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The item is limited to mens health flat stomach order alfuzosin 10mg online the content area that will produce the best match to prostate cancer knee pain discount 10mg alfuzosin the test plan percentages prostate cancer young men proven alfuzosin 10 mg. The computer estimates the candidateís ability based on all previous answers and the difficulty of those items androgen hormone acne buy discount alfuzosin 10mg on-line, and selects an item that the candidate should have a 50 percent chance of answering correctly. This ensures the next item should not be too easy or too difficult and the examination can obtain maximum information about the candidateís ability from the item. Since the diffculty of pretest items are unknown in advance, these items are not included when estimating the candidateís ability and subsequently making pass-fail decisions. When enough responses are collected, the pretest items are statistically analyzed and calibrated. Pretest items appear identical to operational items, therefore it is recommended that candidates give their best effort for every item. The computer will stop administering items when it is 95% certain that the candidateís ability is either clearly above or clearly below the passing standard. Scenario 2: Maximum-Length Exam Some candidateís ability levels will be very close to the passing standard. When this is the case, the computer continues to administer items until the maximum number of items is reached. At this point, the computer disregards the 95% confdence interval rule and considers only the fnal ability estimate: fi If the final ability estimate is above the passing standard, the candidate passes. T) If the candidate runs out of time before reaching the maximum number of items, the computer has not been able to decide whether the candidate passed or failed with 95% certainty. Therefore, an alternate rule must be used: fi If the candidate has not answered the minimum number of items, the result will be a failing exam. These formats may include, but are not limited to: multiple-choice, multiple response, fll-in-the-blank calculation, hot spots, exhibit, ordered response, audio and graphics. All item types may include multimedia, such as charts, tables, graphics, and audio. Prescription: Orders, interventions, remedies or treatments ordered or directed by an authorized primary health care provider. Primary Health Care Provider: Member of the healthcare team (usually a medical physician [or other specialty. Examination Security and Confidentiality Any candidate that violates test center regulations or rules, or engages in irregular behavior, misconduct and/or does not follow a test center administratorís warning to discontinue inappropriate behavior may be dismissed from the test center. Additionally, exam results may be withheld or cancelled and the licensing board may take other disciplinary action such as denial of a license and/or disqualifying the candidate from future registrations for licensure. Candidates should be aware and understand that the disclosure of examination items before, during, or after the examination is a violation of law. Violations of confdentiality and/or candidatesí rules can result in criminal prosecution or civil liability and/or disciplinary actions by the licensing agency including the denial of licensure. The following are examples of how screens in the tutorial may appear with examples of possible item formats. Steps to Item Writing A well-designed, multiple-choice item consists of three main components: a stem (asks a question or poses a statement which requires completion), key (the correct answer/s) and distractor(s) (incorrect option/s). Example Using the Above Steps Below is an example of how to write an item using the above steps. Which of the following statements by the client would indicate a correct understanding of the teachingfi Write an item with four different client scenarios in which one client should be the priority to assess first. Safety and Infection Control the nurse has attended a staff education program about infection control guidelines. Write an item indicating correct understanding of the teaching based on the infection control precautions selected. Health Promotion and Maintenance the nurse has taught a female client about expected findings during pregnancy. Psychosocial Integrity the nurse in a psychiatric unit is caring for a client