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Clinically diabetic plus usa buy repaglinide without a prescription, mitral regurgita • All patients should initially be seen by a cardiologist diabetic diet and carbohydrates generic repaglinide 0.5 mg online, tion is characterized by a pansystolic murmur maximal at who can then decide how often the patient needs cardi the apex blood sugar se x magik discount 2 mg repaglinide amex, radiating to diabetes type 2 test results order 0.5mg repaglinide with visa the axilla and occasionally to the ology follow-up. Erratum in: J Am Coli valve prolapse tends to radiate anteriorly in the presence of Cardiol. Guidelines on the management of valvular heart patients with mitral valve prolapse (until late in the disease disease (version 2012). Severe mitral regurgitation may cause left-sided niques provide qualitative and semiquantitative estimates heart failure. Patients with functional mitral regurgitation may either Doppler echocardiography or cardiac catheteriza improve with biventricular pacing. Some may tion may be useful when the symptoms do not fit the ana require surgical intervention. Treatment & Prognosis asymptomatic patients and appears to have some prognos tic importance. Patients with chronic of regurgitation and its hemodynamic impact along with lesions may thus remain asymptomatic for many years. Early surgery is indicated even in and in menopausal women with coronary risk factors. Its as with papillary muscle dysfnction following myocardial role continues to be defined. In addition, vascular plugging infarction, valve perforation in infective endocarditis, in and occluder devices are being used in selected patients to patients with hypertrophic cardiomyopathy, or when there occlude perivalvular leaks around prosthetic mitral valves. Finally, and can be initially treated with vasodilators or intra-aortic the frst reported cases of the stented mitral valve prosthe balloon counterpulsation, which reduce the amount ofretro sis to replace the mitral valve have been reported. When to Refer reduction in chronic mitral regurgitation, since the lesion All patients with more than mild mitral regurgitation inherently results in a reduction in aferload, and there are no should be referred to a cardiologist for an evaluation. A height Serial examinations and echocardiograms should be ened sypathetic state has led some experts to suggest that obtained and surgical referral made if there is an beta-blockade be considered routinely. Myocardial Disease and Mitral Regurgitation should be done early in the course of the disease to When mitral regurgitation isdueto papillary dysfnction, it improve mortality and morbidity. A randomized controlled phase lib trial of tions is displacement of the papillary muscles and an beta(l)-receptor blockade for chronic degenerative mitral regurgitation. Percutaneous transcatheter mitral valve tion during systole (due to either leaflet prolapse or replacement: an overview of devices in preclinical and early retraction). If mitral valve replacement is performed, mary: a report of the American College of Cardiology/American preservation ofthe chordae to the native valve helps prevent Heart Association Task Force on Practice Guidelines. There may also be a role for cardiac resynchroniza tion therapy with biventricular pacemaker insertion, which has been found to reduce mitral regurgitation related to cardiomyopathy in many patients. Single or multiple mid-systolic clicks often heard biventricular pacing prior to surgical repair in those patients on auscultation. There are several ongoing trials of percutaneous approaches to reducing mitral regurgitation. Often associated with skeletal changes (straight approaches include the use of a mitral clip device to create back, pectus excavatum, and scoliosis) or hyper a double orifice mitral valve, various coronary catheter flexibility ofjoints. Treatment the significance of mild mitral valve prolapse ("foppy" or Beta-blockers in low doses are used to treat the hyperad myxomatous mitral valve), also commonly referred to as renergic state when present and are usually satisfactory for "degenerative" mitral valve disease, has been in dispute treatment of arrhythmias (see Table ll-6). Selective sero because of the frequency with which it is diagnosed by tonin reuptake inhibitors have also been used, especially if echocardiography even in healthy young women (up to orthostatic hypotension or anxiety is associated with mitral 10%). A controversial hyperadrenergic syndrome has also valve prolapse; results have been mixed. Afterload reduc been described (especially in young females) that may be tion has not been shown to change prognosis when mitral responsible for someofthe noncardiac symptoms observed. Fortunately, this hyperadrenergic component attenuates Mitral valve repair is strongly favored overvalve replace with age. Some patients with mitral prolapse have findings ment, and its efcacy has ledmany to recommend interven of a systemic collagen abnormality (Marfan or Ehlers tion earlier and earlier in the course of the disease process. In these conditions, a dilated aortic Mitral repair may include shortening of chordae, chordae root and aortic