze ensure our practitioner that long term relationship building with their patients will be regarded as the rationale for the adequate treatment. For us brand loyalty is an integral part of value adding processes for our doctors and end users.
Parameters Not Formulas:
There is no set formula to devising the marketing and sales strategies. Every product of Efroze is different and respectively faces its own unique confluence of factors influencing its performance over time. The parameters are defined with respect to sales and market share and each of these parameters should be reviewed as frequently as possible through external market conditions, other corporate priorities, pricing changes, and new or revived competitors.
Meeting the Genuine need:
Continuing to meet a genuine need is of crucial importance for us, it means offering a product that deals with customer need that recognise by them for their patients in the mainstream marketplace.
work as the health administrator satisfying the needs of community
at every nick and corner of the State. The optimum health care services
are rendered through Efroze brands which are being considered as a
vital source of health within the end consumers.
The four guiding principles that derives the marketing strategy of Efroze are...
Knowledge Based Promotion:
Marketing platform of Efroze delivers the huge benefit of products through ethically designed promotional strategies. Essentially,these criteria ensure that a products will be promoted in the marketplace with a message that is focused, competitively advantageous, relevant and evocative to target audience segments, clinically supportable, and sustainable over time.
Building Loyalty:
Efroze marketers try to ensure that their product doesn’t either go out of fashion or be entirely superseded by alternative medicines. The continuous medical education programs by Efroze ensure our practitioner that long term relationship building with their patients will be regarded as the rationale for the adequate treatment. For us brand loyalty is an integral part of value adding processes for our doctors and end users.
Parameters Not Formulas:
There is no set formula to devising the marketing and sales strategies. Every product of Efroze is different and respectively faces its own unique confluence of factors influencing its performance over time. The parameters are defined with respect to sales and market share and each of these parameters should be reviewed as frequently as possible through external market conditions, other corporate priorities, pricing changes, and new or revived competitors.
Meeting the Genuine need:
Continuing to meet a genuine need is of crucial importance for us, it means offering a product that deals with customer need that recognise by them for their patients in the mainstream marketplace.
Pfizer Pharmaceutical Facility, Skokie, IL, USA
tart year
2005
Project type
Refurbished biotech campus
Location
Skokie, Illinois, USA
Estimated investment
$43m (but investment could reach $155m over the period from 2005 to 2010)
Completion
2010
Sponsor
Forest City Development, iBIO, Forest City (Bioscience & Technology Group)
Contractor
J.L.Burke Contracting Inc. (Refurbished the parking garage in 2000)
Full specifications
Pharmacia Corporation (now owned by Pfizer) announced in 2000 the opening of its new facility in Skokie, in the state of Illinois (USA). The company was created by an agreement between Monsanto/Searle and Pharmacia & St. John.
Pfizer Inc and Pharmacia Corporation began operating as a unified company in April 2003. Over the years several significant new medicines were discovered and developed at the Skokie site, including the blockbuster drug Celebrex.
In late 2003 Pfizer announced the closure of the Skokie facility in a worldwide reorganisation. The closure affected 1,500 research and administrative jobs in the Chicago area. The vast majority of those were in Skokie. For decades, the facility under different ownerships was a major boon to the village and conducted significant pharmaceutical research on everything from birth control to Nutra Sweet.
"The new facility will contain a range of companies and is expected to create over 3,250 jobs."
In early 2005 developer Forest City Enterprises purchased the former Pfizer Pharmaceuticals property occupying 23.4 acres in downtown Skokie for $43m including 1 million ft² of research and office space across nine buildings. The negotiations took 12 months but Pfizer had promised the local community that they would sell the property to a developer who would bring employment to the area and that is what they did.
FINANCE AND INCENTIVES
Forest City will invest over $155m in the park over a ten year period. The State of Illinois has committed $5m to the project. The Village of Skokie will provide $10m in assistance from the proceeds of two General Obligation Bond issues supported by a new Tax Increment Financing (TIF) district.
The funds are to be provided to Forest City as reimbursement for TIF eligible expenses. The assessed valuation of the Forest City property has significantly declined from a peak of $35,256,000 to a present $17,858,000 valuation. Property improvements are projected to significantly increase the assessed valuation and generate the TIF revenue necessary to pay off the bond issues.
NEW BEGINNING
The new complex will be called the Illinois Technology Innovation Campus. The new facility will contain a range of companies and is expected to create over 3,250 jobs (Skokie’s employment base is around 35,000 and so this represents an increase of around 9.5%). Forest City officials estimate that the campus will generate $1.8bn annually in State-wide economic activity, according to a study conducted by Applied Real Estate Analysis Inc.
The Pfizer property includes nine buildings. Building Q, as it is called, is a state-of-the-art research building and will not need significant renovation. But four buildings will probably be demolished and a couple of other buildings renovated. The campus could have upwards of 14 companies conducting important research combined with the ability to communicate with each other. The refurbished campus is currently being put forward as the perfect site for the location of new bioscience and biopharmaceutical start-up companies.
NEW BIOTECH HUB
The project is being overseen by Forest City’s Boston-based University, Bioscience & Technology Group who will, over a period of five to ten years, develop the old corporate facility into a state-of-the-art multi-tenant research campus with the capacity to expand to meet future demands. Construction work on the campus renovation began in the third quarter of 2005 and is still underway, although tenants have taken up space as well.
David Miller, President of iBIO (Illinois Biotechnology Industry Organization), said: "The importance of the new Illinois Science and Technology Park cannot be overstated… It provides a focal point for creation of a world recognised biosciences node, one which will draw to our community the best scientific and business talent, not to mention outside capital eager to back Illinois companies."
FACILITIES AT THE SITE
From 1998 the Skokie site underwent a series of improvements to enhance production capacity as well as R&D capabilities. The last building constructed was the Q Building. The new facility was designed and built under the USGBC LEED rating system to create a green lab facility with a gold LEED rating that conserved energy, and used recycled and locally available materials.
The Q Building was designed to be 40% more efficient than similar lab buildings, reducing energy requirements and emissions. The steel beams in the construction were 100% recycled steel and the wallboard was made from the purified waste products of power plants. The carpeting and ceiling tiles contained a large percentage of recycled material.
The Q Building was also designed to provide an environment to maximise the collaboration among scientists of different disciplines. Designed primarily as chemistry building, its flexible design was able to accommodate other scientific endeavours. The building has a floor space of 170,000ft² and required an investment of $78m to construct.
"The Q Building was designed to be 40% more efficient than similar lab buildings, reducing energy requirements and emissions."
To address the issue of energy conservation at the Q Building, the building’s designers incorporated a combination of infrared sensors and high-efficiency air-handling units to ensure that the minimal amounts of energy were being expended to operate the building motion sensors allowing for the mechanical monitoring of the presence of occupants.
When there were no lab occupants for a specified period of time, a variety of adjustments were made within the building. For example, lights were automatically turned off; the velocity of air being removed through exhaust hoods was reduced.
Additionally, air-handling units were analysed based on operating costs over an extended period rather than based on initial cost alone.
