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Program Director, University of Nebraska College of Medicine

The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Two other committee members, along with an external expert for select fact sheets, provided secondary peer-review of each fact sheet. Finally, it provides comprehensive, yet succinct information easily shared with healthcare providers requesting information on the potential utility of apheresis in a given clinical setting. Several diseases or conditions underwent review in consideration for the development of a new fact sheet (Table 6). To meet criteria for a new fact sheet, the committee required a minimum of 10 cases published in the last decade in peerreviewed journals, ideally by more than one group. Some previously published fact sheets were renamed to group fact sheets together by similar disease pathology and/or treatment. The total number of diseases and indications addressed in the Eighth Edition are 84 and 157, respectively. A filter based therapeutic procedure that removes pathogenic substances from separated plasma based on their size, which is mainly determined by molecular weight and three-dimensional configuration. The red blood cells are removed and replaced with crystalloid or colloid solution, when necessary. A therapeutic procedure in which plasma of the patient, after membrane based or centrifugal separation from the blood, is passed through a medical device (adsorber column) which has a capacity to remove immunoglobulins by binding them to select ligands on the backing matrix surface (membranes or beads) of the adsorber column. A procedure in which blood of the patient is passed through a medical device which separates out white blood cells. A therapeutic procedure in which blood of the patient is passed through a medical device which separates out high-molecular weight plasma components such as fibrinogen, 2-macroglobulin, low-density lipoprotein cholesterol, and IgM in order to reduce plasma viscosity and red cell aggregation. References are limited to 20 and are not meant to be exhaustive but rather serve as a starting point in a search for more information. This table excludes diseases in which apheresis may be ineffective in some settings, but may potentially be used in other settings in the same disease. In some cases, draft I was also sent to external subject matter experts for comments (see Acknowledgment section below). It is important to note that the grade can be used in support or against the use of the therapeutic intervention. In addition, previously designated weak recommendations for diseases/conditions, such as Grade 2C, are more likely to be affected by additional evidence of higher quality than diseases that already have strong recommendations. Desensitization and antibody mediated rejection are combined because they have the same category and grade. For certain diseases with insufficient data on incidence or prevalence, other terms, such as rare or unknown are used. In such instances, more than one type of therapeutic apheresis modality is listed. This section lists the number of patients reported in the literature who were treated with therapeutic apheresis. The committee used three categories: fewer than 100, between 100 and 300, and more than 300. However, the number of patients treated is often less important than the quality of the scientific reports. This section is used when there are several different therapeutic apheresis procedures used and it was necessary to subdivide available scientific reports, as well as in the situation when different subsets of patients are being analyzed. Example: Two randomized studies with 50 patients in each of two arms and one randomized study with 75 patients in each of two arms is denoted as 3(350). In addition, for some entities the management of standard therapy failure is discussed. However, in some settings, due to significant variability in treatment schedules reported by different groups, the committee suggested what is believed to be the clinically most appropriate frequency. Application of this information may vary depending on the patient and clinical presentation, and is left to the discretion to the treating physician. In some instances, the number of procedures/series which may be reasonably employed in the particular clinical situation is suggested based upon currently available data. For additional information, one textbook in the field of apheresis medicine which users of the Special Issue may find useful is Apheresis: Principles and Practice, Third Edition (McLeod, 2010). This standard approach to consultation may be particularly helpful to readers who may have limited experience in the field of apheresis medicine. As with previous editions, there is a significant expansion in the number of indications (relative to the number of diseases categorized) and is accounted for by some diseases having several categories and recommendation grades due to multiple indications within the same disease, or multiple apheresis modalities used to treat the same disease with different grade recommendations.

