Mara Decker, DrPH

• Assistant Adjunct Professor

https://publichealth.berkeley.edu/people/mara-decker/

In an effort to quantify preoperative cardiac risk medicine emblem order generic leflunomide on line, several tests are used to assess cardiovascular function medicine 377 order leflunomide with visa. Electrocardiogram should be considered for anyone other than asymptomatic persons undergoing low risk procedures permatex rust treatment discount leflunomide 10mg free shipping. Patients who have dyspnea of unknown origin treatment anal fissure discount leflunomide 10 mg free shipping, current or past heart failure medicine cups cheap leflunomide 20mg, prior cardiomyopathy medications requiring prior authorization cheap leflunomide generic, or with any of the above factors and no cardiac assessment in the past 12 months should consider echocardiogram testing preoperatively (179). Exercise stress testing before surgery can identify patients who have ischemic heart disease not apparent at rest. Likewise, it is recommended for patients with greater clinical risk factors or those undergoing high-risk surgery (179). These patients are at increased risk of developing cardiac complications in the perioperative period. In a study of patients undergoing peripheral vascular surgery, a high-risk group of patients was identified who had ischemic electrocardiographic changes when they exercised to less than 75% of their maximal predicted heart rate. In this group, the incidence of perioperative myocardial infarction was 25% and the overall cardiac mortality rate was 18. Conversely, no perioperative infarctions occurred in patients who were able to exercise to more than 75% of their maximal predicted heart rate and who had no electrocardiographic evidence of ischemia (181). The prognostic value of stress testing was not supported in another prospective study that found that only an abnormal preoperative resting electrocardiography result was an independent risk factor (182). The exercise stress test must be selectively applied to a high-risk population because its predictive value depends on the prevalence of the disease. It is not prudent to screen all patients preoperatively; it is preferable to rely on a careful history to identify patients with symptoms of cardiac disease for whom the test would be most predictive. Exercise stress testing is limited in some patients who cannot exercise because of musculoskeletal disease, pulmonary disease, or severe cardiac disease. Dipyridamolethallium scanning may be used to overcome the limitations of exercise stress testing. This study has a high degree of sensitivity and specificity but a low positive predictive value (179,183). It relies on the ability of dipyridamole to dilate normal coronary arteries but not stenotic vessels. Normally perfused myocardium readily takes up thallium when it is given intravenously. Conversely, hypoperfused myocardium does not show good uptake of thallium when scanned 5 minutes after injection. Reperfusion and uptake of thallium 3 hours after injection identify viable but high-risk myocardium. Several studies show an increasing risk of perioperative myocardial infarction dependent on the extent of reperfusion of thallium, or reversible defect, ranging from 3% to 49% (184,185). This method identifies regional cardiac wall motion abnormalities after dobutamine infusion to identify patients at high risk for cardiac events. Positive and negative predictive values are similar to those of dipyridamolethallium testing for a perioperative event (186,187). Dipyridamole-thallium testing is preferred for patients with known cardiac arrhythmias, and dobutamine is preferred for patients with bronchospastic lung disease and in those with severe cardiac stenosis (188). Coronary angiography should be considered only in patients who have an indication for angiography independent of the planned surgery, such as patients with acute coronary syndromes, unstable angina, angina refractory to medical therapy, or high-risk results on noninvasive testing. Controversy exists regarding the accuracy of these tests to provide prognostic information beyond what is obtained from clinical risk stratification for nonvascular procedures. Diagnostic testing should not lead to unnecessary additional testing or harmful delays in s urge ry. The American College of Cardiology and the American Heart Association present an updated detailed algorithm that incorporates risk-factor stratification to guide clinicians to proceed directly to surgery, to delay surgery and obtain preoperative noninvasive testing, or to attempt risk factor modification (179). It is rare for patients who are younger than 50 years and who do not have diabetes, hypertension, hypercholesterolemia, or coronary artery disease to suffer a perioperative myocardial infarction. In contrast, patients with coronary artery disease are at increased risk of myocardial infarction in the postoperative period. Prevention, early recognition, and treatment are important because myocardial infarctions that occur in the postoperative period have mortality rates of up