John G. Augoustides, MD, FASe, FAHA

• Associate Professor
• Cardiovascular and Thoracic Section
• Anesthesiology and Critical Care
• University of Pennsylvania School of Medicine
• Philadelphia, Pennsylvania

If you already have a parasitic infection it should be treated before you start treatment with Dupixent symptoms 5 days after iui order norpace canada. Asthma If you have asthma and are taking asthma medicines medications heart disease generic 100 mg norpace with visa, do not change or stop your asthma medicine without talking to your doctor treatment lyme disease buy discount norpace 100mg online. Talk to your doctor before you stop Dupixent or if your asthma remains uncontrolled or worsens during treatment with this medicine osteoporosis treatment order cheap norpace line. Eye problems (if you have atopic dermatitis) Talk to your doctor if you have any new or worsening eye problems medications ms treatment order norpace us, including eye pain or changes in vision symptoms for hiv discount norpace 150 mg without a prescription. The safety and benefits of Dupixent are not yet known in children with atopic dermatitis below the age of 12. Other medicines for asthma Do not stop or reduce your asthma medicines, unless instructed by your doctor. If you are pregnant, think you may be pregnant, or are planning to have a baby, ask your doctor for advice before using this medicine. The effects of this medicine in pregnant women are not known; therefore it is preferable to avoid the use of Dupixent in pregnancy unless your doctor advises to use it. Driving and using machines Dupixent is unlikely to influence your ability to drive and use machines. Dupixent contains sodium this medicine contains less than 1 mmol sodium (23 mg) per 300 mg dose, i. How to use Dupixent Always use this medicine exactly as your doctor or pharmacist has told you. How Dupixent is given Dupixent is given by injection under the skin (subcutaneous injection). How much Dupixent you will receive Your doctor will decide which dose of Dupixent is right for you. Recommended dose in adults with atopic dermatitis For patients with atopic dermatitis, the recommended dose of Dupixent is: Recommended dose in adolescents with atopic dermatitis the recommended dose of Dupixent for adolescents (12 to 17 years of age) with atopic dermatitis is based on body weight: 118 Body Weight of Initial Dose Subsequent Doses Patient (every other week) less than 60 kg 400 mg (two 200 mg injections) 200 mg 60 kg or more 600 mg (two 300 mg injections) 300 mg Recommended dose in adult and adolescent patients with asthma (12 years of age and older) For patients with severe asthma and who are on oral corticosteroids or for patients with severe asthma and co-morbid moderate-to-severe atopic dermatitis or adults with co-morbid severe chronic rhinosinusitis with nasal polyposis, the recommended dose of Dupixent is: Injecting Dupixent Dupixent is given by injection under your skin (subcutaneous injection). You and your doctor or nurse should decide if you should inject Dupixent yourself. Before injecting Dupixent yourself you must have been properly trained by your doctor or nurse. Your Dupixent injection may also be given by a caregiver after proper training by a doctor or nurse. Read the Instructions for Use? for the pre-filled pen carefully before using Dupixent. If you use more Dupixent than you should If you use more Dupixent than you should or the dose has been given too early, talk to your doctor, pharmacist or nurse. If you forget to use Dupixent If you have forgotten to inject a dose of Dupixent, talk to your doctor, pharmacist or nurse. If you stop using Dupixent Do not stop using Dupixent without speaking to your doctor first. If you have any further questions on the use of this medicine, ask your doctor, pharmacist or nurse. Possible side effects Like all medicines, this medicine can cause side effects, although not everybody gets them. Dupixent can cause serious side effects, including very rare allergic (hypersensitivity) reactions, including anaphylactic reaction; the signs of allergic reaction or anaphylactic reaction may include: Other side effects Very Common (may affect more than 1 in 10 people) atopic dermatitis and asthma: You can also report side effects directly via the national reporting system listed in Appendix V. By reporting side effects you can help provide more information on the safety of this medicine. If necessary, pre-filled pens may be kept at room temperature up to 25?C for a maximum of 14 days. If you need to permanently remove the carton from the refrigerator, write down the date of removal in the space provided on the outer carton, and use Dupixent within 14 days. Do not use this medicine if you notice that the medicine is cloudy, discoloured, or has particles in it. Ask your doctor, pharmacist or nurse how to throw away medicines you no longer use. What Dupixent looks like and contents of the pack 120 Dupixent is a clear to slightly opalescent, colourless to pale yellow solution supplied in a pre-filled pen. Dupixent is available as 300 mg pre-filled pens in a pack containing 1, 2, 3, or 6 pre-filled pens. Tlf: +45 45 16 70 00 Tel: +39 02 39394275 Deutschland Nederland Sanofi-Aventis Deutschland GmbH sanofi-aventis Netherlands B. Tel: +353 (0) 1 403 56 00 Tel: +386 1 560 48 00 Island Slovenska republika Vistor hf. It contains 300 mg of Dupixent for injection under the skin (subcutaneous injection). You must not try to give yourself or someone else the injection unless you have received training from your healthcare professional. In adolescents 12 years and older, it is recommended that Dupixent be administered by or under supervision of an adult. If you need to permanently remove the carton from the refrigerator, write down the date of removal in the space provided on the outer carton, and use Dupixent within 14 days. Do not use the pre-filled pen if the liquid is discolored or cloudy, or if it contains visible flakes or particles. When placing the yellow needle cover on your skin, hold the pre-filled pen so that you can see the window. Press down Press the pre-filled pen firmly against your skin until you cannot see the yellow needle cover, and hold. If the window does not turn completely yellow, remove the pen and call your healthcare provider. After you have completed your injection pull straight up to remove pre-filled pen from the skin and dispose of immediately as described in section D. Dispose of the pre-filled pens, (needle inside), and green caps in a puncture resistant container right away after use. Do not dispose of (throw away) pre-filled pens (needle inside), and green caps in your household trash. Read all of this leaflet carefully