Understanding Generic Architectures the concept of a network as capturing aspects of the connectivity allergy medicine during ivf purchase 5 mg clarinex free shipping, accessibility allergy free recipes buy 5mg clarinex otc, or relatedness of components in a complex system is widely recognized as important to understanding aspects of these systems - so much so that many names of complex systems include the term "network peanut allergy treatment 2013 purchase clarinex 5 mg otc. Networks are anchored by topological information about nodes and links allergy testing gp purchase clarinex 5 mg with amex, with additional information that can include nodal locations and state variables allergy treatment hong kong order clarinex 5 mg fast delivery, link distances allergy medicine good for kittens order clarinex 5mg with amex, capacities, and state variables, and possibly detailed local functional relationships involved in network behaviors. In recent years, there has been significant interest in understanding the role played by the abstract topological structure of networks represented solely by nodes and links (Milgram 1967; Milgram 1992; Watts and Strogatz 1998; Barthйlйmy and Amaral 1999; Watts 1999; Latora and Marchiori 2001; Barabбsi and Albert 1999; Albert, Jeong, and Barabбsi 1999; Huberman and Adamic 1999; Albert, Jeong, and Barabбsi 2000; Jeong et al. This work has focused on understanding the possible relationships between classes of topological networks and their functional capacities. Among the classes of networks contrasted recently are locally connected, random, small-world (Milgram 1967, 1992; Watts and Strogatz 1998; Barthйlйmy and Amaral 1999; Watts 1999), and scale-free networks (Latora and Marchiori 2001; Barabбsi and Albert 1999; Albert, Jeong, and Barabбsi 1999; Huberman and Adamic 1999; Albert, Jeong, and Barabбsi 2000; Jeong et al. Other network architectures include regular lattices, trees, and hierarchically decomposable networks (Simon 1998). Among the issues of functional capacity are which networks are optimal by some measure. The significance of these studies from an engineering perspective is in answering such questions as, What kind of organizational structure is needed to perform what function with what level of reliability? Determining the organizational structures and their tradeoffs is relevant to all scales and areas of the 392 F. Unifying Science and Education converging technologies: nanotechnology, biomedical, information, cognition, and social networks. Understanding (Recognizing) the Paradoxes of Complex Systems the study of complex systems often reveals difficulties with concepts that are used in the study of simpler systems. Many of the paradoxes take the form of the coexistence of properties that, in simpler contexts, appear to be incompatible. In some cases it has been argued that there is a specific balance of properties; for example, the "edge-of-chaos" concept suggests a specific balance of order and chaos. However, in complex systems, order and chaos often coexist, and this is only one example of the wealth of paradoxes that are present. A more complete list would include paired properties such as the following: · · · · · · Stable and adaptable Reliable and controllable Persistent and dynamic Deterministic and chaotic Random and predictable Ordered and disordered · · · · · Cooperative and competitive Selfish and altruistic Logical and paradoxical Averaging and non-averaging Universal and unique While these pairs describe paradoxes of properties, the most direct paradox in complex systems is a recognition that more than one "cause" can exist, so that A causes B, and C causes B are not mutually incompatible statements. The key to understanding paradox in complex systems is to broaden our ability to conceive of the diversity of possibilities, both for our understanding of science and for our ability to design engineered systems that serve specific functions and have distinct design tradeoffs that do not fit within conventional perspectives. Developing Systematic Methodologies for the Study of Complex Systems While there exists a conventional "scientific method," the study of complex systems suggests that many more detailed aspects of scientific inquiry can be formalized. The existence of a unified understanding of patterns, description, and evolution as relevant to the study of complex systems suggests that we adopt a more systematic approach to scientific inquiry. Components of such a systematic approach would include experimental, theoretical, modeling, simulation, and analysis strategies. Among the aspects of a systematic strategy are the capture of quantitative descriptions of structure and dynamics, network analysis, dynamic response, information flow, multiscale decomposition, identification of modeling universality class, and refinement of modeling and simulations. Major Application Areas of Complex Systems Research the following should provide a sense of the integral nature of complex systems to advances in nanotechnology, biomedicine, information technology, cognitive science, and social and global systems. Nanotechnology Development of functional systems based on nanotechnological control is a major challenge beyond the creation of single elements. Indeed, the success of Converging Technologies for Improving Human Performance 393 nanotechnology in controlling small elements can synergize well with the study of complex systems. To understand the significance of complex systems for nanotechnology, it is helpful to consider the smallest class of biological machines, also considered the smallest complex systems - proteins (Fersht 1999). They also have many useful qualities that are not common in artificial systems, including robustness and adaptability through selection. The process of manufacturing a protein is divided into two parts, the creation of the molecular chain and the collapse of this chain to the functional form of the protein. The protein chain "self-organizes" (sometimes with assistance from other proteins) into its functional (folded) form. By manufacturing proteins in a form that is not the functional form, key aspects of the manufacturing process can be simplified, standardized, and made efficient while allowing a large variety of functional machines to be described in a simple language. While proteins are functionally robust in any particular function, their functions can also be changed or adapted by changing the archive, which "describes" their function, but in an indirect and nonobvious way. The rapid parallel process of creation of proteins allows adaptation of new machines through large-scale variation and selection. A good example of this process is found in the immune system response (Perelson and Wiegel 1999; Noest 2000; Segel and Cohen 2001; Pierre et al. The immune system maintains a large number of different proteins that serve as antibodies that can attach themselves to harmful antigens. When there is an infection, the antigens that attach most effectively are replicated in large numbers, and they are also subjected to a process of accelerated evolution through mutation and selection that generates even better-suited antibodies. Since this is not the evolutionary process of organisms, it is, in a sense, an artificial evolutionary process optimized (engineered) for the purpose of creating well-adapted proteins (machines). Antibodies are released into the blood as free molecules, but they are also used as tools by cells that hold them attached to their membranes so that the cells can attach to , or "grab hold of," antigens. Finally, proteins also form complexes and are part of membranes and biochemical networks, showing how larger functional structures can be built out of simple machines. They also illustrate how complex systems concepts of self-organization, description, and evolution are important to nanotechnology. Nanotechnological design and manufacturing may take advantage of the system of manufacture of proteins or other approaches may be used. Understanding complex systems concepts thus will enable the development of practical approaches to nanotechnological design and manufacture and to adaptation to functional requirements of nanotechnological constructs. Biomedical Systems At the current time, the most direct large-scale application of complex systems methods is to the study of biochemical networks (gene regulatory networks, metabolic networks) that reveal the functioning of cells and the possibilities of medical intervention (Service 1999; Normile 1999; Weng, Bhalla and Iyengar 1999). The general studies of network structure described above are complementary to detailed studies of the mechanisms and function of specific biochemical systems (von Dassow et al. High-throughput data acquisition in genomics and proteomics is providing the impetus for constructing functional descriptions of biological systems (Strausberg and Austin 1999). This, however, is only the surface of the necessary applications of complex systems approaches that are intrinsic to the modern effort to understand biological organisms, their relationships to each other, and their relationship to evolutionary history. The key to a wider perspective is recognizing that the large quantities of data currently being collected are being organized into databases that reflect the data acquisition process rather than the potential use of this information. Opportunities for progress will grow dramatically when the information is organized into a form that provides a description of systems and system functions. Since cellular and multicellular organisms, including the human being, are not simply biochemical soups, this description must capture the spatiotemporal dynamics of the system as well as the biochemical network and its dynamics. In the context of describing human physiology from the molecular scale, researchers at the Oak Ridge National Laboratory working towards this goal call it the Virtual Human Project (Appleton 2000). The program of study of complex systems in biology requires not only the study of a particular organism (the human being) or a limited