to 25% and are associated with increased rates of cardiovascular death in the 6 months following surgery (189). Nearly two-thirds of postoperative myocardial infarctions occur during the first 3 days postoperatively (189). Although the pathophysiologic factors are complex, the causes of postoperative myocardial ischemia and infarction are related to decreased myocardial oxygen supply coupled with increased myocardial oxygen requirements. In postoperative patients, conditions that decrease oxygen supply to the myocardium include tachycardia, increased preload, hypotension, anemia, and hypoxia (190). Conditions that increase myocardial oxygen consumption are tachycardia, increased preload, increased afterload, and increased contractility. Tachycardia and increased preload are the most important causes of ischemia, because both conditions decrease oxygen supply to the myocardium while simultaneously increasing myocardial oxygen demand. Tachycardia decreases the diastolic time, which, when the coronary arteries are perfused, decreases the volume of oxygen available to the myocardium. Increased preload increases the pressure exerted by the myocardial wall on the arterioles within it, thus decreasing myocardial blood flow. Other factors associated with perioperative myocardial ischemia include physiologic responses to the stress of intubation, intravenous or arterial line placement, emergence from anesthesia, pain, and anxiety. These stresses result in catecholamine stimulation of the cardiovascular system, resulting in increased heart rate, blood pressure, and contractility, which may induce or worsen myocardial ischemia. Loss of intravascular volume because of third spacing of fluids or postoperative hemorrhage can induce ischemia. Chest pain, which is present in 90% of nonsurgical patients with myocardial infarction, may be present in only 50% of patients with postoperative infarction because myocardial pain may be masked by coexisting surgical pain and the use of analgesics (175). It is important to maintain a high level of suspicion for postoperative infarction in patients with coronary artery disease. The presence of arrhythmia, congestive heart failure, hypotension, dyspnea, or elevations of pulmonary artery pressure may indicate infarction and should prompt a thorough cardiac investigation and electrocardiographic monitoring. Many patients will exhibit P-wave changes that spontaneously resolve and do not represent ischemia or infarction. In a review of over 2,400 patients, the sensitivity of predicting postoperative cardiac events was 55% to 100%, specificity 37% to 85%, positive predictive value 7% to 57%, and negative predictive value 89% to 100% (192). Postoperative management of patients with coronary artery disease is based on maximizing delivery of oxygen to the myocardium and decreasing myocardial oxygen utilization. Anemia is detrimental because of loss of oxygen-carrying capacity and resultant tachycardia and should, therefore, be carefully corrected in high-risk patients. Although transfusion criteria are not absolute, all patients with a hemoglobin less than 6 mg/dL, and hemoglobin of 6 to 10 mg/dL with significant cardiac risk factors should be offered blood transfusion (193). Patients with coronary artery disease may benefit from pharmacologic control of hyperadrenergic states that result from increased postoperative catecholamine production. Beta-blockers decrease heart rate, myocardial contractility, and systemic blood pressure, all of which are increased by adrenergic stimulation. Consider initiating and titrating beta-blockers in patients with coronary artery disease or high cardiac risk (as defined by the presence of more than one clinical risk factor) who are undergoing intermediate-risk surgery (155). Therapy should be initiated at least 1 week before surgery to allow for proper titration. The timing and optimal duration of beta-blocker therapy remains an area of uncertainty. Nevertheless, for patients already on beta-blocker therapy, they should continue it perioperatively because abrupt withdrawal results in a rebound hyperadrenergic state. Prophylactic use of other agents such as nitroglycerin and calcium-channel blockers remains controversial, as data did not show a consistent benefit toward reducing risk of ischemic cardiac events. The postoperative development of pulmonary edema may be associated with a high mortality rate, especially if it occurs in the setting of cardiac ischemia (198,199). Treatment usually relies on aggressive diuretic therapy, although care must be taken to avoid dehydration, which may result in hypotension during the induction of anesthesia. Hypokalemia can result from diuretic therapy and is especially deleterious to patients who are taking digitalis. In addition to diuretics and digitalis, treatment often includes the use of preloadand afterload-reducing agents. It is preferable to continue the usual regimen of cardioactive drugs throughout the perioperative period. Other common postoperative causes are myocardial infarction, systemic infection, pulmonary embolism, and cardiac arrhythmias. The