experiencing an acute or chronic mental illness. Write an item describing what would indicate that the treatment plan has been effective. Basic Care and Comfort the nurse is teaching a client about use of a medical device. Write an item describing information that the nurse should include about use of the selected device. Write an item indicating correct actions for administering the medication via the selected route. Write an item that names the medication; the amount and timeframe that the client would receive the medication; the amount available; the clientís weight in pounds and kilograms; and how much of the medication the client should receive with each administration. The concept of the item should be that the candidate needs to perform a calculation in order to achieve the correct answer. Reduction of Risk Potential the nurse is reviewing laboratory results for assigned clients. Write an item that includes four client scenarios where the nurse needs to determine which client results require follow-up. Write a multiple choice item in which the nurse should recognize the client is having a complication associated with a diagnosis or treatment. References American Educational Research Association, American Psychological Association, and National Council on Measurement in Education. Which of the following statements by the nurse would indicate a correct understanding of the programfi The nurse should follow-up if the client states that which of the following is a normal finding during pregnancyfi Which of the following statements by the client would indicate that the clientís treatment plan has been effectivefi Administer the drops immediately after removing them from the refrigerator to minimize the risk of bacterial growth. Direct the drops along the side of the ear canal to avoid instilling the medication directly onto the eardrum. Gently massage the area immediately posterior to the ear after instilling the drops to facilitate distribution of the medication. How many mL/hr should the nurse set the infusion pump to administer the medication over 120 minutesfi Which of the following clients may be experiencing a complication that the nurse should recognizefi A guideline watch, summarizing significant developments in the scientific literature since publication of this guideline, may be available at. He was involved in the creation of pany, Pfizer, Best Practice, AstraZeneca, Wyeth, Cyberthe Massachusetts General Hospital Psychiatry Academy onics, Novartis, Forest Pharmaceuticals, Inc. He reports serving on speakers bureaus for Pfizer, ship; the curricula from January 2005 to March 2009 inGlaxoSmithKline, and Wyeth. Thase reports that he provided scientific consultathe Institute for Mental Health Research, Forest, Glaxotion to AstraZeneca, Bristol-Myers Squibb, Eli Lilly & SmithKline and Eli Lilly and Company (investigatorCompany, Forest Pharmaceuticals, Inc. He rethe Agency for Healthcare Research and Quality, and ports receiving grant support from the National Institute Sepracor, Inc. His wife was employed as the group scientific director for (2005Ė2010), Basic Books (2005Ė2010), Elsevier (2005Ė Embryon (formerly Advogent), which does business with 2010), and Oxford University Press (2007Ė2010). Trivedi reports that he was a consultant to or on Bristol-Myers Squibb, Cephalon, Cyberonics, Forest Pharspeaker bureaus for Abbott Laboratories, Inc. He netics, Otsuka Pharmaceuticals, Parke-Davis PharmaceutiCopyright 2010, American Psychiatric Association. The Independent Review Panel rePharmaceuticals, VantagePoint, and Wyeth-Ayerst Laboviewed this guideline to assess potential biases and found ratories. DePaulo, Fawcett, Schneck, and Silbersweig, report no Copyright 2010, American Psychiatric Association. Work Group members were selected on the basis of excluding other acceptable methods of care aimed at the their expertise and integrity, and they agreed to dissame results. Such recommendations should incorporate the group was balanced to include some persons with the patientís personal and sociocultural preferences and valminimal industry relationships. As disclosed on pages ues in order to enhance the therapeutic alliance, adherence 2Ė3, from initiation of work in 2005 to approval of the to treatment, and treatment outcomes. Key features of this process inthe chair and vice-chair of the Steering Committee and clude the following: by the Medical Editor, none of whom had relationships with industry.