regurgitation may coexist. In many persons, transfers, wedge resection of redundant valve tissue, or the the "degenerative" myxomatous mitral valve clearly leads to insertion of a mitral annular ring to reduce the annular size, long-term sequelae and is the most common cause of or some combination of these techniques. Mitral repair orreplacement can beachieved regurgitation may develop, occasionally suddenly due to through a right minithoracotomy with or without the use of rupture of chordae tendineae (fail leafet) or gradually a robotic device. The need for ommended for most patients with mitral valve prolapse valve repair or replacement increases with age, so that regardless of the degree of mitral regurgitation. A variety of approximately 2% per year of patients with clinically sig percutaneous techniques and devices have been tried with nificant regurgitation over age 60 years will eventually some success (notably in the mitral clip trials), although require surgery. Symptoms and Signs mitral regurgitation should be seen at least once by a cardiologist. If only mitral clicks are some have skeletal deformities, such as pectus excavatum audible, then serial echocardiography is not warranted. On auscultation, there are characteristic mid-systolic clicks that may be multiple and emanate Basso C et al. Arrhythmic mitral valve prolapse and sudden from the chordae or redundant valve tissue. Epidemiology and pathophysiology of mitral ens, the murmur is heard more and more throughout valve prolapse: new insights into disease progression, genetics, systole. Floppy mitral valve/mitral valve are often accentuated in the standing position or during prolapse syndrome: beta-adrenergic receptor polymorphism the Valsalva maneuver. Diagnostic Studies the diagnosis is primarily clinical and confirmed echocar diographically. Mitral prolapse is often associated with aortic root disease, and any evidence for a dilated aorta by. Surgery considered for asymptomatic patients nents ofthe murmur are heard atthe apex, andthe mur with severe aortic stenosis (mean gradient greater mur may sound like mitral regurgitation (the so-called than 55 mm Hg) or when undergoing heart sur Gallaverdin phenomenon). The frst is due to a congenitally stenosis; importantly, all symptoms tend to occur with abnormal unicuspid or bicuspid valve, rather than tri exertion. Symptoms occur in young or adolescent individu als if the stenosis is severe, but more often emerge at age B. Redefining Severe Aortic Stenosis 50-65 years when calcification and degeneration of the valve become manifest. A dilated ascending aorta, primar There are four different anatomic syndromes that occur in ily due to an intrinsic defect in the aortic root media, may patients with severe aortic stenosis. The common underly accompany the bicuspid valve in about half of these ing measure of severe aortic stenosis is an aortic valve area patients. In the same situ A second pathologic process, degenerative or calcifc ation, "super-severe aortic stenosis" is defned as a mean aortic stenosis, is thought to be related to calcium deposi gradient of greater than 55 mm Hg or peak aortic velocity tion due to processes similar to what occurs in atheroscle greater than 5 m/sec by Doppler. Approximately 25% of patients over In some patients with an aortic valve area of less than age 65 years and 35% ofthose over age 70 years have echo l. O cm2 with a low cardiac output and stroke volume, the cardiographic evidence of aortic valve thickening (sclerosis). Low fow (low output) in these situations is defined likely contributor, at least in some patients. Other associ by an echocardiographic stroke volume index of less than atedgenetic markers have also been described. The risk factors include hypertension, traditional high gradient, low valve area, normal output, hypercholesterolemia, and smoking. If the aortic valve area can be made to increase and a mean gradient of greater than 40 mm Hg cannot be dem A. Symptoms and Signs onstrated by inotropic challenge, the presumption is that Slightly narrowed, thickened, or roughened valves (aortic the low gradient is due to an associated cardiomyopathy sclerosis) or aortic dilation may contribute to the typical and not the aortic valve stenosis. Angina pectoris frequently occurs in (6) when there is evidence of a rapid increase in the peak aortic stenosis due to underperfsion of the endocardium. Syncope, a late fnding, occurs without surgery is poor (50% 3-year mortality rate). This vasodi intervention is indicated for all symptomatic patients with lation results in the need for an increase in stroke volume, evidence ofsignificant aortic stenosis. Severe coronary lesions are usually the conduction system from the aortic valve may occur).