cause of postoperative heart failure must be diagnosed because, to be successful, treatment should be directed simultaneously to the underlying cause. Treatment of pulmonary edema may include the use of intravenous furosemide, supplemental o x yge n, morphine sulfate, and elevation of the head of the bed. Electrocardiography, in addition to laboratory evaluation, including arterial blood gas, serum electrolyte, and renal function chemistry measurements, should be obtained expediently. Arrhythmias Nearly all arrhythmias found in otherwise healthy patients are asymptomatic and of limited consequence. In patients with underlying cardiac disease, however, even brief episodes of arrhythmias may result in significant cardiac morbidity and mortality. Preoperative evaluation of arrhythmias by a cardiologist and anesthesiologist is important because many anesthetic agents and surgical stress contribute to the development or worsening of arrhythmias. In patients undergoing continuous electrocardiographic monitoring during surgery, a 60% incidence of arrhythmias, excluding sinus tachycardia, are reported (201). Patients with heart disease have an increased risk of arrhythmias, most commonly ventricular arrhythmias (201). Patients without cardiac disease are more likely to develop supraventricular arrhythmias during surgery. Patients taking antiarrhythmic medications before surgery should continue taking those drugs during the perioperative period. Initiation of antiarrhythmic medications is rarely indicated preoperatively, but consultation with a cardiologist is recommended for patients in whom arrhythmias are detected before surgery. Before performing surgery on patients with a permanent pacemaker, the type and location of the pacemaker should be determined because electrocautery units may interfere with demand-type pacemakers (203). When performing gynecologic surgery on patients with pacemakers, it is preferable to place the electrocautery unit ground plate on the leg to minimize interference by preventing the pacemaker generator from sitting within the electrocautery circuit and to maximize distance from the pacemaker device. If possible, use of bipolar cautery devices are recommended rather than monopolar devices. In patients with a demand pacemaker in place, the pacemaker should be converted preoperatively to the fixed-rate (or asynchronous) mode. Although this can be accomplished oftentimes by placing a magnet over the pacemaker, it may be better to reprogram the pacemaker preoperatively and then again postoperatively. Patients should be monitored continuously intraoperatively with both telemetry and continuous pulse oximeter. Patients with an implantable cardioverter defibrillator device should have their device programmed off prior to surgery and reprogrammed postoperatively (155). Surgery is not contraindicated in patients with bundle branch blocks or hemiblocks (204). Complete heart block rarely develops during noncardiac surgical procedures in patients with conduction system disease. The presence of a left bundle-branch block may indicate the presence of aortic stenosis, which can increase surgical mortality if it is severe. Patients with significant aortic stenosis appear to be at greatest risk, which is increased in the presence of atrial fibrillation, congestive heart failure, or coronary artery disease. Significant stenosis of aortic or mitral valves should be repaired before elective gynecologic surgery (176). The classic history presented by patients with severe aortic stenosis includes exercise dyspnea, angina, and syncope, whereas symptoms of mitral stenosis are paroxysmal and effort dyspnea, hemoptysis, and orthopnea. Severe stenosis of either valve is considered to be a valvular area of less than 1 cm, and diagnosis can2 be confirmed by echocardiography or cardiac catheterization. Electrocardiogram with high R waves, depressed T waves in lead I, and precordial leads Mitral stenosis 1. Electrocardiogram with large P waves and right axis deviation Patients with valvular abnormalities are subdivided by the American Heart Association into risk groups for the development of subacute bacterial endocarditis following surgery. Patients in the highest risk groups should receive prophylactic antibiotics immediately preoperatively to prevent subacute bacterial endocarditis (Table 22. As defined by the American Heart Association, only patients with prosthetic cardiac valves, congenital heart disease, and cardiac transplantation who develop cardiac valvulopathy should receive perioperative endocarditis prophylaxis (76). All other patients do not require antibiotics for subacute bacterial endocarditis prophylaxis. Patients with aortic and mitral stenosis tolerate sinus tachycardia and other tachyarrhythmias poorly. In patients with aortic stenosis, sufficient levels of digitalis should be provided to correct preoperative tachyarrhythmias, and propranolol may be used to control sinus tachycardia. Patients with mitral valve stenosis often have atrial fibrillation and, if present, digitalis should be used to reduce rapid ventricular response.