PARKING
The campus has a whole range of advantages including adequate parking. In 2000 JL Burke Contracting Inc completed a refurbishment of the parking complex near the front entrance of the campus. They started the work in 1999 for Searle and completed it under the ownership of Pfizer. A two level structure now parks 900 vehicles near the main entrance. The expansion presented the company with a complex engineering situation.
Besides working out the engineering and construction technology to add two levels to the existing facility, they were constrained by being locked in on three sides. JL Burke was able to use a unique piece of equipment from IEI of Milwaukee. This consisted of a pair of dual hydraulic scissors capable of lifting 19t of precast concrete sections with tolerances of only 1/8 in. The lift allowed for construction within the existing facility, while not interfering with the street traffic to the north.
2005
Project type
Refurbished biotech campus
Location
Skokie, Illinois, USA
Estimated investment
$43m (but investment could reach $155m over the period from 2005 to 2010)
Completion
2010
Sponsor
Forest City Development, iBIO, Forest City (Bioscience & Technology Group)
Contractor
J.L.Burke Contracting Inc. (Refurbished the parking garage in 2000)
Full specifications
Pharmacia Corporation (now owned by Pfizer) announced in 2000 the opening of its new facility in Skokie, in the state of Illinois (USA). The company was created by an agreement between Monsanto/Searle and Pharmacia & St. John.
Pfizer Inc and Pharmacia Corporation began operating as a unified company in April 2003. Over the years several significant new medicines were discovered and developed at the Skokie site, including the blockbuster drug Celebrex.
In late 2003 Pfizer announced the closure of the Skokie facility in a worldwide reorganisation. The closure affected 1,500 research and administrative jobs in the Chicago area. The vast majority of those were in Skokie. For decades, the facility under different ownerships was a major boon to the village and conducted significant pharmaceutical research on everything from birth control to Nutra Sweet.
"The new facility will contain a range of companies and is expected to create over 3,250 jobs."
In early 2005 developer Forest City Enterprises purchased the former Pfizer Pharmaceuticals property occupying 23.4 acres in downtown Skokie for $43m including 1 million ft² of research and office space across nine buildings. The negotiations took 12 months but Pfizer had promised the local community that they would sell the property to a developer who would bring employment to the area and that is what they did.
FINANCE AND INCENTIVES
Forest City will invest over $155m in the park over a ten year period. The State of Illinois has committed $5m to the project. The Village of Skokie will provide $10m in assistance from the proceeds of two General Obligation Bond issues supported by a new Tax Increment Financing (TIF) district.
The funds are to be provided to Forest City as reimbursement for TIF eligible expenses. The assessed valuation of the Forest City property has significantly declined from a peak of $35,256,000 to a present $17,858,000 valuation. Property improvements are projected to significantly increase the assessed valuation and generate the TIF revenue necessary to pay off the bond issues.
NEW BEGINNING
The new complex will be called the Illinois Technology Innovation Campus. The new facility will contain a range of companies and is expected to create over 3,250 jobs (Skokie’s employment base is around 35,000 and so this represents an increase of around 9.5%). Forest City officials estimate that the campus will generate $1.8bn annually in State-wide economic activity, according to a study conducted by Applied Real Estate Analysis Inc.
The Pfizer property includes nine buildings. Building Q, as it is called, is a state-of-the-art research building and will not need significant renovation. But four buildings will probably be demolished and a couple of other buildings renovated. The campus could have upwards of 14 companies conducting important research combined with the ability to communicate with each other. The refurbished campus is currently being put forward as the perfect site for the location of new bioscience and biopharmaceutical start-up companies.
NEW BIOTECH HUB
The project is being overseen by Forest City’s Boston-based University, Bioscience & Technology Group who will, over a period of five to ten years, develop the old corporate facility into a state-of-the-art multi-tenant research campus with the capacity to expand to meet future demands. Construction work on the campus renovation began in the third quarter of 2005 and is still underway, although tenants have taken up space as well.
David Miller, President of iBIO (Illinois Biotechnology Industry Organization), said: "The importance of the new Illinois Science and Technology Park cannot be overstated… It provides a focal point for creation of a world recognised biosciences node, one which will draw to our community the best scientific and business talent, not to mention outside capital eager to back Illinois companies."
FACILITIES AT THE SITE
From 1998 the Skokie site underwent a series of improvements to enhance production capacity as well as R&D capabilities. The last building constructed was the Q Building. The new facility was designed and built under the USGBC LEED rating system to create a green lab facility with a gold LEED rating that conserved energy, and used recycled and locally available materials.
The Q Building was designed to be 40% more efficient than similar lab buildings, reducing energy requirements and emissions. The steel beams in the construction were 100% recycled steel and the wallboard was made from the purified waste products of power plants. The carpeting and ceiling tiles contained a large percentage of recycled material.
The Q Building was also designed to provide an environment to maximise the collaboration among scientists of different disciplines. Designed primarily as chemistry building, its flexible design was able to accommodate other scientific endeavours. The building has a floor space of 170,000ft² and required an investment of $78m to construct.
"The Q Building was designed to be 40% more efficient than similar lab buildings, reducing energy requirements and emissions."
To address the issue of energy conservation at the Q Building, the building’s designers incorporated a combination of infrared sensors and high-efficiency air-handling units to ensure that the minimal amounts of energy were being expended to operate the building motion sensors allowing for the mechanical monitoring of the presence of occupants.
When there were no lab occupants for a specified period of time, a variety of adjustments were made within the building. For example, lights were automatically turned off; the velocity of air being removed through exhaust hoods was reduced.
Additionally, air-handling units were analysed based on operating costs over an extended period rather than based on initial cost alone.
PARKING
The campus has a whole range of advantages including adequate parking. In 2000 JL Burke Contracting Inc completed a refurbishment of the parking complex near the front entrance of the campus. They started the work in 1999 for Searle and completed it under the ownership of Pfizer. A two level structure now parks 900 vehicles near the main entrance. The expansion presented the company with a complex engineering situation.
Besides working out the engineering and construction technology to add two levels to the existing facility, they were constrained by being locked in on three sides. JL Burke was able to use a unique piece of equipment from IEI of Milwaukee. This consisted of a pair of dual hydraulic scissors capable of lifting 19t of precast concrete sections with tolerances of only 1/8 in. The lift allowed for construction within the existing facility, while not interfering with the street traffic to the north.
pfizer pharmaceuticals
Each year, Pfizer pharmaceuticals help over 150 million people throughout the world live longer, healthier lives. With medicines across 11 therapeutic areas, we help to treat and prevent many of the most common, and most challenging, conditions of our time. We also build partnerships to help ensure access to our medicines and educate and empower consumers. And, with a broad range of animal vaccines and medicines, we help to protect the health of both pets and farm animals.
CHEST PAIN - Patient Information
INTRODUCTION — It is hard to know what to do when you feel pain or discomfort in the chest. Is it a heart attack or another, less serious problem? Because chest pain can be a sign of a heart attack, it is important to seek help and get treatment as quickly as possible.