If a source is safe for viewing on axis it will be safe under all other viewing conditions at the same distance diabetes insipidus pathophysiology and treatment purchase repaglinide 1mg fast delivery. For the same colour temperature diabetes type 1 joint pain repaglinide 2mg amex, the blue light component of the optical emission can be similar to diabetes vs hyperglycemia buy repaglinide from india that of an incandescent lamp diabetes type 1 natural treatment discount 0.5 mg repaglinide. Optical radiation does not penetrate deeply into the body; the eye and skin are the organs that are most susceptible to damage. The risks following exposure to optical radiation hazards are a complex function of wavelength and exposure conditions. Action spectra for selected wavelength ranges, intensity and exposure duration exist for specific biochemical reactions in the skin and eye. Whether or not the absence of ultraviolet or near infrared wavelengths has any health implications is now under investigation. Published studies show that the blue light-weighted (for eyes) radiance from screens is less than 10% of the blue light photochemical retinal hazard limit, assuming viewing greater than about 3 hours (acute exposure). Reduction factors are used in setting the exposure limits for humans when animal studies are used. However, the full action spectrum for the influence of light on the circadian system requires further research as other wavelengths have an influence as well. At the moment, it is not clear if this evening disturbance of the circadian system leads to long-term adverse health effects. Intensity Radiant intensity (W/sr) is a parameter characterising the emission of the source, while luminous intensity (lm/sr) is important in terms of visual perception including distraction, glare and after-images. The optical radiation incident on a target tissue is expressed in terms of irradiance (W/mfi) or illuminance (lm/mfi or lux). For photochemical processes, the effect is a function of not only the irradiance (or radiance) but also of the exposure duration. The product of these two factors gives the dose (the radiant exposure (J/mfi) or radiance dose (J/mfisr)). However, reversible biological effects in terms of flicker, dazzle, distraction and glare may occur. Animal experiments and in vitro studies suggest that cumulative blue light exposure below the levels causing acute effects can also induce photochemical retinal damage. However, technology is still evolving and it is important to continue to monitor the literature. In addition, the cumulative effect of light on the skin and eyes should be considered. If a source is safe for viewing on axis it will be safe in all other viewing conditions at the same distance. Although a general threshold has been identified for optical radiation based on experimental data, the profile of the dose-response relationship is not well known. Evaluating the retinal blue light hazard effectively requires taking account of the irradiance of the retinal image of the source viewed. For momentary viewing, the retinal image subtends the same angle as does the source. With increasing exposure time, the retinal image is spread over an increasingly large area of the retina due to eye movement (saccades) and task-determined movement, resulting in a corresponding reduction in retinal radiant exposure at any given point on the retina. A time-dependent function of the angular subtense of the retinal image for exposures from 0. Published studies show that the blue light weighted radiance from screens is less than 10% of the blue light hazard limit that is defined to protect the retina regarding photochemically induced injury. There is some evidence that use of screen technology into the evening may impact sleep quality. However, it is not clear whether this is due to the optical radiation or the activity being carried out. The standard does not take into account a product that is not a toy, which may be given to a child to use (for example smartphones or tablets). However, the luminance of the source is very low and the exposure limits are not likely to be exceeded. Some people report disorientation and nausea after extended use of these headsets. This is likely to be due to the motion sickness rather than the optical radiation emitted by the screen. For the same colour temperature, the blue light component of the optical emission is similar to an incandescent lamp. However, the infrared (and possible ultraviolet emission) may be greatly reduced or absent (in comparison with other types of lamps), which might influence (positively or negatively) the normal human physiology. It is good practice in lighting design to ensure that lamps for illumination are either positioned outside of the usual field of view or are of such low luminance that the source does not produce significant glare. A small number of people report adverse health effects such as migraine or headaches. Current examples appear to be blue-rich, which increases glare and scattering, particularly for older observers. These running lights are a greater glare source in fog than more traditional vehicle lighting. There is a European standard for electronic toys that limits the emission of optical radiation from toys. For definitions and abbreviations please, refer to the Glossary of terms and to Abbreviations. Information has also been taken from technical reports from different agencies and bodies. The overall quality of the studies is taken into account in a tiered approach (Figure 1), as well as the relevance of the studies for the issue in question. Tier 1: broad keyword search of the data bases containing peer reviewed papers, industrial