before you start using this medicine because it contains important information for you. What Dupixent is and what it is used for What Dupixent is Dupixent contains the active substance dupilumab. What Dupixent is used for Dupixent is used to treat adults and adolescents 12 years and older with moderate-to-severe atopic dermatitis, also known as atopic eczema. Dupixent may be used with eczema medicines that you apply to the skin or it may be used on its own. Dupixent is used with other asthma medicines for the maintenance treatment of severe asthma in adults and adolescents (12 years of age and older) whose asthma is not controlled with their current asthma medicines. How Dupixent works Using Dupixent for atopic dermatitis (atopic eczema) can improve the condition of your skin and reduce itching. Dupixent has also been shown to improve symptoms of pain, anxiety, and depression associated with atopic dermatitis. In addition, Dupixent helps improve your sleep disturbance and overall quality of life. Dupixent helps prevent severe asthma attacks (exacerbations) and can improve your breathing. Dupixent may also help reduce the amount of another group of medicines you need to control your asthma, called oral corticosteroids, while preventing severe asthma attacks and improving your breathing. Warnings and precautions Talk to your doctor, pharmacist or nurse before using Dupixent: Dupixent is not a rescue medicine and should not be used to treat a sudden asthma attack. Very rarely, Dupixent can cause serious side effects, including allergic (hypersensitivity) reactions and anaphylactic reaction. Rarely patients taking an asthma medicine may develop inflammation of blood vessels or lungs due to an increase of certain white blood cells (eosinophilia). This usually, but not always, happens in people who also take a steroid medicine which is being stopped or for which the dose is being lowered. If you already have a parasitic infection it should be treated before you start treatment with Dupixent. Asthma If you have asthma and are taking asthma medicines, do not change or stop your asthma medicine without talking to your doctor. Talk to your doctor before you stop Dupixent or if your asthma remains uncontrolled or worsens during treatment with this medicine. Eye problems (if you have atopic dermatitis) Talk to your doctor if you have any new or worsening eye problems, including eye pain or changes in vision. The safety and benefits of Dupixent are not yet known in children with atopic dermatitis below the age of 12. Other medicines for asthma Do not stop or reduce your asthma medicines, unless instructed by your doctor. If you are pregnant, think you may be pregnant, or are planning to have a baby, ask your doctor for advice before using this medicine. The effects of this medicine in pregnant women are not known; therefore it is preferable to avoid the use of Dupixent in pregnancy unless your doctor advises to use it. Driving and using machines Dupixent is unlikely to influence your ability to drive and use machines. Dupixent contains sodium this medicine contains less than 1 mmol sodium (23 mg) per 200 mg dose, i. How to use Dupixent Always use this medicine exactly as your doctor or pharmacist has told you. How Dupixent is given Dupixent is given by injection under the skin (subcutaneous injection). How much Dupixent you will receive Your doctor will decide which dose of Dupixent is right for you. Recommended dose in adolescents with atopic dermatitis the recommended dose of Dupixent for adolescents (12 to 17 years of age) with atopic dermatitis is based on body weight: Body Weight of Initial Dose Subsequent Doses Patient (every other week) less than 60 kg 400 mg (two 200 mg injections) 200 mg 60 kg or more 600 mg (two 300 mg injections) 300 mg Recommended dose in adult and adolescent patients with asthma (12 years of age and older) For most patients with severe asthma, the recommended dose of Dupixent is: For patients with severe asthma and who are on oral corticosteroids or for patients with severe asthma and co-morbid moderate-to-severe atopic dermatitis or adults with co-morbid severe chronic rhinosinusitis with nasal polyposis, the recommended dose of Dupixent is: 132. Injecting Dupixent Dupixent is given by injection under your skin (subcutaneous injection). You and your doctor or nurse should decide if you should inject Dupixent yourself. Before injecting Dupixent yourself you must have been properly trained by your doctor or nurse. Your Dupixent injection may also be given by a caregiver after proper training by a doctor or nurse. Read the Instructions for Use? for the pre-filled syringe carefully before using Dupixent. If you use more Dupixent than you should If you use more Dupixent than you should or the dose has been given too early, talk to your doctor, pharmacist or nurse. If you forget to use Dupixent If you have forgotten to inject a dose of Dupixent, talk to your doctor, pharmacist or nurse. If you stop using Dupixent Do not stop using Dupixent without speaking to your doctor first. If you have any further questions on the use of this medicine, ask your doctor, pharmacist or nurse. Possible side effects Like all medicines, this medicine can cause side effects, although not everybody gets them. Dupixent can cause serious side effects, including very rare allergic (hypersensitivity) reactions, including anaphylactic reaction; the signs of allergic reaction or anaphylactic reaction may include: Other side effects Very Common (may affect more than 1 in 10 people) atopic dermatitis and asthma: You can also report side effects directly via the national reporting system listed in Appendix V. By reporting side effects you can help provide more information on the safety of this medicine. If necessary, pre-filled syringes may be kept at room temperature up to 25?C for a maximum of 14 days. If you need to permanently remove the carton from the refrigerator, write down the date of removal in the space provided on the outer carton, and use Dupixent within 14 days. Do not use this medicine if you notice that the medicine is cloudy, discoloured, or has particles in it. Ask your doctor, pharmacist or nurse how to throw away medicines you no longer use. What Dupixent looks like and contents of the pack Dupixent is a clear to slightly opalescent, colourless to pale yellow solution supplied in a glass pre filled syringe. Dupixent is available as 200 mg pre-filled syringes in a pack containing 1 or 2 pre-filled syringes or in a pack containing 3 (3 packs of 1) or 6 (3 packs of 2) pre-filled syringes. Tlf: +45 45 16 70 00 Tel: +39 02 39394275 Deutschland Nederland Sanofi-Aventis Deutschland GmbH sanofi-aventis Netherlands B.