The important causes, typical signs and symptoms, diagnostic tests, and initial treatment of chest pain will be reviewed here.
CAUSES — Chest pain generally originates from one of the organs in the chest (heart, lung, or esophagus) or from the components of the chest wall (skin, muscle or bone). Occasionally, organs close to the chest, such as the gall bladder or stomach, may cause chest pain. Pain in the chest may also be the result of neck pain that is referred to the chest, called referred pain.
Angina — All organs and tissues in the body require oxygen and nutrients carried in the blood. The heart pumps oxygen and nutrient-rich blood through a huge network of arteries throughout the body, which includes vessels that supply blood to the heart muscle. These vessels, called coronary arteries, lie on the surface of the heart muscle and branch into smaller vessels located within the muscle .
In people with coronary heart disease (CHD), the coronary arteries become clogged with fatty deposits . The deposits, called plaques, cause the coronary arteries to narrow and may prevent a normal amount of oxygen-rich blood from reaching the heart muscle. This is called cardiac ischemia. Angina is the term for chest pain caused by ischemia.
Angina is particularly common during physical activity, when the heart rate and pressure are increased due to the heart's demand for more oxygen. Angina develops if the demand for oxygen exceeds the amount of oxygen delivered.
Heart attack — A heart attack, or myocardial infarction (MI), occurs when the surface covering of a fatty plaque ruptures. A blood clot (thrombus) can form on the plaque, which can partially or completely block the artery. This blockage slows or blocks blood flow to the area of heart muscle fed by that artery. If this continues for more than 15 minutes, the muscle can become damaged or infarcted (that is, the tissue in that area dies) . During a heart attack, the patient may feel a discomfort that is similar to an episode of ischemia. A heart attack results from a prolonged period of angina.
Describing chest pain — Chest pain caused by angina or a heart attack may be similar to or different from chest pain caused by other conditions. Depending upon the cause, chest pain can have varying qualities (sharp, dull, burning), can be located in one or several areas (middle of the chest, upper chest, back, arms, jaw, neck, or the entire chest area), pain may improve or worsen with activity or rest, and there may be other associated symptoms (sweating, nausea, rapid heart rate, shortness of breath). Quality of the pain — Patients with ischemia of the heart are likely to report chest discomfort rather than pain. A person may describe their pain as squeezing, tightness, pressure, constriction, strangling, burning, heart burn, fullness in the chest, band-like sensation, knot in the center of the chest, ache, heavy weight on chest or like a bra that is too tight. In some cases, the discomfort cannot be described, but the patient places a fist in the center of the chest, known as the "Levine sign."
People without ischemia may describe their pain as sharp or stabbing. Location of the pain — Ischemic chest pain is usually not felt in any specific spot, but rather throughout the chest. The patient may actually have difficulty saying exactly where the pain is. Cardiac pain often involves the center of the chest or upper abdomen.
If the pain is felt only on the right or left side, and not in the center of the chest, it is less likely to be cardiac ischemia. If the patient is able to point with a finger to one area of pain, it is unlikely to be caused by cardiac ischemia. Radiation of pain — The chest pain of cardiac ischemia often spreads to other areas of the upper body. This may include the neck, throat, lower jaw, teeth (feeling like a toothache), or the shoulders and arms. Sometimes, pain is felt in the wrists, fingers, or back (between the shoulder blades). Timing of the pain — Ischemic pain tends to come on gradually and get worse over time; it generally lasts from 2 to 5 minutes after resting if it is related to exertion.
In contrast, noncardiac pain can begin suddenly and feel worst in the beginning. It is often unrelated to exertion. Noncardiac pain may last only a few seconds or may persist for hours. Pain may improve with nitroglycerin or may persist and be severe. Pain that has been constant over days or weeks is not likely to be angina or a heart attack. Things that make the pain better or worse — The patient will be questioned carefully about things that make the pain better or worse. For example, if the pain begins during an activity that increase physical exertion, such as walking up stairs, sexual intercourse, or raking leaves, and the pain is relieved within minutes of resting, it could be angina. The reason for this is that exercise increases the heart's need for oxygen-rich blood, and the need decreases as the person rests. Other things that can increase oxygen demand in the heart include emotional stress, exposure to cold, and eating a meal.
If the pain is relieved with nitroglycerin, a medicine used to treat angina, it suggests (but does not prove) that ischemia is the cause. Other conditions, especially muscular spasms or esophageal spasm, may also improve with nitroglycerin. If eating a meal or taking antacids always relieves the pain, it could be caused by a problem with the esophagus or stomach.
Finally, the pain of ischemia is not usually affected by taking a deep breath or by pressing on the area of discomfort. Ischemic pain tends to be the same regardless of body position, although some patients with ischemia feel relief when sitting up, especially if they lean forward. Associated symptoms — Patients having severe angina or a heart attack may have other symptoms in addition to (or even instead of) discomfort in the chest. These can include: Shortness of breath Nausea, vomiting, or belching Sweating Cold, clammy skin Irregular or rapid heart rate Palpitations Fatigue Dizziness Fainting Indigestion Vague abdominal discomfort Tingling sensation in either arm (more often the left) or shoulder
Cardiac risk factors — The likelihood that a particular person is having ischemia is based upon their symptoms, physical examination, as well as the person's underlying risk of coronary disease. For example, an elderly person with multiple risk factors, including a prior MI, peripheral vascular disease (claudication), stroke, heavy smoking, high blood pressure, diabetes, high cholesterol, and a family history of heart disease who has unusual symptoms of angina would be treated as a person with a high risk of coronary disease.
On the other hand, if a person in a very low risk category reports chest pain, the remote possibility of coronary disease is not ignored, although other possible causes are also investigated.
Other cardiovascular problems — Some heart-related problems that are not related to blood flow in the coronary arteries can cause pain in the chest. Some people without CHD develop the classic pain of angina. This is called variant angina, which may be caused by a temporary spasm of the coronary arteries. The arteries are usually normal and have no cholesterol-related narrowing or obstruction, although there may be partial blockage occasionally due to spasm in one segment. Pericarditis, or inflammation of the membranes around the heart, can cause chest pain that gets worse with a deep breath. Pain may be relieved when sitting forward. The person may have abnormal heart sounds and characteristic changes in the electrocardiogram (ECG). (See "Patient information: Pericarditis"). Inflammation of the heart muscle itself, called myocarditis, can also cause chest pain, and it may mimic ischemic pain. Myocarditis is often caused by a viral infection. Another cause for a classic pain of angina in people with normal coronary arteries is "syndrome X"; this is more common in women. People with this condition have no known cause of their chest pain. Problems related to the heart valves or the heart muscle (called hypertrophic cardiomyopathy) can sometimes cause typical angina pain. People with a diagnosis of mitral valve prolapse or aortic stenosis, for example, may complain of pain in the chest. An uncommon but serious cause of chest pain is aortic dissection. The aorta is the main artery in the body. It is composed of layers of muscle cells, much like the layers of an onion. Rarely, the layers can separate and rupture, causing the blood to flow into areas of the body outside of the circulatory system. This is a very serious condition that can be corrected with vascular surgery. The pain of aortic dissection is usually severe, comes on very suddenly, is felt in the back or between the shoulder blades, and is described as a ripping or tearing sensation.