Fortunately, the symptom is not serious in most individuals flying at low altitudes. The dramatic expansion of trapped gas as altitude increases is shown in Figure 1-18. The stomach and the small and large intestines normally contain a variable amount of gas at a pressure approximately equivalent to the surrounding atmospheric pressure. The stomach and large intestine contain considerably more gas than does the small intestine. The chief sources of this gas are swallowed air and to a lesser degree, gas formed as a result of digestive processes, fermentation, bacterial decomposition, and decomposition of food undergoing digestion. The gases normally present in the gastrointestinal tract are oxygen, carbon dioxide, nitrogen, hydrogen, methane, and hydrogen sulfide. These occur in varying proportions, although the highest percentage of the gas mixture is always nitrogen. Gastrointestinal pain at high altitude may not only be caused by the absolute volume or location of the gas; sensitivity or irritability of the intestine is a more important cause. Gas pains of even moderate severity may produce marked lowering of blood pressure and loss of consciousness if distension is not relieved. Some foods that commonly produce gas are onions, cabbage, raw apples, radishes, dried beans, cucumbers, and melons. Aircrew members who participate regularly in high-altitude flights should avoid foods that disagree with them. Drinking large quantities of liquids, particularly carbonated beverages, before high altitude missions, and chewing gum during ascent should be avoided. If trapped gas problems exist in the gastrointestinal tract at high altitude, relief is ordinarily obtained by belching or passing flatus. Decompression sickness is a true occupational disease first described in relation to syndromes which developed in caisson or tunnel workers working in closed, pressurized spaces during construction of tunnels. It was also designated the "chokes" when associated with dyspnea and a chocking sensation, the "staggers" when accompanied by vertigo related to inner ear disruption, and the "niggles" which refers to unusual skin sensations. Decompression sickness in naval operations is related to high altitude or underwater activities using compressed gas mixtures. Aviation decompression sickness can occur during low pressure chamber (altitude chamber) activities, flight in depressurized or unpressurized aircraft, and in high altitude high opening (standoff) parachute operations. Altitude decompression sickness is induced by exposure to ambient pressures less than sea level. Aviators are protected from decompression sickness by maintaining cabin altitude via pressurization and by denitrogention by prebreathing oxygen to reduce body nitrogen stores. Prior to flight, aviation personnel can reduce their tissue nitrogen by breathing 100 percent oxygen. Currently the highest rate of altitude-related decompression sickness in naval aviation operations involves low pressure chamber activities. The rate at which nitrogen is eliminated from the body at sea level when pure oxygen is breathed (Clamann, 1961). Bubble Formation Theory Decompression sickness results from bubbles formed as dissolved gases come out of solution in tissues due to a drop in ambient pressure. As nitrogen in air is inhaled, it dissolves in the body and reaches equilibrium with the liquid phase (tissue and blood). As one ascends from depth or climbs in altitude, the partial pressures of the gases in the breathing mixture decrease. If the nitrogen partial pressure in the breathing gas is reduced or eliminated, a gradient is established across the alveoli. Nitrogen is offgassed from the various tissue compartments, and may require 12 hours or more to reach equilibrium. The rate of inert gas uptake and elimination depends on: (1) gas concentration gradient between blood and tissue, (2) tissue blood flow, and (3) the ratio of blood and tissue gas solubilities.

Para-infectious complications include a perivenous inflammatory response and leucoencephalitis. Other post infectious syndromes include cerebellar ataxia, and peripheral nerve disorders, such as GuillainBarre syndrome. Viral encephalitis is classified as (1) arbovirus (arthropod borne), (2) enteroviruses, (3) childhood viruses, (4) other. The most common sporadic (nonepidemic) viral encephalitis is herpes simplex encephalitis. The characteristic clinical course for herpes simplex encephalitis is an acute or subacute syndrome of headache, fever, behavioral disturbance, seizures and progressive cortical dysfunction. Herpes simplex encephalitis causes a necrotizing hemmorrhagic encephalitis, primarily involving the frontal, temporal, and limbic lobes. Spinal fluid analysis reveals red blood cells due to brain hemorrhage and necrosis. Oligoclonal bands on immunoglobin protein electrophoresis may be present in the spinal fluid. Temporal lobe biopsy is the diagnosis of choice and reveals characteristic intranuclear inclusion bodies. Louis encephalitis may present with seizures, tremor, myoclonus, vertigo, or electrolyte imbalance. The most fulminant of the Arboviruses is Eastern Equine Encephalitis, which affects horses and pheasants prior to spread in man. Encephalitis due to mumps and lymphochoriocytic meningitis occur primarily in the winter months. Except for herpes virus there is no specific antiviral therapy other than symptomatic treatment of fever and anticonvulsant therapy if seizures are present. Evaluation and outcome of emergency room patients with transient loss of consciousness. Syncope of unknown origin: the need for a more costeffective approach to its diagnostic evaluation. Structural considerations of the human vertebral column under +Gz impact acceleration. Count 1 through 10 out loud, then repeat the numbers (6 9 4) if help needed use numbers 5 7 3. Take away 7 from 100, then take away 7 from what is left and keep going: 100-7 is (93) 25. General: Head Spine Extremities Cranial nerves: Eyelid Visual Acuity Pupil Size Right. Rinne Weber Palate Position Sensation Phonation Tongue Trapezius Sternocleidomastoid Bone < = > Air Bone < = > Air R = L 7-79 U. Motor Muscle Status Strength Tone Character Tremor Gegenhalten Tenderness, atrophy, fasiculations Drift mirroring 4. Pertinent history should include head trauma, alcohol or drug use, prior seizures. Physical examination including general exam for systemic derangement, infection, organ failure. Specific neurological evaluation should assess postictal confusion, focal neurological deficit. Assess for continued seizure activity, or failure of patient to regain consciousness (see Appendix 7-B. Airway management: Oxygen by nasal cannula or face mask, nasal or oropharyngeal airway, blood pressure, cardiac, and respiratory monitor. Anticonvulsant therapy: Oral loading usually effective if not in Status Epilepticus, single idiopathic seizure may not require therapy 11. Quick assessment of general and neurological state, verify that unconsciousness persists. Note: Very messy drug, smells funny, may melt plastic, and often not routinely available.