set of model organisms, as has been done in the context of genomics until now. The problem is to develop comparative studies of systems, understanding the variety that exists within a particular type of organism. Ultimately, the purpose is to develop an understanding or description of the patterns of biological systems today as well as throughout the evolutionary process. The objective of understanding variety and evolution requires us to understand not just any particular biochemical system, but the space of possible biochemical systems filtered to the space of those that are found today, their general properties, their specific mechanisms, how these general properties carry across organisms, and how they are modified for different contexts. Moreover, new approaches that consider biological organisms through the relationship of Converging Technologies for Improving Human Performance 395 structure and function and through information flow are necessary to this understanding. Increasing knowledge about biological systems is providing us with engineering opportunities and hazards. The great promise of our biotechnology is unrealizable without a better understanding of the systematic implications of interventions that we can do today. The frequent appearance of biotechnology in the popular press through objections to genetic engineering and cloning reveals the great specific knowledge and the limited systemic knowledge of these systems. The example of corn genetically modified for feed and its subsequent appearance in corn eaten by human beings (Quist and Chapela 2001) reveals the limited knowledge we have of indirect effects in biological systems. This is not a call to limit our efforts, simply to focus on approaches that emphasize the roles of indirect effects and explore their implications scientifically. Without such studies, not only are we shooting in the dark, but in addition we will be at the mercy of popular viewpoints. Completion of the virtual human project would be a major advance toward creating models for medical intervention. Such models are necessary when it is impossible to test multidrug therapies or specialized therapies based upon individual genetic differences. The narrow bridge that currently exists between medical double blind experiments and the large space of possible medical interventions can be greatly broadened through systemic models that reveal the functioning of cellular systems and their relationship to cellular function. While today individual medical drugs are tested statistically, the main fruit of models will be as follows: · to reveal the relationship between the function of different chemicals and the possibility of multiple different types of interventions that can achieve similar outcomes · the possibility of discovering small variations in treatment that can affect the system differently · possibly most importantly, to reveal the role of variations among human beings in the difference of response to medical treatment A key aspect of all of these is the development of complex systems representations of biological function that reveal the interdependence of biological system and function. Indeed, the rapid development of medical technologies and the expectation of even more dramatic changes should provide an opportunity for, even require, a change in the culture of medical practice. Conventional homeostatic perspectives on health are being modified to homeodynamic perspectives (Goldberger, Rigney, and West 1990; Lipsitz and Goldberger 1992). What is needed is a better understanding of the functional capabilities of a healthy individual to respond to changes in the external and internal environment for self-repair or -regulation. For example, while physical decline is a problem associated with old age, it is known that repair and regulatory mechanisms begin to slow down earlier. By studying the dynamic response of an individual and changes over his/her life cycle, it should be possible to 396 F. Unifying Science and Education understand these early aspects of aging and to develop interventions that maintain a higher standard of health. More generally, understanding the network of regulatory and repair mechanisms should provide a better mechanism for dynamic monitoring - with biomedical sensors and imaging - health and disease and the impact of medical interventions. This would provide key information about the effectiveness of interventions for each individual, enabling feedback into the treatment process that can greatly enhance its reliability. Information Systems Various concepts have been advanced over the years for the importance of computers in performing large-scale computations or in replacing human beings through artificial intelligence. Today, the most apparent role of computers is as personal assistants and as communication devices and information archives for the socioeconomic network of human beings. The system of human beings and the Internet has become an integrated whole leading to a more intimately linked system. Less visibly, embedded computer systems are performing various specific functions in information processing for industrial age devices like cars. The functioning of the Internet and the possibility of future networking of embedded systems reflects the properties of the network as well as the properties of the complex demands upon it. While the Internet has some features that are designed, others are self-organizing, and the dynamic behaviors of the Internet reflect problems that may be better solved by using more concepts from complex systems that relate to interacting systems adapting in complex environments rather than conventional engineering design approaches. Information systems that are being planned for business, government, military, medical, and other functions are currently in a schizophrenic state where it is not clear whether distributed intranets or integrated centralized databases will best suit function. While complex systems approaches generally suggest that creating centralized databases is often a poor choice in the context of complex function, the specific contexts and degree to which centralization is useful must be understood more carefully in terms of their functions and capabilities, both now and in the future (Bar-Yam 2001). A major current priority is enabling computers to automatically configure themselves and carry out maintenance without human intervention (Horn 2001). Currently, computer networks are manually configured, and often the role of various choices in configuring them are not clear, especially for the performance of networks. Indeed, evidence indicates that network system performance can be changed dramatically using settings that are not recognized by the users or system administrators until chance brings these settings to their attention. The idea of developing more automatic processes is a small part of the more general perspective of developing adaptive information systems. This extends the concept of selfconfiguring and self-maintenance to endowing computer-based information systems with the ability to function effectively in diverse and variable environments. In order for this functioning to take place, information systems must, themselves be able to recognize patterns of behavior in the demands upon them and in their own activity. This is a clear direction for development of both computer networks and embedded systems. Converging Technologies for Improving Human Performance 397 Development of adaptive information systems in networks involves the appearance of software agents. Such agents range from computer viruses to search engines and may have communication and functional capabilities that allow social interactions among them. In the virtual world, complex systems perspectives are imperative in considering such societies of agents. As only one example, the analogy of software agents to viruses and worms has also led to an immune system perspective in the design of adaptive responses (Forrest, Hofmeyr, and Somayaji 1997; Kephart et al. While the information system as a system is an important application of complex systems concepts, complex systems concepts also are relevant to considering the problem of developing information systems as effective repositories of information for human use. This involves two aspects, the first of which is the development of repositories that contain descriptions of complex systems that human beings would like to understand. Other examples are socio-economic systems, global systems, and astrophysical systems. In each case, the key issue is to gain an understanding of how such complex systems can be effectively represented. The second aspect of designing such information repositories is the recognition of human factors in the development of human-computer interfaces (Norman and Draper 1986; Nielsen 1993; Hutchins 1995). This is important in developing all aspects of computer-based information systems, which are used by human beings and designed explicitly or implicitly to serve human beings. More broadly, the networked information system that is being developed serves as part of the human socio-economic-technological system. Various parts of this system, which includes human beings and information systems, as well as the system as a whole, are functional systems. The development and design of such a self-organizing system and the role of science and technology is a clear area of application of complex systems understanding and methods. Since this is a functional system based upon a large amount of information, among the key questions is how should the system be organized when action and information are entangled. However, a comparison of the current experimental observations of cognitive processes with those of biochemical processes of gene expression patterns reveals the limitations that are still present in these observational techniques in studying the complex function of the brain. Indeed, it is reasonable to argue that the activity of neurons of a human being and their functional assignment is no less complex than the expression of genes of a single human cell.