Chest wall pain — A number of conditions can cause the skin, muscles, bones, tendons, soft tissue and cartilage of the chest to become painful. Physical activity that involves the chest muscles, especially when it is new or more strenuous than usual, can cause muscles soreness. The pain is longer-lasting than most episodes of ischemic pain and is often made better or worse by a particular position. Taking a deep breath may make the pain worse, and it may only affect a specific, localized area of the chest. Pressing on this area of the chest usually causes the pain to become worse. Sometimes, the cartilage that connects the ribs to the breastbone can become inflamed, causing pain. This is known as costochondritis. Diseases such as arthritis or fibromyalgia may also cause chest wall pain. Shingles (herpes zoster) affects the nerves of the chest wall and can be quite uncomfortable. Shingles also causes a painful skin rash. Any kind of trauma, including recent surgery, can cause the chest wall to hurt.
Esophagus — The esophagus is the tube that connects the mouth and throat to the stomach. Because the esophagus and the heart are served by some of the same nerves, some cases of esophageal pain can be confused with cardiac ischemia. In some patients, esophageal pain is caused by spasm and may be relieved by nitroglycerin.
A number of conditions can cause pain in the esophagus, including: Gastroesophageal reflux disease — Gastroesophageal reflux, also known as heartburn, causes acid from the stomach to flow back into the esophagus. This can be uncomfortable or painful. Spasm of the esophagus and motility disorder — The muscles around the esophagus contract abnormally, causing pain. Esophagitis — Inflammation of the esophagus, sometimes due to medications.
Gastrointestinal tract — A number of problems related to the stomach and intestines can cause pain that spreads to or even begins in the chest, including ulcers, gallbladder disease, pancreatitis, and irritable bowel syndrome.
Lungs — A number of problems related to the lungs can cause chest pain. Many will cause pain that gets worse with breathing. Pulmonary embolism - A blood clot in the blood vessels of the lung. This almost always occurs in someone who is at high risk for the disorder due to recent surgery, bed rest, pregnancy or recent pelvic surgery, or a long airplane flight. The pain occurs suddenly, is accompanied by shortness of breath, and may be worsened with deep breaths. Pneumonia - Infections in the lungs can cause pain, cough, and fever. Pleurisy or pleuritis - Inflammation of the tissues surrounding the lungs can occur with a viral illness or as a complication of pneumonia, pulmonary embolism, or chest injury. Pneumothorax — A collapsed lung, which allows air to escape to the space between the chest wall and the lung.
Psychological causes — Conditions such as panic disorder or depression may cause a person to feel pain in the chest. Hyperventilation, which is associated with panic attacks, can cause chest pain, sometimes with changes in the ECG.
Referred pain — Referred pain can occur when the same nerves supplying areas of the chest wall also supply the tissues around the lungs, the diaphragm or the lining of the abdomen. A herniated disc or arthritis in the neck can cause "band-like" chest pain.
DIAGNOSIS — Many things can cause pain in the chest. Some signal a serious condition, such as a heart attack, while others require evaluation but are not life-threatening.
Most people think that a heart attack is sudden, intense, and dramatic, but this is not always true. Many heart attacks start slowly as mild pain or discomfort, which builds in intensity with time. It is common for a patient with a heart attack to have other symptoms, such as discomfort in one or both arms, back, neck, jaw, or stomach, shortness of breath, breaking out in a cold sweat, nausea, or light-headedness. However, some heart attacks occur without these symptoms. Studies have shown that people often delay seeking help for a heart attack because they thought the symptoms were not serious or would go away.
The best advice for anyone with chest pain is to seek help immediately since every minute between the start of the attack and correction of blood flow within the heart means increased loss of heart muscle.
Physical examination — Some people have signs of cardiac ischemia that can be seen during a physical examination. For example, the heart rate or blood pressure may be high, or the heart sounds may be abnormal. The physical examination can also reveal important information about possible non-cardiac causes of pain.
Testing
Electrocardiogram — An electrocardiogram, or ECG, depicts the progress of the electrical wave through various parts of the heart muscle (. In people with ischemic chest pain, there are often changes in the ECG. A normal ECG means that a heart attack is less likely, but it does not mean that a person does not have angina or a heart attack.
Blood tests — Blood tests can be used to measure certain enzymes normally found in the heart muscle. During a heart attack, these enzymes leak out of the heart into the blood. Tests of cardiac enzymes are usually repeated over the course of several hours.
Stress test — An exercise stress test is done while the patient walks or runs on a treadmill. It is also helpful in diagnosing ischemia. During this test, the ECG is continuously monitored, looking for evidence of ischemia. If an individual is unable to exercise, a medication can be given to stress the heart. An image of the heart's response to exercise will often be obtained with an echocardiogram or a nuclear scan.
Cardiac catheterization — Cardiac catheterization, also known as coronary angiography, involves using x-ray guidance to pass a small catheter into the coronary arteries, where dye is injected to show the outline of any blockages. Arteriography is usually recommended for people who are considered to have a high risk of coronary artery blockage based upon the results of other factors, such as their heart's status or the results of the exercise tests described above. The results of arteriography can help to determine the best treatment.
Interpreting the data — The clinician will synthesize all of the factors outlined above to determine the cause of chest pain. Even if there is evidence of coronary disease, another problem may still be the most likely cause of pain. Many problems that cause chest pain (described in the next section) can mimic ischemic chest pain. Most cases of chest pain that are evaluated in the emergency department are not caused by angina or a heart attack.
TREATMENT
Use nitroglycerin — If you have had chest pain before or know that you have coronary heart disease, your clinician may prescribe nitroglycerin. Nitroglycerin is a small pill that is placed under the tongue if chest pain occurs. Allow the nitroglycerin to dissolve there. If your mouth is dry, a drink of water can help to moisten the pill. You should sit down (nitroglycerin may make you dizzy or lightheaded) while the nitroglycerin is absorbed. Nitroglycerin should not be swallowed.
After you have taken one dose (one pill) of nitroglycerin, wait five minutes (check a watch or clock). If the chest pain does not go away after five minutes, call 911 immediately and take a second pill unless you have specifically discussed a different plan with your clinician. If you have frequent angina, your clinician may recommend taking an additional (third) dose of nitroglycerin; some clinicians recommend a total of two or three doses (one every five minutes) before calling 911.
When to seek help — If you have chest pain that is new, severe, prolonged, or if chest pain causes concern, call 911 immediately. The emergency medical services (EMS) personnel in your community are prepared to respond rapidly, and will take you to the nearest hospital. For a patient having a heart attack, every minute is important. Remember, the faster you get to a hospital, the sooner you can receive treatment.