Compared with veterans who were reported as unexposed to prostatic hypertrophy buy alfuzosin 10 mg on line Agent Orange mens health belly off quality alfuzosin 10mg, the exposed patients showed a statistically signifcantly lower age of presentation (61 versus 72 years; p = 0 man health in urdu discount 10 mg alfuzosin free shipping. However prostate examination video cheap 10mg alfuzosin otc, providers were not blinded to exposure status, and, because patients were younger, these factors may have infuenced the therapy paradigm used. Information on demographics, laboratory and disease-related parameters at the time of the initial diagnosis, and the type and number of treatments received was taken from medical records. The Cox proportional hazards model included age, Rai stage, and baseline laboratory parameters. Compared with the unexposed, veterans exposed to Agent Orange were diagnosed at younger age (63. M edian overall survival was longer in exposed patientsó quite possibly because they were treated more aggressively because they were young. No other statistically signifcant associations or trends were reported for mortality from other types of cancers. A cleaner analysis would have been to look specifcally at other lymphomas (diffuse large B cell, follicular lymphomas, etc. Computer-assisted personal interviews were conducted in the home of each participant and included questions on demographics, house characteristics, pesticide use in the home and garden, and residential and occupational histories. Dust samples were collected and analyzed from vacuum cleaners for participants who had used their vacuum cleaner within the past year and owned at least half of their carpets or rugs for 5 years or more. Pairwise comparisons were performed to obtain a weighted quantile sum for an index of 27 environmental chemicals. Cases were matched to 270 healthy controls by center, age, gender, and date of blood collection. Cases were categorized into ordered quartiles of exposure for each persistent organic pollutant based on the distribution of exposure in the control population. No difference in median exposure levels was observed between cases and controls for any of the chemical exposures (p > 0. In commonly used laboratory mice, the lifetime incidence of spontaneous B-cell lymphomas is about 30% in females and about 10% in males. Laboratory rats, on the other hand, are less prone to develop lymphomas, although Fisher 344 rats do have an increased incidence of spontaneous mononuclear-cell leukemia of non-specifc origin. The lifetime incidence of leukemia is about 50% in male rats and about 20% in female rats. Neither mice nor rats develop T-cell lymphomas spontaneously at a predictable incidence, but T cellĖderived tumors can be induced by exposure to some carcinogens. Nor has long-term exposure to phenoxy herbicides or cacodylic acid resulted in an increased incidence of lymphomas in laboratory animals. It is known to be increased in B-cell neoplasms, including multiple myeloma and various lymphomas, and especially diffuse large B-cell lymphomas (Hussein et al. The authors found a higher prevalence of cells carrying the translocation in the farmers whose blood had been drawn during a period of high pesticide use than in those whose blood had been drawn during a low-use period. In most cases of follicular lymphoma, tumor cells carry the t(14;18) chromosomal translocation, and there is evidence that an increased frequency of lymphocytes from the peripheral blood carrying this tumor marker may be a necessary but not suffcient step toward the development of follicular lymphoma (Roulland et al. When examining immunoglobulin (IgG, IgA, IgM, IgD, and IgE) and complement (C3 and C4) concentrations measures of humoral immunity, Saberi Hosnijeh et al. Limiting the analyses to workers from Factory A and examining serum concentrations of 16 cytokines, 10 chemokines, and 6 growth factors, Saberi Hosnijeh et al. The evidence was drawn from occupational and other studies in which subjects were exposed to a variety of herbicides and herbicide components. Other studies that showed positive associations have lacked exposure-specifcity in the the populations studied. Plasm a Cell Dyscrasias Plasma cell dyscrasias are a heterogeneous group of disorders characterized by the presence of monoclonal immunoglobulins in the serum, which refects a monoclonal proliferation of lymphoplasmacytic cells in the bone marrow (W ahed and Dasgupta, 2015). Plasma cell neoplasms are lymphoid neoplasms of terminally differentiated B cells, all of which exhibit the expansion of a single clone of Ig-secreting plasma cells. The condition is typically discovered as an incidental fnding when a