Ectopic expression of c-Myc in the skin affects the hair Age-related changes in the meibomian gland medicine 44175 discount norpace 100mg with visa. Hedgehog signaling the emergence of the germ line during development in the regulates sebaceous gland development medications education plans order cheap norpace. Fatty acid chain elongation by sebocyte differentiation involves peroxisome proliferator-acti microsomal enzymes from the bovine meibomian gland medications zanaflex quality 150 mg norpace. Effect of oral isotretinoin -3 fatty acid desaturase by heterologous expression in Arabidop treatment on skin androgen receptor levels in male acneic pa sis 7 medications that cause incontinence norpace 150 mg overnight delivery. Neuroendocrine regulation of sebocytes: long chain alcohols by developing rat brain medications 500 mg buy norpace on line. Proopio Human meibomian glands: a histochemical study for androgen melanocortin peptides and sebogenesis treatment pneumonia order discount norpace online. The distribution of hydroxys research: potential new approaches to acne management. Normal and abnormal functions of meibo ization in cutaneous nerves and merkel cells. Psoriasis and hypogonadism in chronic blepharokeratocon infant Meibomian lipid layer. Sensory and autonomic innervation of the rat eyelid: Neuronal origins and peptide phenotypes. Control of human sebo growth factors have different effects on sebaceous cell growth cyte proliferation in vitro by testosterone and 5-alpha-dihydrotes and differentiation. Immunohistochemical distribution of control of hamster ear sebaceous gland lipogenesis. Oxidative activity of tors and their relevance for sebum production in the sebaceous the type 2 isozyme of 17beta-hydroxysteroid dehydrogenase gland ear model of the Syrian hamster. Activity of type 1 and immunohistochemical localization of 5 alpha-reductase in 5 alpha-reductase is greater in the follicular infrainfundibulum human skin. Effects of testosterone on cholesterol levels and fatty acid composition in the rat. Endocrinologic control of the development and activity of the human sebaceous gland. Effect of androgen on the sebaceous glands of human level androgen receptor expression. Regulatory effect of various steroid ceous gland activity and serum dehydroepiandrosterone sulfate hormones on the incorporation and metabolism of [14C]stearate levels in boys and girls. Direct effects of sex steroid hormones on by steroidal hormones and its use as an end organ for assaying adipose tissues and obesity. The role of testosterone in the metabolic dependent on the localization of the sebaceous glands and their syndrome: a review. Establishment 1-alkyl-2,3-diacylglycerol in the harderian gland of the golden and characterization of an immortalized human sebaceous gland hamster, Mesocricetus auratus. J Investig Derma lation of lipogenic gene expression by androgens: evidence for a tol. Androgens markedly stimulate the accumulation of and estradiol on cell kinetics in the sebaceous gland of the golden neutral lipids in the human prostatic adenocarcinoma cell line hamster ear. Intracrinology: role of the family the sterol regulatory element-binding protein pathway: current of 17 beta-hydroxysteroid dehydrogenases in human physiology insights. J Clin role of estrogen receptors and androgen receptors in sex steroid Endocrinol Metab. Mol ization and characterization of human meibomian gland epithelial Cell Endocrinol. Effect of androgen acterization of the gene and functional assessment as a very long de? Dehydroepiandrosterone Therapy for the protein is less active than isoform 1a in livers of transgenic mice Treatment of Dry Eye Disorders. In: element-binding protein-1 as a key transcription factor for nutri Abstracts of the Centennial Annual Meeting of the American tional induction of lipogenic enzyme genes. Phosphatidylcholine transfer on bone, vagina, and endometrium in postmenopausal women. La Kerato-conjonctivite seche de Gougerot protease synthesis by estrogen in osteoclasts. Inducers of tears: androgens and human gam ocular symptoms associated with the estradiol transdermal estro maglobulin. Inhibition of dihydrotestos terone-mediated hamster sebaceous gland hypertrophy by pro 212. Inhibition of testosterone metabo gland of the hamster ear and its antagonism by tamoxifen. Synergistic antiandrogenic estrogen and androgen on the sebaceous gland turnover time. Direct photomicroscopic evidence for rapid nuclear population: the Blue Mountains Eye Study. Estrogen and progesterone apy for squamous metaplasia of various ocular surface disorders. Isotretinoin ad gen and progesterone control of gene expression in the mouse ministration in treatment of acne vulgaris. The effects of dietary and pharmacological cellular isomerization to all-trans retinoic acid and binding to manipulation on lipid production in the meibomian and hard retinoid acid receptors. Limbal stem cell complicating 13-cis-retinoic acid (isotretinoin) therapy in a labo de? Invest Meibomian gland morphology and tear osmolarity: changes with Ophthalmol Vis Sci. Lacrimal biomicroscopy and photography of meibomian glands in a rabbit function and ocular complications in patients treated with sys model of meibomian gland dysfunction. Chronic blepharoconjunctivitis during a treatment with acitretin Contact lens wear is associated with decrease of meibomian (Soriatane) (in French). Meibomian glands and contact lens terone and all-trans retinoic acid in regulation of androgen recep wear. Histo Down-regulation of androgen receptor expression and inhibition pathological study of the meibomian glands in 72 autopsy cases of lacrimal gland cell proliferation by retinoic acid. Histopathologic melanocortin 5 receptor is expressed in human sebaceous glands study of human lacrimal gland. Regulation of salivary gland function erbB2 in epidermis of transgenic mice results in epidermal hy by autonomic nerves. The treatment response in obstructive meibomian gland disease by in Journal of Nutrition. Demodex Morpho-regulation of ectodermal organs: integument pathology folliculorum and Demodex brevis as a cause of chronic marginal and phenotypic variations in K14-Noggin engineered mice blepharitis. Sex steroids, the meibo ing is required for eyelid closure and to specify conjunctival mian gland and evaporative dry eye. The tortoise and the hair: slow-cycling cells in the stem keratoconjunctivitis sicca. A lipopolysaccharide induce the expression of antimicrobial pep newly developed video-meibography system featuring a newly tides and proin? Contact lens wear, use of eye cosmetics, and Meibo and development of dry eye disease. Meibomian gland dysfunction: some clinical, ese, klinischer Verlauf und therapeutische Ansa? Special Issue the International W orkshop on eibom ian Gland Dysfunction: Report of the Subcom ittee on Tear Film Lipids and Lipid?Protein Interactions in Health and Disease 1 2 3 4 Kari B. Green-Church, Igor Butovich, Mark Willcox, Douglas Borchman, 5 6 7,8 Friedrich Paulsen, Stefano Barabino, and Ben J. The meibomian gland secretions consist of an barrier to