Do not drive yourself to the hospital and do not ask someone else to drive you. Calling 911 is safer than driving for two reasons: From the moment EMS personnel arrive, they can begin evaluating and treating chest pain. If you drive to the hospital, treatment cannot begin until you arrive in the emergency department. If a dangerous complication of a heart attack (eg, a serious irregular heart rhythm) occurs on the way to the hospital, EMS personnel are trained to treat the problem immediately
CARDIOLOGY MNEMONICS
Anti-arrythmics: for AV nodes
"Do Block AV":
Digoxin
B-blockers
Adenosine
Verapamil
Aortic regurgitation: causes
CREAM:
Congenital
Rheumatic damage
Endocarditis
Aortic dissection/ Aortic root dilatation
Marfan’s
Aortic stenosis characteristics
SAD:
Syncope
Angina
Dyspnoea
Apex beat: abnormalities found on palpation, causes of impalpable
HILT:
Heaving
Impalpable
Laterally displaced
Thrusting/ Tapping
_ If it is impalpable, causes are COPD:
COPD
Obesity
Pleural, Pericardial effusion
Dextrocardia
Apex beat: differential for impalpable apex beat
DOPES:
Dextrocardia
Obesity
Pericarditis/ Pericardial tamponade/ Pneumothorax
Emphysema
Sinus inversus/ Student incompetence/ Scoliosis/ Skeletal abnormalities (eg pectus excavatum)
Atrial fibrillation: causes
A S#!T:
Alcohol
Stenosis (mitral valve)
Hypertension
Infarction/ Ischaemia
Thyrotoxicosis
Atrial fibrillation: causes
PIRATES:
Pulmonary: PE, COPD
Iatrogenic
Rheumatic heart: mirtral regurgitation
Atherosclerotic: MI, CAD
Thyroid: hyperthyroid
Endocarditis
Sick sinus syndrome
Atrial fibrillation: management
ABCD:
Anti-coagulate
Beta-block to control rate
Cardiovert
Digoxin
Beck's triad (cardiac tamponade)
3 D's:
Distant heart sounds
Distended jugular veins
Decreased arterial pressure
Betablockers: cardioselective betablockers
"Betablockers Acting Exclusively At Myocardium"
_ Cardioselective betablockers are:
Betaxolol
Acebutelol
Esmolol
Atenolol
Metoprolol
CHF: causes of exacerbation
FAILURE:
Forgot medication
Arrhythmia/ Anaemia
Ischemia/ Infarction/ Infection
Lifestyle: taken too much salt
Upregulation of CO: pregnancy, hyperthyroidism
Renal failure
Embolism: pulmonary
CHF: causes of exacerbation
A SMITH PEAR:
Anemia
Salt/ Stress/ Stopping meds
MI
Infection/ Ischemia
Thyroid (high/low)
HTN
Pericarditis
Endocarditis (valve disease)
Arrhythmia
Rx (beta blocker, etc)
Coronary artery bypass graft: indications DUST:
Depressed ventricular function
Unstable angina
Stenosis of the left main stem
Triple vessel disease
Coronary artery bypass graft: indications
DUST:
Depressed ventricular function
Unstable angina
Stenosis of the left main stem
Triple vessel disease
Depressed ST-segment: causes
DEPRESSED ST:
Drooping valve (MVP)
Enlargement of LV with strain
Potassium loss (hypokalemia)
Reciprocal ST- depression (in I/W AMI)
Embolism in lungs (pulmonary embolism)
Subendocardial ischemia
Subendocardial infarct
Encephalon haemorrhage (intracranial haemorrhage)
Dilated cardiomyopathy
Shock
Toxicity of digitalis, quinidine
ECG: left vs. right bundle block
"WiLLiaM MaRRoW":
W pattern in V1-V2 and M pattern in V3-V6 is Left bundle block.
M pattern in V1-V2 and W in V3-V6 is Right bundle block.
_ Note: consider bundle branch blocks when QRS complex is wide.
ECG: T wave inversion causes
INVERT:
Ischemia
Normality [esp. young, black]
Ventricular hypertrophy
Ectopic foci [eg calcified plaques]
RBBB, LBBB
Treatments [digoxin]
Exercise ramp ECG: contraindications
RAMP:
Recent MI
Aortic stenosis
MI in the last 7 days
Pulmonary hypertension
Heart compensatory mechanisms that 'save' organ blood flow during shock
"Heart SAVER":
Symphatoadrenal system
Atrial natriuretic factor
Vasopressin
Endogenous digitalis-like factor
Renin-angiotensin-aldosterone system
_ In all 5, system is activated/factor is released
Heart failure: signs
TAPED TORCH:
Tachycardia
Ascites
Pulsus alternans
Elevated jugular venous pressure
Displaced apex beat
Third heart sound
Oedema
Right ventricular heave
Crepitations or wheeze
Hepatomegaly (tender)
Heart murmurs
"hARD ASS MRS. MSD":
hARD: Aortic Regurg = Diastolic
ASS: Aortic Stenosis = Systolic
MRS: Mitral Regurg = Systolic
MSD: Mitral Stenosis = Diastolic
Jugular venous pressure (JVP) elevation: causes
HOLT: Grab Harold Holt around the neck and throw him in the ocean:
Heart failure
Obstruction of venea cava
Lymphatic enlargement - supraclavicular
Intra-Thoracic pressure increase
JVP: wave form
ASK ME:
Atrial contraction
Systole (ventricular contraction)
Klosure (closure) of tricusps, so atrial filling
Maximal atrial filling
Emptying of atrium
MI: basic management
BOOMAR:
Bed rest
Oxygen
Opiate
Monitor
Anticoagulate
Reduce clot size
MI: signs and symptoms
PULSE:
Persistent chest pains
Upset stomach
Lightheadedness
Shortness of breath
Excessive sweating
MI: therapeutic treatment
ROAMBAL:
Reassure
Oxygen
Aspirin
Morphine (diamorphine)
Beta blocker
Arthroplasty
Lignocaine
MI: therapeutic treatment
"O BATMAN!":
Oxygen
Beta blocker
ASA
Thrombolytics (eg heparin)
Morphine
Ace prn
Nitroglycerin
MI: therapeutic treatment
MONAH:
Morphine
Oxygen
Nitrogen
Aspirin
Heparin
MI: treatment of acute MI
COAG:
Cyclomorph
Oxygen
Aspirin
Glycerol trinitrate
Mitral regurgitation
When you hear holosystolic murmurs, think "MR-THEM ARE holosystolic murmurs".
Mitral stenosis (MS) vs. regurgitation (MR): epidemiology [ID 996]
MS is a female title (Ms.) and it is female predominant.
MR is a male title (Mr.) and it is male predominant.
Murmur attributes
"IL PQRST" (person has ill PQRST heart waves):
Intensity
Location
Pitch
Quality
Radiation
Shape
Timing
Murmurs: innocent murmur features
8 S's:
Soft
Systolic
Short
Sounds (S1 & S2) normal
Symptomless
Special tests normal (X-ray, EKG)
Standing/ Sitting (vary with position)
Sternal depression
Murmurs: locations and descriptions
"MRS A$$":
MRS: Mitral Regurgitation--Systolic
A$$: Aortic Stenosis--Systolic
Murmurs: louder with inspiration vs expiration
LEft sided murmurs louder with Expiration
RIght sided murmurs louder with Inspiration.