protein electrophoresis test is performed for reasons unrelated to plasma cell dyscrasias. The presence of one of two factors (an abnormal serum free light-chain ratio and a high serum M protein level [fi 1. After an adjustment for competing causes of death, the risk of progression was 10% at 10 years, 18% at 20 years, 28% at 30 years, 36% at 35 years, and 36% at 40 years (Kyle et al. Data and biospecimens were collected prospectively from individuals to whom structured questionnaires and physical exams were given at set times over 20 years, with the fnal exam conducted in 2002. The study included 479 Ranch Hand veterans (who conducted aerial spray missions of the herbicides from 1962 to 1971) and 479 controls (comparison veterans who were also in the Air Force and had similar job duties and were deployed to Southeast Asia during the same period) who participated in the 2002 follow-up examination and had given a serum specimen and were at least 50 years old at the 2002 follow-up. Individuals with a history of multiple myeloma, W aldenstrom macroglobulinemia, solitary plasmacytoma, or amyloidosis were excluded. The Ranch Hand veterans and comparison veterans had similar demographic and lifestyle characteristics and medical histories. The incidence of multiple myeloma is highly age-dependent and is relatively low in people under 40 years old. The incidence is slightly higher in men than in women; for all races the incidence rate for 2009Ė2013 was 8. In the age groups that include most Vietnam veterans, the age-adjusted modeled incidence rate of myeloma for men 50Ė64 years old of all races combined was 13. Few studies of multiple myeloma have been conducted among Vietnam veterans, and most of them have reported no cases of or decreased risks of multiple myeloma (Akhtar et al. Follow-up analyses of the New Zealand cohort of veterans who served in Vietnam found no statistically signifcant increase in the risk of deaths from or incidence of multiple myeloma when compared to the standardized general New Zealand population (M cBride et al. M ost recently, a follow-up analysis of the Cross Canada Study of Pesticides and Health was reviewed by the Update 2014 committee. Pesticides were grouped by type, chemical class, and their carcinogenic potential. Odds ratios were calculated and adjusted for age, residence, medical history, and smoking. A statistically signifcant increased risk of multiple myeloma was observed with exposure to M ecoprop but not with exposure to 2,4-D. An evaluation of days per year of mixing or applying phenoxy herbicides was not statistically signifcant for any category (fi 2 days per year, 2Ė5 days, and > 5 days). It is known to be increased in B-cell neoplasms, including multiple myeloma and various lymphomas (Hussein et al. In comparing the frequency of specifc variants of several metabolic genes between multiple myeloma cases and controls, Gold et al. Most of these cancers also arise from B cells, so the committee hypothesized that it would be etiologically plausible for the association with multiple myeloma to belong with the lymphomas in the suffcient category. Two well-designed studies of well-characterized cohorts were reviewed in the current update. The conditions share several biologic features, notably the clonal hyperproliferation of B cellĖderived plasma cells and the production of abnormal amounts of immunoglobulins. The pattern of organ involvement depends on the nature of the protein; some amyloid proteins are more fbrillogenic than others. Amyloidosis is classifed according to the biochemical properties of the fbril-forming protein. Excessive amyloid protein can have modest clinical consequences, or it can produce severe, rapidly progressive multiple-organ-system dysfunction. The Amyloidosis Foundation estimates that approximately 4,500 new cases are diagnosed each year (Amyloidosis Foundation, 2018). It usually affects people from ages 50 to 80 years and occurs more often in males than in females. Historically, bone marrow biopsies emphasized routine histochemical analysis, but modern immunocytochemistry and fow cytometry now commonly identify monoclonal populations of plasma cells with molecular techniques. Epidemiologic results for amyloidosis were reported for the frst time in Vietnam veterans in the publication from the Korean Veterans Health Study (Yi et al. The National Cancer Institute estimated that in the United States in 2018, 60,300 people would receive a new diagnosis of and 24,370 men and women would die from some form of leukemia. Grouping all different forms of leukemias into a single group is not informative because the different forms have different patterns of incidence and different risk factors.