protect the eye from microbial agents and organic extremely complex mixture of various polar and nonpolar matter, such as dust and pollen. Interestingly, the lower lipid Kentucky Lions Eye Center, Department of Ophthalmology and Visual sublayer is thought to create an interface that helps stabilize Sciences, University of Louisville, Louisville, Kentucky; the 5Department this upper portion. Shine and McCulley13 sug mology and Pathology and Laboratory Science, Jules Stein Eye Institute, University of California Los Angeles, Los Angeles, California. Modern instrumentation possible) redistribution of the lipids of different classes be can detect a wide variety of compounds and provide accurate tween the sublayers and is based on an assumption that the information on their structures. This translocation Handling and storage of lipid samples generally follows the of proteins from the bulk aqueous phase to the air?water recommendations provided in lipid chemistry textbooks and interface is typically accompanied by protein denaturing. This results in the formation of mize (or prevent) sample exposure or contact with any prod a protein layer. Glass, stainless steel, noble In the presence of meibomian lipids, proteins have to com metals, and Te? The preferred conditions for storing lipid samples regard protein attachment to (or association with) the lipid layer. Another to demonstrate that other tear proteins (such as lysozyme 3 technique, the surgical removal of eyelids and/or meibomian and mucins) could also penetrate the lipid layers. The hard expression technique is often de meibum, very long chain (O-acyl) -hydroxy fatty acids, which scribed as a squeeze technique in which a conformer or device may act in the formation of an intermediate surfactant lipid is used behind the lid while pressure is applied to the front of sublayer between the thick outermost nonpolar lipid sublayer the eyelid. The contamination may vary by meibum studies have been published using analysis techniques patient and/or examiner. The basic principle of infrared spectroscopy is that when a Patients accept the Schirmer test strip technique as a gen bond with an electric dipole is changing at the same frequency eral component of an ocular surface examination. From the Schirmer test may be less comfortable for patients than the the intensity and frequency of the absorbed radiation, vibra microcapillary technique. Infrared spectroscopy and Raman spec collecting a pure meibum sample, however, because it is vir troscopy are complimentary techniques; they both measure tually impossible to avoid wetting the strips with aqueous vibrational modes. Consequently, it seems that expression and microcapil more intense in Raman spectra and asymmetric bands more lary tube collection or spatula collection is well suited for intense in infrared absorption spectra. Fluorescence does not collecting samples of pure meibum, whereas microcapillary interfere with infrared spectra like it does with Raman spectra, tube and Schirmer test strips are better suited for collecting but water bands, associated with most biological tissues, can aqueous tears. Additional research evaluating alternate and/or overwhelm and interfere with infrared spectral features. Thus, in a water-in-oil emulsion, polar lipids would concentrate in the aqueous subphase. The borders between these three groups are blurry, C18:1-fatty acid based esters of very-long-chain saturated fatty as there are many factors that in? Their structures; the degree of unsaturation; cis, trans and iso and fatty acids were esteri? Many lipids can isomerize, either detected in meibum can have very long saturated and unsatu induced by enzymatic transformation or spontaneously. Free cholesterol appears to be less than also become more hydrophilic because of the addition of 0. However, given that the meibomian gland recently published and may elucidate the molecular composi secretes through a holocrine mechanism and that cell mem tion of these biomolecules. Finally, some phospholipids are more readily detected meibum, and most meibum components are nonpolar lipids in the negative-ion mode, whereas the opposite is true for of different classes. Several reviews on approach to accurate quantitation of phospholipids by mass the topic has been published,53?56including the most recent spectrometry. This was explained by suggesting that both types of the sam make up only approximately 3% of cow or rabbit 44 meibum. Of particular interest, aqueous tear samples show the spectrometric signals of or the fatty acids and fatty alcohols have also been exam ganic phosphate esters, similar to that found in phosphatidyl ined in detail. Some acids with very long carbon chains, as long as C36, have been found in the -hydroxy Animal studies on meibum lipids have predominantly focused fraction. Anteiso-C25,-C27, and -C23 were the most highly on bovines (castrated bulls) and rabbits, although other species labeled alcohols, con? Some of the differences seen in lipid types associated with Monounsaturated fatty acids belong mainly to the -9 series, different forms of blepharitis may be due to the presence of and saturated acids belong to the iso-, anteiso-, and n-series. People with meibomian seborrhea with a clinical ap of these being iso-C16 and iso-C20. Fatty alcohols are mainly from the androgen insensitivity syndrome, and persons with Sjo? The chains are straight-chain iso, anteiso, and mono and cholesterol93 and a decrease in the amount of monounsat 25 27 unsaturated. The alcohols have corresponding struc ration of the nonpolar fatty acids tends to increase their melt tures. Infrared studies have shown that lipid order and with maxima at C15 to C18 and C25 to C27. Chains are predom phase transition temperatures are higher in meibum of donors inantly iso or anteiso-branched. However, a study of the effect of branched-chain fatty Lipid Deposition acids on cultivated conjunctival human cells treated with iso C and iso-C has shown no effects on the parameters of While lipids from the meibomian gland appear to be essential 16 20 102 cytotoxicity. Overall lipid deposition increases with longer replacement schedules (3 months vs. A particular form of deposit on lenses, often called jelly bump For the silicone hydrogel lenses (groups Vb and Vc), the deposits, was shown to be composed of long and intermediate degree of lipid deposition in vivo appears to be substantially 110 higher than that seen with conventional hydrogels. White spots, a similar par ticular type of deposits found on non-regularly replaced hydro terol was the most commonly deposited lipid, although oleic gel lenses, are predominantly comprised of lipid. This initial interfacial cholesterol in deposits,123 but found very low levels of oleic layer has been shown to be made from cholesterol, cholesterol acid or its methyl ester (summarized in Table 6). Deposition of Lipids onto Contact Lenses107 Amount of Lipid Adsorbed In Vitro (g/lens) Soft Lens Polymer Cholesterol Phosphatidyl Dioleoyl Type Name Cholesterol Oleate Ethanolamine Phosphatidylcholine Group I Polymacon 0.