reports, Commission journals, other evaluations. Setting of inclusion/exclusion criteria for primary screeningnd Tier 2: 2 screening based on quality of information Tier 3: relevance to the specific topic of the opinion Fig. This combined assessment addresses the question of whether or not a hazard exists, i. The shape of the curve in Figure 2 depends on a number of factors, such as the part of the optical spectrum under consideration, time of exposure, prior exposure, possibly age and individual differences (such as photosensitivity, eye pathologies, etc. For example, too little ultraviolet radiation exposure may result in vitamin D deficiency and associated health effects. High levels of ultraviolet radiation may result in sunburn and an increased risk of skin cancer. For light, if the task is reading, there is an optimum illuminance of the page: too little and we cannot see, too much and we are dazzled or in extreme cases risk eye injury. Therefore, reducing the exposure level to as low as achievable may have adverse consequences, some of which will be health related. It may be necessary to quantify the hazard using an appropriate metric, but usually quantification is only relevant if the optical radiation exposure geometry and distance substantiate the risk of exposure of people. Once an exposure scenario has been identified, the optical radiation exposure conditions, for example of the eye or skin, will need to be quantified and compared with relevant limits. In the latter case, exposure from a number of different sources throughout a day will need to be considered. If the exposure is less than the relevant limit, then the risk of adverse health effects is considered low. These effects depend not only on the optical radiation incident on the eye, but also the ambient light level and the task being carried out at the time of exposure. The potential effects may be due to the actual emission of the source as directly viewed, or due to head or eye movement, or to the impact on moving equipment. Photometry is the science of the measurement of light, in terms of its perceived brightness to the human eye. While sharing these identical relationships, photometry also introduces detector response modelled after human visual characteristics. Radiometry deals with the measurement of electromagnetic radiation across the total spectrum (infrared, visible, ultraviolet and beyond). Photometry is concerned only with the visible portion of the spectrum, from about 380 nm to 780 nm and measures luminous flux, luminous intensity, illuminance and luminance. Table 1 indicates the symbols and the units of the quantities; the indices “e” = “energetic”; “v” = “visual”. Table 1: Radiometric and photometric quantities Radiometric Photometric Quantity Symbol Units Quantity Symbol Units Radiant fie W Luminous Flux fiv lumen Power (lm) Radiant Ie W/sr Luminous Iv lm/sr Intensity Intensity 2 2 Irradiance Ee W/m Illuminance Ev lm/m or lux 2 2 Radiance Le W/m sr Luminance Lv lm/m sr the luminosity function or luminous efficiency function describes the average spectral sensitivity of human visual perception of brightness.
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The third (2014c) investigated mortality among members of the veterans’ families diabetes symptoms yellow nails buy repaglinide 1mg mastercard, while the fnal volume (2014d) discussed qualitative information gathered in the course of the entire study diabetes symptoms tired purchase repaglinide 2mg on-line. Although responses were collected on spouses and partners of the veterans diabetes tagalog definition cheap repaglinide 0.5 mg visa, the analyses focused on outcomes reported by the children of the veterans diabetes control juice purchase generic repaglinide from india. The wide range of outcomes examined for the family members them selves included mental health outcomes, pregnancy and birth defect outcomes, physical health, social functioning, and mortality. Because many of the health outcomes reported for these family members are not central to the charge of the committee. From the roster of Australian Vietnam veterans, more than 10,000 Austra lians who had served in the Vietnam W ar were randomly selected and contacted, along with their family members, for potential participation in the study. The Vietnam veterans who were identifed and ultimately selected included 3,940 who were randomly selected and 2,569 who self-selected into the study based on media publications announcing that the study would be conducted. The primary comparison group consisted of family members of non deployed Vietnam-era personnel. These personnel comprised 3,967 randomly selected non-deployed era veterans and 418 who self-selected into the study. Thus, there were far more Australian Vietnam veterans who self-selected into the study than non-deployed Australian Vietnam-era veterans who self-selected, and the percentage of the Vietnam veterans who self-selected was much higher than the percentage of non-deployed Vietnam-era veterans who self-selected. In total, the family members of Vietnam veterans included 2,199 sons and daughters, of whom 1,385 were examined for pregnancy and birth defect–related outcomes. Some analyses have