Other symptoms often associated with this infection include a vaginal discharge allergy treatment systems inc cheap clarinex 5 mg with mastercard, fever allergy testing greenville nc cheap clarinex 5 mg without a prescription, abdominal/pelvic pain allergy eye drops contacts order clarinex 5 mg with amex, or lower back pain allergy testing reading results order clarinex 5 mg amex. Of the most common causes of abnormal bleeding are growths known as myomas allergy symptoms from grass 5mg clarinex otc, more commonly referred to as uterine fibroids allergy symptoms 5 month old buy generic clarinex 5 mg on-line. These tend to be more common in women over the age of 30, particularly women in their 40s. Different kinds of fibroids are discussed in Chapter 19, but submucous fibroids tend to be the most troublesome in terms of heavy bleeding. Endometrial polyps can also cause abnormal bleeding, but the bleeding is usually not heavy. Adenomyosis, a variant of endometriosis, may result in very heavy bleeding associated with menstrual cramping. Endometriosis itself can cause irregular changes in the menstrual cycle, but not typically heavy menses. Finally, bleeding may result from cervical polyps or a simple inflammation of the cervix called cervicitis. Cervical polyps and cervicitis tend to present with intermenstrual bleeding or spotting after intercourse. Malignant Abnormal Bleeding Now let us look at the premalignant and malignant causes of uterine bleeding. Vaginal cancer accounts for only 2 percent of malignancies of the female genital tract. Eighty-five percent of the primary vaginal cancers are squamous cell (a particular cell type) carcinoma. The most common symptoms of invasive squamous cell cancer include vaginal bleeding or foul-smelling discharge. The tragedy of another cancer, cervical cancer, is that it is a preventable disease. It is preceded by a prolonged precancerous state in almost all cases and can be detected at its early precancerous states by annual Pap smears. These earlier states of abnormal cells and cervical dysplasias are easily treatable conditions. Cervical cancer accounts for approximately 18 percent of female genital cancer in the United States. Vaginal bleeding after vaginal sexual activity is the most common symptom occurring in cancer of the cervix. Endometrial hyperplasia is an increased growth of the lining of the uterus (endometrium) and a subsequent thickening. Most cases of endometrial hyperplasia revert to normal, either spontaneously or with hormonal treatment. Endometrial hyperplasia may occur in any age group but is most commonly seen in older women. Chronic lack of ovulation, as seen in the teenage years, after menopause, and as a result of polycystic ovary disease, is a condition where we may see endometrial hyperplasia. Endometrial hyperplasia can be simple or complex, and either atypical, which is precancerous, or without atypia. These distinctions are very important when it comes to treatment and management and can best be made with a procedure called an endometrial biopsy. Pelvic ultrasound has improved to the point where it can detect thickening of the endometrium. Once thickening is observed, a biopsy will probably be recommended to further evaluate the situation. As in cervical dysplasia and cervical cancer, endometrial hyperplasia is the precancerous state; its adequate treatment will prevent the development of endometrial cancer. Endometrial cancer is the most common malignancy of the female genital tract and accounts for approximately 7 percent of all cancers in women. The average age of patients with endometrial cancer is 59 years; the highest range for the incidence is age 50 to 59 years in postmenopausal women. The most common symptom associated with endometrial cancer is abnormal uterine bleeding. Typically, the bleeding is in the form of spotting, especially in postmenopausal women. These cases are due to the immature endocrine system, particularly the immature function of the hypothalamus. Initially there is a decrease in progesterone production, which causes shorter cycles. As the aging process progresses, ovulation becomes less frequent, resulting in a variable length of the menstrual cycle and a variation in the duration of the flow. Eventually, the lack of ovulation puts women in an estrogen-dominant state in the presence of too little progesterone because ovulation must occur in order to produce progesterone. Women who are in a state of chronic anovulation tend to have an excess of estrogen in the body. One theory is that the fluctuating estrogen levels seen in chronic lack of ovulation can cause intermittent estrogen withdrawal bleeding. Another theory is that the continuous estrogen stimulation leads to a thickening of the endometrium, which needs more estrogen in order to maintain itself. Eventually, the need for estrogen surpasses the production and breakthrough bleeding results. Another theory is that some areas of the endometrium outgrow their blood supply, and subsequent bleeding occurs because of the lack of progesterone. It only takes about 30 to 60 seconds, but women can experience mild to significant cramping during that time. A local anesthetic is usually not required, and the cramping generally subsides very quickly once the procedure is over. Endometrial pipelle biopsies can determine the presence of endometrial hyperplasia, uterine cancer, infection (endometritis), a disrupted hormonal effect, a lack of estrogen as is seen in postmenopausal women, or a uterine polyp. If an endometrial biopsy is done at the right time, it can also be used to verify ovulation. Repeated episodes of heavier and prolonged bleeding should be distinguished from acute hemorrhage. My general guidelines are as follows: If a woman is saturating a super tampon or heavy pad every hour for six to eight hours or more she will often need some form of prescription hormone intervention. Herbal/nutritional interventions can be tried, but if there is no change within two to four hours, then hormonal therapies should be utilized. Monitoring physical symptoms, blood pressure, pulse, and hemoglobin and hematocrit levels will help to determine management of these more semiurgent and urgent cases. Use of high-dose oral bioidentical estrogens (estradiol) and bio-identical progesterone (oral micronized progesterone) may be substituted in some cases of heavier semi-acute bleeding, although the net effect is the same as when using conventional hormones. In most states, licensed naturopathic physicians can prescribe bio-identical hormones and conventional hormones. They would approach these dramatic situations with the same high degree of concern and astuteness as would a conventional practitioner and may