Hepatitis D is another virus that infects the liver medications in spanish buy norpace no prescription, but only in people who already have hepatitis B medications 5 rs purchase norpace overnight. This disease appears to be caused by the immune system attacking the liver and causing inflammation treatment meaning norpace 150mg with visa, damage treatment tmj purchase 150 mg norpace visa, and eventually scarring and cirrhosis treatment 2 go generic 150 mg norpace with visa. Alpha-1 antitrypsin deficiency treatment yellow tongue order norpace 150 mg on-line, hemochromatosis, Wilson disease, galactosemia, and glycogen storage diseases are among the inherited diseases that interfere with the way the liver produces, processes, and stores enzymes, proteins, metals, and other substances the body needs to function properly. This type of hepatitis appears to be associated with diabetes, protein malnutrition, obesity, coronary artery disease, and treatment with corticosteroid medications. When the ducts that carry bile out of the liver are blocked, bile backs up and damages liver tissue. In babies, blocked bile ducts are most commonly caused by biliary atresia, a disease in which the bile ducts are absent or injured. In adults, the most common cause is primary biliary cirrhosis, a disease in which the ducts become inflamed, blocked, and scarred. Secondary biliary cirrhosis can happen after gallbladder surgery if the ducts are inadvertently tied off or injured. Severe reactions to prescription drugs, prolonged exposure to environmental toxins, the parasitic infection schistosomiasis, and repeated bouts of heart failure with liver congestion can all lead to cirrhosis. P If Symptoms Many people with cirrhosis have no symptoms in the early stages of the disease. However, as scar tissue replaces healthy cells, liver function starts to fail and a person may experience one or more of the following symptoms: P If Complications of Cirrhosis Loss of liver function affects the body in many ways. When the liver loses its ability to make the protein albumin, water accumulates in the legs (edema) and abdomen (ascites). When the liver slows or stops production of the proteins needed for blood clotting, a person will bruise or bleed easily. Jaundice is a yellowing of the skin and eyes that occurs when the diseased liver does not absorb enough bilirubin. A damaged liver cannot remove toxins from the blood, causing them to accumulate in the blood and eventually the brain. There, toxins can dull mental functioning and cause personality changes, coma, and even death. Signs of the buildup of toxins in the brain include neglect of personal appearance, unresponsiveness, forgetfulness, trouble concentrating, or changes in sleep habits. Because the liver does not remove drugs from the blood at the usual rate, they act longer than expected and build up in the body. Normally, blood from the intestines and spleen is carried to the liver through the portal vein. But cirrhosis slows the normal flow of blood through Cirrhosis of the Liver Information Sheet Ver3. When blood flow through the portal vein slows, blood from the intestines and spleen backs up into blood vessels in the stomach and esophagus. These blood vessels may become enlarged because they are not meant to carry this much blood. The enlarged blood vessels, called varices, have thin walls and carry high pressure, and thus are more likely to burst. If they do burst, the result is a serious bleeding problem in the upper stomach or esophagus that requires immediate medical attention. This hormone, produced by the pancreas, enables blood glucose to be used as energy by the cells of the body. If you have insulin resistance, your muscle, fat, and liver cells do not use insulin properly. Hepatocellular carcinoma, a type of liver cancer commonly caused by cirrhosis, starts in the liver tissue itself. Fluid in the abdomen (ascites) may become infected with bacteria normally present in the intestines. Cirrhosis can also lead to impotence, kidney dysfunction and failure, and osteoporosis. P If Diagnosis the doctor may diagnose cirrhosis on the basis of symptoms, laboratory tests, the medical history, and a physical examination. For example, during a physical examination, the doctor may notice that the liver feels harder or larger than usual and order blood tests that can show whether liver disease is present. Or the doctor might look at the liver using a laparoscope, an instrument that is inserted through the abdomen and relays pictures back to a computer screen. For a biopsy, the doctor uses a needle to take a tiny sample of liver tissue, then examines it under the microscope for scarring or other signs of disease. Treatment P If Liver damage from cirrhosis cannot be reversed, but treatment can stop or delay further progression and reduce complications. Treatment depends on the cause of cirrhosis and any complications a person is experiencing. For example, cirrhosis caused by alcohol abuse is treated by abstaining from alcohol. Treatment for hepatitis-related cirrhosis involves medications used to treat the different types of hepatitis, such as interferon for viral hepatitis and corticosteroids for autoimmune hepatitis. Cirrhosis caused by Wilson disease, in which copper builds up in organs, is treated with medications to remove the copper. These are just a few examples? treatment for cirrhosis resulting from other diseases depends on the underlying cause. In all cases, regardless of the cause, following a healthy diet and avoiding alcohol are essential because the body needs all the nutrients it can get, and alcohol will only lead to more liver damage. For example, for ascites and edema, the doctor may recommend a low-sodium diet or the use of diuretics, which are drugs that remove fluid from the body. Antibiotics will be prescribed for infections, and various medications can help with itching. Protein causes toxins to form in the digestive tract, so eating less protein will help decrease the buildup of toxins in the blood and brain. The doctor may also prescribe laxatives to help absorb the toxins and remove them from the intestines. For portal hypertension, the doctor may prescribe a blood pressure medication such as a beta-blocker. If varices bleed, the doctor may either inject them with a clotting agent or perform a so-called rubber-band ligation, which uses a special device to compress the varices and stop the bleeding. When complications cannot be controlled or when the liver becomes so damaged from scarring that it completely stops functioning, a liver transplant is necessary. In liver transplantation surgery, a diseased liver is removed and replaced with a healthy one from an organ donor. Survival rates have improved over the past several years because of drugs such as cyclosporine and tacrolimus, which suppress the immune system and keep it from attacking and damaging the new liver. Established in 1980, the Clearinghouse provides information about digestive diseases to people with digestive disorders and to their families, health care professionals, and the public. These Information Sheets are designed to provide a brief overview of various medical conditions. Referring to the Information Sheets may help you communicate more effectively with other Cirrhosis of the Liver Information Sheet Ver3. The Information Sheets are by no means an exhaustive description of the disorders. Dual antithrombotic therapy: discontinuation antiplatelet therapy, with a combination or delayed re-initiation of antithrombotic of aspirin plus a P2Y12 receptor inhibitor treatment may lead to thrombosis, while (such as clopidogrel, prasugrel or ticagre too early re-initiation may lead to recur lor), is often necessary for a period of rent haemorrhage. Any decision Manuscript received: indicated in patients with atrial fibrilla has to be based upon limited data from February 10, 2014; tion, thromboembolic venous disease or clinical series, epidemiology, and careful Accepted: a mechanical heart valve, while recently individual assessment of all relevant pa July 29, 2014. The aim of this review is to pro such as dabigatran, rivaroxaban and apix vide useful data that will help the clinician Address: aban, have been used increasingly in non to choose the antithrombotic strategy with Athanasios Pipilis valvular atrial fibrillation and venous the smallest bleeding risk and to provide 2-4 thromboembolism. The gastrointestinal gastrointestinal (non-variceal) haemor tract figures as one of the most common rhage. When the indications are followed