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If a phenotype is of interest man health tips in urdu discount alfuzosin 10 mg without prescription, the Laboratory are trained to prostate cancer doctor generic alfuzosin 10 mg fast delivery identify unexpected androgen hormone in females discount alfuzosin 10mg, mouse and its relatives are bred to prostate cancer cheap 10 mg alfuzosin amex determine whether the deviant phenotypes, which could indicate the occurrence of a spontaneous mutation. Technicians set aside these ďdeviantĒ mice and their littermates, and researchers meet weekly to Induced random mutations view the selected mice. Phenotypes of interest Induced mutations in mice are typically produced by such are tested for heritability by individual treatments as chemicals or ionizing radiation. For chemicallyresearchers or by the Mouse Mutant Resource induced mutations, male mice are injected with a chemical that is group, which also registers mutations from investigators outside of the Jackson Laboratory. For radiation-induced deletions, males are offered to the global research community. Because treatment produces numerous mutations in each mouse, a desired phenotype often is produced by complex We are very serious about recognizing the contribution our caretakers make to our deviant genetics. Animal care technicians who propagated and the critical constellation of mutations is broken discover mutations that result in publications up. As a result, if a line still expresses a deviant phenotype after receive formal acknowledgment in the about five generations, this usually indicates that this deviant manuscripts. Genetic engineering technology allows researchers to create mice with specific mutations for designated genes. In this handbook, we organize genetically engineered mice into two categories: ē Targeted mutant mice produced using homologous recombination, in which a targeted endogenous gene is altered. These chimeras are usually bred with the host strain to test for germline transmission of the targeted mutation. Thus, these heterozygotes must be intercrossed to produce a homozygous ďknockoutĒ or ďknockinĒ mouse. Failure to do so results in mixed 129 a gene would be expressed only in fat cells, and only genotypes. For a list of the 129 strains from which the principal when the animal was under stress. Typically, a Because of the complex history of the 129 strains, transgene will insert as multiple tandem copies. Two nomenclature was problematic, which hampered replication of or more different transgenes also can be co-injected studies (Simpson et al. Committee on Standardized Genetic Nomenclature for Mice approved the new nomenclature. This enables researchers to study the interaction of a specific antigen with T lymphocytes because it greatly amplifies a cellular-level phenomenon impossible to observe by other means. However, the repertoire of the T cell system is artificiallyóand extremelyórestricted in these mice. Creating humanized mice: compounding mutations to ē Tissue-specific knockouts can be achieved with a enable human tissue transplants Cre-lox strategy, involving both homologous Despite the similarities between mice and humans at the recombination and transgenic technologies. A genetic, physiologic, and anatomical levels, some human structural component of the gene to be knocked out diseases can be studied only in human tissue. Leonard Shultz has spent much of his research career at the Jackson Laboratory constructing a succession flanked by the lox sites), depending on the of immunodeficient mouse models, each of which was a orientation of the loxP sites. This strain and crossing mice that have a tissue-specific Cre other similar humanized mouse models are now being used for studies of human hematopoiesis, innate and adaptive recombinase with mice that have a target gene immunity, infectious diseases, cancer biology, regenerative flanked by loxP sites (a ďfloxedĒ locus). It is medicine, and autoimmunity, including type 1 diabetes (Shultz important to note that, although all cells of the et al. As an example, to restrict mouse has inherent immunodeficiences in its innate immune expression of a transgene to the brain and other system, representing strain variation. The scid mutation, which severely impairs adaptive immunity, was a neuronal tissue, a promoter for a neuron-specific spontaneous mutation. The Jackson Laboratory Handbook on Genetically Standardized Mice Chapter 3: Categories of Laboratory MiceóDefinitions, Uses, Nomenclature 49 3. Considerations Considerations for the use of spontaneous, induced, and genetically engineered mutant strains include the following: ē A mutant phenotype of the strain may necessitate special husbandry. The best strategy to minimize this loss is to maintain the line in forced hemizygosity. To increase the probability of expression, it is helpful to include an intron in the transgene. For example, with Cre-lox models, often both the Cre and loxP parental strains must be maintained. The mutations might have been in the sites is no guarantee that the Cre-lox System will work. For example, in generation is no guarantee that it will work in subsequent the C3H family, most strains carry the retinal rd1 generations. Breeding mutant mice and selecting Neither mutation is specified in C3H strain names, such as C3H/HeJ (000659), which carries both controls mutations, or C3HeB/FeJ (000658), which does When developing and expanding a line of mutant mice, several Lps-d not carry Tlr4. Heritability and mode of inheritance strain, the mutation