been conducted among all study participants, and some analyses were stratifed by the type of enroll ment (random versus self-selected). The committee fully recognized the potential reporting biases that may have emanated from the self-selected cohort, and thus it placed considerably more weight on the results derived for the randomly selected cohort, as did the researchers themselves. The 19,240 conscripted male Army veterans deployed to Vietnam (“National Service” veterans) were compared with 24,729 non-deployed coun terparts (“National Service non-veterans”). Those government-sponsored studies of Australian Vietnam veterans did not characterize the veterans’ exposure to the herbicides sprayed in Vietnam beyond the fact that they had served on land or in Vietnamese waters from M ay 23, 1962, through July 1, 1973. In wave 1, conducted in 1990–1993, 641 members of the sample were located and interviewed. The veterans’ self-reported health status was compared with that of the general male Australian population gathered during the government’s administration of the same survey in 1989–1990 and 2004–2005; it is not clear that this instrument was administered to the two groups under comparable conditions. The low response rates make the fndings vulnerable to nonresponse bias, and the self-report measures of health conditions might be of low validity and subject to recall bias. The committee for Update 2010 was skeptical about the reliability of the nearly uniform fndings of statistically increased prevalence of nearly 50 health conditions. However, as mental health outcomes related to combat cannot easily be teased apart from any potential effects of herbicide exposure, such publications are not reviewed in depth. Birth Defects in Australian Infants the Australian government sponsored a case-control study of 8,517 infants with congenital anomalies born in 1966–1979 at 34 hospitals in New South W ales, Victoria, and in the Australian Capital Territory; the infants were matched by period of birth, mother’s age, hospital, and means of hospital payment to live born infants without diagnosed birth defects (Donovan et al. The fathers of infants in both groups were identifed and their names compared with those on the roster of men who had served in the Australian Army in 1962–1972; additional means of verifcation were used to determine whether a child’s father was in the Army during this interval (329 cases and 338 controls) and also whether the father was deployed to Vietnam (127 cases and 123 con trols). After adjustments were made for maternal age, infant sex, multiple births, and father’s place of birth, conditional logistic regression was used to compare the Vietnam veterans (National Service or regular Army) to other era veterans and to all other fathers for all birth anomalies and for seven diagnostic groups. Korean Vietnam -Veteran Studies M ilitary personnel of the Republic of Korea served in Vietnam from 1964 through 1973. Studies of the health of these personnel have been pursued by several researchers. The study involved 720 veterans who served in Vietnam and 25 veterans who did not. The exposure index was based on herbicide-spraying patterns in military regions where Korean personnel served, time and location data on the military units stationed in Vietnam, and an exposure score derived from self-reported activities during service. One analytic sample was prepared from the pooled blood of the 25 veterans who did not serve in Vietnam. The remaining 12 samples were intended to correspond to 12 expo sure categories; each was created by pooling blood samples from 60 veterans. The statistical analyses apparently were based on the assignment of the pooled serum dioxin value to each individual in the exposure group. In a later report on the same exposure groups and serum dioxin data, the authors corrected their analysis (J. A correlation was observed between serum dioxin concentrations and ordinal exposure categories, but the correlation was not statistically signifcant. The authors attributed the lack of statistical signifcance to the small sample size, and they noted that the data exhibited a distinct monotonic upward trend; the average serum dioxin concen trations were 0. The decision to pool blood samples from a large number of persons in each exposure set (J. Instead of 180 samples in each of the fnal exposure categories, the pooled analysis produced only three samples in each category. The narrow range of results makes the biologic relevance of any differences questionable. Furthermore, the range of mean values in the four Vietnam veteran exposure categories was nar row, and all concentrations were relatively low (less than 1 pg/g). The relatively low serum dioxin concentrations observed in the 1990s in those people are the residuals of substantially higher initial concentrations, as has been seen in other Vietnam veteran groups. The Korean authors were able to construct plausible exposure categories based on military records and self-reporting, but they were unable to validate the categories with serum dioxin measurements. Korean (Vietnam) Veterans Health Study Six publications have been reviewed from an exceptionally large epidemio logical study of