cautiously, Incidence of gastrointestinal haemorrhage the risk of bleeding is smaller than the risk of thrombosis and the prescription Gastrointestinal bleeding represents a se of antiplatelet or anticoagulant therapy is rious medical condition, with mortality considered safe and necessary. However, reaching 10%, and one that contributes the risk of a bleeding episode from the to increased health costs worldwide. Pipilis et al incidence of gastrointestinal bleeding is estimated replace the well studied clopidogrel are prasugrel at 100-200 cases per 100,000 general population per and ticagrelor, both already in everyday clinical use. Both are stronger antiplatelet agents and are there the ratio of upper to lower gastrointestinal bleeding fore related to more haemorrhages from the gas is approximately 4-5 to 1, but in the elderly the ratio trointestinal system when compared with clopido 10-12 becomes smaller as diseases of the colon (diverticu grel. In fact, the existing guidelines for the man losis, angiodysplasia, neoplasms) become more fre agement of patients with acute coronary syndromes 7 quent. Mortality remains around while for ticagrelor versus clopidogrel the respective 10% for upper gastrointestinal and around 2-4% for numbers are 22 and 6. For the main indications of anticoagulant thera Any treatment with classical or novel antithrom py, such as atrial fibrillation and a mechanical heart botic drugs is expected to increase the risk of gastro valve, the benefit of reducing thromboembolic com intestinal bleeding. In general, the annual risk of major bleed mary prevention, however, the use of aspirin remains ing with warfarin is estimated at 2-3% and depends controversial and is probably not indicated (unless on the presence of several risk factors (as will be dis there is a very high cardiovascular risk) because of the cussed later). In the collabora in patients with atrial fibrillation are from the gastro 14 tive meta-analysis of the antiplatelet therapy trialists, intestinal system. In cardial infarctions and one vascular death, at a cost comparison with warfarin, rivaroxaban at a dose of of 3 major bleeding episodes (most of which are from 20 mg once daily and dabigatran at a dose of 150 mg 8 the gastrointestinal tract). There is undoubtedly an twice daily increase gastrointestinal bleeding in gen unfavourable benefit-to-risk ratio. Apixaban probably does not in new cardiovascular events at a cost of 10 additional crease gastrointestinal bleeding when compared with 19 major bleeding episodes (1/3 of which were from the warfarin. Here, the benefit-to-risk ratio ed in more gastrointestinal bleeds in comparison with is considered acceptable; thus, dual antiplatelet ther warfarin, while the smaller dose of 30 mg was safer in apy is the established antithrombotic regime follow terms of bleeding but less effective in preventing isch 20 ing an acute coronary syndrome or the implantation aemic strokes. It should be not Risk factors for bleeding from antiplatelets and ed that different antithrombotic strategies were com anticoagulants pared and each study had a different population of patients with different baseline characteristics (for the main risk factors favouring the occurrence of example, the patients in the studies of atrial fibril gastrointestinal bleeding are the presence of an un lation were 8-10 years older than those in the stud derlying pathology, older age, renal dysfunction, a ies of coronary artery disease). As stated earlier, the history of haemorrhage, and the prescription of an newer, more potent antiplatelet drugs (prasugrel and tithrombotic therapy. Peptic ulcer is the most com ticagrelor) increase bleeding when compared with mon cause of upper gastrointestinal bleeding (50% clopidogrel. Dabigatran, rivaroxaban and edoxaban, in older series, but around 33% in more recent ones). Major gastrointestinal haemorrhages in trials of different antithrombotic therapies. Study Indication Duration Antithrombotic Incidence of therapies gastrointestinal bleeding among the compared groups? In patients with atrial Lower gastrointestinal bleeding (data from vari fibrillation, several scoring systems have been pro ous series of patients) is due to diverticulosis (30 posed to calculate bleeding risk. These scores address 40%), haemorrhoids (5-14%), angiodysplasia or isch bleeding risk in general and are not specific for the aemic vascular disease (10-37%), inflammatory dis gastrointestinal tract. Still, they are relevant because ease (9-18%), cancer/polyp (10-14%), or other rarer the majority of bleeding episodes are, indeed, local 30,31 causes. A daily dose of 300 mg haemorrhagic complications, but it must be empha doubles the risk in comparison with a dose of 100 sised that, very frequently, bleeding can occur with 32 36,37 mg. Enteric-coated aspi rin seems to bear a smaller risk for blood loss when Parameters relevant to the re-initiation of antithrombotic compared with plain aspirin, although this matter is 33,34 therapy controversial. Coadministration of a second anti platelet agent with aspirin increases the risk signifi the management of the bleeding episode is beyond cantly (as explained earlier). Of course, discontinuing the with adjustment for multiple risk factors, it was found antithrombotic treatment is important but the rever that the relative risk for upper gastrointestinal bleed sal of the antithrombotic effect of any drug is prob ing was 3. However, re when the dose of aspirin was 300 mg, 100-300 mg and versal may be delayed, followed frequently by a pro 9 thrombotic situation, and carries a risk of adverse re <100 mg, respectively. The most widely effect of rivaroxaban, but data are limited to healthy used is the Rockall score, which combines clinical and volunteers rather than patients with active haemor laboratory findings. Once haemostasis is secure, the clinical ques bleeding after haemostasis and mortality. Patients tion for the treating physician is if, when, and how with a Rockall score <2 are considered at low risk the antithrombotic therapy should be restarted. The for recurrence and patients with a score >8 have high 41 main parameters to take into consideration are the mortality (Table 3). After day 7, the recurrences 42 the thromboembolic risk exceeds the risk of recurrent were rare. In general, the recurrences were fewer ceiving antithrombotic therapy cannot be predicted when a therapeutic intervention was carried out. Regard Many studies of lower gastrointestinal haemorrhage ing the endoscopic findings, in patients with peptic have tried to propose some clinical prognostic cri ulcers and a clean base the recurrence rate is barely teria to stratify patients into high or low risk groups 5%, while in those patients with recent haemorrhagic for recurrences, but no valid prognostic model ex stigmata recurrence may be as high as 55%. Patients with lower gastrointestinal haemor cent review suggests that active bleeding, large ulcer rhage from diverticular disease, without radical sur size (>1-2 cm), and location of the ulcer at the pos gical treatment, have a recurrence rate of 9% within 30 terior duodenal wall or along the lesser gastric cur one year and 25% within 4 years. Scoring system to estimate the risk of recurrent gastrointestinal bleeding (Rockall score). It is logical to conclude that antiplatelet ther What matters most for the clinician is for how long apy should not be discontinued for more than 10 days can a patient stay off any antithrombotic treatment. In fact, taking into consider the risk of arterial or venous thrombosis depends, ation the average lifespan of platelets that are perma of course, on the indication for which the antithrom nently inhibited, it is expected that after 7-10 days of botic therapy was prescribed before the bleeding antiplatelet therapy discontinuation, >90% of plate event. In the case of ticagrelor, which binds reversibly to the P2Y12 receptor, platelets i) Antiplatelet therapy may be fully active after shorter discontinuation peri ods (4-5 days). Conditions with high arterial thrombotic risk, if an tiplatelet therapy is discontinued, include a recent placement of an intracoronary stent (1 month for ii) Anticoagulant therapy a bare-metal stent, 6-12 months for a drug-eluting stent) and a recent acute coronary or cerebrovascular the most usual indication for oral anticoagulation is event (3 months). Moderate risk exists, if therapy is atrial fibrillation or the presence of a mechanical pros discontinued, after any vascular event beyond the first thetic heart valve.