Back to Top Date Sent: 8/25/20 178 these criteria do not imply or guarantee approval symptoms jaw bone cancer buy cheap leflunomide 10 mg on line. Criteria | Codes | Revision History the use of High-dose rate brachytherapy in the treatment of prostate cancer does not meet the Kaiser Permanente Medical Technology Assessment Criteria symptoms after flu shot buy leflunomide paypal. The secondary outcomes were the overall and relapse-free survival medicine grace potter lyrics buy leflunomide 20mg on line, acute and late toxicity symptoms rheumatic fever purchase leflunomide from india, and quality of life medicine cabinets with lights leflunomide 20mg on-line. Moreover medications 44334 white oblong buy generic leflunomide 10 mg online, the followup duration was relatively short, and the primary outcome was biochemical relapse free survival which is a surrogate outcome for overall survival. All published studies on monotherapeutic brachytherapy for organ confined or locally advanced prostate cancer, were case series with variable sizes and duration of follow-up. Back to Top Date Sent: 8/25/20 179 these criteria do not imply or guarantee approval. A recent study by Zwahlen and colleagues was selected for review as it was the only study with a control group. High-dose-rate prostate brachytherapy: An excellent accelerated hypofractionated treatment for favorable prostate cancer. High-dose-rate brachytherapy in combination with conformal external beam radiotherapy in the treatment of prostate cancer. In intracavity brachytherapy, radioactive sources are placed in body cavities that are close to the tumor. High-dose rate is generally accepted as being between 50-500 cGy/minute (Tewari & DiSaia, 2002; Hogberg et al. The lack of a statistically significant finding could be due to a design flaw such as insufficient statistical power or bias. This is particularly true because the results were reported separately by stage of disease which resulted in a smaller sample size for each comparison. There were four studies that compared the outcomes of patients who received high-dose or low-dose brachytherapy. High-dose versus low-dose-rate intracavity therapy for carcinoma of the uterine cervix. The conclusion of the committee was that there was inadequate follow-up data supporting the efficacy of Transperineal Ultrasound Guided Iodine125 or Palladium103 Brachytherapy for Prostate Cancer. The question of Transperineal Ultrasound Guided Iodine125 or Palladium103 Brachytherapy for Prostate Cancer was restated and evaluated at the January 16, 1997 Clinical Policy Committee Meeting. Based on this information the Committee recommended to the Clinical Planning and Improvement Council and the Delivery System Operating Team that brachytherapy be added to the list of covered treatment options for localized prostate cancer. Documentation of the screening criteria used to identification of the eligible candidates is the purpose of this document. Criteria | Codes | Revision History Evidence Conclusion: In late 2001 the criteria were reviewed by Dr. Nico DeWette and updated based on the current practice and experience with Prostate Seed Implant and Combined Therapy. Tumor Control and Morbidity Following Transperineal Iodine 125 Implantation for Stage T1/T2 Prostatic Carcinoma. Detailed Preliminary Analysis of 125Iodine Implantation for Localized Prostate Cancer Using Percutaneous Approach. Primary brain tumors are those that arise from brain tissue itself, rather than metastasizing to the brain from another location. High-grade tumors are by definition, rapidly growing and typically develop at a distinct focus in the brain and become more diffuse in their spread as they progress. Treatment for glioblastoma multiforme typically involves surgery to reduce the size of the tumor and external beam radiation therapy. One proposed treatment for glioblastoma is the use of stereotactically implanted radioactive seeds (brachytherapy) at the site of the tumor. The potential advantage of brachytherapy is that it allows high dose radiation to be applied directly to the tumor site and may avoid radionecrosis caused by high doses of externally applied radiation and toxic effects of chemotherapy. Brachytherapy for malignant brain tumors has been practiced since the early 1980s. Given these limitations, there is insufficient evidence to draw conclusions about the efficacy and safety of brachytherapy for patients with glioblastoma. Permanent Iodine-125 interstitial implants for the treatment of recurrent glioblastoma multiforme. Back to Top Date Sent: 8/25/20 182 these criteria do not imply or guarantee approval. See Evidence Table Radioactive Seeds for Treatment of Recurrent Malignant High-Grade Glioblastoma does not meet Kaiser Permanente Medical Technology Assessment Criteria. Back to Top Date Sent: 8/25/20 184 these criteria do not imply or guarantee approval. For Non-Medicare Members Breast implant removal is covered when All of the following criteria are met: 1. Back to Top