Asthma in Adults: epidemiology, risk factors, and patterns of presentation: a cross sectional questionnaire based study in Baghdad Teaching Hospital. Determination Enterococcus faecalis in Asymptomatic Urinary Tract Infection Associated with Diabetes Type 2 Patients in Suwayrah General Hospital-Iraq Ibtisam H. Enterococci have been documented to cause infection of the urinary tract and other sites. Although several species of Enterococcus have been recognized, Enterococcus faecalis has been considered one of the major agents of urinary tract infections. Method: the study involved a total of 611 participants including 197 diabetes mellitus patients and 414 non-diabetics in Suwayrah-Wasit-Iraq. Mid-stream urine was collected from consented subjects and dipstick, general urine examination and bacterial culture were conducted for each sample. There was no significant difference in resistance between diabetics and non-diabetics (P > 0. Enterococcus faecalis isolates showed (50%) resistance to Erythromycin and Levofloxacin. Keywords: Diabetes mellitus, percentage, asymptomatic bacteriuria, antimicrobial resistance. Introduction Diabetes type-2 has been recently associated with urinary tract infections. The mechanism of pathogenesis for this association is not fully elucidated, however, it is suggested that high glucose concentration in urine may favor the growth of pathogenic microorganisms and stimulate urinary tract infection(1). Most studies reported the percentage to be higher in people with diabetes than people without diabetes (4). The incidence of urinary tract infections due to Enterococcus faecalis has risen steadily over the years and Enterococcus faecalis urinary tract infection now outnumbers Enterococcus faecium urinary tract infection 5:1 (7). The combination of these multiple virulence mechanisms, the ability to survive in harsh conditions, and both intrinsic and acquired resistance to many antibiotics explains the high frequency of infection by Enterococcus faecalis (8). The enterococcal surface protein (Esp) is a highmolecular-weight surface protein of unknown function whose frequency is significantly increased among infection-derived Enterococcus faecalis isolates. Esp is another surface protein and has been shown to promote colonization and persistence in bladder (but not kidneys) Esp also influences, at least in some strains, biofilm formation in vitro (9). Each sample was separated into two parts under sterile conditions; one part for urinalysis and the other for culture. The dip stick test was performed using urine test strips as described by the manufacturer (Condor-Teco, Beijing, China). Wet preparation of centrifuged urine was observed using 40 times objective lens to detect blood, pus and other cells. A calibrated 10l wire loop was used to inoculate uncentrifuged urine into MacConkey, blood and plates incubated aerobically at 37oC for 24 hours. These included; Levofloxacin,Erythromycin, Linezolid,Teicoplanin,Vancomycin,Tetracycline,Tigecycline and Nitrofurantoin (BioMйrieux, France). And five out of 414 asymptomatic non-diabetic patients showed Enterococcus faecalis culture results which considered as a control group. The study participants were educated on how to collect a "clean-catch" midstream urine specimen and the importance to avoid contamination. They were advised on washing of hands prior to collection and labia separation, especially in females. Participants who had difficulties collecting their specimens were assisted by trained personnel. Urine samples were collected into sterile containers, placed in a cool box (0 oC) and transported to the laboratory within 2 hours. The samples were then stored in a refrigerator and analysed within 8 Results Of the 611 participants enrolled into the study 208 were males while 403 were females. Majority of participants were in the age group more than 60 years, while the least age range was less than 40 years as showed in Table (1). However, women demonstrated a higher percentage than men in both diabetic and nondiabetic groups. All Enterococcus faecalis isolates were (100%) sensitive to Linezolid,Teicoplanin,Vancomycin,Tetracycline,Tigecycline and Nitrofurantoin antibiotics while they were (50%) resistant to Levofloxacin and Erythromycin in both diabetes and non-diabetes patients as showed in Table (2). Table 2: Antibiotic resistance of urinary Enterococcus faecalis in diabetics and non-diabetics Antimicrobial agent Levofloxacin Erythromycin Linezolid Teicoplanin Vancomycin Tetracycline Tigecycline Nitrofurantoin Diabetics 4(50%) 4(50%) 0(0 %) 0(0 %) 0(0 %) 0(0 %) 0(0 %) 0(0 %) Non-Diabetics 2(50%) 2(50%) 0(0 %) 0(0 %) 0(0 %) 0(0 %) 0(0 %) 0(0 %) enterococcal surface protein (esp) virulence gene of Enterococcus faecalis was detected in all 12 Enterococcus faecalis isolates showed in Figure (1). Discussion the association of diabetes mellitus and urinary tract infections is increasingly being reported.