is designated in the new Regardless of the origin of a random mutation, the first step in strain name. Analysis of heritability also includes determining the mode of inheritanceódominant, recessive, or additiveóand the degree of the penetrance. Strain background considerations Once investigators have characterized the heritability of a mutation, they must consider the genetic background they will use to carry the mutation. If the mutation arose or was created on a well-characterized strain, and if the strain characteristics do not interfere with the study of the mutation, it can be maintained on the original strain. If, however, the original background is mixed or not well characterized, or if the strain characteristics could interfere with the study of the mutation, it can be moved to another background, creating a congenic (see 3. When choosing a breeding scheme, an important consideration is whether the priority is to create as many mutant mice as quickly as possible or to expand the line more slowly but create littermate controls at the same time. Note: Transgenic mice that are hemizygous are usually maintained by backcrossing to the parental strain. Expansion and maintenance breeding schemes for strains with single-locus mutations. Conditions related to the mutation Applicable breeding schemes Fertility Mode of inheritance Description (genotypes) Offspring Mutants of both genders Dominant or Heterozygous mutant x (M/+), (+/+)* are fertile semi-dominant homozygous wild-type (M/+) x (+/+) Heterozygous mutant x (M/M), (M/+), (+/+)* heterozygous mutant (M/+) x (M/+) Homozygous mutant x (M/M) homozygous mutant (M/M) x (M/M) Recessive Heterozygous carrier x (m/m), (m/+)*, (+/+)* heterozygous carrier (m/+) x (m/+) Homozygous mutant x (m/m) homozygous mutant (m/m) x (m/m) Mutants of only one Dominant or Heterozygous mutant x (M/+), (+/+)* gender are fertile semi-dominant homozygous wild-type (M/+) x (+/+) Homozygous mutant x (M/+) homozygous wild-type (M/M) x (+/+) Recessive Homozygous mutant x (m/m), (m/+)* heterozygous carrier (m/m) x (m/+) Mutants of neither Dominant or Not applicable gender are fertileÜ semi-dominant Recessive Heterozygous carrier x (m/m), (m/+)*, (+/+)* heterozygous carrier (m/+) x (m/+) M = dominant mutant allele; m = recessive mutant allele; + = wild-type allele. This may be more efficient than intercross matings because fewer animals are needed. Mutant genotypes Suitable controls (M/M) ē If a mutantís genetic background is an inbred strain, that inbred strain (coisogenic to the mutant strain) is a suitable control as long as the mutant strain has not become a substrain. Although it is unlikely that an F2 hybrid population will have the same genetic mix as the mutant line, an F2 control is the best option if littermate controls cannot be used. A recessive mutation that is fatal or that causes a critical phenotype such as sterility also can be carried in a balanced stock, in which the mutation is linked to a marker gene (often one for coat color) so that mutant mice and carriers of the mutation can be identified by sight. Balanced stocks are infrequently used today because of the prevalence of genotyping; however, once a balanced stock is created, it is very convenient to use. For details on breeding a balanced stock, refer to Appendix I, ďUsing a Balanced Stock to Carry a Recessive Mutation That Is Sterile or Lethal, Including Embryonic Lethal. Breeding considerations to minimize genetic drift When maintaining a mutant strain, breeding strategies must minimize the creation of genetic differences between the mutant strain and the background strain on which is resides. Use these guidelines: ē If the mutation is on a stable inbred strain, backcross to the parental strain about every 10 generations. Nomenclature Nomenclature for strains with single locus mutations includes information about the background strain or substrain followed by information about the gene and mutant allele. Note that the designation for the mutation is the same whether it is carried homozygously or heterozygously. Huang (Plh); than 5 or unknown number of maintained at the Jackson Laboratory filial generations); hyphen (-); (J). The Jackson Laboratory Handbook on Genetically Standardized Mice Chapter 3: Categories of Laboratory MiceóDefinitions, Uses, Nomenclature 53 3. Research examples A spontaneous mutation used to study the role of leptin in autoimmunity. Had these investigators not been so observant of the new phenotype, they would have missed the opportunity to discover the surprising role of a fat tissue hormone (leptin) in the modification of an autoimmune disease. Cre-lox technology used to demonstrate the relationship of fat to insulin metabolism. Because these Cre-lox mice were more insulin-sensitive than normal, a role for white fat in the development of insulin resistance, which promotes type 2 diabetes, was demonstrated. Interestingly, these Cre-lox mice also lived about 15% longer than the various controls (mice with only the Cre-recombinase transgene, mice with only the floxed insulin receptor, and mice of the same mixed genetic background with neither mutation), demonstrating a role for even normal levels of white fat in limiting lifespan. Congenic and conplastic strains A congenic strain is one in which a short chromosomal segmentócontaining a gene with an allele of interestóis transferred to a different genetic background through selective breeding using either phenotypic or genotypic screening. It is important to note that this chromosomal segment contains other linked genes as well.