more than 180,000 Korean Vietnam veterans, denoted herein as the “Korean study. The research method ology used in the Korean study was very carefully evaluated by the Update 2014 committee (the frst committee to examine these publications) because the study used multiple methods of exposure ascertainment and health outcome ascertain ment. The careful evaluation was done so that across all health outcomes, com mittee members would weigh the results from the Korean study in a consistent manner and take into account the strengths and limitations from this large body of data. For the Assessm ent of the Potential Exposure to Herbicides Publications on the Korean study have relied on multiple methods for the exposure assessment (referred to imprecisely in the Yi articles as Agent Orange). First, a self-report perceived exposure index was used to query Korean veterans as to how they might have been exposed to herbicides in Vietnam (Yi et al. Responses to six questions on a postal survey were used to derive a four-tiered categoriza tion of self-perceived herbicide exposure (Yi et al. The initial four-tier scale (high, moderate, low, and none) was further compressed into simply “high” or “low” for many analyses. The perceived herbicide exposure estimates were highly correlated with the health outcomes, indicating the pos sibility of recall bias. Exposed in other ways (not listed above) Answered “no” to all six questions None 34. The initial four-tier scale (high, moderate, low, and none) was further compressed into simply “high” or “low” for many analyses, the details of which are presented in Tables 5-2 and 5-3. The Update 2014 committee noted that the proportion of veterans in the “high” exposure category may be too large and the individuals too similar to the lower categories to detect the true strength of associations between exposure and adverse health conditions. The committee proposed that an exposure classifcation that put only the top 10% or 15% of individuals in the “high” category would have been better for the purpose of identifying adverse health effects due to exposure. For the Assessm ent of the Health Outcom es of Interest As with exposure assessment, multiple methods were used to ascertain health outcomes in the Korean study. The diseases were classifed into seven groups of diseases: cancers, circulatory diseases, respiratory diseases, digestive diseases, neuromuscular dis eases, endocrine diseases, and other diseases. W ithin the major disease groups, self-reporting was further provided for 17 cancers (including stomach cancer, liver cancer, and lung cancer), 13 circulatory diseases (including hypertension, myocardial infarction, and angina), 5 respiratory diseases (including chronic bronchitis and emphysema), 6 digestive diseases (including gastritis and peptic ulcer), 4 neuromuscular diseases (including central nervous system disorders and peripheral neuropathy), 2 endocrine diseases (diabetes and hypothyroidism), and 4 other diseases (including renal failure and skin disease). Third, prevalent cases of individual disease conditions were identifed by extracting claims data from the Korea National Health Insurance service during the period January 1, 2000, to September 30, 2005. Data on health outcomes were also obtained through a review of medical care covered directly by the Korean government through the Veterans Health Service during the same period. Fourth, vital status of Korean Vietnam veterans and the underlying causes of deaths were ascertained by use of the 1992–2005 death records of the National Statistical Offce. Categories included all causes of death, 23 specifc cancers, and 36 specifc causes other than cancer. Using these multiple methods for exposure classifcation and health outcome as certainment, associations between metrics of herbicide exposure potential and health outcomes were derived. First, in some analyses, the health experiences of Korean Vietnam veterans, as a function of their exposure status, was compared to the health status of age-matched adults in the Korean general population. Second, some analyses were performed among Ko rean Vietnam veterans with the lowest herbicide exposure classifcation serving as the comparison group. The above variations in exposure assessment, health outcome ascertain ment, and the use of internal and external comparison groups have signifcant implications for the appropriate interpretation of results from the Korean study.