Murmurs: questions to ask
SCRIPT:
Site
Character (eg harsh, soft, blowing)
Radiation
Intensity
Pitch
Timing
Murmurs: right vs. left loudness [ID 475]
"RILE":
Right sided heart murmurs are louder on Inspiration.
Left sided heart murmurs are loudest on Expiration.
Murmurs: systolic
MR PV TRAPS:
Mitral
Regurgitation and
Prolaspe
VSD
Tricupsid
Regurgitation
Aortic and
Pulmonary
Stenosis
Murmurs: systolic types
SAPS:
Systolic
Aortic
Pulmonic
Stenosis
_ Systolic murmurs include aortic and pulmonary stenosis.
_ Similarly, it's common sense that if it is aortic and pulmonary stenosis it could also be mitral and tricusp regurgitation].
Murmurs: systolic vs. diastolic
PASS: Pulmonic & Aortic Stenosis=Systolic.
PAID: Pulmonic & Aortic Insufficiency=Diastolic.
Knowledge Level 1, System: Cardiovascular
W. Ciulla, RN, PA-C New Life Medical Clinic
Murmurs: systolic vs. diastolic Hi Yield [ID 980]
Systolic murmurs: MR AS: "MR. ASner".
Diastolic murmurs: MS AR: "MS. ARden".
Myocardial infarctions: treatment
INFARCTIONS:
IV access
Narcotic analgesics (eg morphine, pethidine)
Facilities for defibrillation (DF)
Aspirin/ Anticoagulant (heparin)
Rest
Converting enzyme inhibitor
Thrombolysis
IV beta blocker
Oxygen 60%
Nitrates
Stool Softeners
Pericarditis: causes
CARDIAC RIND:
Collagen vascular disease
Aortic aneurysm
Radiation
Drugs (such as hydralazine)
Infections
Acute renal failure
Cardiac infarction
Rheumatic fever
Injury
Neoplasms
Dressler's syndrome
Pericarditis: EKG
"PericarditiS":
PR depression in precordial leads.
ST elevation.
Peripheral vascular insufficiency: inspection criteria
SICVD:
Symmetry of leg musculature
Integrity of skin
Color of toenails
Varicose veins
Distribution of hair
Pulseless electrical activity: causes
PATCH MED:
Pulmonary embolus
Acidosis
Tension pneumothorax
Cardiac tamponade
Hypokalemia/ Hyperkalemia/ Hypoxia/ Hypothermia/ Hypovolemia
Myocardial infarction
Electrolyte derangements
Drugs
Rheumatic fever: Jones 5 major criteria
STREP:
Sydenhams chorea
Transient migratory arthritis
Rheumatic subcutaneous nodules
Erythema marginatum
Pancarditis (endocarditis, myocarditis, pericarditis)
_ STREP, since Rheumatic fever is caused by group A strep.
Rheumatic fever: Jones criteria
_ Major criteria: CANCER:
Carditis
Arthritis
Nodules
Chorea
Erythema
Rheumatic anamnesis
_ Minor criteria: CAFE PAL:
CRP increased
Arthralgia
Fever
Elevated ESR
Prolonged PR interval
Anamnesis of rheumatism
Leucocytosis
Rheumatic fever: Jones major criteria
JONES:
Joints (migrating polyarthritis)
Obvious, the heart (carditis, pancarditis, pericarditis, endocarditis or valvulits)
Nodes (subcutaneous nodules)
Erythema marginatum
Sydenham's chorea
Rheumatic fever: Revised Jones criteria
JONES PEACE:
_ Major criteria:
Joints: migratory
O (heart shaped) Carditis: new onset murmur
Nodules, subcutaneous: extensor surfaces
Erythema marginatum
Sydenham's chorea
_ Minor criteria:
PR interval, prolonged
ESR elevated
Arthralgias
CRP elevated
Elevated temperature (fever)
_ Need 2 major or 1 major and 2 minor criteria, plus evidence of recent GAS infection (throat cx, rapid antigen test, or rising strep antibody titer).
Rheumatic fever: Revised Jones' criteria
JONES crITERIA:
_ Major criteria:
Joint (arthritis)
Obvious (Cardiac)
Nodule (Rheumatic)
Erythema marginatum
Sydenham chorea
_ Minor criteria:
Inflammatory cells (leukocytosis)
Temperature (fever)
ESR/CRP elevated
Raised PR interval
Itself (previous Hx of Rheumatic fever)
Arthralgia
Sino-atrial node: innervation
Sympathetic acts on Sodium channels (SS).
Parasympathetic acts on Potassium channels (PS).
Sinus bradycardia: aetiology
"SINUS BRADICARDIA"
Sleep
Infections (myocarditis)
Neap thyroid (hypothyroid)
Unconsciousness (vasovagal syncope)
Subnormal temperatures (hypothermia)
Biliary obstruction
Raised CO2 (hypercapnia)
Acidosis
Deficient blood sugar (hypoglycemia)
Imbalance of electrolytes
Cushing's reflex (raised ICP)
Aging
Rx (drugs, such as high-dose atropine)
Deep anaesthesia
Ischemic heart disease
Athletes
Sinus tachycardia
TACH FEVER:
Tamponade/ Thyrotoxicosis
Anemia
CHF
Hypotension
Fever
Excrutiating pain
Volume depletion
Exercise
Rx (Theo, Dopa, Epi, etc)
ST elevation causes in ECG
ELEVATION:
Electrolytes
LBBB
Early repolarization
Ventricular hypertrophy
Aneurysm
Treatment (eg pericardiocentesis)
Injury (AMI, contusion)
Osborne waves (hypothermia)
Non-occlusive vasospasm
Supraventricular tachycardia: treatment
ABCDE:
Adenosine
Beta-blocker
Calcium channel antagonist
Digoxin
Excitation (vagal stimulation)
Ventricular tachycardia: treatment
LAMB:
Lidocaine
Amiodarone
Mexiltene/ Magnesium
Beta-blocker
"Do Block AV":
Digoxin
B-blockers
Adenosine
Verapamil
Aortic regurgitation: causes
CREAM:
Congenital
Rheumatic damage
Endocarditis
Aortic dissection/ Aortic root dilatation
Marfan’s
Aortic stenosis characteristics
SAD:
Syncope
Angina
Dyspnoea
Apex beat: abnormalities found on palpation, causes of impalpable
HILT:
Heaving
Impalpable
Laterally displaced
Thrusting/ Tapping
_ If it is impalpable, causes are COPD:
COPD
Obesity
Pleural, Pericardial effusion
Dextrocardia
Apex beat: differential for impalpable apex beat
DOPES:
Dextrocardia
Obesity
Pericarditis/ Pericardial tamponade/ Pneumothorax
Emphysema
Sinus inversus/ Student incompetence/ Scoliosis/ Skeletal abnormalities (eg pectus excavatum)
Atrial fibrillation: causes
A S#!T:
Alcohol
Stenosis (mitral valve)
Hypertension
Infarction/ Ischaemia
Thyrotoxicosis
Atrial fibrillation: causes
PIRATES:
Pulmonary: PE, COPD
Iatrogenic