Syndromes

• Egg
• Impulsive behavior
• Stiff muscles in neck, face, or back
• Test to view the inside of the bladder (cystoscopy)
• Avoid or limit foods that are high in saturated fat (more than 20% of the total fat). Eating too much saturated fat is one of the major risk factors for heart disease.
• Testosterone gels (in males)
• Blood diseases such as sickle cell anemia
• Diarrhea
• Leukotriene inhibitors
• Low-set or abnormally shaped ears

It occurs when chemicals such as acid or alkali Poor vision and pain Paracetamol medicine xanax cheap norpace online mastercard, refer urgently medications bad for your liver 150mg norpace for sale. Standard Treatment GuidelinesStandard Treatment Guidelines 197197 Diagnostic Criteria? Traces of chemical substance such as cement or herbs and blisters or loss of eyelid skin in open flame injuries treatment 20 initiative purchase generic norpace line. Non-Pharmacological Treatment If a patient gives you history of being in contact with the items mentioned above medicine 752 buy discount norpace 100mg, the following should be done:? Irrigate the eye with clean water or Ringers lactate continually for a minimum of 20?30 minutes to reduce chemical substances medicine tramadol discount norpace 100mg free shipping. Dendritic corneal ulcer seen on staining with fluorescein Pharmacological Treatment C: Acyclocir 3% medications overactive bladder order norpace without a prescription, ophthalmic ointment inserted in the lower conjunctival sac, 4 hourly. Excessive tearing If a patient gives you history of being in contact with the items mentioned above, the? Gray/white spot on the cornea staining with fluorocein minimum of 20?30 minutes to reduce chemical substances. Give antifungal, if fungal infection is suspected or confirmed Diagnostic Criteria C: Natamycin 5%, ophthalmic drops, instil 1 drop 1?2 hourly for 3?4 days? Pharmacological Treatment C: Acyclocir 3%, ophthalmic ointment inserted in the lower Then reduce to 1 drop 3?4 hourly. Majority of the cases are idiopathic where by other cases are due to autoimmune diseases. Diagnostic Criteria It has three main clinical presentations namely acute, chronic and acute on chronic. Visual acuity is usually reduced and the pupil is small or it may be irregular due to syneachia? Slit lamp biomicroscopic examination reveals cells and keratic precipitates and hypopyon may be seen in the anterior chamber Investigations these are indicated in bilateral and granulomatous uveitis as they may not be helpful in unilateral and non granulomatous. Pharmacological Treatment Treatment for uveitis is mainly steroids and specific treatment according to the cause. This should be initiated in a facility where workup and close monitoring can be done. Majority of the cases are idiopathic where by other cases are due to autoimmune diseases. Treatment of uveitis must involve various specialists It has three main clinical presentations namely acute, chronic and acute on chronic. Acute uveitis is a serious problem and the patient should be referred urgently commonest form is anterior uveitis. Clinical features and and hypopyon may be seen in the anterior chamber treatment guideline depends on the type and cause of conjunctivitis. Investigations Note: these are indicated in bilateral and granulomatous uveitis as they may not be helpful in? If conjunctivitis is due to an infection, counsel on the importance of frequent unilateral and non granulomatous. Cold water compresses for 10 minutes four times a day Pharmacological Treatment Adults and children > 6 years of age: C: Oxymetazoline 0. Referral Refer to eye specialist for further specialized care in case of the following:? Treatment of allergic conjunctivitis depends on the severity of the condition and age of the patient. It may be unilateral but usually If no response within 7 days, use mast cell stabilizers such as: bilateral C: Sodium chromoglycate 2% eye drops, instill 6 hourly per day (Doctor initiated) Diagnostic Criteria Use may be seasonal (1?3 months) or long term. Pharmacological Treatment A: Chloramphenicol 1%, ophthalmic ointment, applied 8 hourly for 5 days. It is characterized by inflammation of the conjunctivae, sticky eyes to abundant purulent discharge and eyelids oedema. Causative organisms are Neisseria gonorrhoea, Chlamydia spp and Staphylococcus spp. Patients present with massive edema and redness of eyelids and with purulent and copious discharge from the eyes, clinical presentation ranges 204 Standard Treatment Guidelines Note: Viral conjunctivitis is very contagious so patients and members of the family from mild (small amount of sticky exudates) to severe form (profuse pus should be alerted and swollen eye lids) depending on the causative organism? Purulent discharge Pharmacological Treatment Mild discharge without swollen eyelids and no corneal haziness: A: Chloramphenicol 1%, ophthalmic ointment, applied 8 hourly for 5 days. It is characterized by inflammation of the conjunctivae, sticky eyes to abundant purulent Note: discharge and eyelids oedema. Ceftriaxone should not be used in neonates that are seriously ill or are spp and Staphylococcus spp. Refer urgently all children who present with squint to Paediatric Eye Tertiary Centre (Muhimbili National Hospital, Kilimanjaro Christian Medical Centre And Mbeya Zonal Referral Hospital). Refer urgently all children who Refer all children presenting with a white pupillary reflex, squint and acute painful red present with squint to Paediatric Eye Tertiary Centre (Muhimbili National eye to a qualified eye care personnel/ophthalmologist Hospital, Kilimanjaro Christian Medical Centre And Mbeya Zonal Referral Hospital). The tumour typically occurs on the bulbar conjunctiva, originating pterygium and Squamous cell carcinoma of the conjunctiva. It is diagnosed between the to look for residual or recurrent tumors first 1?3 years of life. Referral: All suspicious cases of Squamous Cell Carcinoma of Conjunctiva must be referred to eye specialist for proper evaluation and management. Feelings of dryness, grittiness, burning and foreign body sensation, usually worse during the day? Educate patients to avoid unprescribed eye medications which may worsen the dryness and control their environmental factors by eg. Fluorescein staining of the cornea shows corneal ulceration All suspicious cases of Squamous Cell Carcinoma of Conjunctiva must be referred to eye? It is an ophthalmic emergency that can cause Diagnostic Criteria blindness that may occur secondary to bacteraemia (endogenous infection) or following? Feelings of dryness, grittiness, burning and foreign body sensation, usually penetrating eye injury of surgery worse during the day? Stringy discharge, redness and transient blurring of vision are also Diagnosis Criteria common. Blood culture should be done to identify the source and how it can be Non-Pharmacological Treatment treated (for bacteraemia)? Educate patients to avoid unprescribed eye medications which may humour should be done worsen the dryness and control their environmental factors by eg. It may be a continuum of preseptal cellulitis, which is