integrate acute antihemorrhagic botanicals or nutrients in combination with the hormonal therapies. Less dramatic cases that still involve heavy menstrual flow will be best managed with both an immediate plan for the semi-acute bleeding episode, which should slow down within a few hours to 48 hours, and a comprehensive plan that should bring results with no further episodes in one to four months. A comprehensive plan may include the use of soy and flax products to regulate the menstrual cycle, herbal extracts to address immediate bleeding episodes, nutrients such as bioflavonoids and bromelain for their natural anti-inflammatory effect, herbal extracts for their ability to bring about ovulation and orderly stimulation of ovarian function, and herbs for their tonifying and astringent effects. The concept of tissue tonification is a key feature of the philosophy of herbal medicine. It is thought that gynecological conditions associated with bleeding may occur as a result of poor tissue tone of the mucous membranes, poor uterine tone, and a constitutional weakness of the tissues that presents as generalized lack of tissue integrity, in this case the uterus. Traditionally, the ability of an astringent herb to stop bleeding has been attributed to the tannin content of the plants. Uterine tone is related to the ability of the uterus to function as a smooth muscle. A hypertonic uterus can be associated with a delayed menses and cramping uterine pains. A hypotonic uterus is frequently accompanied by heavy bleeding and a feeling of pelvic congestion. The timing of the release of these pituitary hormones, as well as of estrogen and progesterone, is what determines a normal, regular menstrual cycle. This timing can be adversely affected by stress, and by the same token, the timing can be improved by stress reduction. A third hormone produced by the pituitary, prolactin, also plays an important role in the menstrual cycle. Nutrition Consume a whole foods diet rich in whole grains, fruits, vegetables, legumes, quality cooking oils (canola and olive), nuts, and seeds. Emphasize fish high in omega-3 oils (salmon, tuna, sardines, halibut, mackerel, herring) and reduce saturated animal fats (beef, chicken, butter, cheese) to promote the preferred prostaglandin pathways that are discussed in Chapters 9 and 13 (in the discussions of heart disease and menstrual cramps). These preferred prostaglandins will reduce inflammation and may thereby help to reduce heavy and profuse menstrual flows. Foods high in iron in particular should be incorporated into the general diet when heavy blood loss persists on a monthly basis. Refined breads and cereals are the single greatest nutritional contributor to iron-deficiency anemia. Although we do have iron "enriched" flour, it has only about one-third the iron content of whole wheat flour. Blackstrap molasses is not only one of the richest sources of iron but also of many other minerals. It supplies about 9 mg of iron per tablespoon; dark unrefined molasses contains 1. Single foods high in iron probably cannot surpass the amount found in liver and kidneys. However, I do not recommend these because it is very difficult to get organic products, and these organs accumulate many metabolic wastes. We often think of dark green leafy vegetables as high in iron, but iron is difficult to absorb in this form. Foods such as yogurt that contain Lactobacillus acidophilus and sour fruits and citrus juices aid in the absorption of iron because of their high vitamin C content. Two foods stand out in their ability to regulate the menstrual cycle: flaxseed and soy protein. Flaxseed contains a group of phytoestrogens called lignans that have been shown to have weakly estrogenic and antiestrogenic properties. Two specific lignans, enterodiol and enterolactone, are absorbed after formation in the intestinal tract from plant precursors particularly abundant in flaxseed. The ingestion of flaxseed powder and its effect on the menstrual cycle was studied in 18 normally cycling women. The second and third flax cycles were compared to the second and third control diet cycles. Three nonovulatory cycles occurred among the 18 women during the control diet (36 total cycles) compared to none during the 36 flaxseed cycles. The ovulatory flax cycles were consistently associated with about one more day in the luteal phase (second half of the cycle) when compared to the ovulatory non-flax cycles. Only one day longer before you bleed and a slight increase in the number of ovulations may not seem like much. However, over a period of months and years, the cumulative effect not only has implications for regulating the menstrual cycle but may also play a positive role in reducing the risk of breast and other hormonally dependent cancers. The influence of a diet containing soy protein on the length of the menstrual cycle in premenopausal women has also been studied. A significant increase in the length of the follicular phase (first half of the menstrual cycle) by an average of 2. Vitamin A deficiency impairs enzyme activity and hormone production in the ovaries of animals,4 and serum levels of vitamin A have been found to be lower in women with menorrhagia than in healthy women. A significant decrease in the amount of blood or a reduction in the duration of the menses or both was obtained in 14 women (35 percent). Smaller doses may produce toxicity symptoms if there are problems in storage and transport of vitamin A. These problems are generally found only in people with cirrhosis of the liver, hepatitis, or malnutrition and in children and adolescents. However, for a period of only one month, as in this study, vitamin A toxicity is of virtually no concern, and I would not hesitate to use it for this amount of time, or up to three months. A deficiency of zinc, vitamin C, protein, or thyroid hormone may impair the conversion of carotenes to vitamin A. Provitamin A carotenes such as beta-carotene require these nutrients for their conversion to vitamin A. There may be a correlation between a nutritional deficiency of vitamin B complex and menorrhagia and metrorrhagia. It has been shown that the liver loses its ability to inactivate estrogen in vitamin B-complex deficiency. We know that some cases of heavy menses and intermenstrual bleeding are due to an excess of estrogen. Fat-soluble chlorophyll is a good source of vitamin K and is found in fresh green juices. Consider increasing the intake of green leafy vegetables and/or supplementing with 150 to 500 mcg per day of vitamin K. Like vitamin C, bioflavonoids have demonstrated a significant ability to reduce heavy menstrual bleeding by strengthening the vessel walls of the capillaries in women with menorrhagia.