Additional Information • Source documents: Oncotype Dx Breast Recurrence Score laboratory report diabetes y alcohol consecuencias order repaglinide australia, other statements in medical record • For further information diabetes 2 medications used purchase repaglinide 1mg amex, see glucose test diabetes mellitus discount 1mg repaglinide overnight delivery. Coding Instructions and Codes Note 1: Physician statement of Oncotype Dx Recurrence Score-Invasive score can be used to diabetes symptoms nausea discount repaglinide 2 mg fast delivery code this data item. Note 2: the Oncotype Dx-Invasive recurrence score is reported as a whole number between 0 and 100. Note 5: Staging for Breast cancer now depends on the Oncotype-Dx-Invasive recurrence score. Coding Instructions and Codes Note 1: Physician statement of Oncotype Dx Risk Level-Invasive can be used to code this data item. Note 2: the Oncotype Dx Risk Level-Invasive test stratifies scores into low, intermediate, and high risk of distant recurrence. Note 4: Ki-67 results are reported as the percentage cell nuclei that stain positive. As of early 2017 there are no established standards for interpretation of results or for cutoffs for positive and negative. Intramammary nodes, located within the breast, are not the same as internal mammary nodes, located along the sternum. Note 2: the clinician’s statement may be based on pathology reports, imaging, and other clinical findings. In English, the organization is the International Federation of Gynecology and Obstetrics. One data item collects the status (positive, negative, unknown) involvement of femoral-inguinal, para-aortic and pelvic lymph nodes. Definition this data item records the appropriate description of involved regional lymph nodes, specifically whether they are unilateral or bilateral involvement. Note 2: Assign the highest applicable code (0-2) in the case of multiple assessments. Note 4: Code 9 is used when there is no relevant nodal information from diagnostic work up, biopsy or surgical resection documented. Code Description 0 Negative mediastinal and scalene lymph nodes 1 Positive mediastinal lymph nodes 2 Positive scalene lymph nodes 3 Positive mediastinal and scalene lymph nodes 8 Not applicable: Information not collected for this case (If this item is required by your standard setter, use of code 8 will result in an edit error. Coding guidelines • Code 00 for when no nodes are examined • Code the exact number of examined nodes 01-99 • Code X1 for 100 or more examined nodes • Code X2 for examined nodes, but unknown how many • Code X6 for aspiration or core biopsy of para-aortic node(s) only • Code X9 when o Not documented in the medical record o Para-Aortic lymph nodes not evaluated (assessed) o Unknown if Para-Aortic lymph nodes not evaluated (assessed) See Number of Positive and Examined Para-Aortic and Pelvic Nodes for additional information Coding Instructions and Codes Note 1: Physician statement of examined para-aortic nodes can be used to code this data item when no other information is available. See Number of Positive and Examined Para-Aortic and Pelvic Nodes for additional information Coding guidelines • Code 00 for when there are no positive nodes • Code the exact number of positive nodes 01-99 • Code X1 for 100 or more positive nodes • Code X2 for positive nodes, but unknown how many • Code X6 for aspiration or core biopsy of pelvic node(s) only • Code X9 when o Not documented in the medical record o Pelvic lymph nodes not evaluated (assessed) o Unknown if Pelvic lymph nodes evaluated (assessed) Additional Information • Source documents: pathology report, imaging reports, physical exam, other statements in medical record Coding Instructions and Codes Note 1: Physician statement of positive pelvic nodes can be used to code this data item when no other information is available. Note 2: Record the number of positive pelvic lymph nodes documented in the medical record. Note 4: Micrometastasis and macrometastasis may be listed separately on the pathology report. Code Description 00 All pelvic nodes examined negative 01-99 1 99 pelvic nodes positive (Exact number of nodes positive) X1 100 or more pelvic nodes positive X2 Positive pelvic nodes identified, number unknown X6 Positive aspiration or core biopsy of pelvic lymph node(s) X8 Not applicable: Information not collected for this case (If this item is required by your standard setter, use of code X8 will result in an edit error. Coding guidelines • Code 00 for when no nodes are examined • Code the exact number of examined nodes 01-99 • Code X1 for 100 or more examined nodes • Code X2 for nodes examined, but unknown how many • Code X6 for aspiration or core biopsy of pelvic(s) nodes only • Code X9 when o Not documented in the medical record o Pelvic lymph nodes not evaluated (assessed) o Unknown if Pelvic lymph nodes not evaluated (assessed) See Number of Positive and Examined Para-Aortic and Pelvic Nodes for additional information Coding Instructions and Codes Note 1: Physician statement of examined pelvic nodes can be used to code this data item when no other information is available. Definition Peritoneal cytology looks for malignant cells in the fluid in the pelvic and peritoneal cavities. Note 2: Peritoneal cytology may also be called peritoneal ascitic fluid instead of peritoneal washing or pelvic washing. Coding guidelines Record the clinician’s interpretation of the highest value prior to treatment from a blood or serum test, based on the reference range used by the lab. The typical human reference ranges are 0 to less than or equal 35 units per milliliter (U/mL). Definition the amount of ovarian tumor and the location of tumor remaining in the patient after initial ovarian or peritoneal cancer surgery are the most important prognostic factors for advanced disease. Information about residual tumor volume will be in the operative report; information about preoperative (neoadjuvant) chemotherapy will be elsewhere in the medical record or