an infection of the soft tissue of the eyelids and periocular region anterior to the orbital septum. The microfilariae invade lymphatic system, subcutaneous and deep tissues producing acute inflammation and chronic inflammation at a later stage. Diagnostic Criteria They are caused by the chronic inflammation which presents with:? Pharmacological Treatment Treatment is done in consultation with dermatologists and infectious disease specialists. The microfilariae invade lymphatic system, subcutaneous and deep tissues producing acute inflammation and chronic inflammation at a later stage. Diagnostic Criteria They are caused by the chronic inflammation which presents with:? Pharmacological Treatment Treatment is done in consultation with dermatologists and infectious disease specialists. Symptoms and diseases affecting this area are common and commonly lead to patients seeking medical care. Pain may become extreme when the ear canal becomes completely occluded with edematous skin and debris. Exclude an underlying chronic suppurative otitis media before commencing treatment. Pharmacological Treatment: C: Ciprofloxacin ear drops 3 drops 8 hourly for 7 days 15. Symptoms and diseases affecting this area are common and commonly lead to patients seeking medical 15. Adults: 1g 6 hourly for 3 days and Children: 10 mg/kg 6 Usually happens in children. Common foreign bodies include beads, stones and seeds hourly for 3 days (bean, maize, orange). In adults foreign bodies include cotton bud and insect Note: Treatment periods shorter than 10 days increase the risk of treatment failure Standard Treatment GuidelinesStandard Treatment Guidelines 217217 Referral:? Children with high fever, severe ear pain, headache, altered state of consciousness? Adults: 250mg 8 hourly for 10 days and Children 1?5 years: 125mg 8 hourly for 10 days Note: Treatment of shorter than 10 days will result into treatment failure 15. Children (1?5 years) 125mg 8 hourly for 10 days 218 Standard Treatment Guidelines Referral:? Children with high fever, severe ear pain, headache, altered state of Note: Treatment shorter than 10 days will result into treatment failure consciousness? Adults: 500mg 12 hourly for 10 days and Children: 10? A child with hearing loss should be detected and intervention started immediately after 20mg/kg 12 hourly for 10 delivery. Bed rest& warm drinks Non-Pharmacological Treatment Aspirate the swelling before incision and drainage, and then referfor mastoidectomy at a Pharmacological Treatment zonal/national hospital A: Ephedrine nasal drops (1% for adults and 0. Children (1?5 years) 125mg 8 hourly for 10 days Standard Treatment GuidelinesStandard Treatment Guidelines 219219 15. Note: Treatment periods shorter than ten days increase the risk of treatment failure Investigations: Nasopharynx lateral view X-ray. Restrain the child before removal using a cerumen hook, if the child cannot be restrained sedation is advised 222 Standard Treatment Guidelines? Give extra fluid Standard Treatment GuidelinesStandard Treatment Guidelines 223223 Pharmacological Treatment A: Epinephrine (adrenaline) inhalation effectively reduces symptoms Table15. Anxiety Investigations: Plain X-ray of the neck, lateral view characteristically presents with a positive thumb sign (edematous epiglottis). Children: 10 mg/kg If severe symptoms persist or worsen after epinephrine inhalation, hospitalization is body weight 8 hourly indicated. Risk factors include cigarette smoking, alcohol intake, gastroesophageal reflux disease and human papilloma virus. Risk factors include wood dust (both soft and hard), wielding dust, lather industry fumes, hydrocarbons fumes, and aflatoxin dust. Hearing loss Referral: Refer the patient to the next facility with adequate expertise and facilities 15. Risk factors include genetic predisposition, Epstein Bar virus, smoked and/or salted foods. Risk factors include cigarette smoking, alcohol Diagnostic Criteria intake, gastroesophageal reflux disease and human papilloma virus. Risk factors include wood dust (both soft and hard), wielding dust, lather industry fumes, hydrocarbons fumes, and aflatoxin dust. Hearing loss Referral: Refer the patient to the next facility with adequate expertise and facilities 15. Risk factors include genetic predisposition, Epstein Bar virus, smoked and/or salted foods. The lesions affecting the maxillofacial region (perioral, jaws and face) are also considered. Clinicians should be able to identify conditions requiring immediate attention by the dentist, do the preliminary urgent and life saving measures where possible before referring the patient to a centre with a dentist/dental surgeon. The damage of the periodontal membrane, periodontal ligaments and eventually alveolar bone leads to formation of pockets which eventually favours more pathogenic bacterial growth. The lesions affecting the maxillofacial region planning (this may need several visits as may be necessary) (perioral, jaws and face) are also considered. Advanced treatment is required if refractory/resistant to treatment or conditions requiring immediate attention by the dentist, do the preliminary urgent and patient has systemic diseases/ conditions. Counsel to perform proper oral hygiene care Remove accumulated plaque and teach oral hygiene on systematic tooth brushing and 16. Patients usually present with soreness and bleeding of the gums and foul smell test (fetor-ex 16. The damage of the periodontal membrane, periodontal ligaments and eventually alveolar bone leads to formation of pockets which Diagnostic Criteria eventually favours more pathogenic bacterial growth. Painful and easily bleeding gingival swelling and erythema of the gingival teeth become loose and may eventually fall out. Simvastatin 10mg/20mg oral once daily : Atorvastatin 20mg daily :Rosuvastatin 10mg-40mg daily x Lipid lowering medicine therapy for patients taking protease inhibitors x Certain antiretroviral medication, particularly protease inhibitors, can cause dyslipidaemia. Lopinavir/ritonavir is associated with a higher risk of dyslipidaemia than atazanavir/ritonavir. Radiation therapy is the mainstay of first-line local treatment for early stage hypopharyngeal carcinoma. For more advanced disease, concurrent chemoradiation reduces the rate of distant metastasis, and improves local control. Salivary gland cancers arise from major or minor salivary glands in the head and neck region. The most common malignant salivary gland tumors are mucoepidermoid carcinoma and adenocarcinoma Depends on primary site involved. For more advanced disease, concurrent chemoradiation reduces the rate of distant metastasis, and improves local control. The most common malignant salivary gland tumors are mucoepidermoid x carcinoma and adenocarcinoma Depends on primary site involved. Several active chemotherapy drugs like carboplatine, cisplatin, paclitaxel, docetaxel, gemcitabine, Capecitabine and targeted therapy (bevacizumab) are available; to administered as single or in combination for adjuvant, unresectable or recurrent and metastatic disease.

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