Bronchitis; cough; lung diseases; skin diseases; decreasing sweating with tuberculosis; increasing urine; redness, swelling, and bleeding of the gums, mouth, and throat; and preventing or stopping bleeding.
The risk of suicide should also be monitored as treatment proceeds allergy forecast zyrtec buy discount clarinex 5mg online, since variations in depressive symptoms may be associated with fluctuations in suicide risk allergy forecast jonesboro ar buy clarinex 5mg without prescription. In youth and young adults allergy or cold test cheap clarinex 5mg overnight delivery, increases in suicidal thoughts and attempts have been reported early in the course of treatment with antidepressants allergy symptoms jaw pain generic clarinex 5mg overnight delivery, although no increases in mortality rates were seen in clinical trials (26) allergy shots and weight loss order clarinex 5mg with visa. Family members can provide information that increases the likelihood of early detection of harmful behaviors allergy choices order 5 mg clarinex free shipping. It is also useful to convey the expectation that family members will call the psychiatrist if concerns for safety emerge (27). Psychosis, substance abuse, impulsivity, and a history of aggression increase this risk (3032). Psychiatrists accordingly should assess not only suicidal risk but also history of violence, homicidal ideation, and plans of violence toward others. Whenever suicidal or violent ideas are expressed or suspected, careful documentation of the decision-making process is essential. In addition, patients who exhibit suicidal or violent ideas or intent require close monitoring. Patients with suicidal or homicidal ideation, intention, or plans require close monitoring. For those at significant risk, measures such as hospitalization should be considered; hospitalization is usually indicated for patients who are considered to pose a serious threat of harm to themselves or others. Patients who refuse can be hospitalized involuntarily if their condition meets the criteria of the local jurisdiction for involuntary admission. Severely ill patients who lack or reject adequate social support outside of a hospital setting should be considered for admission to a hospital or intensive day program, if available. In addition, patients who also have complicating psychiatric or general medical conditions or who have not responded adequately to outpatient treatment may need to be hospitalized. Unfortunately, the spectrum of treatment settings available to patients is often limited by lack of availability of options in the geographic setting, lack of ability to pay for care, and/or limitations imposed by third party payers. Evaluate functional impairment and quality of life the assessment of a patient with major depressive disorder includes a determination of the severity and chronicity of symptoms. Even mild depression can impair function and threaten life and the quality of life. In the extreme, depressed people may be totally unable to function socially or occupationally or even to feed and clothe themselves and maintain minimal personal hygiene. Severely depressed patients may be immobilized to the point of being bedridden, with associated medical complications. The psychiatrist should address impairments in functioning and help the patient to set specific goals appropriate to his or her functional impairments and symptom severity. This will likely involve helping the patient to establish intermediate, pragmatic steps in the course of recovery. For example, the psychiatrist may help patients who are having difficulty meeting commitments to develop a reasonable plan to fulfill their obligations. The psychiatrist may advise other patients not to make major life changes while in the midst of a major depressive episode. Establish the appropriate setting for treatment Treatment settings for patients with major depressive disorder include a continuum of possible levels of care, from involuntary hospitalizations to partial hospital programs, skilled nursing homes, and in-home care. In general, patients should be treated in the least restrictive setting that is most likely to prove safe and effective. Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition tients what bothers them the most about their depression and determining how their current activities and enjoyment of life have been altered by their depressive symptoms. The overall goals of treatment of major depressive disorder should focus on alleviating functional impairments and improving quality of life in addition to achieving symptom resolution and episode remission. He or she may initiate the medical evaluations or coordinate care with other appropriate clinicians. In some situations, review of medical records provided by the patient will suffice. Under some circumstances, all aspects of treatment will be administered by one psychiatrist, and this model of care may improve integration of treatment components (35) or reduce overall treatment cost (36). In other situations, treatment may require the coordinated effort of several clinicians. Because of the diversity and depth of medical knowledge and expertise required for this oversight function, a psychiatrist is generally optimal for this role, although this staffing pattern may not be possible in some health care settings. If the treatment is split, the psychiatrist who is providing the psychiatric management and the medication treatment should meet with the patient frequently enough to monitor his or her care. Ongoing co- ordination of the overall treatment plan is essential and is enhanced by clear role definitions, plans for the management of crises or relapses, and regular communication among the clinicians who are involved in the treatment. Psychiatrists may at times serve as consultants to ongoing treatment of depression by other prescribers. Health care professionals other than psychiatrists may prescribe antidepressant medication for their patients for a variety of reasons, including convenience, financial reasons, stigma, and access to care issues (37). Primary care doctors, obstetricians, and physicians of other disciplines may screen for depression and initiate treatment for patients. In fact, at least one-fourth of patients presenting to primary care settings may have major depressive disorder, and 70%80% of antidepressants are prescribed by a primary care physician or medical subspecialist (38, 39). Regardless of whether the psychiatrist is acting as a consultant or transferring ongoing care to another clinician. Optimal communication with other health care professionals can improve overall treatment by assuring that medical conditions and psychosocial issues are appropriately addressed. Good communication also decreases the risk that patients will receive inconsistent information about treatment options and risks and benefits. Furthermore, communication among clinicians improves vigilance against relapse, side effects, and risk to self or others. In addition, the patient should be monitored for treatment-emergent side effects, some of which may be difficult to distinguish from symptoms of the underlying depressive disorder or co-occurring medical conditions. For example, patients who note worsening irritability, increased difficulty sleeping, racing thoughts, growing impulsivity, euphoria, or rapid shifts in mood should be monitored more closely and may warrant re-evaluation and consideration of a possible bipolar dis- Copyright 2010, American Psychiatric Association. Often family members or caregivers notice changes in the status of the patient first and are therefore able to provide valuable input to the psychiatrist. Items to Monitor Throughout Treatment Symptomatic status, including functional status, and quality of life Degree of danger to self and others Signs of "switch" to mania Other mental disorders, including alcohol and other substance use disorders General medical conditions Response to treatment Side effects of treatment Adherence to treatment plan Although the use of rating scales is not yet common practice in clinical settings, in part due to pragmatic concerns (51), the use of such scales can be valuable in monitoring symptoms and treatment progress. In addition, electronic monitoring is becoming more feasible, as electronic health records are more commonly utilized and patients and psychiatrists have increased access to technological tools that can help monitor and record symptoms. Baseline data and information about