Date Sent: 8/25/20 185 these criteria do not imply or guarantee approval. There is concern and there may be a relationship between silicone breast implants and the development of connective tissue disease, although there is no epidemiological evidence. Silicone breast implants can impede early detection of breast cancer in cases of cosmetic breast augmentation, but do not in cases of breast reconstruction following extractive surgery. Back to Top Date Sent: 8/25/20 186 these criteria do not imply or guarantee approval. Back to Top Date Sent: 8/25/20 187 these criteria do not imply or guarantee approval. Hospital grade breast pump is not considered medically necessary after 12 months of age. Kaiser Permanente will not cover rental of a heavy duty electrical/hospital grade breast pump when requested solely for convenience because it is considered not medically necessary. Purchase of a basic electric consumer pump (E0603) does not require medical necessity review. Background Breast-fed infants have a lower risk of diarrhea and otitis media than bottle-fed infants during the first year of life. Criteria | Codes | Revision History By contrast, the manual and electric breast pumps that are available commercially are not designed for reuse and are most commonly sold to mothers with normal infants who are working, traveling, or for other reasons not always home to breast-feed the baby. Standard electric breast pumps or manual breast pumps may be necessary to initiate breast feeding in the postpartum period, within the first eight weeks following delivery. Current recommendations from the American Academy of Pediatrics are to continue breastfeeding of infants through one year of age. The process involves nipple stimulation with use of an electric breast pump beginning about two months before the adoptive mother expects to begin breast-feeding. Authorized under provisions of the Patient Protection and Affordable Care Act, the U. New health plans and non-grandfathered plans and issuers are required to provide coverage consistent with these guidelines in the first plan year (in the individual market, policy year) that begins on or after August 1, 2012. SurgiMend Autologous fat injections for post-mastectomy breast reconstruction (autologous fat grafting, autologous fat transfer, breast fat grafting, lipoinjection, lipofilling) A. Ongoing surgery for treatment of natural changes due to age or weight changes is considered cosmetic and not covered. Background While breast reconstructive surgery can be considered a cosmetic procedure, under both state and federal law, carriers must provide coverage for this type of surgery in certain clinical circumstances. Washington state law also has provisions for the coverage of reconstructive surgery following a mastectomy. Since then, several surgeons have used free fat grafts for the reconstruction of breast defects. Autologous fat is considered an ideal injectable agent for soft tissue augmentation; it is easily available for most patients, easy to use, inexpensive, nontoxic, biocompatible, and potentially long lasting, and removable (Mu 2009, Fraser 2011, Bucky 2011). Breast fat grafting is a promising technique to correct contour deformities in breasts reconstructed with either prosthesis or autologous tissues. The mechanism underlying the survival of dissected autologous fat after grafting is unknown but is believed to be dependent on revascularization of fat granules. One of the main concerns with autogenous fat grafting for the breast is the development of fat necrosis leading to liponecrotic cysts and microcalcifications that could be mistaken for cancerous calcifications. Compression of the breast tissue by the transferred fat may also make it difficult to identify subtle changes in architectural patterns seen with early breast cancer presentation. Other complications with autologous fat transfer include edema, hematoma, induration, infection, granuloma formation, oil cyst formation, fat liquefaction, sclerosis and resorption (Pulagam 2006, Mu 2009, Mizuno 2010, Fraser 2011, Bucky 2011, Rietjens 2011, Serra-Renom 2011). The interest in autologous fat grafting for aesthetic and reconstructive purposes was renewed in the 1980s with the introduction of liposuction that provided a minimally invasive means of obtaining large amounts of adipose tissue in a semiliquid form. Several harvesting and transplantation techniques have been developed and refined, yet no standard procedures have been adopted by all practitioners. There is no consensus on the ideal cannula, technique for harvesting, processing, or grafting the fat. Back to Top Date Sent: 8/25/20 192 these criteria do not imply or guarantee approval. For grafting, the fat is injected with a variety of delivery methods using sharp or blunt needles. The studies used different techniques, donor site, volume of fat transplant, as well as various outcome measures and follow-up durations. Most of the series included patients undergoing the procedure for