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Assign 15 if chemotherapy is planned but has not started and date is not available prostate cancer stages buy cheap alfuzosin 10 mg on-line. If chemotherapy was expected to mens health xp generic 10 mg alfuzosin free shipping be given or was planned as part of the first course of therapy prostate cancer pathophysiology discount 10 mg alfuzosin otc, but information was not known if the chemotherapy had been started or had not been started at the time of the most recent follow-up man health online generic alfuzosin 10mg on-line, attempt to follow-up to assure complete information is collected. As information is learned, update this item, Date Chemotherapy Started, and Chemotherapy. Code Description 00 None, chemotherapy was not part of the planned first course of therapy; diagnosed at autopsy 01 Chemotherapy administered as first course therapy, but the type and number of agents is not documented in the patient record 02 Single agent chemotherapy administered as first course therapy 03 Multi-agent chemotherapy administered as first course therapy 82 Chemotherapy was not recommended/administered because it was contraindicated due to patient risk factors (comorbid conditions, advanced age, etc. It was recommended by the patientís physician but was not administered as part of the first course of therapy. It was recommended by the patientís physician, but the treatment was refused by the patient, a patientís family member, or the patientís guardian. Example 2: Patient diagnosed with breast cancer November 1, 2012, and begins receiving Rituximab January 30, 2013, as part of first course therapy. Code the Rituximab in the chemotherapy data field because the patient was diagnosed prior to January 1, 2013. Definitions Chemotherapy recommended: A consult recommended chemotherapy, or the attending physician documented that chemotherapy was recommended. Multiple agent chemotherapy: Planned first course of therapy included two or more chemotherapeutic agents and those agents were administered. The planned first course of therapy may or may not have included other agents such as hormone therapy, immunotherapy, or other treatment in addition to the chemotherapeutic agents. Single agent chemotherapy: Only one chemotherapeutic agent was administered to destroy cancer tissue during the first course of therapy. The chemotherapeutic agent may or may not have been administered with other drugs classified as immunotherapy, hormone therapy, ancillary, or other treatment. Code the chemotherapeutic agents whose actions are chemotherapeutic only; do not code the method of administration 2. When chemotherapeutic agents are used as radiosensitizers or radioprotectants, they are given at a much lower dosage and do not affect the cancer. Review the radiation-oncology progress notes for information about radiosensitizing chemotherapy. Note: Do not assume that a chemo agent given with radiation therapy is a radiosensitizer. The physician may change a drug during the first course of therapy because the patient cannot tolerate the original agent a. Code as treatment for both primaries when the patient receives chemotherapy for invasive carcinoma in one breast and also has in situ carcinoma in the other breast. The medical record documents chemotherapy was not given, was not recommended, or was not indicated b. If the treatment plan offered multiple treatment options and the patient selected treatment that did not include chemotherapy d. Patient diagnosed at autopsy Example: Patient is diagnosed with plasma cell myeloma. Assign code 00 since there is no reason to suspect that the patient had been treated. Do not code combination of ancillary drugs administered with single agent chemotherapeutic agents as multiple chemotherapy. Assign code 82 when chemotherapy is a customary option for the primary site/histology but it was not administered due to patient risk factors, such as a. The patient made a blanket refusal of all recommended treatment and chemotherapy is a customary option for the primary site/histology c. The patient refused all treatment before any was recommended and chemotherapy is a customary option for the primary site/histology 9. Insertion of port-a-cath Note: Review cases coded 88 periodically for later confirmation of chemotherapy. Assign code 99 when there is no documentation that chemotherapy was recommended or administered a. Although they are toxic to all cells, they are most active in