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O. Carlos, M.B. B.A.O., M.B.B.Ch., Ph.D.

Co-Director, University of Oklahoma College of Medicine

Perioperative imaging studies, including chest X-ray, computerized tomography scans, and magnetic resonance imaging, may identify distant metastases. Staging may be modified by imaging studies or clinical findings obtained prior to the initiation of treatment. Laparotomy or laparoscopy with resection of tubal masses, usually including hysterectomy and bilateral oophorectomy, form the basis for the operative management of fallopian tube carcinoma. Widespread intraabdominal disease is common; therefore, adequate evaluation of potentially early stage lesions requires multiple biopsies of commonly involved sites, such as omentum, pelvic peritoneum, mesentery, bowel serosa, diaphragm, and regional nodes, in order to rule out microscopic metastases to any of these sites. Cytologic studies of ascites (if present) or of pelvic and abdominal peritoneal washings (if no ascites are present) should be included in the staging. Staging is based on the findings at the time the abdomen is opened, not on the residual disease after debulking. Tumor differentiation is an important prognostic characteristic in all stages of disease. In patients with localized tumors, depth of invasion into the tubal musculature and rupture of the tube have prognostic importance. With advanced disease, the volume of residual tumor after surgical debulking appears to be related to prognosis. The 5-year survival in early disease is approximately 70%, but surgical staging is often inadequate. At 5 years, the overall survival for patients with advanced disease is about 20% (Figure 38. Carcinoma of the fallopian tube: a clinicopathological study of 105 cases with observations on staging and prognostic factors. Carcinoma of the fallopian tube: clinicopathologic study of 151 patients treated at the Norwegian Radium Hospital. Usually as a result of a genetic accident in the developing egg, the maternal chromosomes are lost, and the paternal chromosomes duplicate (46xx). The resulting tumor is known as a complete hydatidiform mole: There are no fetal parts; the tumor is composed of dilated, avascular, "grape-like" vesicles that may grow as large as, or larger than, the normal pregnancy that it replaces. There is obviously no heartbeat detected, and the patient may have vaginal bleeding similar to a miscarriage. Many times, the diagnosis is not made until a dilatation and curettage is done and the tissue is examined pathologically. In some patients, fetal parts will be found in association with mild proliferative trophoblastic (placental) tissue. Such patients have a partial hydatidiform mole, which has a 69xxx or 69xxy chromosomal complement resulting from twice the normal number of paternal chromosomes. Both of these tumors usually follow a benign course, resolving completely after evacuation by dilatation and suction or curettage, but approximately 20% of complete moles and 5% of partial moles persist locally or metastasize and thus require chemotherapy. This solid, anaplastic, vascular, and aggressively proliferative tumor is easily recognized microscopically and may present with symptoms of vaginal bleeding (as with a hydatidiform mole). However, metastatic lesions may be the first sign of this lesion, which can follow any pregnancy event, including an incomplete abortion or a full-term pregnancy. Gestational trophoblastic tumors are very responsive to chemotherapy, with cure rates approaching 100%. Further modifications have been made in an attempt to merge several prognostic classification systems. Trophoblastic tumors not associated with pregnancy (ovarian teratomas) are not included in this classification. The following criteria are suggested for the diagnosis of trophoblastic tumors requiring chemotherapy: Primary Site. By definition, gestational trophoblastic tumors arise from placental tissue in the uterus. Although most of these tumors are noninvasive and are removed by dilatation and suction evacuation, local invasion of the myometrium can occur. When this is diagnosed on a hysterectomy specimen (rarely done these days), it may be reported as an invasive hydatidiform mole. Nodal involvement in gestational trophoblastic tumors is rare but has a very poor prognosis when diagnosed. This is a highly vascular tumor that results in frequent, widespread metastases when these lesions become malignant.