physician notes. Note 2: the surgery to remove as much cancer in the pelvis and/or abdomen as possible, reducing the "bulk" of the cancer, is called "debulking" or "cytoreductive" surgery. It is performed when there is widespread evidence of advanced stage of ovarian cancer with obvious spread to other organs outside the ovary, typically in the upper abdomen, intestines, the omentum (the fat pad suspended from the transverse colon like an apron), the diaphragm, or liver. Note 4: Gross residual tumor after primary cytoreductive surgery is a prognostic factor that has been demonstrated in large studies. Code the clinician’s statement of the total point value for the Prognostic Index in priority over the clinician’s statement of risk. This is mainly determined by physical examination and includes statements such as fixed or matted nodes. Other names include: extranodal spread, extracapsular extension, or extracapsular spread. Note 4: Code the status of extranodal extension assessed on the surgical resection specimen for the most involved regional lymph node(s). Although originally not intended to be a screening test, this relatively simple blood test has become a very common method of detecting new prostate cancer in its earliest stages. The lab value may be recorded in the lab report, history and physical, or clinical statement in the pathology report, etc. A lab value expressed in micrograms per liter (ug/L) is equivalent to the same value expressed in nanograms per milliliter (ng/ml) Record 0. When a patient undergoes radical prostatectomy, the pathologist may look for a third or tertiary pattern in the specimen. Studies indicate that a Gleason score 7, with tertiary pattern 5, is associated with a worse prognosis than without tertiary pattern 5 and is similar to the prognosis for Gleason score 8 – 10. Gleason grades (patterns) range from 1 (small, uniform gland) to 5 (lack of glands, sheets of cells. A low Gleason score means the cancer tissue is similar to normal prostate tissue and the tumor is less likely to spread; a high Gleason score means the cancer tissue is very different from normal and the tumor is more likely to spread. Note 3: Code the Gleason primary and secondary patterns prior to neoadjuvant treatment. Note 5: If different patterns are documented on multiple needle core biopsies, code the pattern that reflects the highest or most aggressive score regardless if the pathologist provides an overall pattern in a final summary. Note 7: Do not infer Gleason Primary and Secondary Pattern from Grade Group (Code X9). These two numbers are added together to create a pattern score, ranging from 2 to 10. Note 5: If different scores are documented on multiple needle core biopsies, code the highest or most aggressive score. This data item represents the Gleason primary and secondary patterns from prostatectomy or autopsy. Coding Instructions and Codes Note 1: Physician statement of Gleason Patterns Pathological can be used to code this data item when there is no other information available. Coding Instructions and Codes Note 1: Physician statement of Gleason Score Pathological can be used to code this data item when there is no other information available. Note 2: Code the Gleason Score Pathological from prostatectomy or autopsy only in this field. This data item represents the tertiary pattern value from prostatectomy or autopsy. Code Description 10 Tertiary pattern 1 20 Tertiary pattern 2 30 Tertiary pattern 3 40 Tertiary pattern 4 50 Tertiary pattern 5 X7 No prostatectomy/autopsy performed X8 Not applicable: Information not collected for this case (If this information is required by your standard setter, use of code X8 may result in an edit error. For Prostate, there are 2 data items that record information on the number of cores positive and examined. Coding Instructions and Codes Note 1: Physician statement of Number of Cores Positive can be used to code this data item when there is no other information available. Code Description 00 All examined cores negative 01-99 1 99 cores positive (Exact number of cores positive) X1 100 or more cores positive X6 Biopsy cores positive, number unknown X7 No needle core biopsy performed X8 Not applicable: Information not collected for this case (If this information is required by your standard setter, use of code X8 may result in an edit error. Note 3: If the pathology report contains a summary of the number of cores positive and examined, use the summary provided. Code Description 01-99 1 99 cores examined (Exact number of cores examined) X1 100 or more cores examined X6 Biopsy cores examined, number unknown X7 No needle core biopsy performed X8 Not applicable: Information not collected for this case (If this information is required by your standard setter, use of code X8 may result in an edit error. For patients with nonseminomas, the degree of tumor-marker elevation after the cancerous testicular has been removed is one of the most significant predictors of prognosis. Note 3: A lab value expressed in micrograms/liter (ug/l) is equivalent to the same value expressed in ng/mL. Note 3: A lab value expressed in micrograms/liter (ug/L) is equivalent to the same value expressed in nanograms/milliliter (ng/mL).