breast augmentation, reconstructive surgery after mastectomy, as well as other indications. The largest published series of 880 patients over 10 years was reported by Delay, et al in 2009. The intervention was not compared to another procedure, and the study had several limitations including, but not limited to , lack of reporting inclusion/exclusion criteria, patient characteristics, and lack of clearly defined outcomes and reporting of duration or completeness of follow-up. They reported that the incidence of fat necrosis was 15% for the first 50 patients and declined to 3% for the last 100 patients suggesting a surgical learning curve. Illouz and Sterodimas (2009), reported on a series of 820 consecutive patients who underwent autologous fat transplantation over 25 years. These included patients undergoing the procedure for breast reconstruction after a mastectomy, patients with congenital asymmetry, or women requesting breast augmentation. The authors indicted that the majority of patients were satisfied with the results. They indicate that calcifications, cysts, and cancer were not apparent in the first year after the procedure and thought that they may not be directly associated with the procedure. Articles: Assessment objective: To determine the safety and efficacy of autologous fat grafting for postmastectomy breast reconstruction. The two largest published series of patients who underwent autologous fat transplantation to the breast, mainly for reconstruction after mastectomy, were selected for critical appraisal. Autologous fat transplantation to the breast: A personal technique with 25 years of experience Aesth Plast Surg. It is not clear from the study if patients seeking reconstruction following mastectomy were included or excluded (Khouri, Eisenmann-Klein et al. Articles were limited to those published in English language and enrolling human subjects. Screening of Articles: A literature search was conducted and revealed one publication (funded by the manufacturer) on the use of the Brava system plus autologous fat transfer in breast augmentation. The literature also suggests that this modality of therapy can modify the inflammatory process, reduce edema, and enhance tissue repair. Electromagnetic therapy is currently being used in physical medicine, orthopedic and sports injuries, and other musculoskeletal conditions. The results of the study showed a significant difference between the active and sham therapies in the pain experienced and in the use of postoperative pain medication. Effects of pulsed electromagnetic fields on postoperative pain: A double-blind randomized pilot study in breast augmentation patients. Effects of pulsed electromagnetic fields on interleukin-1fi and postoperative pain: A double-blind, placebo-controlled, pilot study in breast reduction patients. Once expansion was complete with drain placement, the second stage of surgery was performed, where the expander was replaced with a permanent breast implant. Adverse events occurred in 18 of the 71 patients with 1-year follow-up after stage I surgery, and most occurred within the first 6 months. Back to Top Date Sent: 8/25/20 196 these criteria do not imply or guarantee approval. Criteria | Codes | Revision History L8039 Breast prosthesis, not otherwise specified *Note: Codes may not be all-inclusive. Back to Top Date Sent: 8/25/20 197 these criteria do not imply or guarantee approval. Background Asthma is an increasingly prevalent disease that affects over 20 million people in the United States. It is estimated that 15 20% of asthma patients have a severe condition despite receiving the new effective therapies.

Fetal loss rate after ultrasonically documented cardiac activity between 6 and 14 weeks medicine 4212 buy leflunomide 10mg lowest price, menstrual age medicine bow order leflunomide visa. Characteristics of women with fetal loss in symptomatic first trimester pregnancies with documented fetal cardiac activity symptoms leukemia order discount leflunomide online. Age-specific risk of fetal loss observed in a second trimester serum screening population treatment 5 alpha reductase deficiency discount leflunomide 10mg otc. Early transvaginal ultrasound following an accurately dated pregnancy: the importance of finding a yolk sac or fetal heart motion 9 treatment issues specific to prisons leflunomide 20mg for sale. Spontaneous abortion: a prospective cohort study of younger women from the general population in Denmark medications to treat bipolar disorder buy leflunomide pills in toronto. Paternal and maternal smoking habits before conception and during the first trimester: relation to spontaneous abortion. Ultrasound criteria for diagnosis of early pregnancy failure and ectopic pregnancy. Double-blind controlled trial of progesterone substitution in threatened abortion. A comparative study of human chorionic gonadotropin, placebo, and bed rest for women with early threatened abortion. Threatened abortion: a risk factor for poor pregnancy