treatment-emergent changes can be collected systematically from the patient and electronically transmitted via telephone or the Internet. In addition to providing secure electronic capture of patient data, computerized decision support systems can be useful in implementing evidence-based treatment for major depressive disorder (52). Integrate measurements into psychiatric management the integration of measurement tools into psychiatric management, which has been referred to as measurement-based care, may enhance the quality of care and improve clinical outcomes (40). Clinician-rated and/or self-rated scales can help determine the trajectory of disease course and effects of treatment. Self-rated scales are convenient to use but require review, interpretation, and discussion with the patient. Systematic measurement of side effects can also assist in the provision of treatment. Several self-report rating scales have been developed for assessing side effects of antidepressant treatment and are available in English and Spanish versions. A clinician-administered scale, the Toronto Side Effects Scale, that focuses on antidepressant medication side effects is also available ww1. Major depressive disorder is often a chronic or recurrent condition that requires patients to participate actively in and adhere to treatment plans for long periods, despite the fact that side effects or requirements of treatments may be burdensome. Patients may have strong preferences for modality of treatment or medication choice, particularly if they or a family member have had past experience with the treatment or medication. During the acute phase, patients with major depressive disorder may be poorly motivated, unduly pessimistic about their chances of recovery with treatment, suffering from deficits in memory, or poorly caring for themselves. Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition maintenance phase, euthymic patients may undervalue the benefits of and focus on the burdens of treatment. The psychiatrist should recognize these possibilities, emphasize the importance of adherence for successful treatment and prophylaxis, and encourage the patient to articulate any concerns regarding adherence. Patient and family attitudes about depression and its treatment can also influence adherence. Family members can play an important role in promoting optimism about treatment, assisting patients with adherence and providing the psychiatrist with input on side effects or other treatment-related concerns that may influence adherence. For example, patients in psychotherapy may experience increased anxiety as they confront fearful or difficult topics. This anxiety, in turn, may decrease adherence to psychotherapy, and patients may begin to arrive late to or miss therapy sessions. In patients who are beginning treatment with a medication, common side effects of medication options should be discussed. Patients should be involved in treatment decisions and encouraged to convey input on side effects that they consider reasonable or unbearable. Side effects such as weight gain, cognitive dulling, sexual side effects, sedation or fatigue, and agitation may represent different burdens to different individuals. Emphasizing the following specific topics improves adherence: 1) explaining when and how often to take the medicine; 2) suggesting reminder systems, such as pill boxes, alarms, etc. Behavioral tailoring, which involves developing an individualized approach to incorporating medication into the daily routine and can also include simplifying the medication regimen, has demonstrated efficacy for individuals with schizophrenia and may also be applicable to individuals with other psychiatric illnesses (54). Adherence may also be improved by minimizing the cost and complexity of medication regimens. Most antidepressant medications are available in generic forms, which are generally less costly. For individuals who cannot afford needed medications, some pharmaceutical companies offer patient assistance programs. Information on such programs is available from pharmaceutical company Web sites, from the Web site of the Partnership for Prescription Assistance 29. Provide education to the patient and the family Education concerning major depressive disorder and its treatments should be provided to all patients. Specific topics to discuss may include that major depressive disorder is a medical illness and that effective treatments are both necessary and available. This information may be especially important for patients who attribute their illness to a moral defect, or for family members who are convinced that there is nothing wrong with the patient. Education regarding available treatment options will help patients make informed decisions, anticipate side effects, and adhere to treatments. Patients with depression can become easily discouraged in treatment, especially if there is less than a full initial response. The psychiatrist should encourage and educate patients to distinguish between the hopelessness that is a symptom of depression and the relatively hopeful actual prognosis. Given the chronic, episodic nature of major depressive disorder, exacerbations are common. Patients, as well as their families, if appropriate, should be instructed about the significant risk of relapse. They should be educated to identify early signs and symptoms of new episodes and the stressors that may precede them. Patients should also be instructed to seek adequate treatment as early in the course of the new episode as possible to decrease the likelihood of a full-blown exacerbation or complications. Patient and family education also includes general promotion of healthy behaviors such as good sleep hygiene and decreased use of caffeine, tobacco, alcohol, and other potentially deleterious substances. Data generally support at least a modest improvement in mood symptoms for patients with major depressive disorder who engage in aerobic exercise (5561) or resistance training (62, 63). Regular exercise may also reduce the prevalence of depressive symptoms in the general population, with specific benefit found in older adults (64, 65) and individuals with co-occurring medical problems (57, 66). In addition, patients who have had a history of only partial response to adequate trials of single treatment modalities may benefit from combined treatment. Poor adherence with pharmacotherapy may also warrant combined treatment with medications and psychotherapy focused on treatment adherence. Electroconvulsive therapy should be considered as a potential treatment option for all patients with major depressive disorder who have psychotic features or catatonia and for those with an urgent need for response, such as patients who are suicidal or who are nutritionally compromised as a result of refusing food. Electroconvulsive therapy may also be the treatment modality of choice for patients with major depressive disorder who have a high degree of symptom severity. The dose of exercise and adherence to an exercise regimen may be particularly important to monitor in the assessment of whether an exercise intervention is useful for major depressive disorder (69, 70). If mood fails to improve after a few weeks with exercise alone, the psychiatrist should recommend medication or psychotherapy. For patients with depression of any severity and no medical contraindication to exercise, physical activity is a reasonable addition to a treatment plan for major depressive disorder. Choice of initial treatment modality the acute phase of treatment lasts a minimum of 612 weeks. Psychiatrists should present patients with information concerning the evidence for a broad range of treatment options, including somatic therapies and psychosocial interventions. Antidepressant medications can be used as an initial treatment modality by patients with mild, moderate, or severe major depressive disorder. Clinical features that may suggest that medications are the preferred treatment modality include a history of prior positive response to antidepressant medications, the presence of moderate to severe symptoms, significant sleep or appetite disturbances, agitation, patient preference, and anticipation of the need for maintenance therapy. Psychotherapy may also be considered as monotherapy for patients with mild to moderate major depressive disorder. The availability of clinicians with appropriate training and expertise in specific psychotherapeutic approaches can be a factor in choosing a psychotherapy (67).