the resting phase of the cell. Alkylating agents are used to treat many different cancers including acute and chronic leukemia, lymphoma, Hodgkin disease, multiple myeloma, sarcoma, and cancers of the lung, breast, and ovary. When the cells incorporate these substances into the cellular metabolism, they are unable to divide. Antimetabolites are classified according to the substances with which they interfere. Plant Alkaloids are cell-cycle specific which means they attack the cells during various phases of division. Antitumor antibiotics are also cell-cycle specific and act during multiple phases of the cell cycle. They are made from natural products and were first produced by the soil fungus Streptomyces. Targeted cancer therapies are sometimes called "molecularly targeted drugs," "molecularly targeted therapies," "precision medicines," or similar names. Examples of molecularly targeted therapy are imatinib (Gleevec), lapatinib (Tykerb), erlotinib (Tarceva), sunitinib (Sutent). This permits a higher concentration of drug to be in contact with the tumor for a longer period of time. Radioembolization: Tumor embolization combined with the injection of small radioactive beads or coils into an organ or tumor. Tumor embolization: the intentional blockage of an artery or vein to stop the flow of blood through the desired vessel. Coding Instructions Code as Chemotherapy when the embolizing agent(s) is a chemotherapeutic drug(s). Use codes 01, 02, 03 as specific information regarding the agent(s) is documented. From a procedure report: Under x-ray guidance, a small catheter is inserted into an artery in the groin. The catheterís tip is threaded into the artery in the liver that supplies blood flow to the tumor. Chemotherapy is injected through the catheter into the tumor and mixed with particles that embolize or block the flow of blood to the tumor. Record the date of the first/earliest hormone therapy if hormone therapy was given as part of the first course of therapy a. Hormone therapy date should be the same as the Date Therapy Initiated when hormone therapy is the only treatment administered 3. Code Label Definition Blank A valid date value is provided in Date Hormone Therapy Started 10 No information No information whatsoever can be inferred 11 Not applicable No proper value is applicable in this context 12 Unknown A proper value is applicable but not known 15 Planned Treatment planned but not yet started Coding Instructions 1. Leave this item blank if Date Hormone Therapy Started has a full or partial date recorded a. Assign code 11 when no hormone therapy was given as part of the first course of therapy or initial diagnosis was at autopsy d. Assign code 12 if the Date Hormone Therapy Started cannot be determined, and the patient did receive first course treatment. Assign code 15 if hormone therapy is planned but has not started and date is not available. If hormone therapy was expected to be given or was planned as part of the first course of therapy, but information was not known if the hormone therapy had been started or had not been started at the time of the most recent follow-up, attempt to followup to assure complete information is collected. Note: Surgical removal of organs for hormone manipulation is not coded in this data item. Code these procedures in the data field Hematologic Transplant and Endocrine Procedures. Code Description 00 None, hormone therapy was not part of the planned first course of therapy; not usually administered for this type and/or stage of cancer; diagnosed at autopsy only 01 Hormone therapy administered as first course therapy 82 Hormone therapy was not recommended/administered because it was contraindicated due to patient risk factors (comorbid conditions, advanced age, etc. It was recommended by the patientís physician, but this treatment was refused by the patient, a patientís family member, or the patientís guardian. The medical record states that hormone therapy was not given, was not recommended, or was not indicated b. Patient elected to pursue no treatment following the discussion of hormone therapy treatment. Hormone treatment was given for a non-reportable condition or as chemoprevention prior to diagnosis of a reportable condition Example 1: Tamoxifen given for hyperplasia of breast four years prior to breast cancer diagnosis. Example 2: Patient with a genetic predisposition to breast cancer is on preventative hormone therapy.

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