Copies of nonexempt information shall be provided to the requesting party, or their designee, when permitted by this section. All requests for copies of any record shall be in writing, and it shall clearly identify the document or material to be copied. No charge shall be made when copies are furnished in lieu of a physical inspection of the full record. Employees shall not engage in debates, justification, or discussions regarding departmental actions. Employees shall make genuine, reasonable efforts, when requested, to assist the requester in understanding nonexempt information being inspected. The keeper of the record being contested if the source person is not as described above or if the source person is no longer available. For appeals from employees and persons other that inmates and parolees, the request shall be in writing and shall include the following: A copy of all previous requests to amend and any prior correspondence concerning amending the record. Full documentation to support and justify the request to review the refusal to amend the record. Inmate/parolee appeals shall be handled within the established time limits for appeals. While no arbitrary limit is placed upon the length of the statement, the statement must be limited to a length reasonable to the circumstance or information disputed (normally from one to three pages). The statement of disagreement shall be made available to any person eligible to review the disputed information, and when the disputed information is disclosed, the statement of disagreement shall be included with the disclosure. If the statement of disagreement contains exempt personal information, for the purpose of future disclosure, it shall be screened, classified, and treated like any other information in the record. Any decision based upon the disputed information shall include a review of the statement of disagreement and a consideration of its contents. Administrative, technical, and physical safeguards shall be established and implemented to ensure compliance with the provisions of this section, to ensure the security and confidentiality of records, and to protect against reasonably anticipated threats and hazards which could result in damage to , dissemination of, or destruction of departmental records. Records shall not be taken from their usual place of use or storage unless specifically approved by policy or procedures. Records containing exempt personal (formerly confidential) information shall be stored in locked areas designed to protect the privacy and integrity of the records. When exempt personal information is not under the physical control and observation of a person authorized to review it, the record shall be returned to the locked area. The authorized person reviewing exempt personal information shall assure its security while it is under their control. Immediately after they have served their purpose, all preliminary drafts, carbon sheets, plates, stencils, stenographic notes, work sheets, and similar items shall be destroyed by the person responsible for their preparation. Employees should be aware that if the designated person at the address is not available, the package or envelope shall not be opened until that person is available or other permission is obtained from the sender. Every effort shall be made to protect the privacy of the information when it is being destroyed. All personal information in departmental records shall be shredded by hand or by machine. Fails to maintain any record concerning an individual with accuracy, timeliness, and completeness where the failure results in a determination adverse to the individual about whom the information pertains. The intentional disclosure of medical, psychiatric, or psychological information is punishable as a misdemeanor if the wrongful disclosure results in economic loss or personal injury to the individual, except when the disclosure is required or permitted by law. Writing - Any handwriting, typewriting, printing, photostating, photographing, photocopying, transmitting by electronic mail or facsimile, and every other means of recording upon any tangible thing any form of communication or representation, including letters, words, pictures, sounds, symbols, or combinations thereof, and any record thereby created, regardless of the manner in which the record has been stored. The removal of any document or the altering of any record during a public inspection is prohibited. Employees shall be sensitive to any request from the public for the review of any records. Any questions concerning whether a requested record may be publicly disclosed shall be directed to the Office of Legal Affairs. Gather and perform any necessary redaction of exempt information contained in the requested records.

Higher doses are recommended in patients with cystic fibrosis, neutropenia, or burns. Trough: <1 mg/L; recommended serum sampling time within 30 min before the second dose. Serum levels should be rechecked with changing renal function, poor clinical response, and at a minimum of once weekly for prolonged therapies. Transient tinnitus, decreased appetite, and hearing loss have been reported nebulized dosage form. Aphonia, discolored sputum, and malaise have been reported with the powder for inhalation. Use with other inhaled medications in cystic fibrosis, use the following order of administration: bronchodilator first, chest physiotherapy, other inhaled medications (if indicated), and tobramycin last. Pregnancy category is "D" for injection and inhalation routes of administration and "B" for the ophthalmic route. If needed, dose may be further increased at weekly intervals by 100 mg/24 hr up to a recommended max. Use with caution in renal and hepatic dysfunction (decreased clearance) and sulfa hypersensitivity. Common side effects (incidence lower in children) include ataxia, cognitive dysfunction, dizziness, nystagmus, paresthesia, sedation, visual disturbances, nausea, dyspepsia, and kidney stones (incidence higher in children). Secondary angle closure glaucoma characterized by ocular pain, acute myopia, and increased intraocular pressure has been reported and may lead to blindness if left untreated. Patients should be instructed to seek immediate medical attention if they experience blurred vision or periorbital pain. Oligohidrosis and hyperthermia have been reported primarily in children and should be monitored especially during hot weather and with use of drugs that predispose patients to heat-related disorders. Topiramate may decrease valproic acid, digoxin, and ethinyl estradiol (to decrease oral contraceptive efficacy), but may increase phenytoin levels. Safety and efficacy in migraine prophylaxis in pediatrics have not been established; an increase in serum creatinine has been reported in a clinical trial. May cause angle-closure glaucoma in patients with anatomically narrow angles who do not have an iridectomy. In combination with clindamycin: 12 yr and adult: Gently wash face with a mild soap, pat the skin dry, and wait 20 to 30 min before use. If stinging or irritation occurs, decrease frequency of administration to every other day. Concomitant use of other topical acne products may lead to significant skin irritation. Rare reports of bone mineral density loss and osteoporosis has been reported with prolonged use of inhaled dosage form. Nasal preparations may cause epistaxis, cough, fever, nausea, throat irritation, dyspepsia, and fungal infections (rarely). Topical preparations may cause dermal atrophy, telangiectasias, and hypopigmentation.