Legal norms demonstrating these legalnorms arealso boundup inextricably theworkings international with of which institutions allergy shots ulcerative colitis safe 5mg clarinex, havebeena central of all in years allergy medicine starts with c generic clarinex 5mg on-line. Ideational swept phenomena or new strategies maximize to whichreduces "information allergy medicine hbp cheap clarinex 5mg line," uncertainty provides the which hardly poliis utilities allergy symptoms morning and night clarinex 5mg with mastercard. Emotions be politically can and we dangerous undein that sirable politics; after is affect allergy symptoms ears order clarinex 5 mg on line, Buttopretend affect empathy too allergy shots for hives discount clarinex 5mg online. Scholars are divided, abouttherolethat choiceplaysin norm-based however, behavior, aboutwhatmotivates choice,andabouttherolepersuasion playsin normative processesandhowto treat No schoolofthought thediscipline entirely in it. Five Things Patients and Providers Should Question 1 Do not perform a laparotomy for the management of non-malignant disease when surgical management is indicated and a vaginal, laparoscopic or robotic-assisted approach is feasible and appropriate. Selection of an endoscopic approach should be tailored to patient selection, surgeon ability, and equipment ability. The surgeon should take into consideration how the procedure may be performed cost-effectively with the fewest complications. Outside of high-risk populations, the association of oophorectomy with increased mortality in the general population has substantial implications, particularly as it relates to higher rates of coronary heart disease and cardiovascular death. The long-term risks associated with salpingo-oophorectomy are most pronounced in women who are younger than 4550 years who were not treated with estrogen. The use of prophylactic antibiotics in women undergoing gynecologic surgery is often inconsistent with published guidelines. Although the appropriate use of antibiotic prophylaxis for hysterectomy is high, antibiotics are increasingly being administered to women who are less likely to receive benefit. The potential results are significant resource use and facilitation of antimicrobial resistance. Though conservative management may be appropriate in some patients, hysteroscopic polypectomy is the mainstay of treatment. Removal without the aid of direct visualization should be avoided due to its low sensitivity and negative predictive value of successful removal compared to hysteroscopy and guided biopsy. Patients have a right to appropriate assessment and management of pain; however, opioid misuse has become a public health crisis. Providers must also educate and screen for risk factors for opioid misuse and follow patients on chronic opioid therapy for any signs of misuse. Patients with any specific questions about the items on this list or their individual situation should consult their physicians. The subcommittee of expert surgeons in the field of minimally invasive surgery recommended and developed a more effective use of health care resources, along with safe techniques to practice. Systematic Review of Robotic Surgery in Gynecology: Robotic Techniques Compared with Laparoscopy and Laparotomy, J Minim Invasive Gynecol. Use of Guideline Based Antibiotic Prophylaxis in Women Undergoing Gynecologic Surgery, Obstet Gynecol 2013; 122:1145-1153. Can We Rely on Blind Endometrial Biopsy for Detection of Focal Intrauterine Pathology? Substantial functional decline and recurrent or progressive medical illnesses may indicate that a patient who is not eating is unlikely to obtain any significant or long-term benefit from artificial nutrition. Feeding tubes are often placed after hospitalization, frequently with concerns for aspirations, and for those who are not eating. Assistance with oral feeding is an evidence-based approach to provide nutrition for patients with advanced dementia and feeding problems. In this situation, it is reasonable to obtain a urine culture if there are objective signs of systemic infection such as fever (increase in temperature of equal to or greater than 2°F [1. The therapeutic goal of the use of antipsychotic medications is to treat patients who present an imminent threat of harm to self or others, or are in extreme distress not to treat nonspecific agitation or other forms of lesser distress. In fact, studies show that elderly patients with the lowest cholesterol have the highest mortality after adjusting other risk factors. In addition, a less favorable risk-benefit ratio may be seen for patients older than 85, where benefits may be more diminished and risks from statin drugs more increased (cognitive impairment, falls, neuropathy and muscle damage). Appropriate indications for indwelling urinary catheter placement include acute retention or outlet obstruction, to assist in healing of deep sacral or perineal wounds in patients with urinary incontinence, and to provide comfort at the end of life if needed. Benefits of cancer screening occur only after a lag time of 10 years (colorectal or breast cancer) or more (prostate cancer). Patients with a life expectancy shorter than this lag time are less likely to benefit from screening. Prostate cancer screening by prostate-specific antigen testing is not recommended for asymptomatic patients because of a lack of life-expectancy benefit. False positive "test-of-cure" specimens may complicate clinical care and result in additional courses of inappropriate anti-C. Therefore, for some frail elders, the balance of benefits and harms of hospital-level care may be unfavorable. To avoid unnecessary hospitalizations, care providers should engage in advance care planning by defining goals of care for the patient and discussing the risks and benefits of various interventions, including hospitalization, in the context of prognosis, preferences, indications, and the balance of risks and benefits. Patients who opt for less-aggressive treatment options are less likely to be subjected to unnecessary, unpleasant and invasive interventions and the risks of hospitalization. Using a reliable, representative method of taking blood pressures with special attention to orthostatic hypotension is important, as orthostatic hypotension has been associated with increased mortality and cardiovascular events. In addition, moderate or high-intensity treatment of hypertension has been associated with an increased risk of serious falls and injury in frail older adults. Suggested elements were considered for appropriateness, relevance to the core of the specialty and opportunities to improve patient care. A literature search was conducted to provide supporting evidence or refute the activities. The list was modified and a second round of selection of the refined list was sent to the workgroup for paring down to the final "top five" list. Comfort feeding only: a proposal to bring clarity to decision-making regarding difficulty with eating for persons with advanced dementia. The standard of caring: why do we still use feeding tubes in patients with advanced dementia? The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. The prevalence and persistence of sliding scale insulin use among newly admitted elderly nursing home residents with diabetes mellitus. Management of diabetes mellitus in hospitalized patients: efficiency and effectiveness of sliding-scale insulin therapy. Glycemic control and sliding scale insulin use in medical inpatients with diabetes mellitus. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer Criteria. Treatment of bacteriuria without urinary signs, symptoms, or systemic infectious illness (S/S/S). Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. Sustained reduction in inappropriate treatment of asymptomatic bacteriuria in a long-term care facility through an educational intervention. Can urine cultures and reagent test strips be used to diagnose urinary tract infection in elderly emergency department patients without focal urinary symptoms? Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomized controlled trial. Optimizing antibiotics in residents of nursing homes: protocol of a randomized trial. Antipsychotics in the treatment of delirium in older hospitalized adults: a systematic review. Risk of death associated with the use of conventional versus atypical antipsychotic drugs among elderly patients. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence. Variability in the prescription of cardiovascular medications in older patients: correlates and potential explanations. Cholesterol and all-cause mortality in elderly people from the Honolulu Heart Program: a cohort study. Lack of association between cholesterol and coronary heart disease mortality and morbidity and all-cause mortality in persons older than 70 years. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Personalizing age of cancer screening cessation based on comorbid conditions: model estimates of harms and benefits. Should colorectal cancer screening be considered in elderly persons without previous screening? Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents. Care transitions in older adults from nursing homes to hospitals: implications for long-term care practice, geriatrics education, and research. Systolic blood pressure goals to reduce cardiovascular disease among older adults. Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. Association between orthostatic hypotension and cardiovascular risk, cerebrovascular risk, cognitive decline and falls as well as overall mortality: a systematic review and meta-analysis. Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged75 Years: A Randomized Clinical Trial. The use of other tests or methods to diagnose allergies is unproven and can lead to inappropriate diagnosis and treatment. Appropriate diagnosis and treatment is both cost effective and essential for optimal patient care. Antibiotics are not recommended for patients with uncomplicated acute rhinosinusitis who have mild illness and assurance of follow-up. If a decision is made to treat, amoxicillin should be first-line antibiotic treatment for most acute rhinosinusitis. Routine extensive testing is neither cost effective nor associated with improved clinical outcomes. Skin or serum-specific IgE testing for inhalants or foods is not indicated, unless there is a clear history implicating an allergen as a provoking or perpetuating factor for urticaria. Low levels of immunoglobulins (isotypes or subclasses), without impaired antigen-specific IgG antibody responses, do not indicate a need for immunoglobulin replacement therapy. Exceptions include IgG levels <150mg/dl and genetically defined/suspected disorders. Measurement of IgG subclasses is not routinely useful in determining the need for immunoglobulin therapy. Selective IgA deficiency is not an indication for administration of immunoglobulin. Therefore spirometry is essential to confirm the diagnosis in those patients who can perform this procedure. Beyond the increased costs of care, repercussions of misdiagnosing asthma include delaying a correct diagnosis and treatment. Data indicate that antihistamines are overused as the first-line treatment of anaphylaxis. By definition, anaphylaxis has cardiovascular and respiratory manifestations, which require treatment with epinephrine. Overuse of antihistamines, which do not treat cardiovascular or respiratory manifestations of anaphylaxis, can delay the effective first-line treatment with epinephrine. Epinephrine should be administered as soon as the diagnosis of anaphylaxis is suspected. Antihistamines are second-line supportive therapy for cutaneous non-life-threatening symptoms (hives), but do not replace epinephrine as the first-line treatment for anaphylaxis. Fatalities during anaphylaxis have been associated with delayed administration of epinephrine. Indiscriminate screening results in inappropriate avoidance of foods and wastes healthcare resources. IgE testing for specific foods must be driven by a history of signs or symptoms consistent with an IgE-mediated reaction after eating a particular food. Ordering IgE testing in individuals who do not have a history consistent with or suggestive for food allergy based on history frequently reveals positive tests that are unlikely to be clinically relevant. The diagnostic utility of IgE testing for specific foods is optimal when a history compatible with or suggestive for the diagnosis of food allergy is present. In the absence of a compatible or suggestive history, the pre-test probability for a diagnosis of food allergy is low and a positive skin or in vitro IgE test does not establish a diagnosis of food allergy. Skin testing or serum testing for specific-IgE to food antigens has excellent sensitivity and high negative predictive value, but has low specificity and low positive predictive value. Considering that 50 to 90 percent of presumed cases of food allergy do not reflect IgE-mediated (allergic) pathogenesis and may instead reflect food intolerance or symptoms not causally associated with food consumption, ordering panels of food tests leads to many incorrectly identified food allergies and inappropriate recommendations to avoid foods that are positive on testing. Although the exact mechanism for contrast media reactions is unknown, there is no cause and effect connection with seafood allergy. Consequently there is no reason to use more expensive agents or pre-medication before using contrast media in patients with a history of seafood allergy. A prior history of anaphylaxis to contrast media is an indication to use low- or iso-osmolar agents and pretreat with corticosteroids and antihistamines. Patients with a history of seafood allergy are not at elevated risk for anaphylaxis from iodinated contrast media. Similarly, patients who have had anaphylaxis from contrast media should not be told that they are allergic to seafood.
References
FDA. Food additives permitted for direct addition to food for human consumption; vitamin D3 and fruit juices and juice drinks. Federal Register 2003;69:9000-9003.
Dawson LA, Ten HRK. Partial volume tolerance of the liver to radiation. Semin Radiat Oncol. 2005;15(4):279-283.
Wang JC, Derynck MK, Nonaka D, et al. Chromatin immunoprecipitation (ChIP) scanning identifies primary glucocorticoid receptor target genes. Proc Natl Acad Sci USA. 2004;101:15603.
AMERICAN ACADEMY OF PEDIATRICS SUBCOMMITTEE ON MANAGEMENT OF ACUTE OTITIS MEDIA: Diagnosis and management of acute otitis media. Pediatrics 113:1451, 2004.
Stein HJ, Feith M, Mueller J, et al: Limited resection for early adenocarcinoma in Barrett's esophagus. Ann Surg 232:733, 2000.
Gammie JS, et al. Trends in mitral valve surgery in the United States: results from the Society of Thoracic Surgeons adult cardiac surgery database. Ann Thorac Surg 2009;87:1431-1437; discussion 1437-1439.