outcome, a populationbased screening study. A comparison of medical management with misoprostol and surgical management for early pregnancy failure. History and physical examination to estimate the risk of ectopic pregnancy: validation of a clinical prediction model. Predictive value of history and physical examination in patients with suspected ectopic pregnancy. Tubal anastomosis: pregnancy success following reversal of Falope ring or monopolar cautery sterilization. The reversibility of female sterilization with the use of microsurgery: a report on 102 patients with more than one year of follow-up. Analysis of failure of microsurgical anastomosis after midsegment, noncoagulation tubal ligation. Tubal lesions subsequent to sterilization and their relation to fertility after attempts at reversal. Medical management should be routinely used as primary therapy for ectopic pregnancy. A cohort study of 1,844 women with laparoscopically verified disease and 657 control women with normal laparoscopic results. Risk factors for ectopic pregnancy: a case-control study in France, with special focus on infectious factors. Serologic evidence for the role of Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma hominis in the etiology of tubal factor infertility and ectopic pregnancy. Recurrent chlamydial infections increase the risks of hospitalization for ectopic pregnancy and pelvic inflammatory disease. Risks and benefits, advantages and disadvantages of levonorgestrel-releasing contraceptive implants. An association between clomiphene citrate and ectopic pregnancy: a preliminary report. In-vitro fertilization and embryo transfer: a collaborative study of 1163 pregnancies on the incidence and risk factors of ectopic pregnancies. An unexpectedly high rate of ectopic pregnancy following the induction of ovulation with human pituitary and chorionic gonadotrophin. Outcome in 242 in vitro fertilization-embryo replacement or gamete intrafallopian transfer-induced pregnancies. The role of tubal pathology and other parameters in ectopic pregnancies occurring in in vitro fertilization and embryo transfer. The incidence of combined intrauterine and extrauterine pregnancy after in vitro fertilization and embryo transfer. Risk factors for ectopic pregnancy: a comprehensive analysis based on a large case-control, population-based study in France. A significant association between spontaneous abortion and tubal ectopic pregnancy. Long-term physical and psychological health consequences of induced abortion: review of the evidence. Salpingitis isthmica nodosa: a review of the literature, discussion of clinical significance, and consideration of patient management. Endometrial stripe thickness and pregnancy outcome in first trimester pregnancies with pain bleeding or both. International reference preparation of human chorionic gonadotrophin for immunoassay; potency estimates in various bioassays and protein binding assay systems; and international reference preparations of the alpha and beta subunits of human chorionic gonadotrophin for immunoassay. False diagnosis and needless therapy of presumed malignant disease in women with falsepositive human chorionic gonadotropic concentration. Serum beta-human chorionic gonadotropin levels relate poorly with the size of a tubal pregnancy. The predictive value of a single, early human chorionic gonadotropin measurement and the influence of maternal age on pregnancy outcome in an infertile population. Improved sensitivity and specificity of a single measurement of serum progesterone over serial quantitative beta-human chorionic gonadotrophin in screening for ectopic pregnancy. Receiver operator characteristics, efficiency analysis, and predictive value of serum progesterone concentration as a test for abnormal gestations. Progesterone, estradiol, and alpha-human chorionic gonadotropin secretion in patients with ectopic pregnancy. Predictive value of the active renin assay for the diagnosis of ectopic pregnancy. Placental growth factor: a promising diagnostic biomarker for tubal ectopic pregnancy. Serum biomarkers of tubal ectopic pregnancy: current candidates and future possibilities. C-reactive protein levels in ectopic pregnancy, pelvic infection and carcinoma of the cervix. The accuracy of transvaginal ultrasonography for the diagnosis of ectopic pregnancy prior to surgery. The optimal timing of an ultrasound scan to assess the location and viability of an early pregnancy. Gestational-pseudogestational sac: a new ultrasonic criterion for differential diagnosis. The double sac sign of early intrauterine pregnancy: use in exclusion of ectopic pregnancy. Comparison of transvaginal and transabdominal sonography in the detection of early pregnancy and its complications. Early pregnancy complications: endovaginal sonographic findings correlated with human chorionic gonadotropin levels. Transvaginal sonography for diagnosing ectopic pregnancy: positivity criteria and performance characteristics. Diagnostic efficacy of