Rheumatic heart: mirtral regurgitation
Atherosclerotic: MI, CAD
Thyroid: hyperthyroid
Endocarditis
Sick sinus syndrome
Atrial fibrillation: management
ABCD:
Anti-coagulate
Beta-block to control rate
Cardiovert
Digoxin
Beck's triad (cardiac tamponade)
3 D's:
Distant heart sounds
Distended jugular veins
Decreased arterial pressure
Betablockers: cardioselective betablockers
"Betablockers Acting Exclusively At Myocardium"
_ Cardioselective betablockers are:
Betaxolol
Acebutelol
Esmolol
Atenolol
Metoprolol
CHF: causes of exacerbation
FAILURE:
Forgot medication
Arrhythmia/ Anaemia
Ischemia/ Infarction/ Infection
Lifestyle: taken too much salt
Upregulation of CO: pregnancy, hyperthyroidism
Renal failure
Embolism: pulmonary
CHF: causes of exacerbation
A SMITH PEAR:
Anemia
Salt/ Stress/ Stopping meds
MI
Infection/ Ischemia
Thyroid (high/low)
HTN
Pericarditis
Endocarditis (valve disease)
Arrhythmia
Rx (beta blocker, etc)
Coronary artery bypass graft: indications DUST:
Depressed ventricular function
Unstable angina
Stenosis of the left main stem
Triple vessel disease
Coronary artery bypass graft: indications
DUST:
Depressed ventricular function
Unstable angina
Stenosis of the left main stem
Triple vessel disease
Depressed ST-segment: causes
DEPRESSED ST:
Drooping valve (MVP)
Enlargement of LV with strain
Potassium loss (hypokalemia)
Reciprocal ST- depression (in I/W AMI)
Embolism in lungs (pulmonary embolism)
Subendocardial ischemia
Subendocardial infarct
Encephalon haemorrhage (intracranial haemorrhage)
Dilated cardiomyopathy
Shock
Toxicity of digitalis, quinidine
ECG: left vs. right bundle block
"WiLLiaM MaRRoW":
W pattern in V1-V2 and M pattern in V3-V6 is Left bundle block.
M pattern in V1-V2 and W in V3-V6 is Right bundle block.
_ Note: consider bundle branch blocks when QRS complex is wide.
ECG: T wave inversion causes
INVERT:
Ischemia
Normality [esp. young, black]
Ventricular hypertrophy
Ectopic foci [eg calcified plaques]
RBBB, LBBB
Treatments [digoxin]
Exercise ramp ECG: contraindications
RAMP:
Recent MI
Aortic stenosis
MI in the last 7 days
Pulmonary hypertension
Heart compensatory mechanisms that 'save' organ blood flow during shock
"Heart SAVER":
Symphatoadrenal system
Atrial natriuretic factor
Vasopressin
Endogenous digitalis-like factor
Renin-angiotensin-aldosterone system
_ In all 5, system is activated/factor is released
Heart failure: signs
TAPED TORCH:
Tachycardia
Ascites
Pulsus alternans
Elevated jugular venous pressure
Displaced apex beat
Third heart sound
Oedema
Right ventricular heave
Crepitations or wheeze
Hepatomegaly (tender)
Heart murmurs
"hARD ASS MRS. MSD":
hARD: Aortic Regurg = Diastolic
ASS: Aortic Stenosis = Systolic
MRS: Mitral Regurg = Systolic
MSD: Mitral Stenosis = Diastolic
Jugular venous pressure (JVP) elevation: causes
HOLT: Grab Harold Holt around the neck and throw him in the ocean:
Heart failure
Obstruction of venea cava
Lymphatic enlargement - supraclavicular
Intra-Thoracic pressure increase
JVP: wave form
ASK ME:
Atrial contraction
Systole (ventricular contraction)
Klosure (closure) of tricusps, so atrial filling
Maximal atrial filling
Emptying of atrium
MI: basic management
BOOMAR:
Bed rest
Oxygen
Opiate
Monitor
Anticoagulate
Reduce clot size
MI: signs and symptoms
PULSE:
Persistent chest pains
Upset stomach
Lightheadedness
Shortness of breath
Excessive sweating
MI: therapeutic treatment
ROAMBAL:
Reassure
Oxygen
Aspirin
Morphine (diamorphine)
Beta blocker
Arthroplasty
Lignocaine
MI: therapeutic treatment
"O BATMAN!":
Oxygen
Beta blocker
ASA
Thrombolytics (eg heparin)
Morphine
Ace prn
Nitroglycerin
MI: therapeutic treatment
MONAH:
Morphine
Oxygen
Nitrogen
Aspirin
Heparin
MI: treatment of acute MI
COAG:
Cyclomorph
Oxygen
Aspirin
Glycerol trinitrate
Mitral regurgitation
When you hear holosystolic murmurs, think "MR-THEM ARE holosystolic murmurs".
Mitral stenosis (MS) vs. regurgitation (MR): epidemiology [ID 996]
MS is a female title (Ms.) and it is female predominant.
MR is a male title (Mr.) and it is male predominant.
Murmur attributes
"IL PQRST" (person has ill PQRST heart waves):
Intensity
Location
Pitch
Quality
Radiation
Shape
Timing
Murmurs: innocent murmur features
8 S's:
Soft
Systolic
Short
Sounds (S1 & S2) normal
Symptomless
Special tests normal (X-ray, EKG)
Standing/ Sitting (vary with position)
Sternal depression
Murmurs: locations and descriptions
"MRS A$$":
MRS: Mitral Regurgitation--Systolic
A$$: Aortic Stenosis--Systolic
Murmurs: louder with inspiration vs expiration
LEft sided murmurs louder with Expiration
RIght sided murmurs louder with Inspiration.
Murmurs: questions to ask
SCRIPT:
Site
Character (eg harsh, soft, blowing)
Radiation
Intensity
Pitch
Timing
Murmurs: right vs. left loudness [ID 475]
"RILE":
Right sided heart murmurs are louder on Inspiration.
Left sided heart murmurs are loudest on Expiration.
Murmurs: systolic
MR PV TRAPS:
Mitral
Regurgitation and
Prolaspe
VSD
Tricupsid
Regurgitation
Aortic and
Pulmonary
Stenosis
Murmurs: systolic types
SAPS:
Systolic
Aortic
Pulmonic
Stenosis
_ Systolic murmurs include aortic and pulmonary stenosis.
_ Similarly, it's common sense that if it is aortic and pulmonary stenosis it could also be mitral and tricusp regurgitation].
Murmurs: systolic vs. diastolic
PASS: Pulmonic & Aortic Stenosis=Systolic.
PAID: Pulmonic & Aortic Insufficiency=Diastolic.
Knowledge Level 1, System: Cardiovascular
W. Ciulla, RN, PA-C New Life Medical Clinic
Murmurs: systolic vs. diastolic Hi Yield [ID 980]
Systolic murmurs: MR AS: "MR. ASner".