Family planning plays a significant role in improving thehealthofwomenandprovidesauniqueopportunity to optimize pregnancy outcomes by helping couples to control childbearing until conditions are favorable for them. As such, family planning contributes substantially to individual health care, to public health, and even to population control and environmentalwell-being. Muchofthecontroversy is based on a misunderstanding about reproductive facts, the safety of modern contraception, and the health risks posed by pregnancy and childbirth. Box 27-1 lists some important family planning facts and misconceptionsheldbymanywomenandmen. Overview Beforegoingintodetailaboutthevariousmethodsof family planning, it is important to note several facts about reproductive health. About 85% of sexually active couples having unprotected intercourse for 1 year will experience pregnancy. Pregnancy is not established within the uterus until about 7 days after conception,whichitselfmaynotoccurforupto5to7 daysfollowingintercourse. Halfofallconceptionsare lostbeforeimplantation,andat least 10-15% of established pregnancies spontaneously abort. Although the goal of family planning is to provide coupleswith the abilitytoplanandprepareforpregnancy,effortstodatehavefallenfarshortofthatgoal. Most women underestimate the health risks of pregnancy and overestimate the risks of contraception. Thereisnomethodofcontraceptionthataclinicianwouldprescribetoawomanthatisashazardous to her health as pregnancy itself. The contraceptive needs of a couple are often given lower priority and maynotbementioned,evenwhencliniciansprescribe drugsthatmaybeteratogenictowomenofreproductive age. The controversy that surrounds family planningmakesitessentialforthosecaringforwomenof reproductiveagetobeinformedaboutalltheavailable methods of birth control and to be dedicated to educatingcouplesabouttheirimportanceandsafety. Contraception Ongoing contraceptive methods themselves may be categorizedintoreversiblemethodsusedbeforeintercourse and those methods that are permanent. Any method is more effective than unprotectedintercourse,andevenoneofthelower-tier methodscanbemadequiteeffectiveifthegapbetween typicaluseandcorrectandconsistentuseisreduced. Differentformsofemergencycontraceptionareavailable after coitus to provide a second chance of pregnancy prevention when nonuse or method misuse occurs. Eachofthesesetsofguidelinesisperiodicallyupdatedbasedonthelatestavailableevidence, andbothsetsintheirentiretycanbeaccessedonline: C H A P T E R 27 Family Planning 329. Addedtothisevaluation isaconsiderationoftherisksthatawomanwouldface with pregnancy and the likelihood she would experience a pregnancy if she were to use the method. For example, a woman with advanced diabetes may not experience any direct medical harm by using male condoms,butthe18%chanceofpregnancywithtypical use of condoms poses significant risks to her health. It also offers advice on managing potential side effects associated with each of the methods. Condition that exposes a woman to increased risk as a result of unintended pregnancy. Laboratory tests: All methods were rated Category C for the following tests: glucose, lipids, liver enzymes, hemoglobin, presence of thrombogenic mutations, cervical cytology, and human immunodeficiency virus. It measures 4cm in length and 2mm in diameter (Figure 27-1), and it releases the etonogestrel through a surrounding releasing membrane that is 0. Thiscontraceptiveimplantcanbeusedbyvirtuallyany woman; only a history of recent breast cancer is an absolute contraindication. In addition, it has unsurpassed contraception effectiveness, is extremely convenient,andisrapidlyreversible. The implant suppresses ovulation in all users for at least 30 monthsandinvirtuallyallwomen(97%)for atleastitsfull36monthsofapprovedlife. Theprogestinalsothickenscervicalmucustopreventspermfrom ascending into the upper genital tract, which would prevent fertilization in any case where ovulation may occur. Decreased efficacy is demonstrated only in womentakingmedicationsthatincreasehepaticclearance of sex steroids, particularly anticonvulsants and St. Italsoisthemosteffectivemedical therapy for heavy menstrual bleeding because it induceshighratesofamenorrheabydirectlysuppressing the endometrium, thus leaving estradiol levels in thenormalrange. It can be more easily (and more comfortably) placedintoawomanwhohasnotdeliveredvaginally, and its lower progestin dose induces amenorrhea for fewerwomen(onlyabout12%). The most common reason for the comparatively high failure rate was inconsistent use or nonuse.