endovaginal color Doppler flow imaging in an ectopic pregnancy screening program. Vaginal sonography versus serum human chorionic gonadotropin in early detection of pregnancy. Treatment of unruptured tubal pregnancy by local injection of methotrexate under transvaginal sonographic control. Qualitative assessment of uteroplacental blood flow: early screening test for high-risk pregnancies. The conservative management of early pregnancy complication: a review of the literature. Intermediate trophoblast: a distinctive form of trophoblast with specific morphological, biochemical, and functional features. Serum progesterone and uterine curettage in the differential diagnosis of ectopic pregnancy. Ectopic pregnancy: diagnostic and therapeutic algorithms minimizing surgical intervention. A comparison of laparoscopy and laparotomy for the treatment of ectopic pregnancy. Adhesion formation after laparoscopic surgery in tubal pregnancy: a randomized trial versus laparotomy. A randomized controlled comparison of minilaparotomy and laparotomy in ectopic pregnancy cases. Persistent tubal ectopic gestation: patterns of circulating beta-human chorionic gonadotropin and progesterone, and management options. Comparison of persistent ectopic pregnancy after laparoscopic salpingostomy versus salpingectomy at laparotomy for ectopic pregnancy. Current evidence on surgery, systemic methotrexate and expectant management in the treatment of tubal ectopic pregnancy: a systematic review and meta-analysis. Management of unruptured ectopic gestation by linear salpingostomy: a prospective, randomized clinical trial of laparoscopy versus laparotomy. Treatment of interstitial ectopic pregnancy with methotrexate: report of a successful case. Ectopic pregnancy rate and treatment utilization in a large managed care organization. Analysis of three hundred fifteen women with tubal ectopic pregnancies treated with single-dose methotrexate. Establishing a human chorionic gonadotropin cutoff to guide methotrexate treatment of ectopic pregnancy: a systematic review. Methotrexate for ectopic pregnancy: a randomized single dose compared with multiple dose. Comparison of success rates in the medical management of ectopic pregnancy with single-dose and multiple dose administration of methotrexate: a prospective, randomized clinical trial. Methotrexate with citrovorum factor rescue: reduced chemotherapy toxicity in the management of gestational trophoblastic neoplasms. No increase in second tumors after cytotoxic chemotherapy for gestational trophoblastic tumors. Randomized trial of systemic methotrexate versus laparoscopic salpingostomy in tubal pregnancy. Clinical and pregnancy outcome following ectopic pregnancy; a prospective study comparing expectancy, surgery and systemic methotrexate treatment. Fertility outcome after systemic methotrexate and laparoscopic salpingostomy for tubal pregnancy. Methotrexate treatment of ectopic pregnancy: 100 cases treated by primary transvaginal injection under sonographic control. Ultrasound-guided injection of methotrexate versus laparoscopic salpingotomy in ectopic pregnancy. Transvaginal injection of potassium chloride and methotrexate for the treatment of tubal pregnancy with a live fetus. Prediction of persistent trophoblastic activity after local prostaglandin F2a injection for ectopic pregnancy. Comparison of a local injection of hyperosmolar glucose solution with salpingostomy for the conservative treatment of tubal pregnancy. The treatment of unruptured tubal pregnancy with intratubal methotrexate injection under laparoscopic control. Phase I clinical trial of monoclonal anti-human chorionic gonadotropin antibody in women with an ectopic pregnancy. Low human chorionic somatomammotropin fails to predict spontaneous resolution of unruptured ectopic pregnancies. Declining serum concentrations of the beta-subunit of human chorionic gonadotropin and ruptured ectopic pregnancy. Serum human chorionic gonadotropin dynamics during spontaneous resolution of ectopic pregnancy. Persistent trophoblast after conservative treatment of tubal pregnancy: prediction and detection. Treatment of persistent trophoblastic tissue after salpingostomy with methotrexate. Methotrexate therapy for persistent ectopic pregnancy after conservative laparoscopic management. Low-dose oral methotrexate as second-line therapy for persistent trophoblast after conservative treatment of ectopic pregnancy. Analysis of ectopic pregnancies resulting from in-vitro fertilization and embryo transfer.

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Diseases

• Jansen type metaphyseal chondrodysplasia
• Ventriculo-arterial discordance, isolated
• Oculo dento digital dysplasia
• Congenital hemidysplasia with ichtyosiform erythroderma and limbs defects
• Curtis Rogers Stevenson syndrome
• Hemoglobinopathy
• Muscular fibrosis multifocal obstructed vessels
• Cranio osteoarthropathy
• Uveal diseases
• Pili torti

References

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