Diastolic murmurs: MS AR: "MS. ARden".
Myocardial infarctions: treatment
INFARCTIONS:
IV access
Narcotic analgesics (eg morphine, pethidine)
Facilities for defibrillation (DF)
Aspirin/ Anticoagulant (heparin)
Rest
Converting enzyme inhibitor
Thrombolysis
IV beta blocker
Oxygen 60%
Nitrates
Stool Softeners
Pericarditis: causes
CARDIAC RIND:
Collagen vascular disease
Aortic aneurysm
Radiation
Drugs (such as hydralazine)
Infections
Acute renal failure
Cardiac infarction
Rheumatic fever
Injury
Neoplasms
Dressler's syndrome
Pericarditis: EKG
"PericarditiS":
PR depression in precordial leads.
ST elevation.
Peripheral vascular insufficiency: inspection criteria
SICVD:
Symmetry of leg musculature
Integrity of skin
Color of toenails
Varicose veins
Distribution of hair
Pulseless electrical activity: causes
PATCH MED:
Pulmonary embolus
Acidosis
Tension pneumothorax
Cardiac tamponade
Hypokalemia/ Hyperkalemia/ Hypoxia/ Hypothermia/ Hypovolemia
Myocardial infarction
Electrolyte derangements
Drugs
Rheumatic fever: Jones 5 major criteria
STREP:
Sydenhams chorea
Transient migratory arthritis
Rheumatic subcutaneous nodules
Erythema marginatum
Pancarditis (endocarditis, myocarditis, pericarditis)
_ STREP, since Rheumatic fever is caused by group A strep.
Rheumatic fever: Jones criteria
_ Major criteria: CANCER:
Carditis
Arthritis
Nodules
Chorea
Erythema
Rheumatic anamnesis
_ Minor criteria: CAFE PAL:
CRP increased
Arthralgia
Fever
Elevated ESR
Prolonged PR interval
Anamnesis of rheumatism
Leucocytosis
Rheumatic fever: Jones major criteria
JONES:
Joints (migrating polyarthritis)
Obvious, the heart (carditis, pancarditis, pericarditis, endocarditis or valvulits)
Nodes (subcutaneous nodules)
Erythema marginatum
Sydenham's chorea
Rheumatic fever: Revised Jones criteria
JONES PEACE:
_ Major criteria:
Joints: migratory
O (heart shaped) Carditis: new onset murmur
Nodules, subcutaneous: extensor surfaces
Erythema marginatum
Sydenham's chorea
_ Minor criteria:
PR interval, prolonged
ESR elevated
Arthralgias
CRP elevated
Elevated temperature (fever)
_ Need 2 major or 1 major and 2 minor criteria, plus evidence of recent GAS infection (throat cx, rapid antigen test, or rising strep antibody titer).
Rheumatic fever: Revised Jones' criteria
JONES crITERIA:
_ Major criteria:
Joint (arthritis)
Obvious (Cardiac)
Nodule (Rheumatic)
Erythema marginatum
Sydenham chorea
_ Minor criteria:
Inflammatory cells (leukocytosis)
Temperature (fever)
ESR/CRP elevated
Raised PR interval
Itself (previous Hx of Rheumatic fever)
Arthralgia
Sino-atrial node: innervation
Sympathetic acts on Sodium channels (SS).
Parasympathetic acts on Potassium channels (PS).
Sinus bradycardia: aetiology
"SINUS BRADICARDIA"
Sleep
Infections (myocarditis)
Neap thyroid (hypothyroid)
Unconsciousness (vasovagal syncope)
Subnormal temperatures (hypothermia)
Biliary obstruction
Raised CO2 (hypercapnia)
Acidosis
Deficient blood sugar (hypoglycemia)
Imbalance of electrolytes
Cushing's reflex (raised ICP)
Aging
Rx (drugs, such as high-dose atropine)
Deep anaesthesia
Ischemic heart disease
Athletes
Sinus tachycardia
TACH FEVER:
Tamponade/ Thyrotoxicosis
Anemia
CHF
Hypotension
Fever
Excrutiating pain
Volume depletion
Exercise
Rx (Theo, Dopa, Epi, etc)
ST elevation causes in ECG
ELEVATION:
Electrolytes
LBBB
Early repolarization
Ventricular hypertrophy
Aneurysm
Treatment (eg pericardiocentesis)
Injury (AMI, contusion)
Osborne waves (hypothermia)
Non-occlusive vasospasm
Supraventricular tachycardia: treatment
ABCDE:
Adenosine
Beta-blocker
Calcium channel antagonist
Digoxin
Excitation (vagal stimulation)
Ventricular tachycardia: treatment
LAMB:
Lidocaine
Amiodarone
Mexiltene/ Magnesium
Beta-blocker
TECHNIQUE FOR USE OF METERED DOSE INHALAR (MDI)
Shake canister vigorously for 5 seconds.
Uncap mouthpiece and check for loose objects in the device.
Insert MDI into spacer. Hold the MDI upright with the index finger on the top of the medication canister and the thumb supporting the bottom of the inhaler. You may need to use the other hand to hold the spacer.
Breathe out normally.
Close lips around spacer. For spacers that have a mask, hold the mask snugly to the face. If no spacer is available, close lips around mouthpiece or position it about 4 cm from the mouth.
Keep tongue away from the spacer opening or mouthpiece.
Press down the top of the medication canister with the index finger to release the medication.
At the same time as the canister is pressed, inhale deeply and slowly through the mouth until the lungs are completely filled; this should take four to six seconds.
Hold the medication in the lungs as long as possible (4 to 10) seconds before exhaling. If using a spacer, you may inhale a second time and hold the breath if needed.
If a second puff is needed, wait approximately 15 to 30 seconds between puffs, or long enough to perform the next inhalation properly. Shake canister again before use.
Recap mouthpiece.
These instructions do NOT apply to dry powder inhalers. Cleaning instructions are provided separately.
Uncap mouthpiece and check for loose objects in the device.
Insert MDI into spacer. Hold the MDI upright with the index finger on the top of the medication canister and the thumb supporting the bottom of the inhaler. You may need to use the other hand to hold the spacer.
Breathe out normally.
Close lips around spacer. For spacers that have a mask, hold the mask snugly to the face. If no spacer is available, close lips around mouthpiece or position it about 4 cm from the mouth.
Keep tongue away from the spacer opening or mouthpiece.
Press down the top of the medication canister with the index finger to release the medication.
At the same time as the canister is pressed, inhale deeply and slowly through the mouth until the lungs are completely filled; this should take four to six seconds.
Hold the medication in the lungs as long as possible (4 to 10) seconds before exhaling. If using a spacer, you may inhale a second time and hold the breath if needed.
If a second puff is needed, wait approximately 15 to 30 seconds between puffs, or long enough to perform the next inhalation properly. Shake canister again before use.
Recap mouthpiece.
These instructions do NOT apply to dry powder inhalers. Cleaning instructions are provided separately.
ACNE VULGARIS- A patient information
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